Editing Bone fracture (section)

==Treatment==
[[File:K-Knie-z2.jpg|thumb|X-ray showing the proximal portion of a fractured [[tibia]] with an [[intramedullary rod|intramedullary nail]] ]]
[[File: The patriotic open osteosynthesis.jpg|thumb|The surgical treatment of [[Mandible|mandibular]] angle fracture; fixation of the bone fragments by the plates, the principles of osteosynthesis are stability (immobility of the fragments that creates the conditions for bones coalescence) and functionality]]
[[File:Proximal femur nail.jpg|100px|thumb|right|Proximal femur nail with locking and stabilisation screws for treatment of femur fractures of left thigh]]
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 opened surgically, regardless of whether the fracture is an [[#Classification|open]] or [[#Classification|closed fracture]].<ref>{{cite web|url=https://www.lecturio.com/concepts/overview-of-bone-fractures/|title=Overview of Bone Fractures|website=The Lecturio Medical Concept Library|access-date=25 July 2021|archive-date=25 July 2021|archive-url=https://web.archive.org/web/20210725113420/https://www.lecturio.com/concepts/overview-of-bone-fractures/|url-status=live}}</ref>

===Pain management===
In arm fractures in children, [[ibuprofen]] has been found to be as effective as a combination of [[paracetamol]] and [[codeine]].<ref>{{cite journal |doi=10.1016/j.annemergmed.2009.06.005 |pmid=19692147 |title=A Randomized Clinical Trial of Ibuprofen Versus Paracetamol with Codeine for Acute Pediatric Arm Fracture Pain |journal=Annals of Emergency Medicine |volume=54 |issue=4 |pages=553–60 |year=2009 |last1=Drendel |first1=Amy L. |last2=Gorelick |first2=Marc H. |last3=Weisman |first3=Steven J. |last4=Lyon |first4=Roger |last5=Brousseau |first5=David C. |last6=Kim |first6=Michael K. }}</ref> In the [[Emergency medical services|EMS]] setting it might be applicable to administer 1mg/kg of iv [[ketamine]] to achieve a dissociated state.

===Immobilization===
Since [[bone healing]] is a natural process that will occur most often, fracture treatment aims to ensure the best possible ''function'' of the injured part after healing. Bone fractures typically are 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 (orthopedic surgery)|reduction]], in a good position and verifying the improved alignment with an X-ray is all that is needed. This process is extremely painful without [[anaesthesia]], about as painful as breaking the bone itself. To this end, a fractured limb usually is immobilized with a [[plaster]] or [[glass-reinforced plastic|fibreglass]] [[Orthopedic cast|cast]] or splint that holds the bones in position and immobilizes the joints above and below the fracture. 

When the initial post-fracture [[oedema]] or swelling goes down, the fracture may be placed in a removable brace or [[orthosis]]. If being treated with surgery, [[intramedullary rod|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 apparatus|Ilizarov method]] which is a form of an external fixator.

Occasionally smaller bones, such as phalanges of the [[toes]] and [[finger]]s, may be treated without the cast, by [[buddy wrapping]] them, which serves a similar function to making a cast. A device called a [[Suzuki frame]] may be used in cases of deep, complex intra-articular digit fractures.<ref name="pmid16217475">{{cite journal|vauthors=Keramidas EG, Miller G|date=October 2005|title=The Suzuki frame for complex intraarticular fractures of the thumb|journal=Plastic and Reconstructive Surgery|volume=116|issue=5|pages=1326–31|doi=10.1097/01.prs.0000181786.39062.0b|pmid=16217475|s2cid=31890854}}</ref> By allowing only limited movement, immobilization helps preserve anatomical alignment while enabling [[Fibrocartilage callus|callus]] formation, toward the target of achieving union.

Splinting results in the same outcome as casting in children who have a distal radius fracture with little shifting.<ref>{{cite journal |doi=10.1503/cmaj.100119 |pmid=20823169 |pmc=2950182 |title=Cast versus splint in children with minimally angulated fractures of the distal radius: A randomized controlled trial |journal=Canadian Medical Association Journal |volume=182 |issue=14 |pages=1507–12 |year=2010 |last1=Boutis |first1=K. |last2=Willan |first2=A. |last3=Babyn |first3=P. |last4=Goeree |first4=R. |last5=Howard |first5=A. }}</ref>

===Surgery===
[[Surgery|Surgical]] methods of treating fractures have their own risks and benefits, but usually, surgery is performed only if conservative treatment has failed, is very likely to fail, or is likely to result in a poor functional outcome.<ref>{{cite web
| url=https://www.hopkinsmedicine.org/health/conditions-and-diseases/fractures
| title=Fractures
| website=Johns Hopkins Medicine
| date=28 February 2020
| access-date=25 July 2021
| archive-date=25 July 2021
| archive-url=https://web.archive.org/web/20210725060148/https://www.hopkinsmedicine.org/health/conditions-and-diseases/fractures
| url-status=live
}}</ref> With some fractures such as [[hip fracture]]s (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.<ref>{{cite web|url=https://www.lecturio.com/concepts/hip-fractures/|title=Hip Fractures|website=The Lecturio Medical Concept Library|access-date=24 July 2021|archive-date=24 July 2021|archive-url=https://web.archive.org/web/20210724221923/https://www.lecturio.com/concepts/hip-fractures/|url-status=live}}</ref> 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 cell]]s to an injury to fight infection. For this reason, open fractures and [[Osteotomy|osteotomies]] call for very careful [[antiseptic]] procedures and [[prophylactic]] use of antibiotics.

Occasionally, [[bone grafting]] is used to treat a fracture.<ref>{{cite book | vauthors = Klokkevold PR, Jovanovic SA |chapter=Advanced Implant Surgery and Bone Grafting Techniques | veditors = Newman MG, Takei HM, Carranza FA |title=Carranza's Clinical Periodontology |publisher=W.B. Saunders |year=2002 |pages=907–8 |edition=9th |isbn=9780721683317}}</ref>

Sometimes bones are reinforced with metal.<ref>{{cite web
| url=https://www.hopkinsmedicine.org/health/conditions-and-diseases/fractures
| title=Fractures
| website=Johns Hopkins Medicine
| date=28 February 2020
| access-date=25 July 2021
| archive-date=26 July 2024
| archive-url=https://web.archive.org/web/20240726175204/https://www.hopkinsmedicine.org/health/conditions-and-diseases/fractures
| url-status=live
}}</ref> These [[implant (medicine)|implant]]s 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-[[Young's modulus|modulus]] materials, including [[titanium]] and its alloys. The heat generated by the friction of installing hardware can accumulate easily 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 [[ion]]s produced can damage the [[bone]] locally and may cause systemic effects as well.

=== Bone stimulation ===
Bone stimulation with either [[electromagnetic]] or [[ultrasound]] waves may be suggested as an alternative to surgery to reduce the healing time for non-union fractures.<ref name=":4">{{cite journal |last1=Leighton|first1= R. |last2= Watson |first2=J.T |last3= Giannoudis|first3=P.|last4=Papakostidis|first4=C.|last5=Harrison|first5=A. |last6=Steen|first6=R.G. |title= Healing of fracture nonunions treated with low-intensity pulsed ultrasound (LIPUS): A systematic review and meta-analysis|journal=Injury|date=May 2017|volume=48|issue=7|pages=1339–1347|pmid= 28532896 |doi=10.1016/j.injury.2017.05.016|doi-access=free}}</ref><ref name="VictoriaPetrisor2009">{{cite journal|last1=Victoria|first1=Galkowski|last2=Petrisor|first2=Brad|last3=Drew|first3=Brian|last4=Dick|first4=David|title=Bone stimulation for fracture healing: What′s all the fuss?|journal=Indian Journal of Orthopaedics|volume=43|issue=2|year=2009|pages=117–20|issn=0019-5413|doi=10.4103/0019-5413.50844|doi-broken-date=1 November 2024 |pmid=19838359|pmc=2762251 |doi-access=free }}</ref> The proposed mechanism of action is by stimulating osteoblasts and other proteins that form bones using these modalities. The evidence supporting the use of ultrasound and shockwave therapy for improving unions is very weak<ref name=":4" /> and it is likely that these approaches do not make a clinically significant difference for a delayed union or non-union.<ref>{{Cite journal |last1=Searle |first1=Henry Kc |last2=Lewis |first2=Sharon R. |last3=Coyle |first3=Conor |last4=Welch |first4=Matthew |last5=Griffin |first5=Xavier L. |date=2023-03-03 |title=Ultrasound and shockwave therapy for acute fractures in adults |url= |journal=The Cochrane Database of Systematic Reviews |volume=2023 |issue=3 |pages=CD008579 |doi=10.1002/14651858.CD008579.pub4 |issn=1469-493X |pmc=9983300 |pmid=36866917 }}</ref>

=== Physical therapy ===
[[Physical therapy]] exercises (either home-based or physiotherapist-led) to improve functional mobility and strength, gait training for hip fractures, and other physical exercise are also often suggested to help recover physical capacities after a fracture has healed.<ref>{{Cite journal |last1=Pradhan |first1=Sara |last2=Chiu |first2=Sarah |last3=Burton |first3=Claire |last4=Forsyth |first4=Jacky |last5=Corp |first5=Nadia |last6=Paskins |first6=Zoe |last7=van der Windt |first7=Danielle A. |last8=Babatunde |first8=Opeyemi O. |date=2022-06-03 |title=Overall Effects and Moderators of Rehabilitation in Patients With Wrist Fracture: A Systematic Review |url= |journal=Physical Therapy |volume=102 |issue=6 |pages=pzac032 |doi=10.1093/ptj/pzac032 |issn=1538-6724 |pmid=35421234|doi-access=free }}</ref><ref>{{Cite journal |last1=Fairhall |first1=Nicola J. |last2=Dyer |first2=Suzanne M. |last3=Mak |first3=Jenson Cs |last4=Diong |first4=Joanna |last5=Kwok |first5=Wing S. |last6=Sherrington |first6=Catherine |author-link6=Cathie Sherrington |date=2022-09-07 |title=Interventions for improving mobility after hip fracture surgery in adults |url= |journal=The Cochrane Database of Systematic Reviews |volume=2022 |issue=9 |pages=CD001704 |doi=10.1002/14651858.CD001704.pub5 |issn=1469-493X |pmc=9451000 |pmid=36070134}}</ref>