A bone fracture (sometimes abbreviated FRX or Fx, Fx, or #) 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 termed pathological fracture. Although broken bone and bone break are common colloquialisms for a bone fracture, break is not a formal orthopedic term.

OrthopedicIn 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, while 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; they require antibiotic treatment and usually urgent surgical treatment (debridement). This involves removal of all dirt, contamination, and dead tissue. Multi-fragmentary fractures, known as comminuted fractures, involve the bone splitting into multiple pieces. A simple, closed fracture is much easier to treat and has a much better prognosis than an open, comminuted fracture.

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. Another type of bone fracture is a compression fracture. It 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. 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. Compacted fracture: A fracture caused when bone fragments are driven into each other.

Holstein-Lewis fracture: A fracture of the distal third of the humerus resulting in entrapment of the radial nerve. Since the triceps brachii and all muscles distal of the break are innervated by the radial nerve, they will be significantly affected by the fracture.

[edit] OTA classificationThe Orthopaedic Trauma Association, an association for orthopaedic surgeons, adopted and then extended the classification of Mller and the AO foundation [1] ("The Comprehensive Classification of the Long Bones") an elaborate classification system to describe the injury accurately and guide treatment.[2][3] There are five parts to the code:

Bone: Description of a fracture starts by coding for the bone involved:

(1) Humerus, (2) Radius/Ulna, (3) Femur, (4) Tibia/Fibula, (5) Spine, (6) Pelvis, (24) Carpus, (25) Metacarpals, (26) Phalanx (Hand), (72) Talus, (73) Calcaneus, (74) Navicular, (75) Cuneiform, (76) Cuboid, (80) LisFranc, (81) Metatarsals, (82) Phalanx (Foot), (45) Patella, (06) Clavicle, (09) Scapula

Location: a code for the part of the bone involved (e.g. shaft of the femur): proximal=1, diaphyseal=2, distal=3 (at the ankle the malleolar region is considered separately due to the pre-existing Weber classification and coded as 4[4]). Except at the proximal femur the distal and proximal regions of the bone are defined by a square that is as wide as the as the distance between the condyles. The diaphysis is considered to be the rest of the bone between these two squares. Type: It is important to note whether the fracture is simple or multifragmentary and whether it is closed or open: A=simple fracture, B=wedge fracture, C=complex fracture Group: The geometry of the fracture is also described by terms such as transverse, oblique, spiral, or segmental. Subgroup: Other features of the fracture are described in terms of displacement, angulation and shortening. A stable fracture is one which is likely to stay in a good (functional) position while it heals; an unstable one is likely to shorten, angulate or rotate before healing and lead to poor function in the long term.

[edit] Other classification systemsThere are other systems used to classify different types of bone fractures:

"Denis classification": spine[5] "Frykman classification": radius and ulna "Gustilo open fracture classification"[6] "Letournel and Judet Classification": Acetabular Fractures[7]

"Neer classification": humerus[8][9] "Seinsheimer's Classification": femur[10]

[edit] Signs and symptomsAlthough bone tissue itself contains no nociceptors, bone fracture is very painful for several reasons:[11]

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

[edit] PathophysiologyMain article: Bone healing The natural process of healing a fracture starts when the injured bone and surrounding tissues bleed, forming a fracture Hematoma. The blood coagulates to form a blood clot situated between the broken fragments. Within a few days blood vessels grow into the jelly-like matrix of the blood clot. The new blood vessels bring phagocytes to the area, which gradually remove the non-viable material. The blood vessels also bring fibroblasts in the walls of the vessels and these multiply and produce collagen 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. At this stage, some of the fibroblasts begin to lay down bone matrix (calcium hydroxyapatite) in the form of insoluble crystals. This mineralization of the collagen matrix stiffens it and transforms it into bone. In fact, bone is a mineralized collagen matrix; if the mineral is dissolved out of bone, it becomes rubbery. Healing bone callus is on average sufficiently mineralized to show up on X-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 remodeling, the woven bone is replaced by mature "lamellar" bone. The whole process can 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. Several factors can help or hinder the bone healing process. For example, any form of nicotine hinders the process of bone healing, and adequate nutrition (including calcium 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. The bone shards can also embed in the muscle causing great pain. Although there are theoretical concerns about NSAIDs slowing the rate of healing,

there is not enough evidence to warrant withholding the use of this type analgesic in simple fractures.[12]

[edit] DiagnosisA bone fracture can be diagnosed clinically, based on the history given and the physical examination performed by a healthcare professional. Usually there will be an area of swelling, abrasion, bruising and/or tenderness at the suspected fracture site. Open fractures may be obvious if bone is exposed but small wounds may need surgical exploration to determine if they are only superficial or connected to the fracture. X-ray radiographs can be requested to view the bone suspected of being fractured. In situations where x-ray alone is insufficient, a computed tomograph (CT scan) may be performed.

Pain managementIn arm fractures in children ibuprofen has been found to be equally effective as the combination of acetaminophen and codeine.[13]

[edit] ImmobilizationSince 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 verify 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 postfracture 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.

[edit] 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 their limited blood flow. 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 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.

In childrenMain article: Child bone fracture In children, whose bones are still developing, there are risks of either a growth plate injury or a greenstick fracture.

A greenstick fracture occurs due to mechanical failure on the tension side. That is, since the bone is not as brittle as it would be in an adult, it does not completely fracture, but rather exhibits bowing without complete disruption of the bone's cortex in the surface opposite the applied force. Growth plate injuries, as in Salter-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 an osteotomy (bone cut) to realign the bone if it is fixed and cannot be realigned by closed methods. Certain fractures are known to occur mainly in pediatric age group, as fracture clavicle & supracondylar fracture of humerus.

A fracture is the (local) separation of an object or material into two, or more, pieces under the action of stress. The word fracture is often applied to bones of living creatures, or to crystals or crystalline materials, such as gemstones or metal. Sometimes, in crystalline materials, individual crystals fracture without the body actually separating into two or more pieces. Depending on the substance which is fractured, a fracture reduces strength (most substances) or inhibits transmission of light (optical crystals). A detailed understanding of how fracture occurs in materials may be assisted by the study of fracture mechanics. In brittle fracture, no apparent plastic deformation takes place before fracture. In brittle crystalline materials, fracture can occur by cleavage as the result of tensile stress acting normal to crystallographic planes with low bonding (cleavage planes). In amorphous solids, by contrast, the lack of a crystalline structure results in a conchoidal fracture, with cracks proceeding normal to the applied tension. The theoretical strength of a crystalline material is (roughly)

where: E is the Young's modulus of the material, is the surface energy, and ro is the equilibrium distance between atomic centers. On the other hand, a crack introduces a stress concentration modeled by

(For sharp cracks) where: applied is the loading stress, a is half the length of the crack, and is the radius of curvature at the crack tip. Putting these two equations together, we get

Looking closely, we can see that sharp cracks (small ) and large defects (large a) both lower the fracture strength of the material. Recently, scientists have discovered supersonic fracture, the phenomenon of crack motion faster than the speed of sound in a material.[citation needed] This phenomenon was recently also verified by experiment of fracture in rubber-like materials. In ductile fracture, extensive plastic deformation takes place before fracture. Many ductile metals, especially materials with high purity, can sustain very large deformation of 50100% or more strain before fracture under favorable loading condition and environmental condition. The strain at which the fracture happens is controlled by the purity of the materials. At room temperature, pure iron can undergo deformation up to 100% strain before breaking, while cast iron or high-carbon steels can barely sustain 3% of strain.[citation needed]. Because ductile rupture involves a high degree of plastic deformation, the fracture behavior of a propagating crack as modeled above changes fundamentally. Some of the energy from stress concentrations at the crack tips is dissipated by plastic deformation before the crack actually propagates. The basic steps sample of smallest cross-sectional area), void formation, void coalescence (also known as crack formation), crack propagation, and failure, often resulting in a cup-and-cone shaped failure surface.

[edit] Crack separation modes

The three fracture modes. There are three ways of applying a force to enable a crack to propagate:

Mode I crack Opening mode (a tensile stress normal to the plane of the crack) Mode II crack Sliding mode (a shear stress acting parallel to the plane of the crack and perpendicular to the crack front) Mode III crack Tearing mode (a shear stress acting parallel to the plane of the crack and parallel to the crack front)

Considerations

It is hard to tell a dislocated bone from a broken bone. However, both are emergency situations, and the basic first aid steps are the same.Causes

The following are common causes of broken bones:

Fall from a height Motor vehicle accidents Direct blow Child abuse Repetitive forces, such as those caused by running, can cause stress fractures of the foot, ankle, tibia, or hip

Symptoms

A visibly out-of-place or misshapen limb or joint Swelling, bruising, or bleeding Intense pain Numbness and tingling Broken skin with bone protruding Limited mobility or inability to move a limb

First Aid 1. Check the person's airway and breathing. If necessary, call 911 and begin rescue breathing, CPR, or bleeding control. 2. Keep the person still and calm. 3. Examine the person closely for other injuries. 4. In most cases, if medical help responds quickly, allow the medical personnel to take further action. 5. If the skin is broken, it should be treated immediately to prevent infection. Don't breathe on the wound or probe it. If possible, lightly rinse the wound to remove visible dirt or other contamination, but do not vigorously scrub or flush the wound. Cover with sterile dressings. 6. If needed, immobilize the broken bone with a splint or sling. Possible splints include a rolled up newspaper or strips of wood. Immobilize the area both above and below the injured bone. 7. Apply ice packs to reduce pain and swelling. 8. Take steps to prevent shock. Lay the person flat, elevate the feet about 12 inches above the head, and cover the person with a coat or blanket. However, DO NOT move the person if a head, neck, or back injury is suspected.

CHECK BLOOD CIRCULATION

Check the person's blood circulation. Press firmly over the skin beyond the fracture site. (For example, if the fracture is in the leg, press on the foot). It should first blanch white and then "pink up" in about two seconds. Other signs that circulation is inadequate include pale or blue skin, numbness or tingling, and loss of pulse. If circulation is poor and trained personnel are NOT quickly available, try to realign the limb into a normal resting position. This will reduce swelling, pain, and damage to the tissues from lack of blood. TREAT BLEEDING1. Place a dry, clean cloth over the wound to dress it. 2. If the bleeding continues, apply direct pressure to the site of bleeding. DO NOT apply a tourniquet to the extremity to stop the bleeding unless it is lifethreatening. DO NOT

DO NOT move the person unless the broken bone is stable. DO NOT move a person with an injured hip, pelvis, or upper leg unless it is absolutely necessary. If you must move the person, pull the person to safety by his clothes (such as by the shoulders of a shirt, a belt, or pant-legs). DO NOT move a person who has a possible spine injury. DO NOT attempt to straighten a bone or change its position unless blood circulation appears hampered. DO NOT try to reposition a suspected spine injury. DO NOT test a bone's ability to move.

When to Contact a Medical Professional

Call 911 if:

There is a suspected broken bone in the head, neck, or back. There is a suspected broken bone in the hip, pelvis, or upper leg. You cannot completely immobilize the injury at the scene by yourself. There is severe bleeding. An area below the injured joint is pale, cold, clammy, or blue. There is a bone projecting through the skin.

Even though other broken bones may not be medical emergencies, they still deserve medical attention. Call your health care provider to find out where and when to be seen. If a young child refuses to put weight on an arm or leg after an accident, won't move the arm or leg, or you can clearly see a deformity, assume the child has a broken bone and get medical help.Prevention

Wear protective gear while skiing, biking, roller blading, and participating in contact sports. This includes helmets, elbow pads, knee pads, and shin pads.

Create a safe home for young children. Gate stairways and keep windows closed. Teach children how to be safe and look out for themselves. Supervise children carefully. There is no substitute for supervision, no matter how safe the environment or situation appears to be. Prevent falls by not standing on chairs, counter tops, or other unstable objects. Remove throw rugs and electrical cords from floor surfaces. Use handrails on staircases and non-skid mats in bathtubs. These steps are especially important for the elderly.

Alternative Names

Bone - broken; Fracture; Stress fracture Bones form the skeleton of the body and allow the body to be supported against gravity and to move and function in the world. Bones also protect some body parts, and the bone marrow is the production center for blood products. Bone is not a stagnant organ. It is the body's reservoir of calcium and is always undergoing change under the influence of hormones. Parathyroid hormone increases blood calcium levels by leeching calcium from bone, while calcitonin has the opposite effect, allowing bone to accept calcium from the blood.

What causes a fracture?When outside forces are applied to bone it has the potential to fail. Fractures occur when bone cannot withstand those outside forces. Fracture, break, or crack all mean the same thing. One term is not better or worse than another. The integrity of the bone has been lost and the bone structure fails. Broken bones hurt for a variety of reasons including:

The nerve endings that surround bones contain pain fibers and and these fibers become irritated when the bone is broken or bruised. Broken bones bleed, and the blood and associated swelling (edema) causes pain. Muscles that surround the injured area may go into spasm when they try to hold the broken bone fragments in place, and these spasms cause further pain.

Often a fracture is easy to detect because there is obvious deformity. However, at times it is not easily diagnosed. It is important for the physician to take a history of the injury to decide what potential problems might exist. Moreover, fractures don't always occur in isolation, and there may be associated injuries that need to be addressed.

Fractures can occur because of direct blows, twisting injuries, or falls. The type of forces on the bone may determine what type of injury that occurs. Descriptions of fractures can be confusing. They are based on:

where in the bone the break has occurred, how the bone fragments are aligned, and whether any complications exist.

The first step in describing a fracture is whether it is open or closed. If the skin over the break is disrupted, then an open fracture exists. The skin can be cut, torn, or abraded (scraped), but if the skin's integrity is damaged, the potential for an infection to get into the bone exists. Since the fracture site in the bone communicates with the outside world, these injuries need to be cleaned out aggressively and many times require anesthesia in the operating room to do the job effectively. Next, there needs to be a description of the fracture line. Does the fracture line go across the bone (transverse), at an angle (oblique) or does it spiral? Is the fracture in two pieces or is it comminuted, in multiple pieces?

Stress fractureA stress fracture is an overuse injury. Because of repeated micro-trauma, the bone can fail to absorb the shock that is being put upon it and become weakened. Most often it is seen in the lower leg, the shin bone (tibia), or foot. Athletes are at risk the most, because they have repeated footfalls on hard surfaces. Tennis players, basketball players, jumpers, and gymnasts are typically at risk. A March fracture is the name given to a stress fracture of the metatarsal or long bones of the foot. (It is named because it often occurs in soldiers who are required to march long distances.) Diagnosis is made by history and physical exam, though on occasion a bone scan may be done to confirm the diagnosis. Treatment is conservative, rest, ice, and anti-inflammatory medication like ibuprofen. These fractures can take six to eight weeks to heal (as long as the fracture can be seen on x-ray). Trying to return too quickly can cause re-injury, and may also allow the stress fracture to extend through the entire bone. Shin splints may have very similar symptoms as a stress fracture of the tibia but they are due to inflammation of the lining of the bone, called the periosteum. Shin splints are caused by overuse, especially in runners, walkers, dancers, including those who do aerobics. Muscles that run through the periosteum and the bone itself may also become inflamed. Treatment is similar to a stress fracture and physical therapy can be helpful.

Compression fractureAs people age, there is a potential for the bones to develop osteoporosis, a condition where bones lose their calcium content. This makes bone more susceptible to breaking. One such type of injury is a compression fracture to the spine, most often the thoracic or lumbar spine. Since we are an upright animal, if the bones of the back are weaker than the force of gravity these bones can crumple. Pain is the major complaint, especially with movement. Compression injuries of the back may or may not be associated with nerve or spinal cord injury. An x-ray of the back can reveal the bone injury, however, sometimes a CT scan or MRI will be used to insure that no damage is done to the spinal cord. Treatment includes pain medication and often a back brace. Some compression fractures can also be treated with vertebroplasty. Vertebroplasty involves inserting a glue-like material into the center of the collapsed spinal vertebra in order to stabilize and strengthen the crushed bone. The glue (methylmethacrylate) is inserted with a needle and syringe through anesthetized skin into the midportion of the vertebra under the guidance of specialized x-ray equipment. Once inserted, the glue soon hardens, forming a cast-like structure with the locally broken bone.

Rib fractureThe ribs are especially vulnerable to injury and are prone to breaking due to a direct blow. Rib xrays are rarely taken as it doesn't matter if the rib is broken or just bruised. A chest x-ray is usually taken to make certain there is no collapse or bruising of the lung. When we breathe, it is like a bellows. We inhale air into our lungs and the ribs move out and the diaphragm moves down. When a person has a rib injury, the pain associated with it makes breathing difficult, and the person has a tendency to not take deep breaths. If the lung underlying the injury does not expand, it is at risk for infection. The person is then susceptible to pneumonia (lung infection),which is characterized by fever, cough, and shortness of breath. As opposed to other parts of the body that can rest when they are injured, it is very important to take deep breaths to prevent pneumonia when rib fractures are present. The treatment for bruised and broken ribs is the same: ice to the chest wall, ibuprofen as an anti-inflammatory, deep breaths and pain medication. Even if all goes well, there will be significant pain for four to six weeks. With lower rib fractures, there may be concern about organs in the abdomen that the ribs protect. The liver is located under the ribs on the right side of the chest, and the spleen under the ribs on the left side of the chest. Many times your doctor may be more worried about abdominal injury than about the broken rib itself. Ultrasound or CT scan may help diagnosis intra-abdominal injuries.

Skull fracture

With the wide availability of CT scans, skull x-rays are rarely taken to diagnose head injury. If a head injury exists, the physician will feel or palpate the scalp and skull to determine if there may be a skull fracture. He will also look into the ears to see if there is blood behind the ear drumm and he will also complete a neurologic examination. The skull is a flat, compact bone and it takes significant force to break it. If a skull fracture exists, there is an increased likelihood of bleeding in the brain, especially in children. There are guidelines that are available to decide whether a CT scan is indicated (needed). Minor head injury is defined as witnessed loss of consciousness, definite amnesia, or witnessed disorientation in patients with a GCS (Glasgow Coma Score) score of 13-15. With minor head injury, the following risk groups are considered when evaluating need for CT brain scan: High risk for potential neurosurgical operation

Abnormal neurologic exam within two hours after injury Suspected open or depressed skull fracture Any sign of basal skull fracture (blood behind the ear drum, blackened eyes, clear fluid running from the ears, or bruising behind the ear) Vomiting - two episodes 65 years of age or older

Medium risk (for brain injury on CT)

Amnesia before impact - more than 30 minutes Dangerous mechanism (pedestrian struck by motor vehicle, occupant ejected from motor vehicle, fall from height greater than 3 feet or five stairs)

Children can break bones and yet have normal x-rays. Fractures appear as clear lines through the bone on an x-ray through the bone. If calcium hasn't yet accumulated in the repairing bone, the break may not be apparent. This lack of calcification happens in two ways. 1. Bones mature at different times in a child's development and while the bony structure is there, it may have more cartilage than calcium.

2. The second situation is associated with growth plates. Each bone has an area where cell activity is maximal and where the bone grows. These areas appear as lucent lines on xray. It may be one of the weaker points in the bone as well, and a fracture through the growth plate may not be seen.

The doctor needs to match the history and physical exam with what is seen on x-ray to make to a diagnosis. Sometimes, the child is placed in a cast for a period of time to protect the broken limb. As fractures heal, the body lays down extra calcium as building material and then remodels it to normal shape. After 7-10 days, there may be evidence on x-ray of the healing calcium to confirm the fracture. Growth plate fractures are classified by Salter-Harris category. When a break occurs through the growth plate, it can involve different parts of the bone on each side of the plate. It is important that these fractures are aligned properly so that the bone grows properly as the child ages. For more, please read the Growth Plate Fractures in Children article. Children are more flexible than adults until the calcium completely solidifies their bone. If you think of an arm or leg bone as tubular, sometimes only one side of the bone breaks, just like an immature branch on a tree. This is referred to as a greenstick fracture, and may need to be "set" so that it heals properly. Sometimes the bones can bend but not break because they are so pliable. This is called a plastic deformity and again will need to be set or aligned to allow proper healing. When you arrive for medical care, the doctor will take a history of the injury. Where, when, and why did the injury occur? Did the person trip and fall, or did they pass out before the fall? Are there other injuries that take precedence over the fracture? For example, a person who falls and hurts their wrist because they had a stroke or heart attack will have their fracture care delayed to allow care for the life threatening illness. The injured area will be examined and a search will happen for potential associated injuries. These include damage to skin, arteries and nerves. Pain control is a priority and many times, pain medication will be prescribed before the diagnosis is made. If the doctor believes that an operation is likely, pain medication will be given through an intravenous (IV) line or by an injection into the muscle. This allows the stomach to remain empty for potential anesthesia. A decision will be made whether x-rays are required, and which type of x-ray should be taken to make the diagnosis and better assess the injury. There are guidelines in place to help doctors decide if an x-ray is necessary. Some include the Ottawa ankle and knee x-ray rules. The body is three dimensional, and plain film x-rays are only two dimensional. Therefore, two or three x-rays of the injured areas may be taken in different positions and planes to give a true picture of the injury. Sometimes the fracture will not be seen in one position, but is easily seen in another. There are areas of the body where one bone fracture is associated with another fracture at a more distant part. For example, the bones of the forearm make a circle and it is difficult to break just one bone in that circle. Think of trying to break a pretzel in just one place, it is difficult to do. Therefore broken bones at the wrist may be associated with an elbow injury. Similarly, an ankle injury can be accompanied by a knee fracture. The doctor may x-ray areas of the body that don't initially appear to be injured.

Occasionally, the broken bone isn't easily seen, but there may be other signs that a fracture exists. In elbow injuries, fluid seen in the joint on x-ray is an indicator of a subtle fracture. And in wrist injuries, fractures of the scaphoid or navicular bone may not show up on x-ray for one to two weeks, and diagnosis is made solely on physical examination with swelling and tenderness over the snuffbox at the base of the thumb.

In children, bones may have numerous growth plates that can cause confusion when reading an x-ray. Sometimes, the doctor will choose to x-ray the opposite arm or leg to determine what normal is for the child before dWhat is the treatment of a fracture?Initial treatment for fractures of the arms, legs, hands and feet in the field include splinting the extremity in the position it is found, elevation and ice. Immobilization will be very helpful with initial pain control. For injuries of the neck and back, many times, first responders or paramedics may choose to place the injured person on a long board and in a neck collar to protect the spinal cord from potential injury. Once the fracture has been diagnosed, the initial treatment for most limb fractures is a splint. Padded pieces of plaster or fiberglass are placed over the injured limb and wrapped with gauze and an elastic wrap to immobilize the break. The joints above and below the injury are immobilized to prevent movement at the fracture site. This initial splint does not go completely around the limb. After a few days, the splint is removed and replaced by a circumferential cast. Circumferential casting does not occur initially because fractures swell (edema). This swelling would cause a build up of pressure under the cast, yielding increased pain and the potential for damage to the tissues under the cast. Surgery Surgery on fractures are very much dependent on what bone is broken, where it is broken, and whether the orthopedic surgeon believes that the break is at risk (for staying where it is) once the bone fragments have been aligned. If the surgeon is concerned that the bones will heal improperly, an operation will be needed. Sometimes bones that appear to be aligned normally are splinted, and at a recheck appointment, are found to be unstable and require surgery. Surgery can include closed reduction and casting, where under anesthesia, the bones are manipulated so that alignment is restored and a cast is placed to hold the bones in that alignment. Sometimes, the bones are broken in such a way that they need to have metal hardware inserted to hold them in place. Open reduction means that, in the operating room, the skin is cut open and pins, plates, or rods are inserted into the bone to hold it in place until healing occurs. Depending on the fracture, some of these pieces of metal are permanent (never removed), and some are temporary until the healing of the bone is complete and surgically removed at a later time. 1. A fracture is a break in the continuity of the bone. 2. Common fracture sites:

Clavicle Humerus In subpracondylar fractures, which occur when child falls backward on hands with elbows straight, there is a high incidence of neurovascular complications due to the anatomic relationship of the brachial artery and nerves to the fracture site. Radius and ulna Femur (often associated with child abuse) Epiphyseal plates (potential for growth deformity)

Types of Fracture

Closed or simple fracture The bone is broken, but the skin is not lacerated. Open or compound fracture - The skin may be pierced by the bone or by a blow that breaks the skin at the time of the fracture. The bone may or may not be visible in the wound. Transverse fracture The fracture is at right angles to the long axis of the bone. Greenstick fracture - Fracture on one side of the bone, causing a bend on the other side of the bone. Comminuted fracture - A fracture that results in three or more bone fragments. Oblique Fracture The fracture is diagonal to a bones long axis. Spiral Fracture At least one part of the bone has been twisted.

4. Complications of fractures include:

problems associated with immobility (muscle atrophy, joint contracture, pressure sores) growth problems ( in children) infection shock venous stasis and thromboembolism pulmonary emboli and fat emboli and bone union problems

B. Etiology 1. Fractures in children usually are the result of trauma from motor vehicle accidents, falls or child abuse. 2. Because of the resilience of the soft tissue of children, fractures occur more often than soft tissue injuries. C. Pathopysiology 1. Fractures occur when the resistance of bone against the stress being exerted yields to the stress force. 2. Fractures most commonly seen in children:

Bend Fracture is characterized by the bone bending to the breaking point and not straightening without intervention. Buckle fracture results from compression failure of the bone, with the bone telescoping on itself. Greenstick fracture is an incomplete fracture.

D. Assessment Findings 1. Clinical Manifestations The five Ps pain, pulse, pallor, paresthesia, and paralysis are seen with all types of fractures. Other characteristic findings include deformity, swelling, bruising, muscle spasms, tenderness, pain, impaired sensation, loss of function, abnormality, crepitus, shock or refusal to walk (in small children).

2. Laboratory and diagnostic findings Radiographic examination reveals initial injury and subsequent healing progress. A comparison film of an opposite, unaffected extremity is often used to look for subtle changes in the affected extremity. Blood studies reveal bleeding (decreased hemoglobin and hematocrit) and muscle damage (elevated aspartate transaminase (AST) and lactic dehygrogenase (LHD).

E. Nursing Management 1. Provide emergency management when situation warrants, for a new fracture.

Assess the five Ps. Determine the mechanism of injury. Immobilize the part. Move injured parts as little as possible. Cover any open wounds with a sterile, or clean dressing. Reassess the five Ps. Apply traction if circulatory compromise is present. Elevate the injured limb, if possible. Apply cold to the injured area. Call emergency medical services.

2. Assess for circulatory impairment (cyanosis, coldness, mottling, decreased peripheral pulses, positive blanch sign, edema not relieved by elevation, pain or cramping). 3. Assess for neurologic impairment (lack of sensation or movement, pain, or tenderness, or numbness and tingling). 4. Administer analgesic medications.

5. Explain fracture management to the child and family. Depending on the type of break and its location, repair (by realignment or reduction) may be made by closed or open reduction followed by immobilization with a splint, traction or a cast. 6. Maintain skin integrity and prevent breakdown. Institute appropriate measures for cast and appliance care. 7. Prevent Complications Prevent circulatory impairment by assessing pulses, color and temperature, and by reporting changes immediately. Prevent nerve compression syndromes by testing sensation and motor function, including subjective symptoms of pain, muscular weakness, burning sensation, limited ROM, and altered sensation. Correct alignment to alleviate pressure if appropriate, and notify the health care provider. Prevent compartment syndrome by assessing for muscle weakness and pain out of proportion to injury. Early detection is critical to prevent tissue damage. o Causes of compartment syndrome include tight dressings or casts, hemorrhage. trauma, burns and surgery. o Treatment entails pressure relief, which sometimes require performing a fasciotomy.

8. Prevent infection, including osteomyelitits, bys using infection control measures. 9. Prevent renal calculi by encouraging fluids, monitoring I&O, and mobilizing the child as much as possible. 10. Prevent pulmonary emboli by carefully monitoring adolescents and children with multiple fractures. Emboli generally occur within the first 24 hours.