What does a Hip Fracture feel like?


What does a hip fracture feel like? A hip fracture, like any broken bone, causes pain. The fracture makes putting weight on the leg extremely difficult.

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Hip fracture
A hip fracture is a femoral fracture that occurs in the proximal end of the femur (the long bone running through the thigh), near the hip. The term "hip fracture" is commonly used to refer to four different fracture patterns and is often due to osteoporosis; in the vast majority of cases, a hip fracture is a fragility fracture due to a fall or minor trauma in someone with weakened osteoporotic bone. Most hip fractures in people with normal bone are the result of high-energy trauma such as car accidents, or cycling accidents. In the UK, the mortality following a fractured neck of femur is between 20% and 35% within one year in patients aged 82, ± 7 years, of which 80% were women. The classic clinical presentation of a hip fracture is an elderly patient who sustained a low-energy fall and now has pain and is unable to bear weight. On examination, the affected extremity is often shortened and unnaturally, externally rotated compared to the unaffected leg. Hip fracture following a fall is likely to be a pathological fracture. The most common causes of weakness in bone are: X-rays of the affected hip usually make the diagnosis obvious; AP and lateral views should be obtained. In situations where a hip fracture is suspected but not obvious on x-ray, an MRI is the next test of choice. If an MRI is not available or the patient can not be placed into the scanner a CT may be used as a substitute. MRI sensitivity for radiographically occult fracture is greater than CT. Bone scan is another useful alternative however substantial drawbacks include decreased sensitivity, early false negative results, and decreased conspicuity of findings due to age related metabolic changes in the elderly. As the patients most often require an operation, full pre-operative general investigation is required. This would normally include blood tests, ECG and chest x-ray. Femoral neck fractures involve the narrow neck between the round head of the femur and the shaft. This fracture often disrupts the blood supply to the head of the femur. British orthopaedic surgeon Robert Symon Garden described a classification system for this type of fracture, referred to as the Garden classification and consisting of four grades: The blood supply of the femoral head is much more likely to be disrupted in Garden types 3 or 4 fractures. Surgeons may treat these types of fracture by replacing the fractured bone with a prosthesis arthroplasty. Alternatively the treatment is to reduce the fracture (manipulate the fragments back into a good position) and fix them in place with metal screws. Common practice is to use repair Garden 1 and 2 fractures with screws, and to replace Garden 3 and 4 fractures with arthroplasty, except in young patients in whom screw repair is attempted first, followed by arthroplasty if necessary. This is done in an effort to conserve the natural joint since prosthetic joints ultimately wear out and have to be replaced. A serious but common complication of a fractured femoral neck is avascular necrosis. The vasculature to the femoral head is easily disturbed during fractures or from swelling inside the joint capsule. This can lead to strangulation of the blood supply to the femoral head and death of the bone and cartilage. Intertrochanteric fractures occur between the greater and lesser trochanters. They are usually fixed with a sliding hip screw and plate. Healing is usually good when the patient is healthy. The hip joint, an enarthrodial joint, can be described as a ball and socket joint. The femur connects at the acetabulum of the pelvis and projects laterally before angling medially and inferiorly to form the knee. Although this joint has three degrees of freedom, it is still stable due to the interaction of ligaments and cartilage. The labrum lines the circumference of the acetabulum to provide stability and shock absorption. Articular cartilage covers the concave area of acetabulum, providing more stability and shock absorption. Surrounding the entire joint itself is a capsule secured by the tendon of the psoas muscle and three ligaments. The iliofemoral, or Y, ligament is located anteriorly and serves to prevent hip hyperextension. The pubofemoral ligament is located anteriorly just underneath the iliofemoral ligament and serves primarily to resist abduction, extension, and some external rotation. Finally the ischiofemoral ligament on the posterior side of the capsule resists extension, adduction, and internal rotation. When considering the biomechanics of hip fractures, it is important to examine the mechanical loads the hip experiences during low energy falls. The hip joint is unique in that it experiences combined mechanical loads. An axial load along the shaft of the femur results in compressive stress. Bending load at the neck of the femur causes tensile stress along the upper part of the neck and compressive stress along the lower part of the neck. While osteoarthritis and osteoporosis are associated with bone fracture as we age, these diseases are not the cause of the fracture alone. In a study conducted in Umea, Sweden, Bergsten et al. discovered that low energy falls from heights of one meter or less were the leading cause of hip fracture in the elderly adult population . Taking into account that falls were the leading cause of hip fracture, Hwang et al studied how the manner in which a fall occurs affects the chances of hip fracture. In their study, they found three contributing factors, with fall direction being the strongest predictor. During a sideways fall, the chances of hip fracture see a 15-fold and 12-fold increase in elderly males and females, respectively. This is likely due to a mechanical load experienced by bones weakened by osteoporosis. For example, in case studies by Kelly and Kelly, two elderly females experienced a low energy fall with impact occurring to the knee in a flexed position. Compression along the shaft of the femur caused the neck of the femur at the hip to experience a bending load. The stresses experienced at the neck of the femur resulted in a fracture in both cases. Figure 1 shows the forces acting at the hip visually, while Figure 2 displays the kind of hip fracture discussed. Neither one of the women had osteoporosis, but the manner in which the hip joint was mechanically loaded resulted in a hip fracture. For hip fracture prevention, it is important to consider both onset of osteoporosis and mechanical loading during a fall. EVANS CLASSIFICATION Type 1 : Fracture line extends upwards and outwards from the lesser trochanter (STABLE) Type 2 : Fracture line extends downwards and outwards from the lesser trochanter Ramadier's classification Briot's grading of diaphyseo-trochanteric fractures Ender's classification Trochanteric eversion fractures 1: Simple fractures 2: Fractures with a posterior fragment 3: Fractures with lateral and proximal displacement Trochanteric inversion fractures 4: With a pointed proximal fragment spike 5: With a rounded proximal fragment beak 6: Intertrochanteric fractures Subtrochanteric fractures 7: and 7a Transverse or reversed obliquity fractures 8: and 8a Spiral fractures Boyd and Griffin's classification Tronzo's classification Hip fractures are treated in one of two ways: Traction or orthopedic surgery. Most hip fractures are treated by orthopedic surgery, which involves implanting an orthosis. The surgery is a major stress on the patient, particularly in the elderly. Pain is significant, forcing the patient to remain immobilized. Since prolonged immobilization can be more of a health risk than the surgery itself, post-op patients are encouraged to become mobile as soon as possible, often with the assistance of rehabilitation professionals such as occupational therapy and physical therapy (physiotherapy). Skeletal traction pending surgery is not supported by the evidence. 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 no longer an alternative in developed countries with modern health care.][ For low-grade fractures (Garden types 1 and 2), standard treatment is fixation of the fracture in situ with screws or a sliding screw/plate device. This treatment can also be offered for displaced fractures after the fracture has been reduced... In elderly patients with displaced or intracapsular fractures many surgeons prefer to undertake a hemiarthroplasty, replacing the broken part of the bone with a metal implant. The advantage is that the patient can mobilize without having to wait for healing. Traction is contraindicated in femoral neck fractures due to it affecting blood flow to the head of the femur. An intertrochanteric fracture, below the neck of the femur, has a good chance of healing. Treatment involves stabilizing the fracture with a lag screw and plate device to hold the two fragments in position. A large screw is inserted into the femoral head, crossing through the fracture; the plate runs down the shaft of the femur, with smaller screws securing it in place. The fracture typically takes 3–6 months to heal. As it is only common in elderly, removal of the dynamic hip screw is usually not recommended to avoid unnecessary risk of second operation and the increased risk of re-fracture after implant removal. The most common cause for hip fractures in the elderly is osteoporosis; if this is the case, treatment of the osteoporosis can well reduce the risk of further fracture. Only young patients tend to consider having it removed; the implant may function as a stress riser, increasing the risk of a break if another accident occurs. In some hip fractures, the doctor completely removes the head and neck of the femur, and replaces it with a prosthetic implant. Hip fractures are a debilitating injury that is primarily seen in elderly people. Rehabilitation has been proven to increase daily functional status (activities of daily living). Nonunion, failure of the fracture to heal, is common (20%) in fractures of the neck of the femur, but much more rare with other types of hip fracture. The rate of nonunion is increased if the fracture is not treated surgically to immobilize the bone fragments. Malunion, healing of the fracture in a distorted position, is very common. The thigh muscles tend to pull on the bone fragments, causing them to overlap and reunite incorrectly. Shortening, varus deformity, valgus deformity, and rotational malunion all occur often because the fracture may be unstable and collapse before it heals. This may not be as much of a concern in patients with limited independence and mobility. Avascular necrosis of the femoral head occurs frequently (20%) in fractures of the neck of femur, because the blood supply is interrupted. It is rare after intertrochanteric fractures. Hip fractures rarely result in neurological or vascular injury. Deep or superficial wound infection has an approximate incidence of 2%. It is a serious problem as superficial infection may lead to deep infection. This may cause infection of the healing bone and contamination of the implants. It is difficult to eliminate infection in the presence of metal foreign bodies such as implants. Bacteria inside the implants are inaccessible to the body's defence system and to antibiotics. The management is to attempt to suppress the infection with drainage and antibiotics until the bone is healed. Then the implant should be removed, following which the infection may clear up. Implant failure may occur; the metal screws and plate can break, back out, or cut out superiorly and enter the joint. This occurs either through inaccurate implant placement or if the fixation does not hold in weak and brittle bone. In the event of failure, the surgery may be redone, or changed to a total hip replacement. Mal-positioning: The fracture can be fixed and subsequently heal in an incorrect position; especially rotation. This may not be a severe problem or may require subsequent osteotomy surgery for correction. Many of patients are unwell before breaking a hip; it is common for the break to have been caused by a fall due to some illness, especially in the elderly. Nevertheless, the stress of the injury, and a likely surgery, does increase the risk of medical illness including heart attack, stroke, and chest infection. Blood clots may result. Deep venous thrombosis (DVT) is when the blood in the leg veins clots and causes pain and swelling. This is very common after hip fracture as the circulation is stagnant and the blood is hypercoagulable as a response to injury. DVT can occur without causing symptoms. A pulmonary embolism (PE) occurs when clotted blood from a DVT comes loose from the leg veins and passes up to the lungs. Circulation to parts of the lungs are cut off which can be very dangerous. Fatal PE may have an incidence of 2% after hip fracture and may contribute to illness and mortality in other cases. Mental confusion is extremely common following a hip fracture. It usually clears completely, but the disorienting experience of pain, immobility, loss of independence, moving to a strange place, surgery, and drugs combine to cause delirium or accentuate pre-existing dementia. Urinary tract infection (UTI) can occur. Patients are immobilized and in bed for many days; they are frequently catheterised, commonly causing infection. Prolonged immobilization and difficulty moving make it hard to avoid pressure sores on the sacrum and heels of patients with hip fractures. Whenever possible, early mobilization is advocated; otherwise, alternating pressure mattresses should be used. References: Hip fractures are very dangerous episodes especially for elderly and frail patients. The risk of dying from the stress of the surgery and the injury in the first few days is about 10%.][ If the condition is untreated the pain and immobility imposed on the patient increase that risk. Problems such as pressure sores and chest infections are all increased by immobility. The prognosis of untreated hip fractures is very poor. Among those affected over the age of 65, 40% are transferred directly to long-term care facilities, long-term rehabilition 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%. Preventing hip fractures is a major concern for the elderly because it is an extremely hard rehabilitation process to go through at that age. The most common way that elderly individuals endure hip fractures is by falling and concurrently suffering from osteoporosis. Many studies have been conducted in order to find the best way to prevent them from happening. Two studies that were conducted in Norway showed that external hip protectors could reduce the number of hip fractures by almost 50%. Another study in Norway wanted to see the effect of hip protectors as a prevention strategy when offered as a regular part of the healthcare for residents in a nursing home. These external hip protectors were placed securely in special undergarments and were made out of stiff polypropylene on the outside and soft plastozote on the inside. The hip protectors diverted a “direct impact away from the greater trochanter during falls from standing heights. If an individual were to fall, the hip protector would transmit released energy to the tissues and muscles surrounding the femoral bone. The study showed that the use of these hip protectors had a 39% reduction rate in the incidence of hip fractures compared to those who did not wear hip protectors. There are many other prevention strategies that do not include wearing hip protectors. Hip fracture prevention strategies can be broken up into components of primary, secondary, and tertiary prevention. Primary prevention is aimed towards populations at high risk. Prevention of bone mineral density would need to start around the time of menopause for woman due to the fluctuation of hormones even though the average age of fractures occurs in individuals aged 65 or older. Secondary prevention involves the screening of osteoporosis to identify those who may have a high risk. Tertiary prevention involves those who have already endured an osteoporotic fracture and are susceptible in causing a new one This table, created by myself, shows the preventive strategies broken down into the three subparts. The types of strategies used are decided by a health practitioner and the individual. The prevention strategies can be broken into drug regimens and non-drug regimens. Hormonal replacement therapy or HRT is a prevention strategy used for women that has a fracture-reducing potential based on observational studies. Calcium and vitamin D supplementation are also used in high risk groups. The cost of this strategy is low and was found to prevent new fractures in individuals in the tertiary group. Several large studies have been performed on primary fracture prevention with calcium and vitamin D supplementation and have shown a reduction in fractures with vitamin D dosages of at least 700 IU/day. Bisphosphonates , which help to prevent the loss of bone mass, include the drugs Alendronate, Etidronate, and Residronate. They have been used in secondary and tertiary prevention. They are types of drugs that are used to treat osteoporosis and have shown to reduce hip fractures although more studies are currently being conducted. Other drug prevention therapies that are being used and studied are calcitonin, thiazide diuretics, and selective estrogen receptor modulators. Non-drug prevention strategies that are used are external hip protectors, general preventative measures, and home visits. “General” preventative measures include gait training, use of canes or other equipment to help with balance and gait, and the removal of hazardous material in homes such as loose flooring or improvement of the lightning in the home for the reduction of falls. A home visit by trained therapists or nurses specifically trained in this field is a preventative measure that is very costly. Hip fractures are seen globally and is serious concern at the individual and population level. In fact, by the year 2050 it is estimated that there will be 6 million cases of hip fractures worldwide. In the U.S alone 310,000 individuals were hospitalized due to hip fractures, which can account for 30% of American’s who were hospitalized that same year. Falling, poor vision, weight and height are all seen as risk factors. Falling is one of the most common risk factors for hip fractures. Approximately 90% of hip fractures are attributed to falls from standing height. All populations experience hip fractures but numbers vary within race, gender, and age. When comparing genders, women suffer hip fractures more often than men. In a lifetime, men are estimated to have a 6% risk whereas women, who are postmenopausal, are estimated to have a 14% risk of having a hip fracture occur. These statistics provide insight over a lifespan and conclude that women are twice as likely to suffer a hip fractures. When comparing race, Caucasians are more likely to suffer hip fractures more than any other race. According to recent research African Americans and Hispanics are the least likely to suffer hip fractures, which is sought to be attributed to a higher bone density found in both of African Americans and Hispanics. Age is the most dominant factor in hip fracture injuries. The increase of age is related to the increase of hip fractures incidences. As we know, falls are the most common cause of hip fractures, around 30- 60% of older aduls fall each year. This increase the risk for hip fracture and leads to the increase risk of death in older individuals, the rate of one year mortality is seen from 12-37%. For those remaining patients who don’t suffer from mortality, half of them need assistance and cannot live independently. Also, older adults sustain hip fractures because of osteoporosis, which is a degenerative disease due to age and decrease in bone mass. The average age for suffering a hip fracture is 77 years old for women and 72 years old for men. This shows how closely age is related to hip fractures. M: BON/CAR anat (c/f/k/f, u, t/p, l)/phys/devp/cell noco/cong/tumr, sysi/epon, injr proc, drug (M5) M: TTH anat/devp/phys noco/cong/jaws/tumr, epon, injr dent, proc (endo, orth, pros)

Duverney fracture
Duverney fractures are isolated pelvic fractures involving only the iliac wing. They are caused by direct trauma to the iliac wing, and are generally stable fractures as they do not disrupt the weight bearing pelvic ring. The fracture is named after the French surgeon Joseph Guichard Duverney who described the injury in his book Maladies des Os which was published posthumously in 1751. Duverney fractures can usually be seen on pelvic X-rays, but CT scans are required to fully delineate the fracture and to look for associated fractures involving the pelvic ring. Malunion and deformity of the iliac wing can occur. Injury to the internal iliac artery can occur, leading to hypovolaemic shock. Perforation of the bowel can occur, leading to sepsis. Damage to the adjacent nerves of the lumbosacral plexus has also been described. Since fractures that do not involve the weight bearing part of the pelvic ring tend to be stable fractures, they can often be managed without surgery. These fractures tend to be very painful, so walking aids such as crutches or walking frames may be needed until the pain settles. Open reduction internal fixation is sometimes required to correct deformity, and surgery may be required if there is damage to blood vessels, nerves or organs, or if the fracture is open. M: BON/CAR anat (c/f/k/f, u, t/p, l)/phys/devp/cell noco/cong/tumr, sysi/epon, injr proc, drug (M5) M: TTH anat/devp/phys noco/cong/jaws/tumr, epon, injr dent, proc (endo, orth, pros)

Bone fracture
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 properly termed a pathologic fracture. Although broken bone and bone break are common colloquialisms for a bone fracture, break is not a formal orthopedic term. Although bone tissue itself contains no nociceptors, bone fracture is painful for several reasons: 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. 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 in the form of collagen monomers. These monomers spontaneously assemble to form the bone matrix, for which bone crystals (calcium hydroxyapatite) are deposited in amongst, 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. 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. Smokers generally have lower bone density than non-smokers, so have a much higher risk of fractures. There is also evidence that smoking delays bone healing. Some research indicates, for example, that it delays tibial shaft fracture healing from a median healing time of 136 to a median healing time of 269 days. This means that the fracture healing time was approximately doubled in smokers. Although some other studies show less extreme effects, it is still shown that smoking delays fracture healing. 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) or MRI may be performed. In 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: 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. Other types of fracture are: An anatomical classification may begin with specifying the involved body part, such as the head or arm, followed with more specific localization. Fractures that have additional definition criteria than merely localization can often be classified as subtypes of fractures that merely are, such as a Holstein-Lewis fracture being a subtype of a humerus fracture. However, most typical examples in an orthopedic classification given in previous section cannot appropriately be classified into any specific part of an anatomical classification, as they may apply to multiple anatomical fracture sites. The Orthopaedic Trauma Association, an association for orthopaedic surgeons, adopted and then extended the classification of Müller and the AO foundation ("The Comprehensive Classification of the Long Bones") an elaborate classification system to describe the injury accurately and guide treatment. There are five parts to the code: (1) Humerus fracture, (2) Radius fracture/Ulnar fracture, (3) Femoral fracture, (4) Tibial fracture/Fibular fracture, (5) Spinal fracture, (6) Pelvic fracture, (24) Carpal fracture, (25) Metacarpal fracture, (26) Phalanx fracture of the hand, (72) Talus fracture, (73) Calcaneus fracture, (74) Navicular fracture, (75) Cuneiform bone fracture, (76) Cuboid bone fracture, (80) LisFranc fracture, (81) Metatarsal fracture, (82) Phalanx fracture of the foot, (45) Patella fracture, (06) Clavicular fracture, (09) Scapular fracture There are other systems used to classify different types of bone fractures: 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 treatment refers to any treatment in which the fracture site is surgically opened, regardless of whether the fracture itself is an open or closed fracture. In arm fractures in children, ibuprofen has been found to be equally effective as the combination of acetaminophen and codeine. 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 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. Splinting results in the same outcome as casting in children who have a distal radius fracture with little shifting. Surgical methods of treating fractures have their own risks and benefits, but usually surgery is done only if conservative treatment has failed, is very likely to fail, or likely to result in a poor functional outcome. With some fractures such as hip fractures (usually caused by osteoporosis), surgery is offered routinely because non-operative treatment results in prolonged immobilisation, which commonly results in complications including chest infections, pressure sores, deconditioning, 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 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. Some fractures can lead to serious complications including a condition known as compartment syndrome. If not treated, compartment syndrome can eventually require amputation of the affected limb. Other complications may include non-union, where the fractured bone fails to heal or mal-union, where the fractured bone heals in a deformed manner. Complications of fractures can be classified into three broad groups depending upon their time of occurrence. These are as follows -
In children, whose bones are still developing, there are risks of either a growth plate injury or a greenstick fracture. M: BON/CAR anat (c/f/k/f, u, t/p, l)/phys/devp/cell noco/cong/tumr, sysi/epon, injr proc, drug (M5) M: TTH anat/devp/phys noco/cong/jaws/tumr, epon, injr dent, proc (endo, orth, pros)

Pathologic fracture
A pathologic fracture is a broken bone caused by disease leading to weakness of the bone. This process is most commonly due to osteoporosis, but may also be due to other pathologies such as: cancer, infection, inherited bone disorders,or a bone cyst. Only a small number of conditions are commonly responsible for pathological fractures, including osteoporosis, osteomalacia, paget's disease, osteitis, osteogenesis imperfecta, benign bone tumours and cysts, secondary malignant bone tumours and primary malignant bone tumours. Fragility fracture is a type of pathologic fracture that occurs as result of normal activities, such as a fall from standing height or less. There are three fracture sites said to be typical of fragility fractures: vertebral fractures, fractures of the neck of the femur, and Colles fracture of the wrist. This definition arises because a normal human being ought to be able to fall from standing height without breaking any bones, and a fracture therefore suggests weakness of the skeleton. Pathological fractures present as a chalkstick fracture in long bones, and appear as a transverse fractures nearly 90 degrees to the long axis of the bone. In a pathological compression fracture of a spinal vertebra fractures will commonly appear to collapse the entire body of vertebra. In circumstances where other pathologies are excluded (for example, cancer), a pathologic fracture is diagnostic of osteoporosis irrespective of bone mineral density. M: BON/CAR anat (c/f/k/f, u, t/p, l)/phys/devp/cell noco/cong/tumr, sysi/epon, injr proc, drug (M5) M: TTH anat/devp/phys noco/cong/jaws/tumr, epon, injr dent, proc (endo, orth, pros)

Pelvic fracture
Pelvic fracture is a disruption of the bony structure of the pelvis, including the hip bone, sacrum and coccyx. The most common cause in elderly is a fall, but the most significant fractures involve high-energy forces such as a motor vehicle accident, cycling accidents, or a fall from significant height. Diagnosis is made on the basis of history, clinical features and special investigations usually including X-ray and CT. Because the pelvis cradles so many internal organs, pelvic fractures may produce significant internal bleeding which is invisible to the eye. Emergency treatment consists of advanced trauma life support management. After stabilisation, the pelvis may be surgically reconstructed. The bony pelvis consists of the ilium (i.e., iliac wings), ischium, and pubis, which form an anatomic ring with the sacrum. Disruption of this ring requires significant energy. When it comes to the stability and the structure of the pelvis, or pelvic girdle, understanding its function as support for the trunk and legs helps to recognize the effect a pelvic fracture has on someone. The pubic bone, the ischium and the ilium make up the pelvic girdle, fused together as one unit. They attach to both sides of the spine and circle around to create a ring and sockets to place hip joints. Attachment to the spine is important to direct force into the trunk from the legs as movement occurs, extending to one’s back. This requires the pelvis to be strong enough to withstand pressure and energy. Various muscles play important roles in pelvic stability.Because of the forces involved, pelvic fractures frequently involve injury to organs contained within the bony pelvis. In addition, trauma to extra-pelvic organs is common. Pelvic fractures are often associated with severe hemorrhage due to the extensive blood supply to the region. Pelvic fractures are most commonly described using one of two classification systems. The different forces on the pelvis result in different fractures. Sometimes they are determined based on stability or instability. The Tile classification system is based on the integrity of the posterior sacroiliac complex. In type A injuries, the sacroiliac complex is intact. The pelvic ring has a stable fracture that can be managed nonoperatively. Type B injuries are caused by either external or internal rotational forces resulting in partial disruption of the posterior sacroiliac complex. These are often unstable. Type C injuries are characterized by complete disruption of the posterior sacroiliac complex and are both rotationally and vertically unstable. These injuries are the result of great force, usually from a motor vehicle crash, fall from a height, or severe compression. The Young classification system is based on mechanism of injury: lateral compression, anteroposterior compression, vertical shear, or a combination of forces. Lateral compression (LC) fractures involve transverse fractures of the pubic rami, either ipsilateral or contralateral to a posterior injury. There are multiple ways to classify pelvic fractures, one of them being the Young-Burgess classification, which includes Anteroposterior compression type I, II and III, Lateral compression types I, II and III, and Vertical Shear. The most common force type, Lateral Compression (LC) forces, from side-impact automobile accidents and pedestrian injuries, can result in an internal rotation. The superior and inferior pubic rami may fracture anteriorly, for example. Injuries from shear forces, like falls from above, can result in disruption of ligaments or bones. When multiple forces occur, it is called combined mechanical injury (CMI). One specific kind of pelvic fracture is known as an 'open book' fracture. This is often the result from a heavy impact to the groin (pubis), a common motorcycling accident injury. In this kind of injury, the left and right halves of the pelvis are separated at front and rear, the front opening more than the rear, i.e. like opening a book. Depending on the severity, this may require surgical reconstruction before rehabilitation. Forces from an anterior or posterior direction, like head-on car accidents, usually cause external rotation of the hemipelvis, an “open-book” injury. Open fractures have increased risk of infection and hemorrhaging from vessel injury, leading to higher mortality. A pelvic fracture is often complicated and treatment can be a long and painful process. Depending on the severity, pelvic fractures can be treated with or without surgery. 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. 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. Pelvic Fractures can be dangerous to one’s physical health. As we get older, our bones become more weak and brittle and are therefore more susceptible to fractures. Certain precautions are crucial in order to lower the risk of getting pelvic fractures. The most damaging is one from a car accident, cycling accident, or falling from a high building which can result in a high energy injury. This can be very dangerous because the pelvis supports many internal organs and can damage these organs without knowing. Other parts of the body such as the head and chest usually occur due to pelvic fractures. Falling is one of the most common causes of a pelvic fracture. Therefore, proper precautions should be taken to prevent this from happening. There are a couple precautions that may decrease the risk of getting a pelvic fracture. One study that examined the effectiveness of vitamin D supplementation found that oral vitamin D supplements reduced the risk of hip and nonvertebral fractures in older people. Certain types of equipment may help prevent pelvic fractures for the most at-risk groups. Complications are likely to result in cases of excess blood loss or punctures to certain organs, possibly leading to shock Swelling and bruising may result, more so in high-impact injuries. Pain in the affected areas may differ where severity of impact increases its likelihood and may radiate if symptoms are aggravated when one moves around. Mortality rates in patients with pelvic fractures are between 10 and 16 percent. However, death is typically due to associated trauma affecting other organs, such as the brain. Death rates due to complications directly related to pelvic fractures, such as bleeding, are relatively low. About 10 percent of patients that seek treatment at a level 1 trauma center after a blunt force injury have a pelvic fracture. Motorcycle injuries are the most common cause of pelvic fractures, followed by injuries to pedestrians caused by motor vehicles, large falls (over 15 feet), and motor vehicle crashes. Personal Journeys after pelvic fracture M: BON/CAR anat (c/f/k/f, u, t/p, l)/phys/devp/cell noco/cong/tumr, sysi/epon, injr proc, drug (M5) M: TTH anat/devp/phys noco/cong/jaws/tumr, epon, injr dent, proc (endo, orth, pros)

Strain (injury)
A strain is an injury to a muscle or tendon] [ in which the muscle fibers tear as a result of overstretching. A strain is also colloquially known as a pulled muscle. The equivalent injury to a ligament is a sprain. Typical symptoms of a strain include localized stiffness, discoloration and bruising around the strained muscle. Strains are a result of muscular-fiber tears due to overstretching. They can happen while doing everyday tasks and are not restricted to athletes. Nevertheless, people who play sports are more at risk of developing a strain due to increased muscle.][ Strains may be very painful. The first-line treatment for a muscular strain in the acute phase include five steps commonly known as P.R.I.C.E. The ice and compression (cold compression therapy) will stop the pain and swelling while the injury starts to heal itself. Controlling the inflammation is critical to the healing process and the icing further restricts fluid leaking into the injured area as well as controlling pain. Cold compression therapy wraps are a useful way to combine icing and compression to stop swelling and pain. This immediate treatment is usually accompanied by the use of nonsteroidal anti-inflammatory drugs (e.g., ibuprofen), which both reduce the immediate inflammation and relieve pain. However, NSAIDs, including aspirin and ibuprofen, affect platelet function (this is why they are known as "blood thinners") and should not be taken during the period when tissue is bleeding because they will tend to increase blood flow, inhibit clotting, and thereby bleeding and swelling. After the bleeding has stopped, NSAIDs can be used with some effectiveness to reduce inflammation and pain. It is recommended that the person injured should consult a medical provider if the injury is accompanied by severe pain, if the limb cannot be used, or if there is noticeable tenderness over an isolated spot. These can be signs of a broken or fractured bone, a sprain, or a complete muscle tear. Therapeutic ultrasound can be used to break down poorly healed muscle strains and permit them to heal properly. M: JNT anat (h/c, u, t, l)/phys noco (arth/defr/back/soft)/cong, sysi/epon, injr proc, drug (M01C, M4) M: MUS, DF+DRCT anat (h/n, u, t/d, a/p, l)/phys/devp/hist noco (m, s, c)/cong (d)/tumr, sysi/epon, injr proc, drug (M1A/3)

Femoral fracture
A femoral fracture is a bone fracture that involves the femur. It includes hip fractures. A femoral fracture that involves the femoral head, femoral neck or the shaft of the femur immediately below the lesser trochanter may be classified as a hip fracture, especially when associated with osteoporosis. • Three types of femoral shaft fractures Type 1: Spiral or transverse Type 2: Comminuted Type 3: Open
Femoral shaft fractures can be classified with the Winquist and Hansen classification, which is based on the amount of comminution: Treatment depends on the part of the femur that is fractured. Traction may be useful for femoral shaft fractures but is contraindicated in femoral neck fractures. M: BON/CAR anat (c/f/k/f, u, t/p, l)/phys/devp/cell noco/cong/tumr, sysi/epon, injr proc, drug (M5) M: TTH anat/devp/phys noco/cong/jaws/tumr, epon, injr dent, proc (endo, orth, pros)
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