Abone fracture (abbreviatedFRX orFx,Fx, or#) is a medical condition in which there is a partial or complete break in the continuity of anybone in the body. In more severe cases, the bone may be broken into several fragments, known as acomminuted fracture.[1] An open fracture (or compound fracture) is a bone fracture where the broken bone breaks through the skin.[2]
A bone fracture may be the result of high forceimpact orstress, or a minimal trauma injury as a result of certain medical conditions that weaken the bones, such asosteoporosis,osteopenia,bone cancer, orosteogenesis imperfecta, where the fracture is then properly termed apathologic fracture.[3] Most bone fractures require urgent medical attention to prevent further injury.
Involuntarymuscle spasms trying to hold bone fragments in place.
Damage to adjacent structures such as nerves, muscles or blood vessels,spinal cord, and nerve roots (for spine fractures), or cranial contents (for skull fractures) may cause other specific signs and symptoms.[5]
An old fracture withnonunion of the fracture fragments
Some fractures may lead to serious complications, including a condition known ascompartment syndrome. If not treated, eventually, compartment syndrome may requireamputation of the affected limb. Other complications may include non-union, where the fractured bone fails to heal, or malunion, where the fractured bone heals in a deformed manner. One form of malunion is the malrotation of a bone, which is especially common after femoral and tibial fractures.[6]Complications of fractures may be classified into three broad groups, depending upon their time of occurrence. These are as follows –
Immediate complications – occurs at the time of the fracture.
Early complications – occurring in the initial few days after the fracture.
Late complications – occurring a long time after the fracture.
Stages in Fracture Repair: The healing of a bone fracture follows a series of progressive steps: (a) A fracture hematoma forms. (b) Internal and external calli form. (c) Cartilage of the calli is replaced by trabecular bone. (d) Remodeling occurs.
The natural process of healing a fracture starts when the injured bone and surrounding tissues bleed, forming a fracturehematoma. Theblood coagulates to form a bloodclot situated between the broken fragments.[7] Within a few days,blood vessels grow into the jelly-like matrix of the blood clot. The new blood vessels bringphagocytes to the area, which gradually removes the non-viable material. The blood vessels also bringfibroblasts in the walls of the vessels and these multiply and producecollagen fibres. In this way, the blood clot is replaced by a matrix of collagen. Collagen's rubbery consistency allows bone fragments to move only a small amount unless severe or persistent force is applied.[citation needed]
At this stage, some of the fibroblasts begin to lay downbone matrix in the form of collagen monomers. These monomers spontaneously assemble to form the bone matrix, for which bone crystals (calcium hydroxyapatite) are deposited in amongst, in the form of insolublecrystals. This mineralization of the collagen matrix stiffens it and transforms it into bone. In fact, boneis a mineralized collagen matrix; if the mineral is dissolved out of bone, it becomes rubbery. Healing bonecallus on average is sufficiently mineralized to show up onX-ray within 6 weeks in adults and less in children. This initial "woven" bone does not have the strong mechanical properties of mature bone. By a process of remodelling, the woven bone is replaced by mature "lamellar" bone. The whole process may take up to 18 months, but in adults, the strength of the healing bone is usually 80% of normal by 3 months after the injury.[citation needed]
Several factors may help or hinder the bone healing process. For example,tobacco smoking hinders the process of bone healing,[8] and adequate nutrition (includingcalcium intake) will help the bone healing process. Weight-bearing stress on bone, after the bone has healed sufficiently to bear the weight, also builds bone strength.
Although there are theoretical concerns aboutNSAIDs slowing the rate of healing, there is not enough evidence to warrant withholding the use of this type analgesic in simple fractures.[9]
Smokers generally have lower bone density than non-smokers, so they have a much higher risk of fractures. There is also evidence that smoking delays bone healing.[10]
Radiography to identify possible fractures after a knee injury
A bone fracture may be diagnosed based on the history given and the physical examination performed.Radiographic imaging is often performed to confirm the diagnosis. Under certain circumstances, radiographic examination of the nearby joints is indicated to exclude dislocations and fracture-dislocations. In situations where projectional radiography alone is insufficient,Computed Tomography (CT) orMagnetic Resonance Imaging (MRI) may be indicated.[citation needed]
Compare healthy bone with different types of fractures: (a) closed fracture (b) open fracture (c) transverse fracture (d) spiral fracture (e) comminuted fracture (f) impacted fracture (g) greenstick fracture (h) oblique fractureOpen ankle fracture with luxationPeriprosthetic fracture of left femur
Inorthopedicmedicine, fractures are classified in various ways. Historically, they are named after the physician who first described the fracture conditions; however, there are more systematic classifications as well.[citation needed]
They may be divided into stable versus unstable depending on the likelihood that they may shift further.[citation needed]
Traumatic fracture – a fracture due to sustained trauma. e.g., fractures caused by a fall,road traffic accident, fight, etc.
Pathologic fracture – A fracture through a bone that has been made weak by some underlying disease is called a pathological fracture. e.g., a fracture through a bone weakened bymetastasis.Osteoporosis is the most common cause of pathological fracture.
Periprosthetic fracture – a fracture at the point of mechanical weakness at the end of animplant.
Closed/simple fractures are those in which the overlying skin is intact[11]
Open/compound fractures involve wounds that communicate with the fracture, or where fracturehematoma is exposed, and may thus expose bone tocontamination. Open injuries carry a higher risk ofinfection. Reports indicate an incidence of infection after internal fixation of closed fractures of 1-2%, rising to 30% in open fractures.[12]
Linear fracture – a fracture that is parallel to the bone's long axis
Transverse fracture – a fracture that is at a right angle to the bone's long axis
Oblique fracture – a fracture that is diagonal to a bone's long axis (more than 30°)
Spiral fracture – a fracture where at least one part of the bone has been twisted
Compression fracture/wedge fracture – usually occurs in the vertebrae, for example when the front portion of avertebra in the spine collapses due toosteoporosis (a medical condition which causes bones to become brittle and susceptible to fracture, with or without trauma)
Impacted fracture – a fracture caused when bone fragments are driven into each other
Avulsion fracture – a fracture where a fragment of bone is separated from the main mass
Incomplete fracture – a fracture in which the bone fragments are still partially joined; in such cases, there is a crack in the osseous tissue that does not completely traverse the width of the bone.
Complete fracture – a fracture in which bone fragments separate completely.
Comminuted fracture – a fracture in which the bone has broken into several pieces.
An anatomical classification may begin with specifying the involved body part, such as the head or arm, followed by more specific localization. Fractures that have additional definition criteria than merely localization often may be classified as subtypes of fractures, such as aHolstein-Lewis fracture being a subtype of ahumerus fracture. Most typical examples in an orthopaedic classification given in the previous section cannot be classified appropriately into any specific part of an anatomical classification, however, as they may apply to multiple anatomical fracture sites.
Le Fort fracture of skull – facial fractures involving themaxillary bone and surrounding structures in a usually bilateral and either horizontal, pyramidal, or transverse way.
Maisonneuve fracture – a spiral fracture of the proximal third of the fibula associated with a tear of the distal tibiofibular syndesmosis and the interosseous membrane
The Orthopaedic Trauma Association Committee for Coding and Classification published its classification system[21] in 1996, adopting a similar system to the 1987AO Foundation system.[22] In 2007, they extended their system,[23] unifying the two systems regarding wrist, hand, foot, and ankle fractures.
Both high- and low-force trauma can cause bone fracture injuries.[30][31] Preventive efforts to reduce motor vehicle crashes, the most common cause of high-force trauma, include reducing distractions while driving.[32] Common distractions are driving under the influence and texting or calling while driving, both of which lead to an approximate 6-fold increase in crashes.[32] Wearing a seatbelt can also reduce the likelihood of injury in a collision.[32] 30km/h or 20mphspeed limits (as opposed to the more common intracity 50 km/h / 30 mph) also drastically reduce the risk of accident, serious injury and even death in crashes between motor vehicles and humans.Vision Zero aims to reducetraffic deaths to zero through better traffic design and other measures and to drastically reducetraffic injuries, which would prevent many bone fractures.
A common cause of low-force trauma is an at-home fall.[30][31] When considering preventative efforts, theNational Institute of Health (NIH) examines ways to reduce the likelihood of falling, the force of the fall, and bone fragility.[33] To prevent at-home falls they suggest keeping cords out of high-traffic areas where someone could trip, installing handrails and keeping stairways well-lit, and installing an assistive bar near the bathtub in the washroom for support.[33] To reduce the impact of a fall the NIH recommends to try falling straight down on your buttocks or onto your hands.[33]
Some sports have a relatively high risk of bone fractures as a commonsports injury. Preventive measures depend to some extent on the specific sport, but learning proper technique, wearingprotective gear and having a realistic estimation of one's own capabilities and limitations can all help reduce the risk of bone fracture. Incontact sports, rules have been put in place to protect athlete health, such as the prohibition ofunnecessary roughness inAmerican football.
Taking calcium and vitamin D supplements can help strengthen your bones.[33] Vitamin D supplements combined with additional calcium marginally reduces the risk of hip fractures and other types of fracture in older adults; however, vitamin D supplementation alone did not reduce the risk of fractures.[34] Taking vibration therapy can also help strengthening bones and reducing the risk of a fracture.[35][36]
Usually occurs in the vertebrae, for example, when the front portion of avertebra in the spine collapses due toosteoporosis (a medical condition which causes bones to become brittle and susceptible to fracture, with or without trauma)
X-ray showing the proximal portion of a fracturedtibia with anintramedullary nailThe surgical treatment ofmandibular angle fracture; fixation of the bone fragments by the plates, the principles of osteosynthesis are stability (immobility of the fragments that creates the conditions for bones coalescence) and functionalityProximal femur nail with locking and stabilisation screws for treatment of femur fractures of left thigh
Treatment of bone fractures are broadly classified as surgical or conservative, the latter basically referring to any non-surgical procedure, such as pain management, immobilization or other non-surgical stabilization. A similar classification isopen versusclosed treatment, in whichopen treatment refers to any treatment in which the fracture site is opened surgically, regardless of whether the fracture is anopen orclosed fracture.[38]
In arm fractures in children,ibuprofen is as effective as a combination ofparacetamol andcodeine.[39] In theEMS setting it might be applicable to administer 1mg/kg of ivketamine to achieve a dissociated state.
Sincebone healing is a natural process that will occur most often, fracture treatment aims to ensure the best possiblefunction of the injured part after healing. Bone fractures typically are treated by restoring the fractured pieces of bone to their natural positions (if necessary), and maintaining those positions while the bone heals. Often, aligning the bone, calledreduction, in a good position and verifying the improved alignment with an X-ray is all that is needed. This process is extremely painful withoutanaesthesia, about as painful as breaking the bone itself. To this end, a fractured limb usually is immobilized with aplaster orfibreglasscast or splint that holds the bones in position and immobilizes the joints above and below the fracture.
When the initial post-fractureoedema or swelling goes down, the fracture may be placed in a removable brace ororthosis. If being treated with surgery,surgical nails, screws, plates, and wires are used to hold the fractured bone together more directly. Alternatively, fractured bones may be treated by theIlizarov method, which is a form of an external fixator.
Occasionally, smaller bones, such as phalanges of thetoes andfingers, may be treated without the cast, bybuddy wrapping them, which serves a similar function to making a cast. A device called aSuzuki frame may be used in cases of deep, complex intra-articular digit fractures.[40] By allowing only limited movement, immobilization helps preserve anatomical alignment while enablingcallus formation, toward the target of achieving union.
Splinting results in the same outcome as casting in children who have a distal radius fracture with little shifting.[41]
Surgical methods of treating fractures have their own risks and benefits, but usually, surgery is performed only if conservative treatment has failed, is very likely to fail, or is likely to result in a poor functional outcome.[42] With some fractures such aship fractures (usually caused byosteoporosis), surgery is offered routinely because non-operative treatment results in prolonged immobilisation, which commonly results in complications including chest infections, pressure sores, deconditioning,deep vein thrombosis (DVT), andpulmonary embolism, which are more dangerous than surgery.[43] When a joint surface is damaged by afracture, surgery is also commonly recommended to make an accurate anatomical reduction and restore the smoothness of the joint.
Infection is especially dangerous in bones, due to the recrudescent nature of bone infections. Bone tissue is predominantlyextracellular matrix, rather than living cells, and the fewblood vessels needed to support this low metabolism are only able to bring a limited number ofimmune cells to an injury to fight infection. For this reason, open fractures andosteotomies call for very carefulantiseptic procedures andprophylactic use of antibiotics.
Sometimes bones are reinforced with metal.[45] Theseimplants must be designed and installed with care.Stress shielding occurs when plates or screws carry too large of a portion of the bone's load, causingatrophy. This problem is reduced, but not eliminated, by the use of low-modulus materials, includingtitanium and its alloys. The heat generated by the friction of installing hardware can accumulate easily and damagebone tissue, reducing the strength of the connections. If dissimilar metals are installed in contact with one another (i.e., a titanium plate withcobalt-chromium alloy orstainless steel screws), galvaniccorrosion will result. The metalions produced can damage thebone locally and may cause systemic effects as well.
Bone stimulation with eitherelectromagnetic orultrasound waves may be suggested as an alternative to surgery to reduce the healing time for non-union fractures.[46][47] The proposed mechanism of action is by stimulating osteoblasts and other proteins that form bones using these modalities. The evidence supporting the use of ultrasound and shockwave therapy for improving unions is very weak[46] and it is likely that these approaches do not make a clinically significant difference for a delayed union or non-union.[48]
Physical therapy exercises (either home-based or physiotherapist-led) to improve functional mobility and strength, gait training for hip fractures, and other physical exercises are also often suggested to help recover physical capacities after a fracture has healed.[49][50]
In children, whose bones are still developing, there are risks of either a growth plate injury or agreenstick fracture.
A greenstick fracture occurs due to mechanical failure on the tension side. That is, since the bone is not so brittle as it would be in an adult, it does not completely fracture, but rather exhibits bowing without complete disruption of the bone'scortex in the surface opposite the applied force.
Growth plate injuries, as inSalter-Harris fractures, require careful treatment and accurate reduction to make sure that the bone continues to grow normally.
Plastic deformation of the bone, in which the bone permanently bends, but does not break, is also possible in children. These injuries may require anosteotomy (bone cut) to realign the bone if it is fixed and cannot be realigned by closed methods.
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