Osteitis deformans

Definition

A fracture is a complete or incomplete break in a bone resulting from the application of excessive force. An injury may be classified as a fracture-dislocation when a fracture involves the bony structures of any joint with associated dislocation of the same joint.

Description

Fractures usually result from traumatic injury to a bone causing the continuity of bone tissues or bony cartilage to be disrupted or broken. Fracture classifications include simple, compound, incomplete and complete. Simple (more recently termed closed fractures) are not obvious on the surface as the skin has not been ruptured and remains intact. Compound (now commonly referred to as open fractures) rupture the skin, exposing bone and causing additional soft tissue injury and possible infection. Single and multiple fractures refer to the number of breaks in the same bone. Fractures are termed complete if the break is completely through the bone and described as incomplete or "greenstick" if the fracture occurs partly across a bone shaft. This latter type of fracture is often the result of bending or crushing mechanisms on the bone.

Fractures are also named by the specific portion of the bone involved and the nature of the break. The identification of the fracture line can further classify fractures. Types include linear, oblique, transverse, longitudinal, and spiral fractures. Fractures can be further subdivided by the positions of bony fragments and are described as comminuted, non-displaced, impacted, overriding, angulated, displaced, avulsed, and segmental.

Fractures line identification

Linear fractures have a break that runs parallel to the bone's axis or direction of the bone's shaft. For example, a linear fracture of the arm bone could extend the entire length of the bone. Oblique and transverse fractures differ in that the oblique fracture crosses the bone at approximately a 45° angle to the bone's axis. In contrast, the transverse fracture crosses the bone's axis at a 90° angle. A longitudinal fracture is similar to a linear fracture. Its fracture line extends along the shaft but is more irregular in shape and does not run parallel to the bone's axis. Spiral fractures are described as crossing the bone at an oblique angle, creating a spiral pattern. This break usually occurs in the long bones of the body such as the arm bone (humerus) or the thigh bone (femur).

Bony fragment position identification

Comminuted fractures have two or more fragments broken into small pieces, in addition to the upper and lower halves of the fractured bone. Fragments of bone that maintain their normal alignment following a fracture are described as non-displaced. An impacted fracture is characterized as a bone fragment forced into or onto another fragment resulting from a compressive-type force. Overriding is a term used to describe bony fragments overlapping and shortening the total length of the bone. Angulated fragments result in pieces of bone being at angles to each other. A displaced bony fragment occurs from disruption of normal bone alignment with deformity of these segments separate from one another. An avulsed fragment occurs when bone fragments are pulled from their normal position by forceful muscle contractions or resistance from ligaments. Segmental fragmental positioning occurs if fractures in two adjacent areas happen with an isolated central segment. An example of segmental alignment is when the arm bone fractures in two separate places, with displacement of the mid section of bone.

Causes & symptoms

Individuals with a high activity level appear to have a greater risk of fractures. This group includes children and athletes participating in contact sports. Because of an increase in bone brittleness with the aging process, the elderly are also included in this high-risk population. It has been recognized that up to the age of 50, more men suffer from fractures than women because of occupational hazards. However, after the age of 50, more women suffer fractures than men. Specific diseases causing an increased risk of fractures include Paget's disease, rickets, osteogenesis imperfecta, osteoporosis, and prolonged disuse of a nonfunctional body part such as after a stroke.

Symptoms of fractures usually begin with pain and swelling at the involved site. There may also be a great deal of tenderness in the area near the fracture. The skin in the area may be pale and obvious deformity may be present. In more severe cases, there may be a loss of pulse below the fracture site, such as in the extremities, with numbness, tingling, or paralysis below the fracture. An open or compound fracture is often accompanied by bleeding or bruising. If a leg is fractured, weakness will usually accompany the injury causing difficulty with weight bearing.

Diagnosis

Diagnosis begins immediately with the individual's own observation of symptoms. A thorough medical history and physical exam completed by a physician often provides enough information to determine if further testing is necessary. An x ray of the injured area is the most common test used to determine the presence of a bone fracture and associated displacement. However, it is important to note that not all fractures are apparent on an initial x ray. Rib fractures are often difficult to diagnose and may require several views at different angles to see the fracture lines. If the fracture is open and occurs in conjunction with soft tissue injury, further laboratory studies are often done to determine blood loss.

In the event of exercise-related stress fractures (micro-fractures due to excessive stress), a tuning fork can provide a simple, inexpensive test. The tuning fork is a metal instrument with a stem and two prongs that vibrate when struck. If a patient has increased pain when the tuning fork is placed on the bone, such as the lower leg bone or shinbone, the likelihood of a stress fracture is high. Bone scans also are helpful in detecting stress fractures. In this diagnostic procedure, a radioactive tracer is injected and images are taken of specific areas or the entire skeleton.

Treatment

Fracture treatment depends on fracture type, severity, the individual's age, and his or her general health. The first priority in treating any fracture is to address the entire medical status of the individual. If an open fracture is accompanied by serious soft tissue injury, it may be necessary to control bleeding and the shock that can accompany loss of blood.

First aid is the initial treatment in emergency situations. It includes proper splinting, control of blood loss, and monitoring vital signs such as breathing and circulation.

Immobilization

Immobilization of the fracture site can be done internally or externally. The primary goal of immobilization is to maintain the realignment of the bone long enough for healing to start and progress. Immobilization by external fixation uses splints, casts, or braces; this may be the primary and only procedure for fracture treatment. Splinting to immobilize a fracture can be done with or without traction. In emergency situations, splinting is a useful form of fracture management, if the injured individual must be moved by someone other than a trained medical person. It should be done without causing additional pain and without moving the bone segments. In a clinical environment, plaster of Paris casts are used for immobilization. Braces are useful as they often allow movement above and below the fracture site. Treatments for stress fractures include rest and decreasing or stopping any activity that causes or increases pain.

Fracture reduction

Fracture reductions are either closed or open. Closed reduction refers to realigning the bones without breaking the skin. It is accomplished using manipulation and/or traction and is commonly done with some kind of anesthetic. Open reduction primarily refers to surgery that is performed to realign the bones. Fractures with little or no displacement may not require any form of reduction.

Traction is used to help reposition the bone. It works by applying pressure to restore proper alignment. The traction device immobilizes the area and maintains the realignment as the bone heals. The fractured bone is immobilized by applying opposing force at both ends of the injured area, using an equal amount of traction and countertraction. Weights provide the traction pull needed or the pull is achieved by positioning the individual's body weight. Traction is a form of closed reduction and is sometimes used as an alternative to surgery. Since it restricts movement of the affected limb or body part, it may confine the patient to bed rest for an extended period of time.

A patient may need open reduction if he or she has an open, severe, or comminuted fracture. This procedure allows the physician to examine and surgically correct associated soft tissue damage while reducing the fracture and if necessary applying internal or external devices. Internal fixation is a surgical procedure that is required when the fracture cannot be reduced by closed fracture methods. Internal fixation devices include plates, nails, screws, and rods. When healing is complete, the physician may or may not elect to remove these devices.

Alternative treatment

Aside from the importance of calcium for strong bones, many alternative treatment approaches advocate mineral supplements to help build and maintain a healthy, resilient skeleton. Some physical therapists use electro-stimulation over a fractured site to promote and expedite healing. Chinese traditional medicine may be helpful by working to reconnect the chi through the meridian lines along the line of a fracture. Homeopathy can enhance the body's healing process. Two particularly useful homeopathic remedies are Arnica (Arnica montana) and Symphytum (Symphytum officinalis). If possible, applying contrast hydrotherapy to an extremity (e.g., a hand or foot) of the fractured area can assist healing by enhancing circulation.

Prognosis

Fractures can normally be cured with proper first aid and appropriate aftercare. If determined necessary by a physician, the fractured site should be manipulated, realigned, and immobilized as soon as possible. Realignment has been shown to be much more difficult after six hours. Healing time varies from person to person with the elderly generally needing more time to heal completely. A non-union fracture may result when a fracture does not heal, such as in the case of an elderly person or an individual with medical complications. Recovery is complete when there is no bone motion at the fracture site, and x rays indicate complete healing.

Prevention

Adequate calcium intake is necessary for strong bones and can help decrease the risk of fractures. People who do not get enough calcium in their diets can take a calcium supplement. Exercise can help strengthen bones by increasing bone density, thereby decreasing the risk of fractures from falls. A University of Southern California study reported that older people who exercised one or more hours per day had approximately half the incidence of hip fractures as those who exercised less than 30 minutes per day or not at all.

Fractures can be prevented if safety measures are taken seriously. These measures include the use of seat belts in cars and encouraging children to wear protective sports gear. Estrogen replacement for women past the age of 50 has been shown to help prevent osteoporosis and the fractures that may result from this condition. In one study, elderly women on estrogen replacement therapy demonstrated the lowest risk of hip fractures when compared to similar women not on estrogen replacement therapy.

Key Terms

Avulsion fracture

A fracture caused by the tearing away of a fragment of bone where a strong ligament or tendon attachment forcibly pulls the fragment away from the bone tissue.

Axis

A line that passes through the center of the body or body part.

Comminuted fracture

A fracture where there are several breaks in the bone creating numerous fragments.

Contrast hydrotherapy

A series of hot and cold water applications. A hot compress (as hot as the patient can tolerate) is applied for three minutes followed by an ice cold compress for 30 seconds. These applications are repeated three times each ending with the cold compress.

Osteogenesis imperfecta

A genetic disorder involving defective development of the connective tissue characterized by brittle and fragile bones that are easily fractures by the slightest trauma.

Osteoporosis

Literally meaning "porous bones," this condition occurs when bones lose an excessive amount of their protein and mineral content, particularly calcium. Over time bone mass and strength are reduced leading to increased risk of fractures.

Paget's disease

a common disease of the bone of unknown cause usually affecting middle-aged and elderly people, characterized by excessive bone destruction and unorganized bone repair.

Reduction

The restoration of a body part to its original position after displacement, such as the reduction of a fractured bone by bringing ends or fragments back into original alignment. A fracture may be reduced using local or general anesthesia. If performed by outside manipulation only, the reduction is described to be closed; if surgery is necessary, it is described as open.

Rickets

A condition caused by the deficiency of vitamin D, calcium, and usually phosphorus, seen primarily in infancy and childhood, and characterized by abnormal bone formation.

Traction

The process of placing a bone, limb, or group of muscles under tension by applying weights and pulleys. The goal is to realign or immobilize the part or to relive pressure on that particular area to promote healing and restore function.

Further Reading

For Your Information

Books

• American Red Cross. Community First Aid and Safety. St. Louis: Mosby, 1993.
• Arnheim, Daniel D. Modern Principals of Athletic Training. St. Louis: Mosby, 1989.

  Periodicals

• "Exercise Reduces the Risk of Hip Fractures in Elderly." USC Medicine (Univ of Southern California School of Medicine) 38 (Winter 1991): 26-27.
• Gorden, Everett J. "Fractures and Dislocations: An Overview." Trauma 37 (February 1996): 5-36.
• Lesho, Emil P. "Tuning Fork Test Finds Fractures." Military Medicine 162 (1997): 802-803.

  Organizations

• American College of Sports Medicine. P.O. Box 1440, Indianapolis, IN 46206-1440. Street 401 W. Michigan St., Indianapolis, IN 46202. (317) 637-9200, Fax: (317) 634-7817.

Gale Encyclopedia of Medicine. Gale Research, 1999.