BONE FRACTURE A bone fracture (sometimes abbreviated FRX or Fx, Fx) is a medical condition in which there is a break in the

continuity of the bone. A bone fracture can be the result of high force impact or stress, or trivial injury as a result of certain medical conditions that weaken the bones, such as osteoporosis, bone cancer, or osteogenesis imperfecta, where the fracture is then properly termed a pathologic fracture.

Orthopedic In orthopedic medicine, fractures are classified in various ways. Historically they are named after the doctor who first described the fracture conditions. However, there are more systematic classifications in place currently. All fractures can be broadly described as:
 

Closed (simple) fractures are those in which the skin is intact Open (compound) fractures involve wounds that communicate with the fracture, or where fracture hematoma is exposed, and may thus expose bone to contamination. Open injuries carry a higher risk of infection.

Other considerations in fracture care are displacement (fracture gap) and angulation. If angulation or displacement is large, reduction (manipulation) of the bone may be required and, in adults, frequently requires surgical care. These injuries may take longer to heal than injuries without displacement or angulation.


Compression fractures usually occurs in the vertebrae, for example when the front portion of a vertebra in the spine collapses due to osteoporosis (a medical condition which causes bones to become brittle and susceptible to fracture, with or without trauma).

Other types of fracture are:

 

   

Complete fracture: A fracture in which bone fragments separate completely. 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.[1] 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. Spiral fracture: A fracture where at least one part of the bone has been twisted.

 

Comminuted fracture: A fracture in which the bone has broken into a number of pieces. Impacted fracture: A fracture caused when bone fragments are driven into each other.

Diagnosis A bone fracture can be diagnosed clinically based on the history given and the physical examination performed. Imaging by X-ray is often performed to view the bone suspected of being fractured. In situations where x-ray alone is insufficient, a computed tomograph (CT scan) may be performed.

Treatment 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 is open versus closed treatment, in which open treatment refers to any treatment in which the fracture site is surgically opened, regardless of whether the fracture itself is an open or closed fracture.

Pain management In arm fractures in children, ibuprofen has been found to be equally effective as the combination of acetaminophen and codeine.[22]

Immobilization Since bone healing is a natural process which will most often occur, fracture treatment aims to ensure the best possible function of the injured part after healing. Bone fractures are typically 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, called reduction, in good position and verifying the improved alignment with an X-ray is all that is needed. This process is extremely painful without anesthesia, about as painful as breaking the bone itself. To this end, a fractured limb is usually immobilized with aplaster or fiberglass cast or splint which holds the bones in position and immobilizes the joints above and below the fracture. When the initial post-fracture edema or swelling goes down, the fracture may be placed in a removable brace or orthosis. 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 the Ilizarov method which is a form of external fixator. Occasionally smaller bones, such as phalanges of the toes and fingers, may be treated without the cast, by buddy wrapping them, which serves a similar function to making a cast. By allowing only limited movement, fixation helps preserve anatomical alignment while enabling callus formation, towards the target of achieving union.

Splinting results in the same outcome as casting in children who have a distal radius fracture with little shifting.[23]

Surgery Surgical methods of treating fractures have their own risks and benefits, but usually surgery is done only if conservative treatment has failed or is very likely to fail. With some fractures such as hip fractures (usually caused by osteoporosis or osteogenesis Imperfecta), surgery is offered routinely, because the complications of non-operative treatment include deep vein thrombosis (DVT) and pulmonary embolism, which are more dangerous than surgery. When a joint surface is damaged by a fracture, 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 predominantly extracellular matrix, rather than living cells, and the few blood vessels needed to support this low metabolism are only able to bring a limited number of immune cells to an injury to fight infection. For this reason, open fractures and osteotomies call for very careful antiseptic procedures and prophylactic antibiotics. Occasionally bone grafting is used to treat a fracture. Sometimes bones are reinforced with metal. These implants 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, causing atrophy. This problem is reduced, but not eliminated, by the use of low-modulus materials, including titaniumand its alloys. The heat generated by the friction of installing hardware can easily accumulate and damage bone tissue, reducing the strength of the connections. If dissimilar metals are installed in contact with one another (i.e., a titanium plate with cobalt-chromium alloy or stainless steel screws), galvaniccorrosion will result. The metal ions produced can damage the bone locally and may cause systemic effects as well. Electrical bone growth stimulation or osteostimulation has been attempted to speed or improve bone healing. Results however do not support its effectiveness.[24] Complications Some fractures can lead to serious complications including a condition known as compartment syndrome. If not treated, compartment syndrome can result in amputation of the affected limb. Other complications may include non-union, where the fractured bone fails to heal or mal-union, where the fractured bone heals in a deformed manner.

OPEN FRACTURE An open fracture is a broken bone that penetrates the skin. This is an important distinction because when a broken bone penetrates the skin there is a need for immediate treatment, and an operation is often required to clean the area of the fracture. Furthermore, because of the risk of infection, there are more often problems associated with healing when a fracture is open to the skin. What causes an open fracture? Open fractures are typically caused by high-energy injuries such as car crashes, falls, or sports injuries. Joe Theismann, a professional football player, famously ended his career with an open fracture that occurred on national television. What is the treatment of an open fracture? As mentioned previously, open fractures often require immediate surgery to clean the area of the injury. Because of the break in the skin, debris and infection can travel to the fracture location, and lead to a high rate of infection in the bone. Once an infection is established, it can be a difficult problem to solve. Treatment of established bone infections often requires multiple surgeries, prolonged antibiotic treatment, and long-term problems. Therefore, every effort is made to prevent this potential problem with early treatment. Despite this early treatment, patients with an open fracture are still susceptible to bone infections. What is the recovery from an open fracture? Open fractures usually take longer to heal because of the extent of injury to the bone and the surrounding soft-tissues. Open fractures also have a high rate of complications including infection and non-union. What if I sustain an open fracture? As stated, early treatment can help avoid problems associated with open fractures. Emergency care will involve antibiotics, cleaning of the fracture site, and stabilization of the bones. Also Known As: Compound Fracture

Anterior Cruciate Ligament Injury An injury to the anterior cruciate ligament can be a debilitating musculoskeletal injury to the knee, seen most often in athletes. Non-contact tears and ruptures are the most common causes of ACL injury. The anterior cruciate ligament (ACL) is an important ligament for proper movement. ACL injury more commonly causes knee instability than does injury to other knee ligaments.[1] Injuries of the ACL range from mild such as small tears to severe when the ligament is completely torn. There are many ways the ACL can be torn; the most prevalent is when the knee is bent too much toward the back and when it goes too far to the side. Tears in the anterior cruciate ligament often take place when the knee receives a direct impact from the front while the leg is in a stable position, for example a standing football player is tackled sideways when his feet are firmly planted. Torn ACL s are most often related to high impact sports or when the knee is forced to make sharp changes in movement and during abrupt stops from high speed Signs and symptoms Symptoms of an ACL injury include hearing a sudden popping sound, swelling, and instability of the knee (i.e., a "wobbly" feeling). Pain is also a major symptom in an ACL injury and can range from moderate to severe. Treatment The ACL primarily serves to stabilize the knee in an extended position and when surrounding muscles are relaxed; so if the muscles are strong, many people can function without it. Fluids will also build the muscle. The term for non-surgical treatment for ACL rupture is "conservative management", and it often includes physical therapy and using a knee brace. Lack of an ACL increases the risk of other knee injuries such as a torn meniscus, so sports with cutting and twisting motions are strongly discouraged. For patients who frequently participate in such sports, surgery is often indicated. Patients who have suffered an ACL injury should always be evaluated for other knee injuries that often occur in combination with an ACL tear. These include cartilage/meniscus injuries, bone bruises, PCL tears, posterolateral injuries and collateral ligament injuries. Surgery If the tear is severe, surgery may be necessary because the ACL cannot heal independently because there is a lack of blood supply going to this ligament. Surgery is usually required among athletes because the ACL is needed in order to perform sharp movements safely and with stability. The surgery of the ACL is usually done several weeks after the injury in order to allow the swelling and inflammation to go

down. During surgery the ACL is not repaired instead, it is reconstructed using other ligaments in the body. There are three different types of ACL surgery. Patella tendon-bone auto graft and hamstring auto graft are the most common and preferred and tend to produce the best results. For the Patella tendonbone auto graft, the central 1/3 of the patella tendon is removed along with a piece of bone at the attachment sites on the kneecap and tibia. The advantages of using this method is that the patella tendon and ACL are relatively the same length and it uses a bone to bone attachment which most surgeons agree is much stronger than other healing methods. Disadvantages of this method is common anterior knee pain due to the removal of bone from the kneecap. For the hamstring auto graft, two tendons are taken from the hamstring muscles and wrapped together forming the new ACL. Advantages of this method are less pain associated with post surgery healing than that of the patella tendon-bone graft due to the fact no bone was removed and the incision is small. Disadvantages of this method is that it takes longer to heal since there is no bone to bone healing and the tendon to bone takes awhile to become rigid.[13] After the surgery, rehabilitation is required in order to strengthen the surrounding muscles and stabilize the joint. There are two main options for ACL graft selection, allograft and autograft. Autografts are the persons own tissues, and options include the hamstring tendons or middle third of the patella tendon but it is not known which is best.[14] Allograft is cadaveric tissue sourced from a tissue bank. Each method has its own advantages and disadvantages; hamstring and middle third of patella tendon having similar outcomes. Patellar grafts are often incorrectly cited as being stronger, but the site of the harvest is often extremely painful for weeks after surgery and some patients develop chronic patellartendinitis. Replacement via a posthumous donor involves a slightly higher risk of infection. Additionally, donor grafts eliminate tendon harvesting which, due to improved arthroscopic methods, is responsible for most post-operative pain. The surgery is typically undertaken arthroscopically, with tunnels drilled into the femur and tibia at approximately the original ACL attachments. The graft is then placed into position and held in place. There are a variety of fixation devices available, particularly for hamstring tendon fixation. These include screws, buttons and post fixation devices. The graft typically attaches to the bone within six to eight weeks[citation needed]. The original collagen tissue in the graft acts as a scaffold and new collagen tissue is laid down in the graft with time. Hence the graft takes over six months to reach maximal strength.[citation
needed]

After surgery, the knee joint loses flexibility, and the muscles around the knee and in the thigh tend to atrophy. All treatment options require extensive physical therapy to regain muscle strength around the knee and restore range of motion (ROM). For some patients, the lengthy rehabilitation period may be more difficult to deal with than the actual surgery. In general, a rehabilitation period of six months to a year is required to regain pre-surgery strength and use.[citation
needed]

This is very dependent on the

rehabilitation assignment provided by the surgeon as well as the person who is receiving the surgery. External bracing is recommended for athletes in contact and collision sports for a period of time after reconstruction. It is important however to realize that this type of prevention is given by a 'surgeon to surgeon' basis; all surgeons will prescribe a brace and crutches for post surgery recovery. Total usage time is one month. After surgery, no sports are allowed for 6 to 7 months. Whether the ACL deficient knee is reconstructed or not, the patient is susceptible to early onset of chronic degenerative joint disease. Rehabilitation The rehabilitation process is a very important part of the surgery. There is a long and rigorous process involved in getting back to one hundred percent. The doctor will start the patient on the rehabilitation program, which is broken down into phases: Phase 1: This step is called the early rehabilitation phase. This is basically the things that were covered in short term, things to reduce pain and swelling while gaining movement. Phase 2: This phase covers weeks 3 and 4. At this point the pain should be subsiding and the patient will be ready to try more things that their knee isn t willing to perform. That is why there is a lot of emphasis put on joint protection during this step. The patient will be able to start doing exercises such as mini wall sits and riding stationary bikes. The aim of this is to be able to bend the knee 100 degrees. Phase 3: This phase is known as the controlled ambulation phase and it covers weeks 4 to 6. At this point the patient will be doing the same exercises from phase 2 plus some more challenging ones. The patient will try to get their knee to bend 130 degrees during this stage. The aim during this period is to focus heavily on improving balance. Phase 4: This is the moderate protection phase and it covers weeks 6 to 8. In this period the patient will try to obtain full range of motion as well as increase resistance for the workouts. Phase 5: This is the light activity phase and it covers weeks 8 to 10. This period will place particular emphasis on strengthening exercises, with increased concentration on balance and mobility. Phase 6: This is the return to activity phase and it lasts from week 10 until the target activity level is reached. At this point the patient will be able to start jogging and performing moderately intense agility drills. Somewhere between month 3 and month 6 the surgeon will probably request that the patient perform physical tests so s/he can monitor the activity level. When the doctor feels comfortable with the progress of the patient, s/he will clear that person to resume a fully active lifestyle.[15]