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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.
The first line treatment should be reduction of movements for 6 to 12 weeks. Wooden-soled shoes or a cast should be given for this purpose. In rare cases in which stress fracture occurs with a cavus foot, plantar fascia release may be appropriate.
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.
Most olecranon fractures are displaced and are best treated surgically:
Single intramedullary screws can be used to treat simple transverse or oblique fractures. Plates can be used for all proximal ulna fracture types including Monteggia fractures, and comminuted fractures.
Initial treatment is typically in a cast, without any weight being placed on it, for at least six weeks. If after this period of time healing has not occurred a further six weeks of casting may be recommended. Up to half, however may not heal after casting.
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.
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.
It is often seen as a repetitive stress injury, and thus lifestyle modification is typically the basic course of management strategies. For example, a person should begin doing foot and calf workouts. Strong muscles in the calves and lower legs will help take the stress off the bone and thus help cure or prevent heel spurs. Icing the area is an effective way to get immediate pain relief.
Rehabilitation has been proven to increase daily functional status. It is unclear if the use of anabolic steroids effects recovery.
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.
If intraarticular trapeziometacarpal fractures (such as the Bennett or Rolando fractures) are allowed to heal in a displaced position, significant post-traumatic osteoarthritis of the base of the thumb is virtually assured. Some form of surgical treatment (typically either a CRPP or an ORIF) is nearly always recommended to ensure a satisfactory outcome for these fractures, if there is significant displacement.
The long-term outcome after surgical treatment appears to be similar, whether the CRPP or the ORIF approach is used. Specifically, the overall strength of the affected hand is typically diminished, and post-traumatic osteoarthritis tends to develop in almost all cases. The degree of weakness and the severity of osteoarthritis does however appear to correlate with the quality of reduction of the fracture. Therefore, the goal of treatment of Bennett fracture should be to achieve the most precise reduction possible, whether by the CRPP or the ORIF approach.
Treatment may be with or without surgery, depending on the type of fracture.
Treatment options for distal radius fractures include non-operative management, external fixation, and internal fixation. Indications for each depend on a variety of factors such as patient's age, initial fracture displacement, and metaphyseal and articular alignment, with the ultimate goal to maximize strength, and function in the affected upper extremity. Surgeons use these factors combined with radiologic imaging to predict fracture instability, and functional outcome in order to help decide which approach would be most appropriate. Treatment is often directed to restore normal anatomy to avoid the possibility of malunion, which may cause decreased strength in the hand and wrist. The decision to pursue a specific type of management varies greatly by geography, physician specialty (hand surgeons vs. orthopedic surgeons), and advancements in new technology such as the volar locking plating system.
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.
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.
Treatment of ankle fractures is dictated by the stability of the ankle joint. Certain fractures patterns are deemed stable, and may be treated similar to ankle sprains. All other types require surgery, most often an open reduction and internal fixation (ORIF), which is usually performed with permanently implanted metal hardware that holds the bones in place while the natural healing process occurs. A cast or splint will be required to immobilize the ankle following surgery.
In children recovery may be faster with an ankle brace rather than a full cast in those with otherwise stable fractures.
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.
Pelvic fractures that are treatable without surgery are treated with bed rest. Once the fracture has healed enough, rehabilitation can be started with first standing upright with the help of a physical therapist, followed by starting to walk using a walker and eventually progressing to a cane.
Though these fractures commonly appear quite subtle or even inconsequential on radiographs, they can result in severe long-term dysfunction of the hand if left untreated. In his original description of this type of fracture in 1882, Bennett stressed the need for early diagnosis and treatment in order to prevent loss of function of the thumb CMC joint, which is critical to the overall function of the hand.
- In the most minor cases of Bennett fracture, there may be only small avulsion fractures, relatively little joint instability, and minimal subluxation of the CMC joint (less than 1 mm). In such cases, closed reduction followed by immobilization in a thumb spica cast and serial radiography may be all that is required for effective treatment.
- For Bennett fractures where there is between 1 mm and 3 mm of displacement at the trapeziometacarpal joint, closed reduction and percutaneous pin fixation (CRPP) with Kirschner wires is often sufficient to ensure a satisfactory functional outcome. The wires are not employed to connect the two fracture fragments together, but rather to secure the first or second metacarpal to the trapezium.
- For Bennett fractures where there is more than 3 mm of displacement at the trapeziometacarpal joint, open reduction and internal fixation (ORIF) is typically recommended.
Regardless of which approach is employed (nonsurgical, CRPP, or ORIF), immobilization in a cast or thumb spica splint is required for four to six weeks.
This treatment consists of aligning a bone or bones by a gentle, steady pulling action. The pulling may be transmitted to the bone or bones by a metal pin through a bone or by skin tapes. This is a preliminary treatment used in preparation for other secondary treatments.
Surgery is often required for pelvic fractures. Many methods of pelvic stabilization are used including external fixation or internal fixation and traction. There are often other injuries associated with a pelvic fracture so the type of surgery involved must be thoroughly planned.
Ice is applied to relieve pain and swelling. Any open wounds are cleansed to avoid infection.
For most fractures with less than 70 degrees of angulation, buddy taping and a tensor bandage resulted in similar outcomes to reduction with splinting.
In rare cases surgery may be required to place pins or plates in the bone to hold the pieces in place.