injuries and poisoning
Overview of Fractures
Treatment of Fractures
Treatment of serious complications Pain relief Protection, rest, ice, compression, and elevation (PRICE) Realignment (reduction) of parts that are out of place Immobilization, usually with a splint or cast Sometimes surgery Serious fractures and serious related injuries and complications, if present, are treated immediately (for example, Treatment or If people think that they have a fracture or another severe injury, they should go or be taken to an emergency department. If they cannot walk or have several injuries, they should go by ambulance. Until they can get medical help, they should do the following: Prevent the injured limb from moving (immobilize it) and support it with a makeshift splint, sling, or a pillow Elevate the limb, above the level of the heart if possible, to limit swelling Apply ice (wrapped in a towel or cloth) to control pain and swelling Fractures in children are often treated differently from those in adults because the bones in children are smaller, more flexible, less brittle, and still growing. Children’s fractures heal much faster and more perfectly than adult fractures do. Several years after most fractures in children, the bone can look almost normal on x-ray. For children, doctors often prefer treatment with casts over surgery because Children have less stiffness after wearing a cast than adults do. They are more likely to be able to move normally after being in a cast. Surgery near a joint can damage the part of the bone that enables children to grow (the growth plate). In the emergency department, doctors check for injuries that require immediate treatment. If the skin is torn, the wound is cleaned, usually after a local anesthetic is used to numb the area, and covered with a sterile dressing. Also, the injured person is given a Diphtheria-Tetanus-Pertussis Vaccine and antibiotics to prevent infection. To make sure the injured part is not deprived of blood, doctors surgically repair damaged arteries unless the arteries are small and blood flow is not affected. Severed nerves are also repaired surgically, but this surgery can be delayed until several days after the injury if necessary. If nerves are bruised or damaged, they may heal on their own. Pain is treated as soon as possible, typically with opioid pain relievers and/oracetaminophenor an anesthetic injected into nerves in the area (called a nerve block). A nerve block prevents the nerves from sending pain signals to the brain. and other Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) are sometimes not recommended due to the risk of bleeding. However, if no operation is planned, NSAIDs can be used. PRICE refers to the combination of Protection Rest Ice Compression (pressure) Elevation If people who have a fracture also have soft-tissue injuries, they may benefit from PRICE. PRICE is used to treat injured muscles, ligaments, and tendons. Protectionhelps prevent further injury that could worsen the original one. It may involve limiting the use of the injured part, avoiding putting weight on the injured body part, using crutches, and/or wearing a splint or cast. Restprevents further injury and may speed healing. Iceandcompressionminimize swelling and pain. Ice is enclosed in a plastic bag, towel, or cloth and applied for 15 to 20 minutes at a time, as often as possible during the first 24 to 48 hours. Usually, compression is applied to the injury with an elastic bandage. Elevatingthe injured limb helps drain fluid away from the injury and thus reduces swelling. The injured limb is elevated above heart level for the first 2 days. After 48 hours, people can periodically apply heat (for example, with a heating pad) for 15 to 20 minutes at a time. Heat may relieve pain. However, whether heat or ice is best is unclear, and what works best may vary from one person to another. Often, broken bones must be moved back into their normal position (realigned, or reduced). For example, reduction is usually necessary if Pieces of a broken bone have become separated. Pieces of a broken bone are out of alignment. Certain fractures in children do not need to be realigned because the bone, which is still growing, can correct itself. If possible, reduction is done without surgery (called closed reduction), by manipulating the bones or bone fragments back into place. After reduction is done, doctors usually take x-rays to determine whether the fractured bones are in their normal position. Some injuries must be realigned surgically (called Surgery ). Because reduction is usually painful, people are usually given pain relievers, sedatives, and/or an Anesthesia before the procedure. The types of drugs that are used depend on how severe the injury is and how reduction is to be done: Closed reduction of minor fractures (such as those of the fingers or toes): A local anesthetic, such aslidocaine, injected near the injured part, may be all that is needed. Closed reduction of major fractures (such as those of the arm, shoulder, or lower leg): People may be given a sedative and pain relievers by vein. The sedative makes them drowsy but not unconscious. They may also be given a local anesthetic by injection. For example, if people have a shoulder dislocation,lidocainemay be injected into the shoulder joint. Open reduction: People are given a general anesthetic by injection or through a face mask, making them unconscious. This procedure is usually done in an operating room. After being realigned, the injury must be kept from moving (be immobilized). Casts, splints, or slings are usually used after closed reduction of a fracture. Hardware devices, such as pins, screws, rods, and plates, are often used during open reduction of a fracture. This procedure is called Surgery (ORIF). Immobilization reduces pain and helps with healing by preventing further injury to surrounding tissues. If a leg or an arm bone is fractured, immobilization may help prevent Fat embolism . Immobilization is helpful for most moderate or severe fractures. Joints on both sides of the fracture are immobilized. If immobilization lasts too long (for example, for more than a few weeks in young adults), the joint may become stiff, sometimes permanently, and muscles may shorten (causing contractures) or shrink (waste away, or atrophy). Blood clots may develop. Such problems can develop quickly, and contractures can become permanent, usually in older people. Consequently, doctors encourage movement as soon as the fracture heals. They also tend to use treatments that enable older people to walk as soon as possible (such as surgical repair of a hip fracture), rather than ones that require them to be immobilized for a long time (such as bed rest or a cast). Physical therapists can advise people about what they can do while their injured part is immobilized to maintain as much strength, range of motion, and function as possible. After immobilization has ended, physical therapists can help people with exercises to strengthen and stabilize the injured part. These exercises can help prevent future injuries and impairment. Whether immobilization is required and which technique is used depend on the type of fracture. Most fractures are immobilized with a cast, splint, or sling until they heal. Without immobilization, the broken ends are likely to move, healing is slower, and the bones may not grow back together. If the broken bones have been separated or are out of alignment, they usually must be realigned (reduced) before being immobilized. Castsare usually used for injuries that must be kept immobilized for weeks. If the cast causes persistent or worsening pain, feels excessively tight, or causes new numbness or weakness, people should contact a doctor or go to the emergency department immediately. To apply a cast, doctors wrap the injured part in cloth, then apply a layer of soft cottony material to protect the skin from pressure and rubbing. Over this padding, doctors wrap dampened plaster-filled cotton bandages or fiberglass strips, which harden when they dry. Plaster is often used to immobilize broken bones that have been separated because it molds well and is less likely to rub against the body. Fiberglass casts are stronger, lighter, and longer-lasting. After a week or so, the swelling goes down. Then, the plaster cast can sometimes be replaced with a fiberglass cast to fit the limb more snugly. People who require a cast are given special instructions for its care. If a cast is not correctly cared for, problems can develop. For example, if the cast becomes wet, the protective padding under the cast may become wet, and drying it completely may be impossible. As a result, the skin can soften and break down, and sores may form. Also, if a plaster cast gets wet, it can fall apart and thus no longer protect and immobilize the injured area. People are instructed to keep the cast elevated as much as possible at or above heart level, especially for the first 24 to 48 hours. They should also regularly flex and extend their fingers or wiggle their toes. These strategies help blood drain from the injured limb and thus prevent swelling. If the cast causes persistent or worsening pain, feels excessively tight, or causes new numbness or weakness, people must contact a doctor or go to the emergency department immediately. These symptoms may be due to a developing Pressure Sores or When bathing, enclose the cast in a plastic bag and carefully seal the top with rubber bands or tape or use a waterproof cover designed to cover a cast. Such covers are commercially available, convenient to use, and more reliable. If a cast becomes wet, the padding under the cast may retain moisture. A hair dryer can remove some dampness. Otherwise, the cast must be changed to prevent skin from breaking down. Never put an object inside the cast (for example, to scratch an itch). Check the skin around the cast every day, and report any red or sore area to a doctor. Check the edges of the cast every day, and if they feel rough, place soft adhesive tape, tissues, cloth, or another soft material to pad them and keep them from injuring the skin. When resting, position the cast carefully, possibly using a small pillow or pad, to prevent the cast's edge from pinching or digging into the skin. Elevate the cast regularly, as directed by the doctor, to control swelling. Contact a doctor immediately if the cast causes persistent pain or feels excessively tight. These symptoms may result from pressure sores or swelling, which may require immediate removal of the cast. Contact a doctor if the cast gives off an odor or if a fever develops. These symptoms may indicate an infection. Contact a doctor if the cast causes worsening pain or new numbness or weakness. These symptoms may indicate compartment syndrome. Asplintcan be used to immobilize some fractures, particularly if they need to be kept immobile for only a few days or less. Splints allow people to apply ice. A splint is a long, narrow slab of plaster, fiberglass, or aluminum applied with elastic wrap or tape. Because the slab does not completely encircle the limb, there is room for some expansion in case the injured area swells. Thus, a splint does not increase the risk of developing compartment syndrome. Some injuries that eventually require a cast are first immobilized with a splint until most of the swelling resolves. For finger fractures, aluminum splints lined with foam are commonly used. Aslingby itself can provide sufficient support and comfort for many shoulder and elbow fractures. The weight of the arm pulling downward helps keep many shoulder fractures aligned. Slings can be useful when complete immobilization has undesirable effects. For example, if a shoulder is completely immobilized, the tissues around the joint may become stiff, sometimes within days, preventing the shoulder from moving (called frozen shoulder). Slings limit movement of the shoulder and elbow but allow movement of the hand. Aswathe,which is a piece of cloth or a strap, may be used with a sling to prevent the arm from swinging outward, especially at night. The swathe is wrapped around the back and over the injured part. Problems Due to Bed Rest , Sometimes fractures must be reduced and repaired surgically, as for the following: Open fractures:Because the skin was broken, bacteria and debris can enter the body. Doctors must carefully clean the area around the fracture to remove all traces of debris. Doing so reduces the risk of infection. Displaced fractures that cannot be aligned or kept aligned by closed reduction:When a piece of bone has shifted or a tendon is in the way, doctors may not be able to realign the broken bones by manipulating them from the outside (closed reduction). Or the fracture can be realigned using closed reduction, but the muscles pull on the pieces of bone and keep them from staying in place. Joint surface fractures:These fractures extend into a joint, fracturing the cartilage at the ends of the bones in the joint. To prevent people from developing arthritis later, doctors must almost perfectly realign the fractured cartilage. Realignment can be more precise when it is done surgically. Pathologic fractures in a bone weakened by cancer:Bone weakened by cancer may not heal normally after a fracture. Surgery may be needed to prevent the fragments of bone from becoming displaced. Also, stabilizing the joint surgically reduces the pain and enables people to use the joint more quickly. Fractures known to require surgery:Certain kinds of fractures (such as hip fractures and thighbone fractures) are known to heal more rapidly and have a better outcome when they are surgically repaired. Fractures that would otherwise require a long period of immobilization or bed rest:Surgery shortens the time people have to stay in bed. For example, surgery enables people who have had a hip fracture to get out of bed and begin walking soon after the operation, often as soon as the first day after surgery (with the help of a walker). Complicated fractures:Surgery may be required to treat certain injuries that occur with a fracture, such as damaged arteries or severed nerves. Inopen reduction with internal fixation (ORIF),surgery is done to restore the bone’s original shape and alignment. X-rays are used to help surgeons see how to align the bones. After making an incision to expose the fracture, the surgeon uses special instruments to align the bone fragments. Then, the fragments are held in place using some combination of metal wires, pins, screws, rods, and plates. For example, metal plates may be shaped as needed and attached to the outside of the bone with screws. Metal rods may be inserted from one end of the bone into the interior of the bone (marrow). These hardware devices are made of stainless steel, high-strength alloy metal, or titanium. The devices that have been made in the last 15 to 20 years do not interfere with the strong magnets used in magnetic resonance imaging (MRI). Most do not set off security devices at airports. Some of these devices are permanently left in place, and some are removed after the fracture has healed. Joint replacement(arthroplasty) may be needed, usually when fractures severely damage the upper end of the thighbone (femur), which is part of the hip joint, or the upper arm bone (humerus), which is part of the shoulder joint. Inbone grafting,doctors use chips of bone taken from another part of the body (such as the pelvis). This procedure may be done immediately if the gap between pieces of bone is too large. It may be done later if the healing process has slowed (delayed union) or stopped (nonunion). 