Orthopedic nursing is a nursing specialty focused on the prevention and treatment of musculoskeletal disorders. Orthopaedic issues range from acute problems such as fractures or hospitalization for joint replacement to chronic systemic disorders such as loss of bone density or lupus erythematosus.

Orthopaedic nurses have specialized skills such as neurovascular status monitoring, traction, continuous passive motion therapy, casting, and care of patients with external fixation.

Orthopedic surgery or orthopedics (also spelled orthopaedics) is the branch of surgery concerned with conditions involving the musculoskeletal system. Orthopedic surgeons use both surgical and non-surgical means to treat musculoskeletal trauma, sports injuries, degenerative diseases, infections, tumors, and congenital conditions.

Nicholas Andry coined the word "orthopaedics", derived from Greek words for orthos ("correct", "straight") and paideion ("child"), in 1741, when at the age of 81 he published Orthopaedia: or the Art of Correcting and Preventing Deformities in Children.

In the United States the spelling orthopedics is standard, although the majority of university and residency programs, and even the AAOS, still use Andry's spelling. Elsewhere, usage is not uniform; in Canada, both spellings are common; orthopaedics usually prevails in the rest of the Commonwealth, especially in Britain.

Training

In the United States and Canada, orthopedic surgeons have typically completed four years of undergraduate education and four years of medical school. Subsequently, these medical school graduates undergo residency training in orthopedic surgery. The five-year residency consists of one year of general surgery training followed by four years of training in orthopedic surgery.

Selection for residency training in orthopedic surgery is extremely competitive--candidates for orthopedic residencies generally graduate at the top of their medical school classes. Approximately 650 physicians complete orthopedic residency training per year in the United States. About 7 percent of current orthopedic surgery residents are women; about 20 percent are members of minority groups. There are approximately 20,400 actively practicing orthopaedic surgeons and residents in the United States.[1] According to the latest Occupational Outlook Handbook (2006–2007) published by the United States Department of Labor, between 3–4% of all practicing physicians are orthopedic surgeons.

Many orthopedic surgeons elect to do further subspecialty training, or "fellowships", after completing their residency training. Fellowship training in an orthopedic subspeciality is typically one year in duration (sometimes two) and sometimes has a research component involved with the clinical and operative training. Examples of orthopedic subspecialty training in the United States are:

Hand surgery Shoulder and elbow surgery Total joint reconstruction (arthroplasty) Pediatric orthopedics Foot and ankle surgery Spine surgery Musculoskeletal oncology Surgical sports medicine Orthopedic trauma

These specialty areas of medicine are not exclusive to Orthopaedic Surgery. For example, Hand surgery is practiced by some plastic surgeons and spine surgery is practiced by most neurosurgeons. Additionally, foot and ankle surgery is practiced by board certified Doctors of Podiatric Medicine (D.P.M.) in the United States. Some family practice physicians practice sports medicine, however their scope of practice is non-operative.

After completion of specialty residency/registrar training, an orthopedic surgeon is then eligible for board certification. Certification by the American Board of Orthopaedic Surgery means that the orthopaedic surgeon has met the specified educational, evaluation, and examination requirements of the Board[2]. The process requires successful completion of a standardized written exam followed by an oral exam focused on the surgeon's clinical and surgical performance over a 6 month period. In Canada, the certifying organization is the Royal College of Physicians and Surgeons of Canada; in Australia and New Zealand it is the Royal Australasian College of Surgeons.

In the United States, specialists in hand surgery and sports medicine may obtain a Certificate of Added Qualifications (CAQ) in addition to their board certification by successfully completing a separate standardized examination. There is no additional certification process for the other subspecialties.

Orthopedic surgeons use tools that are similar to carpenters and metal workers tools.

Practice

According to applications for board certification from 1999 to 2003, the top 25 most common procedures (in order) performed by orthopedic surgeons are as follows[3]:

1. Knee arthroscopy and meniscectomy2. Shoulder arthroscopy and decompression3. Carpal tunnel release4. Knee arthroscopy and chondroplasty5. Removal of support implant6. Knee arthroscopy and anterior cruciate ligament reconstruction7. Knee replacement 8. Repair of femoral neck fracture9. Repair of trochanteric fracture10. Debridement of skin/muscle/bone/fracture11. Knee arthroscopy repair of both menisci12. Hip replacement 13. Shoulder arthroscopy/distal clavicle excision14. Repair of rotator cuff tendon15. Repair fracture of radius (bone)/ulna16. Laminectomy 17. Repair of ankle fracture (bimalleolar type)18. Shoulder arthroscopy and debridement19. Lumbar spinal fusion20. Repair fracture of the distal part of radius21. Low back intervertebral disc surgery22. Incise finger tendon sheath23. Repair of ankle fracture (fibula)24. Repair of femoral shaft fracture25. Repair of trochanteric fracture

A typical schedule for a practicing orthopedic surgeon involves 50–55 hours of work per week divided among clinic, surgery, various administrative duties and possibly teaching and/or research if in an academic setting. In 2007, the median salary for an orthopedic surgeon in the United States is $388,784.[4]

History

Orthopedic implants to repair fractures to the radius and ulna. Note the visible break in the ulna. (right forearm)

Jean-Andre Venel established the first orthopedic institute in 1780, which was the first hospital dedicated to the treatment of children's skeletal deformities. He is considered by some to be the father of orthopedics or the first true orthopedist in consideration of the establishment of his hospital and for his published methods.

Antonius Mathysen, a Dutch military surgeon, invented the plaster of Paris cast in 1851. Many developments in orthopedic surgery resulted from experiences during wartime. On the battlefields of the Middle Ages the injured were treated with bandages soaked in horses' blood which dried to form a stiff, but unsanitary, splint. Traction and splinting developed during World War I. The use of intramedullary rods to treat fractures of the femur and tibia was pioneered by Gerhard Küntscher of Germany. This made a noticeable difference to the speed of recovery of injured German soldiers during World War II and led to more widespread adoption of intramedullary fixation of fractures in the rest of the world. However, traction was the standard method of treating thigh bone fractures until the late 1970s when the Harborview Medical Center in Seattle group popularized intramedullary fixation without opening up the fracture. External fixation of fractures was refined by American surgeons during the Vietnam War but a major contribution was made by Gavril Abramovich Ilizarov in the USSR. He was sent, without much orthopedic training, to look after injured Russian soldiers in Siberia in the 1950s. With no equipment he was confronted with crippling conditions of unhealed, infected, and malaligned fractures. With the help of the local bicycle shop he devised ring external

fixators tensioned like the spokes of a bicycle. With this equipment he achieved healing, realignment and lengthening to a degree unheard of elsewhere. His Ilizarov apparatus is still used today as one of the distraction osteogenesis methods.

David L. MacIntosh pioneered the first successful surgery for the management of the torn anterior cruciate ligament of the knee. This common and serious injury in skiers, field athletes, and dancers invariably brought an end to their athletics due to permanent joint instability. Working with injured football players, Dr. MacIntosh devised a way to re-route viable ligament from adjacent structures to preserve the strong and complex mechanics of the knee joint and restore stability. The subsequent development of ACL reconstruction surgery has allowed numerous athletes to return to the demands of sports at all levels.

Modern orthopaedic surgery and musculoskeletal research has sought to make surgery less invasive and to make implanted components better and more durable.

Arthroscopy

The use of has been particularly important for injured patients. Arthroscopy was pioneered in the early 1950's by Dr. Masaki Watanabe of Japan to perform minimally invasive cartilage surgery and re-constructions of torn ligaments. Arthroscopy helped patients recover from the surgery in a matter of days, rather than the weeks to months required by conventional, 'open' surgery. Knee arthroscopy is one of the most common operations performed by orthopedic surgeons today and is often combined with meniscectomy or chondroplasty.

Joint replacement

The modern total hip replacement was pioneered by Sir John Charnley in England in the 1960s.[5] He found that joint surfaces could be replaced by metal or high density polyethylene implants cemented to the bone with methyl methacrylate bone cement. Since Charnley, there have been continuous improvements in the design and technique of joint replacement (arthroplasty) with many contributors, including W. H. Harris, the son of R. I. Harris, whose team at Harvard pioneered uncemented arthroplasty techniques with the bone bonding directly to the implant.

Knee replacements using similar technology were started by McIntosh in rheumatoid arthritis patients and later by Gunston and Marmor for osteoarthritis in the 1970s.developed by Dr. John Insall and Dr. Chitranjan Singh Ranawat in New York utilizing a fixed bearing,[6] and by Dr Frederick Buechel and Dr Michael Pappas utilizing a mobile bearing.[7] Uni-compartment knee replacement, in which only one side of an arthritic knee is replaced, is a smaller operation and has become popular recently.

Joint replacements are available for other joints on a limited basis, most notably shoulder, elbow, wrist, ankle, and fingers.

In recent years, surface replacement of joints, in particular the hip joint, have become more popular amongst younger and more active patients. This type of operation delays the need for the more traditional and less bone-conserving total hip replacement, but carries significant risks of early failure from fracture and bone death.

One of the main problems with joint replacements is wear of the bearing surfaces of components. This can lead to damage to surrounding bone and contribute to eventual failure of the implant. Use of alternative bearing surfaces has increased in recent years, particularly in younger patients, in an attempt to improve the wear characteristics of joint replacement components. These include ceramics and all-metal implants (as opposed to the original metal-on-plastic). The plastic (actually ultra high-molecular-weight polyethylene) can also be altered in ways that may improve wear characteristics

Orthopedic cast

From Wikipedia, the free encyclopedia

cast

A short arm cast being cut and removed with a specialized cast saw.

An orthopedic cast, or surgical cast, is a shell, frequently made from plaster, encasing a limb (or, in some cases, large portions of the body) to hold a broken bone (or bones) in place until healing is confirmed. It is similar in function to a splint.

Plaster bandages consist of a cotton bandage that has been impregnated with plaster of paris, which hardens after it has been made wet. Plaster of Paris is calcined Gypsum, ground to a fine powder by milling. When water is added, the more soluble form of calcium sulfate returns to the relatively insoluble form, and heat is produced.

2 (CaSO4·½ H2O) + 3 H2O → 2 (CaSO4.2H2O) + Heat[1]

The setting of unmodified plaster starts about 10 minutes after mixing and is complete in about 45 minutes; the cast is not fully dry though for 72 hours.[2]

Nowadays bandages of synthetic materials are often used, often knitted fiberglass bandages impregnated with polyurethane, sometimes bandages of thermoplastic. These are lighter and dry much faster than plaster bandages. However, plaster can be more easily moulded to make a snug and therefore more comfortable fit. In addition, plaster is much smoother and does not snag clothing or abrade the skin. Plaster casts are generally made available only to patients who insist on them, because they take more time to apply, or when the cost of the fiberglass material is a consideration.

History

Hippocrates: a conventionalized image in a Roman "portrait" bust (19th century engraving)

The earliest methods of holding a reduced fracture involved using splints. These are rigid strips laid parallel to each other alongside the bone. The Ancient Egyptians used wooden splints made of bark wrapped in linen. They also used stiff bandages for support that were probably derived from embalming techniques. The use of Plaster of Paris to cover walls is evident, but it seems it was never used for bandages. Ancient Hindus treated fractures with bamboo splints, and the writings of Hippocrates discuss management of fractures in some detail, recommending wooden splints plus exercise to prevent muscle atrophy during the immobilization. The ancient Greeks also used waxes and resins to create stiffened bandages and the Roman Celsus, writing in AD 30, describes how to use splints and bandages stiffened with starch. Arabian doctors used lime derived from sea shells and albumen from egg whites to stiffen bandages. The Italian School of Salerno in the twelfth century recommended bandages hardened with a flour and egg mixture as did Medieval European bonesetters, who used casts made of egg white, flour, and animal fat. By the sixteenth century the famous French surgeon Ambroise Paré; (1517-1590), who championed more humane treatments in medicine and promoted the use of artificial limbs made casts of wax, cardboard, cloth, and parchment that hardened as they dried.

These methods all had merit, but the standard method for the healing of fractures however was bed rest and restriction of activity. The search for a simpler less time consuming method led to the development of the first modern occlusive dressings, stiffened at first with starch and later with plaster-of-paris. The ambulatory treatment of fractures was the direct result of these innovations. The innovation of the modern cast can be traced to, among others, four Military surgeons, Dominique Jean Larrey, Louis Seutin, Antonius Mathijsen, and Nikolai Ivanovich Pirogov.[3]

Dominique Jean Larrey(1768 - 1842) was born in a small town in southern France. He first studied medicine with his uncle, a surgeon in Toulouse. After a short tour of duty as a naval surgeon, he returned to Paris, where he became caught up in the turmoil of the Revolution, being present at the Storming of the Bastille. From then on, he made his career as a surgeon in France's revolutionary and Napoleonic armies, which he accompanied throughout Europe and the Middle East. As a result, Larrey accumulated a vast experience of military medicine and surgery.

One of his patients after the Battle of Borodino in 1812 was an infantry officer whose arm had to be amputated at the shoulder. The patient was evacuated immediately following the operation and passed from Russia, through Poland and Germany. On his arrival at his home in France the dressing was removed and the wound found to be healed. Larrey concluded that the fact that the wound had been undisturbed had facilitated healing. After the war, Larrey began stiffening bandages using camphorated alcohol, lead acetate and egg whites beaten in water.

An improved method was introduced by Louis Seutin, (1793 - 1865) of Brussels. In 1835 Seutin had served in the allied armies in the war against Napoleon and was on the field of Waterloo. At the time of the development of his bandage he was chief surgeon in the Belgium army. Seutin’s “bandage amidonnee” consisted of cardboard splints and bandages soaked in a solution of starch and applied wet. These dressings required 2 to 3 days to dry, depending on the temperature and humidity of the surroundings. The substitution of Dextrin for starch, advocated by Velpeau, the man widely regarded as the leading French surgeon at the beginning of the 19th century, reduced the drying time to 6 hours. Although this was a vast improvement, it was still a long time, especially in the harsh environment of the battlefield.

A good description of Seutin’s technique was provided by Samson Gamgee who learned it from Seutin in France during the winter of 1851-52 and went on to promote its use in Britain. The limb was initially wrapped in wool, especially over any bony prominences. Pasteboard was then cut into shape to provide a splint and dampened down in order that it could be molded to the limb. The limb was then wrapped in bandages before a starch coating was applied to the outer surface. Suetin’s technique for the application of the starch apparatus formed the basis of the technique used with plaster of Paris dressings today. The use of this method led to the early mobilization of patients with fractures and a marked reduction in hospital time required.

Gypsum from New South Wales, Australia

Although these bandages were an improvement over Larrey’s method, they were far from ideal. They required a long time to apply and dry and there was often shrinkage and distortion. A great deal of interest had been aroused in Europe around 1800 by a British diplomat, consul William Eton, who described a method of treating fractures that he had observed in Turkey. He noted that Gypsum (plaster of paris) was moulded around the patient’s leg to cause immobilization. If the cast became loose due to a reduction in swelling, then liquid gypsum was poured into a hole to fill the space. Adapting the use of plaster of Paris for use in hospitals, however, took some time. In 1828, doctors in Berlin were treating leg fractures by aligning the bones in a long narrow box which was then filled with moist sand. The substitution of Plaster of Paris for the sand was the next logical step. Such plaster casts did not succeed however as the patient was confined to bed due to the casts being heavy and cumbersome.

A box of Plaster of Paris bandages, Ca. 1960

Plaster of Paris bandages were introduced in different forms by 2 army surgeons, one at a peacetime home station and another on active service at the front. Antonius Mathijsen (1805 - 1878) was born in Budel, the Netherlands, where his father was the village doctor. He was educated in Brussels, Maastricht and Utrecht obtaining the degree of doctor of medicine at Gissen in 1837. He spent his entire career as a medical officer in the Dutch Army. While he was stationed at Haarlem in 1851, he developed a method of applying Plaster of Paris bandages. A brief note describing his method was published on January 30, 1852; it was followed shortly by more complete accounts. In these accounts Mathijsen emphasised that only simple materials were required and the bandage could be quickly applied without assistance. The bandages hardened rapidly, provided an exact fit and could be windowed or bivalved easily. Mathijsen used coarsely woven materials,

usually linen, into which dry Plaster of Paris had been rubbed thoroughly. The bandages were then moistened with a wet sponge or brush as they were applied and rubbed by hand until they hardened.

Plaster of Paris dressings were first employed in the treatment of mass casualties in the 1850s during the Crimean War by Nikolai Ivanovich Pirogov (1810-1881). Pirogov was born in Moscow and received his early education there. After obtaining a medical degree at Dorpat he studied at Berlin and Gottingen before returning to Dorpat as a professor of Surgery. In 1840, he became the professor of surgery at the Academy of military medicine in St. Petersburg. Pirogov introduced the use of ether anaesthesia into Russia and made important contributions to the study of cross-sectional human anatomy. With the help of his patron, the grand duchess Helene Pavlovna, he introduced female nurses into the military hospitals at the same time that Florence Nightingale was beginning a similar program in British military hospitals.

Seutin had travelled through Russia demonstrating his Starched Bandage, and his technique had been adopted by both the Russian army and navy by 1837. Pirogov had observed the use of plaster of Paris bandages in the studio of a sculptor who used strips of linen soaked in liquid plaster of Paris for making models. Pirogov went on to develop his own methods, although he was aware of Mathijsen's work. Pirogov's method involved soaking coarse cloth in a plaster of Paris mixture immediately before application to the limbs, which were protected either by stockings or cotton pads. Large dressings were reinforced with pieces of wood.

A plaster impregnated bandage Ca. 2005 still in its packaging.

As time passed and the method moved more into the mainstream some disagreement arose as to the problems associated with cutting off air to skin contact, and also some improvements were made. Eventually Pirogov's method gave way to Mahjisens. Among the improvements suggested as early as 1860 was that of making the dressing resistant to water by painting the dried plaster of Paris with a mixture of shellac dissolved in alcohol. The first commercial bandages were not produced until 1931 in Germany, and were called Cellona. Before that the bandages were made by hand at the hospitals.

As a plaster cast is applied, it expands by approximately ½ %. The less water is used, the more linear expansion occurs. Potassium Sulphate can be used as an accelerator and sodium borate as a retarder in order that the plaster can be caused to set more quickly or slowly.

Limitations of Plaster casts

SEM micrograph of S. aureus colonies; note the grape-like clustering common to Staphylococcus species.

Due to the nature of the dressing in that the limb is unreachable during treatment; the skin under the plaster becomes dry and scaly because the discarded outer skin cells are not washed or brushed off. Also, plaster of Paris casts can result in cutaneous complications including macerations, ulcerations, infections, rashes, itching, burns, and allergic contact dermatitis, which may also be due to the presence of formaldehyde within the plaster bandages. In hot weather, staphylococcal infection of the hair follicles and sweat glands can lead to severe and painful dermatitis.

Other limitations of plaster casts include their weight, which can be quite considerable, thus restricting movement, especially of a child. Removal of the cast can only be done by destroying the cast itself. The process is often noisy making use of a circular saw to cut through the tough plaster shell. Although the removal is painless, this can be distressing for the patient, especially children. Additionally, plaster of Paris casts break down if patients get them wet.

fibreglass and polyurethane casting material, 4ply

Cotton and plaster casting material,(plaster cast) 4 ply.

Due to the limitations of plaster-of-paris surgeons have also experimented with other types of materials for use as splints. An early plastic like material was Gutta-Percha obtained from the latex of trees found in Malaya. It resembled rubber, but contained more resins. When dry it was hard and inelastic, but when warmed it became soft and malleable. In 1851 Utterhoeven, described the use of splints made from this material for the treatment of fractures. In the 1970s, the development of fibreglass casting tape made it possible to produce a cast that was lighter and more durable than the traditional plaster cast and also resistant to water (although the bandages underneath were not) allowing the patient to be more active.

In 1990s the introduction of new cast lining has meant that fiberglass casts with this liner are completely waterproof, allowing patients to bathe, shower, and swim while wearing a cast. The waterproof cast liner however adds approximately 2 to 3 more minutes to the application time of the cast and increases the cost of the cast.[4] Drying time, however, can be inconvenient enough to warrant a cast and bandage moisture protector. These waterproof covers allow for bathing and showering while wearing either a plaster or fiberglass cast.

Cast types

Upper extremity casts

Left Arm cast from a wrist injury

Upper extremity casts are those which encase the arm, wrist, and/or hand. A long arm cast encases the arm from the hand to about 2 inches below the arm pit, leaving the fingers and thumbs free. A short arm cast, in contrast, stops just below the elbow. Both varieties may, depending on the injury and the doctor's decision, include one or more fingers or the thumb, in which case it is called a finger spica or thumb spica cast.

Lower extremity casts

Newly applied short leg cast

Lower extremity casts are classified similarly, with a cast encasing both the foot and the leg to the hip being called a long leg cast, while one covering only the foot and the lower leg is called a short leg cast. A walking heel may be applied, or a canvas or leather cast shoe provided to the patient who is expected to walk on the immobilized limb during convalescence (referred to as being weight bearing). Where the patient is not to walk on the injured limb, crutches or a wheelchair may be provided. The sole of a leg cast may also be extended to the tip of the toes, if providing a toeplate. This addition may be made to offer support to and stabilize the metatarsals and to protect the toes from additional trauma. This is a common treatment for a broken foot. Toeplates are infrequently used in the USA, and are more common in continental Europe. Toeplates are also used during a broken toe.

Cylinder cast

In some cases, a cast may include the upper and lower arm and the elbow, but leaves the wrist and hand free, or the upper and lower leg and the knee, leaving the foot and ankle free. Such a cast may be called a cylinder cast, or may simply be called a long arm or long leg cast.

Body casts

Body casts, which cover the trunk of the body, and in some cases the neck up to or including the head (see Minerva Cast, below) or one or more limbs, are rarely used today, and are most commonly used in the cases of small children, who cannot be trusted to comply with a brace, or in cases of radical surgery to repair an injury or other defect. A body cast which encases the trunk (with "straps" over the shoulders) is usually referred to as a body jacket.

Spica cast

A cast which includes the trunk of the body and one or more limbs is called a spica cast, just as a cast which includes the "trunk" of the arm and one or more fingers or the thumb is. For example, a shoulder spica includes the trunk of the body and one arm, usually to the wrist or hand. Shoulder spicas are almost never seen today, having been replaced with specialized splints and slings which allow early mobility of the injury so as to avoid joint stiffness after healing.

A hip spica includes the trunk of the body and one or more legs. A hip spica which covers only one leg to the ankle or foot may be referred to as a single hip spica, while one which covers both legs is called a double hip spica. A one-and-a-half hip spica encases one leg to the ankle or foot and the other to just above the knee. The extent to which the hip spica covers the trunk depends greatly on the injury and the surgeon; the spica may extend only to the navel, allowing mobility of the spine and the possibility of walking with the aid of crutches, or may extend to the rib cage or even to the armpits in some rare cases. Hip spicas were formerly common in reducing femoral fractures, but today are rarely used except for congenital hip dislocations, and then mostly while the child is still an infant.

In some cases, a hip spica may only extend down one or more legs to above the knee. Such casts, called pantaloon casts, are occasionally seen to immobilize an injured lumbar spine or pelvis, in which case the trunk portion of the cast usually extends to the armpits.

Other casts

Other body casts which were used in decades past to protect an injured spine or as part of the treatment for a spinal deformity (see scoliosis) which are rarely seen today include the Minerva cast and Risser cast. The Minerva cast includes the trunk of the body (sometimes extending down only so far as the rib cage) as well as the patient's head, with openings provided for the patient's face, ears, and usually the top of the head and hair. The Risser cast was similar, extending from the patient's hips to the neck and sometimes including part of the head. Both of these casts could, with care and the doctor's permission, be walked in during convalescence. However, in some cases the Risser cast would extend into one or more pantaloons, in which case mobility was far more restricted.

Aside from the above common forms, body casts could come in nearly any size and configuration. For example, from the 1910s to the 1970s, use of a turnbuckle cast, which used metal turnbuckles to twist two halves of the cast so as to forcibly straighten the spine before surgery, was common. The turnbuckle cast had no single configuration, and could be as small as a body jacket split in half, or could include the head, one or both legs to the knees or feet, and/or one arm to the elbow or wrist depending on the choice of the doctor.

Despite the large size and extreme immobilization some casts, particularly those used in or before the 1970s, the popular term full body cast is something of a misnomer. The popular and media-driven conception of a massive cast encasing all four limbs, the trunk, and the head - sometimes leaving only small slits for the eyes, nose, and mouth - is a true rarity in recorded medical history, and this type of large scale cast appears more commonly in various Hollywood movies and on television shows. The term body cast (or full body cast) is sometimes casually used by laymen to describe any of a number of body and/or spica casts, from a simple body jacket to a more extensive hip spica.

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. While many fractures are the result of high force impact or stress, bone fracture can also occur as a result of certain medical conditions that weaken the bones, such as osteoporosis, certain types of cancer, or osteogenesis imperfecta, where the fracture is then termed pathological fracture. Although broken bone and bone break are common colloquialisms for a bone fracture, break is not a formal orthopedic term.

Classification systems

Orthopedic

In orthopedic medicine, fractures are classified in various ways.

Closed (simple) fractures are those in which the skin is intact, while open (compound) fractures involve wounds that communicate with the fracture, or where fracture hematoma is exposed, and may thus expose bone to contamination. Open injuries carry a higher risk of infection; they require antibiotic treatment and usually urgent surgical treatment (debridement). This involves removal of all dirt, contamination, and dead tissue.

multi-fragmentary fractures, known as comminuted fractures, involve the bone splitting into multiple pieces. A simple, closed fracture is much easier to treat and has a much better prognosis than an open, comminuted fracture.

Other considerations in fracture care are displacement (fracture gap) and angulation. If angulation or displacement is large, reduction (manipulation) of the bone may be required and, in adults, frequently requires surgical care. These injuries may take longer to heal than injuries without displacement or angulation.

Another type of bone fracture is a compression fracture. It usually occurs in the vertebrae, for example when the front portion of a vertebra in the spine collapses due to osteoporosis (a medical condition which causes bones to become brittle and susceptible to fracture, with or without trauma).

A broken toe caused by performing martial arts.

Other types of fracture are:

Complete fracture: A fracture in which bone fragments separate completely. Incomplete fracture: A fracture in which the bone fragments are still partially

joined. Linear fracture: A fracture that is parallel to the bone's long axis. Transverse fracture: A fracture that is at a right angle to the bone's long axis. Oblique fracture: A fracture that is diagonal to a bone's long axis. Spiral fracture: A fracture where at least one part of the bone has been twisted. Compacted fracture: A fracture caused when bone fragments are driven into each

other.

OTA classification

The Orthopaedic Trauma Association, an association for Orthopaedic surgeons, devised an elaborate classification system to describe the injury accurately and guide treatment.[1]

[2] There are five parts to the code:

Bone: Description of a fracture starts by naming the bone:

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

Location: the part of the bone involved (e.g. shaft of the femur): proximal, diaphyseal, distal, malleolar.

Type: It is important to note whether the fracture is simple or multifragmentary and whether it is closed or open: A=simple fracture, B=wedge fracture, C=complex fracture

Group: The geometry of the fracture is also described by terms such as transverse, oblique, spiral, or segmental.

Subgroup: Other features of the fracture are described in terms of displacement, angulation and shortening. A stable fracture is one which is likely to stay in a good (functional) position while it heals; an unstable one is likely to shorten, angulate or rotate before healing and lead to poor function in the long term.

Other classification systems

There are other systems used to classify different types of bone fractures:

"Neer classification": humerus [3] [4]

"Denis classification": spine [5]

"Seinsheimer's Classification": femur [6] "Frykman classification": radius and ulna

"Letournel and Judet Classification": Acetabular Fractures [7]

Pain

Although bone tissue itself contains no nociceptors, bone fracture is very painful for several reasons:[8]

Breaking in the continuity of the periosteum, with or without similar discontinuity in endosteum, as both contain multiple nociceptors.

Edema of nearby soft tissues caused by bleeding of torn periosteal blood vessels evokes pressure pain.

Muscle spasms trying to hold bone fragments in place

Bone healing

Main article: Bone healing

The natural process of healing a fracture starts when the injured bone and surrounding tissues bleed, forming what's called fracture Hematoma. The blood coagulates to form a blood clot situated between the broken fragments. Within a few days blood vessels grow into the jelly-like matrix of the blood clot. The new blood vessels bring phagocytes to the area, which gradually remove the non-viable material. The blood vessels also bring fibroblasts in the walls of the vessels and these multiply and produce collagen fibres. In this way the blood clot is replaced by a matrix of collagen. Collagen's rubbery consistency allows bone fragments to move only a small amount unless severe or persistent force is applied.

At this stage, some of the fibroblasts begin to lay down bone matrix (calcium hydroxyapatite) in the form of insoluble crystals. This mineralization of the collagen matrix stiffens it and transforms it into bone. In fact, bone is a mineralized collagen matrix; if the mineral is dissolved out of bone, it becomes rubbery. Healing bone callus is on average sufficiently mineralized to show up on X-ray within 6 weeks in adults and less in children. This initial "woven" bone does not have the strong mechanical properties of mature bone. By a process of remodeling, the woven bone is replaced by mature "lamellar" bone. The whole process can take up to 18 months, but in adults the strength of the healing bone is usually 80% of normal by 3 months after the injury.

Several factors can help or hinder the bone healing process. For example, any form of nicotine hinders the process of bone healing, and adequate nutrition (including calcium intake) will help the bone healing process. Weight-bearing stress on bone, after the bone has healed sufficiently to bear the weight, also builds bone strength. The bone shards can also embed in the muscle causing great pain. Although there are theoretical concerns about NSAIDs slowing the rate of healing, there is not enough evidence to warrant withholding this type analgesic.[9]

Treatment

X-ray showing the proximal portion of a fractured tibia with an intramedullary nail.

X-ray showing the distal portion of a fractured tibia and intramedular nail.

At the hospital, closed fractures are diagnosed by taking an X-ray photograph of the injury.

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, a physician will align the bone, called reduction, in good position and verify the improved alignment with an X-ray. 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 toes, 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.

Surgical methods of treating fractures have their own risks and benefits, but usually surgery is done only if conservative treatment has failed or is very likely to fail. With some fractures such as hip fractures (usually caused by osteoporosis or Osteogenesis Imperfecta), surgery is offered routinely, because the complications of non-operative treatment include deep vein thrombosis (DVT) and pulmonary embolism, which are more dangerous than surgery. When a joint surface is damaged by a fracture, surgery is also commonly recommended to make an accurate anatomical reduction and restore the smoothness of the joint. Infection is especially dangerous in bones, due to their limited blood flow. Bone tissue is predominantly extracellular matrix, rather than living cells, and the few blood vessels needed to support this low metabolism are only able to bring a limited number of immune cells to an injury to fight infection. For this reason, open fractures and osteotomies call for very careful antiseptic procedures and prophylactic antibiotics.

Occasionally a surgeon uses bone grafting 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.

Some doctors further treat bones using electrical bone growth stimulation or osteostimulation or both.In children

Main article: Child bone fracture

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

A greenstick fracture occurs due to mechanical failure on the tension side. That is, since the bone is not as brittle as it would be in an adult, it does not completely fracture, but rather exhibits bowing without complete disruption of the bone's cortex in the surface opposite the applied force.

Growth plate injuries, as in Salter-Harris fractures, require careful treatment and accurate reduction to make sure that the bone continues to grow normally.

Plastic deformation of the bone, in which the bone permanently bends but does not break, is also possible in children. These injuries may require an osteotomy (bone cut) to realign the bone if it is fixed and cannot be realigned by closed methods.

Certain fractures are known to occur mainly in pediatric age group, as fracture clavicle & supracondylar fracture of Humerus.

n its most general form, Gait training is the act of learning how to walk. However, the term is more often used in reference to a person learning how to walk again after injury or with a disability. Physical therapists, or physiotherapists, generally helps their patients with gait training.[1]

Gait training can take a number of forms, but repetition of the actual motions performed during walking is the most important factor. Parallel bars are often used to help with gait training. They involve a person walking between two handrails to support themselves, often with the therapist either helping to support the patient or physically moving the patient's legs.

In recent years there have been advancements in how the patient can increase the duration of therapy safely to make for more effective treatment. Body-weight support systems or unweighting devices are starting to become more and more popular and have been the subject of much study.[2]

Gait training can be useful for people with the following conditions:

Amputation Osteoarthritis Muscular Dystrophy Cerebral Palsy Brain/Spinal Cord injuries After surgery Sports injury