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Deep Learning Technology: Sebastian Arnold, Betty van Aken, Paul Grundmann, Felix A. Gers and Alexander Löser. Learning Contextualized Document Representations for Healthcare Answer Retrieval. The Web Conference 2020 (WWW'20)
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Removable splints result in better outcomes than casting in children with torus fractures of the distal radius.
A Cochrane review of low-intensity pulsed ultrasound to speed healing in newly broken bones found insufficient evidence to justify routine use. Other reviews have found tentative evidence of benefit. It may be an alternative to surgery for established nonunions.
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.
Galeazzi fractures are best treated with open reduction of the radius and the distal radio-ulnar joint. It has been called the "fracture of necessity," because it necessitates open surgical treatment in the adult. Nonsurgical treatment results in persistent or recurrent dislocations of the distal ulna. However, in skeletally immature patients such as children, the fracture is typically treated with closed reduction.
A Salter–Harris fracture is a fracture that involves the epiphyseal plate or growth plate of a bone. It is a common injury found in children, occurring in 15% of childhood long bone fractures.
Most hip fractures are treated surgically by implanting an orthosis. Surgical treatment outweighs the risks of nonsurgical treatment which requires extensive bedrest. Prolonged immobilization increases risk of thromboembolism, pneumonia, deconditioning, and decubitus ulcers. Regardless, the surgery is a major stress, particularly in the elderly. Pain is also significant, and can also result in immobilization, so patients are encouraged to become mobile as soon as possible, often with the assistance of physical therapy. Skeletal traction pending surgery is not supported by the evidence. Regional nerve blocks are useful for pain management in hip fractures.
Red blood cell transfusion is common for people undergoing hip fracture surgery due to the blood loss sustained during surgery and from the injury. Adverse effects of blood transfusion may occur and are avoided by restrictive use of blood transfusion rather than liberal use. Restrictive blood transfusion is based on symptoms of anemia and thresholds lower than the 10 g/dL haemoglobin used for liberal blood transfusion.
If operative treatment is refused or the risks of surgery are considered to be too high the main emphasis of treatment is on pain relief. Skeletal traction may be considered for long term treatment. Aggressive chest physiotherapy is needed to reduce the risk of pneumonia and skilled rehabilitation and nursing to avoid pressure sores and DVT/pulmonary embolism Most people will be bedbound for several months. Non-operative treatment is now limited to only the most medically unstable or demented patients, or those who are nonambulatory at baseline with minimal pain during transfers.
The greenstick fracture pattern occurs as a result of bending forces. Activities with a high risk of falling are risk factors. Non-accidental injury more commonly causes spiral (twisting) fractures but a blow on the forearm or shin could cause a green stick fracture. The fracture usually occurs in children and teens because their bones are flexible, unlike adults whose more brittle bones usually break.
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 so 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, also is 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 mainly occur in children, including fracture of the clavicle and supracondylar fracture of the humerus.
Among those affected over the age of 65, 40% are transferred directly to long-term care facilities, long-term rehabilitation facilities, or nursing homes; most of those affected require some sort of living assistance from family or home-care providers. 50% permanently require walkers, canes, or crutches for mobility; all require some sort of mobility assistance throughout the healing process.
Among those affected over the age of 50, approximately 25% die within the next year due to complications such as blood clots (deep venous thrombosis, pulmonary embolism), infections, and pneumonia.
Patients with hip fractures are at high risk for future fractures including hip, wrist, shoulder, and spine. After treatment of the acute fracture, the risk of future fractures should be addressed. Currently, only 1 in 4 patients after a hip fracture receives treatment and work up for osteoporosis, the underlying cause of most of the fractures. Current treatment standards include the starting of a bisphosphonate to reduce future fracture risk by up to 50%.
Over 2.5 million child abuse and neglect cases are reported every year, and thirty-five out of every hundred cases are physical abuse cases. Bone fractures are sometimes part of the physical abuse of children; knowing the symptoms of bone fractures in physical abuse and recognizing the actual risks in physical abuse will help forward the prevention of future abuse and injuries. Astoundingly, these abuse fractures, if not dealt with correctly, have a potential to lead to the death of the child.
Fracture patterns in abuse fractures that are very common with abuse are fractures in the growing part of a long bone (between the shaft and the separated part of the bone), fractures of the humeral shaft (long bone between the shoulder and elbow), ribs, scapula, outer end of the clavicle, and vertebra. Multiple fractures of varying age, bilateral fractures, and complex skull fractures are also linked to abuse. Fractures of varying ages occur in about thirteen percent of all cases.
Treatment of this fracture depends on the severity of the fracture. An undisplaced fracture may be treated with a cast alone. A fracture with mild angulation and displacement may require closed reduction. Significant angulation and deformity may require an open reduction and internal fixation. An open fracture will always require surgical intervention.
Bone mineral density decreases with increasing age. Osteoporotic bone loss can be prevented through an adequate intake of vitamin C and vitamin D, coupled with exercise and by being a non-smoker. A study by Cheng et al. in 1997, showed that greater bone density indicated less risk for fractures in the calcaneus.
If the coccyx fracture is severe enough, short-term hospitalisation may be required, although this is extremely rare. More often, self-care at home is administered.
Sitting on soft surfaces is recommended, as this reduces pressure on the coccyx. A 'donut' or 'wedge' cushion may be purchased – these are simply cushions with a hole in them to ensure that no weight is placed in the injured tailbone. Painkillers such as ibuprofen are also recommended, as is a diet high in fibre to soften stools and avoid constipation.
Doctors will not usually attempt to correct a bad alignment, as muscles in the area are powerful and can pull the bone back into the 'bad' position. The bone is also very difficult to immobilise simply due to the sheer number of muscles attached to it, as well as the position.
Distal radius fractures are the most common fractures seen in adults, with incidence in females outnumbering incidence in males by a factor of 2-3. Men who sustain distal radius fractures are usually younger, generally in their fifth decade (vs. seventh decade in females). The elderly are more susceptible because of the osteopenia and osteoporosis commonly seen in this age group. The majority of these fractures are extra-articular (i.e. not involving the joint).
This is also a common injury in children which may involve the growth plate (Salter-Harris fracture).
In young adults, the injury is often severe as a greater force is necessary to produce the injury.
For several reasons, a Jones fracture may not unite. The diaphyseal bone (zone II), where the fracture occurs, is an area of potentially poor blood supply, existing in a watershed area between two blood supplies. This may compromise healing. In addition, there are various tendons, including the peroneus brevis and fibularis tertius, and two small muscles attached to the bone. These may pull the fracture apart and prevent healing.
Zones I and III have been associated with relatively guaranteed union and this union has taken place with only limited restriction of activity combined with early immobilization. On the other hand, zone II has been associated with either delayed or non-union and, consequently, it has been generally agreed that fractures in this area should be considered for some form of internal immobilization, such as internal screw fixation.
These zones can be identified anatomically and on x-ray adding to the clinical usefulness of this classification.
It should be emphasized that surgical intervention is not, by itself, a guarantee of cure and has its own complication rate. Other reviews of the literature have concluded that conservative, non-operative, treatment is an acceptable option for the non-athlete.
Children in general are at greater risk because of their high activity levels. Children that have risk-prone behaviors are at even greater risk.
Treatment consist of a long leg orthopedic cast for several weeks.
The use of surgery to treat a Jefferson fracture is somewhat controversial. Non-surgical treatment varies depending on if the fracture is stable or unstable, defined by an intact or broken transverse ligament and degree of fracture of the anterior arch. An intact ligament requires the use of a soft or hard collar, while a ruptured ligament may require traction, a halo or surgery. The use of rigid halos can lead to intracranial infections and are often uncomfortable for individuals wearing them, and may be replaced with a more flexible alternative depending on the stability of the injured bones, but treatment of a stable injury with a halo collar can result in a full recovery. Surgical treatment of a Jefferson fracture involves fusion or fixation of the first three cervical vertebrae; fusion may occur immediately, or later during treatment in cases where non-surgical interventions are unsuccessful. A primary factor in deciding between surgical and non-surgical intervention is the degree of stability as well as the presence of damage to other cervical vertebrae.
Though a serious injury, the long-term consequences of a Jefferson's fracture are uncertain and may not impact longevity or abilities, even if untreated. Conservative treatment with an immobilization device can produce excellent long-term recovery.
In athletes or if the pieces of bone are separated by more than 2 mm surgery may be considered. Otherwise surgery is recommended if healing does not occur after 12 weeks of casting.
The aim of treatment is to minimize pain and to restore as much normal function as possible. Most humerus fractures do not require surgical intervention. One-part and two-part proximal fractures can be treated with a collar and cuff sling, adequate pain medicine, and follow up therapy. Two-part proximal fractures may require open or closed reduction depending on neurovascular injury, rotator cuff injury, dislocation, likelihood of union, and function. For three- and four-part proximal fractures, standard practice is to have open reduction and internal fixation to realign the separate parts of the proximal humerus. A humeral hemiarthroplasty may be required in proximal cases in which the blood supply to the region is compromised. Fractures of the humerus shaft and distal part of the humerus are most often uncomplicated, closed fractures that require nothing more than pain medicine and wearing a cast or sling for a few weeks. In shaft and distal cases in which complications such as damage to the neurovascular bundle exist, then surgical repair is required.
Triplane fracture is a fracture at the epiphyseal plate of the tibia in early adolescence with involvement of the epiphysis and metaphysis of the tibia. The link presents two types of imaging. The first four images (figures 1-4) are radiographic images while the last 3 are CT scans of the left distal tibia and fibula. The first radiographic image is an anterior-posterior view of the distal third of the left tibia and fibula. The image presents a fracture of the distal epiphyseal plate of the tibia and fibula. The primary imaging (radiograph) identifies the abnormality in the anatomy of subject’s left distal tibia and fibula. However, it is difficult to view the extent of the fracture and classify the fracture based on radiographic image. Figure four is a CT scan of the posterior aspect of the left distal tibia and fibula. Note that in this image the extent of the fracture is more visible extending to the epiphysis and metaphysis. The type of fracture is a Salter-Harris type IV. The CT scan was an appropriate choice of advance imaging which helps clinicians determine the extent of the fracture and enable us to address the problem appropriately.
Colles fractures occur in all age groups, although certain patterns follow an age distribution.
- In the elderly, because of the weaker cortex, the fracture is more often extra-articular.
- Younger individuals tend to require a higher energy force to cause the fracture and tend to have more complex intra-articular fractures. In children with open epiphyses, an equivalent fracture is the "epiphyseal slip", as can be seen in other joints, such as a slipped capital femoral epiphysis in the hip. This is a Salter I or II fracture with the deforming forces directed through the weaker epiphyseal plate.
- More common in women because of post-menopausal osteoporosis.
Following a coccyx fracture, surgery is not usually required; however, if the pain continues even after the fracture has healed, and is severe enough to cause disability, a coccygectomy may be required. Coccygectomy is the surgical removal of the coccyx.
Evaluating soft-tissue involvement is the most important aspect of the clinical examination because of its association with patient outcome. Skin blisters may become infected if medical attention is delayed, which can lead to necrotizing fasciitis or osteomyelitis, causing permanent damage to muscle or bone. Ligament and tendon involvement should also be explored. Achilles tendon injury can be seen with posterior (Type C) fractures. Since calcaneal fractures are related to falls from height, other concomitant injuries should be evaluated. Vertebral compression fractures occur in approximately 10% of these patients. A trauma-focused clinical approach should be implemented; tibial, knee, femur, hip, and head injuries should be ruled out by means of history and physical exam.
Treatment may be with or without surgery, depending on the type of fracture.
Non-displaced or minimally displaced fractures may be treated conservatively. Open reduction and internal fixation is reserved for cases that are severely angulated or comminuted. The purpose of fixation is to restore the normal appearance of the face. Specific attention is given to the position of the malar eminence and reduction of orbital volume by realigning the zygoma and sphenoid. Failure to correct can result in rotational deformity and increase the volume of the orbit, causing the eye to sink inwards.
Fractures with displacement require surgery consisting of fracture reduction with miniplates, microplates and screws. Gillie's approach is used for depressed zygomatic fractures. The prognosis of tripod fractures is generally good. In some cases there may be persistent post-surgical facial asymmetry, which can require further treatment.