Bone fracture

A bone fracture 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 .

CAUSES:
1. Traumatic fracture - This is a fracture due to sustained trauma. eg- Fractures caused by a fall, road traffic accident, fight etc. 2. Pathological fracture - A fracture through a bone which has been made weak by some underlying disease is called pathological fracture. eg- a fracture through a bone weakened by metastasis. Osteoporosis is the commonest cause of pathological fracture.

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 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

Signs and symptoms

Although bone tissue itself contains no nociceptors, bone fracture is very painful for several reasons:

Breaking in the continuity of the periosteum, with or without similar discontinuity in endosteum, as both contain multiple nociceptors.

Edema of nearby soft tissues caused by bleeding of torn periosteal blood vessels evokes pressure pain.

Muscle spasms trying to hold bone fragments in place

Damage to adjacent structures such as nerves or vessels, spinal cord and nerve roots (for spine fractures), or cranial contents (for skull fractures) can cause other specific signs and symptoms.

Pathophysiology of fracture Stress placed on the bone, exceeds the bone ability to absorb

Injury in the bone

Disruption in continuity of the bone

Disruption of muscle and blood vessels attached to the end of the bone

Soft tissue damage

Bleeding

Hematoma forms in midullary canal

Bone tissue surrounds the fractured site dies

Inflammatory response

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 treatmentrefers 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 a plaster 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 methodwhich 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 byosteoporosis 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 prophylacticantibiotics. 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 shieldingoccurs 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 titanium and 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), galvanic corrosion 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.