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There is no specific treatment for rib fractures, but various supportive measures can be taken. In simple rib fractures, pain can lead to reduced movement and cough suppression; this can contribute to formation of secondary chest infection. Flail chest is a potentially life-threatening injury and will often require a period of assisted ventilation. Flail chest and first rib fractures are high-energy injuries and should prompt investigation of damage to underlying viscera (e.g., lung contusion) or remotely (e.g., cervical spine injury). Spontaneous fractures in athletes generally require a cessation of the cause, e.g., time off rowing, while maintaining cardiovascular fitness.
Treatment options for internal fixation/repair of rib fractures include:
- Judet and/or sanchez plates/struts are a metal plate with strips that bend around the rib and then is further secured with sutures.
- Synthes matrixrib fixation system has two options: a precontoured metal plate that uses screws to secure the plate to the rib; and/or an intramedullary splint which is tunneled into the rib and secured with a set screw.
- Anterior locking plates are metal plates that have holes for screws throughout the plate. The plate is positioned over the rib and screwed into the bone at the desired position. The plates may be bent to match the contour of the section.
- U-plates can also be used as they clamp on to the superior aspect of the ribs using locking screws.
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%.
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.
Medication can be prescribed to ease the pain. Antibiotics and tetanus vaccination may be used if the bone breaks through the skin. Often, they are treated without surgery. In severe cases, surgery may be done.
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.
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.
X-rays of the chest are taken in people with chest trauma and symptoms of sternal fractures, and these may be followed by CT scanning. Since X-rays taken from the front may miss the injury, they are taken from the side as well.
Management involves treating associated injuries; people with sternal fractures but no other injuries do not need to be hospitalized. However, because it is common for cardiac injuries to accompany sternal fracture, heart function is monitored with electrocardiogram. Fractures that are very painful or extremely out of place can be operated on to fix the bone fragments into place, but in most cases treatment consists mainly of reducing pain and limiting movement. The fracture may interfere with breathing, requiring tracheal intubation and mechanical ventilation.
Patients who have experienced a pathologic fracture will be investigated for the cause of the underlying disease, if it is unknown. Treatment of any underlying disease, such as chemotherapy if indicated for bone cancer, may help to improve the pain of a sternal fracture.
Removable splints result in better outcomes than casting in children with torus fractures of the distal radius.
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.
Treatment involves pain medication and immobilization at first; later, physical therapy is used. Ice over the affected area may increase comfort. Movement exercises are begun within at least a week of the injury; with these, fractures with little or no displacement heal without problems. Over 90% of scapular fractures are not significantly displaced; therefore, most of these fractures are best managed without surgery. Fractures of the scapular body with displacement may heal with malunion, but even this may not interfere with movement of the affected shoulder. However, displaced fractures in the scapular processes or in the glenoid do interfere with movement in the affected shoulder if they are not realigned properly. Therefore, while most scapular fractures are managed without surgery, surgical reduction is required for fractures in the neck or glenoid; otherwise motion of the shoulder may be impaired.
The arm must be supported by use of a splint or sling to keep the joint stable and decrease the risk of further damage. Usually, a figure-of-eight splint that wraps the shoulders to keep them forced back is used and the arm is placed in a clavicle strap for comfort.
Current practice is generally to provide a sling, and pain relief, and to allow the bone to heal itself, monitoring progress with X-rays every week or few weeks. Surgery is employed in 5–10% of cases. However, a recent study supports primary plate fixation of completely displaced midshaft clavicular fractures in active adult patients.
If the fracture is at the lateral end, the risk of nonunion is greater than if the fracture is of the shaft.
Hangman's fractures treatments are both non-surgical and surgical according to Sasso from the Department of Orthopedic Surgery at Indiana University School of Medicine.
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.
If the fracture is small, it is usually sufficient to treat with rest and support bandage, but in more severe cases, surgery may be required. Ice may be used to relieve swelling.
Displaced avulsion fractures are best managed by either open reduction and internal fixation or closed reduction and pinning. Open reduction (using surgical incision) and internal fixation is used when pins, screws, or similar hardware is needed to fix the bone fragment.
Treatment may be with or without surgery, depending on the type of fracture.
Scapular fracture is present in about 1% of cases of blunt trauma and 3–5% of shoulder injuries. An estimated 0.4–1% of bone fractures are scapular fractures.
The injury is associated with other injuries 80–90% of the time. Scapular fracture is associated with pulmonary contusion more than 50% of the time. Thus when the scapula is fractured, other injuries such as abdominal and chest trauma are automatically suspected. People with scapular fractures often also have injuries of the ribs, lung, and shoulder. Pneumothorax (an accumulation of air in the space outside the lung), clavicle fractures, and injuries to the blood vessels are among the most commonly associated injuries. The forces involved in scapular fracture can also cause tracheobronchial rupture, a tear in the airways. Fractures that occur in the scapular body are the type most likely to be accompanied by other injuries; other bony and soft tissue injuries accompany these fractures 80–95% of the time. Associated injuries can be serious and potentially deadly, and usually it is the associated injuries, rather than the scapular fracture, that have the greatest effect on the outcome. Scapular fractures can also occur by themselves; when they do, the death rate (mortality) is not significantly increased.
The mean age of people affected is 35–45 years.
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.
Rib fractures can occur with or without direct trauma during recreational activity. Cardiopulmonary resuscitation (CPR) has also been known to cause thoracic injury, including but not limited to rib and sternum fractures. They can also occur as a consequence of diseases such as cancer or rheumatoid arthritis. While for elderly individuals a fall can cause a rib fracture, in adults automobile accidents are a common event for such an injury.
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.
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.
As a result, Barsa et al. showed that the result of fracture fusion reduced after one year but only one patient died of other disease during the follow-up. Hakalo and Wronski (2008) showed the benefits of operative treatment such as using transoral C2-C3 discectomy with plate-cage stabilization or posterior direct pars screw repair for the reducing and healing process.
In deliberate or suicidal hanging, asphyxia is much more likely to be the cause of death due to associated prevertebral swelling.
A common sign is a constricted pupil (Horner's syndrome) on the ipsilateral side due to loss of sympathetic innervation to the eye, caused by damage to the sympathetic trunk in the neck.
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.
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.
Undisplaced fracture can usually be treated by casting. Even some displaced fractures can be treated with casting as long as a person can straighten their leg without help. Typically the leg is immobilized in a straight position for the first three weeks and then increasing degrees of bending are allowed.
A cast, or brace, that allows limited movement of the nearby joints is acceptable for some fractures.