Armis
Professor in
Orthopaedic and Traumatologic
UGM, Sardjito
Hospital, Yogjakarta
INDONESIA
INTRODUCTION
Fracture is a discontinuity of
bone structures. If the soft tissues around the fracture site are intact is
called CLOSED FRACTURE, vice versa the soft tissues and skin around the
fracture site are not intact, therefore the fracture site is related with external
environment is called OPEN FRACTURE. The
fracture is caused by high energy trauma may produce many fracture fragments is
called FRACTURE COMMUNITIVE or produce many regions of bone fractures and also
bones in different part of the body is called MULTIPLE FRACTURES. The high
energy trauma is associated more than one body system is called MULTIPLE
TRAUMA. If fracture is caused by low energy trauma is called FRAGILITY
FRACTURE.
Fig. 1 A and B. Open fracture type IIIA of the segmental
comminuted distal left femur and open intercondylar left femur fracture T type.
C. Open comminuted fracture type IIIA of the left tibial plateau Schatacker VI
and fracture lines extend to distal of the tibia (OPEN COMMINUTED OF THE DISTAL
LEFT FEMUR and OPEN COMMINUTED OF THE PROXIMAL TIBIA/MULTIPLE FRACTURE)
EPIDEMIOLOGY
Fig. 2: Overall fracture age and gender distribution (Schwart AF)
Figure 2: The total of in and out patients at the Royal Infirmary of
Edinburg (UK) was 5953. The average age of the patients was 49.1 years with
gender ratio of 50:50 (the fracture’s incidence in men was 11.67/1000 per year
and in women was 10.65/1000 per year).
This graphic showed a relative increasing of the incidence after post
menopause women compare with men. The incidences of the young men were an
increasing (at 20 years old) then gradually decrease until about 60 years old
and it rises again. But the older men peak was lower than the older women (the
highest incidence of fracture in women was 49.7/1000 per year between 90 and 99
years of age. In men there were two similar peaks with an incidence of 21.9/1000
per year and 23.2/1000 per year between 90 and 99 years).
Table 1: Estimated risks of fracture at various ages
(van Staa TP, Dennison EM, at al. Bone 29:617-522)
Age
(%)
|
Any fractures
(%)
|
Radius/ulna(%)
|
Femur/hip
(%)
|
Vertebra
(%)
|
|
Lifetime risk women
|
50
60
70
80
|
53.2
45.5
36.9
28.6
|
16.6
14.0
10.4
6.9
|
11.4
11.6
12.1
12.3
|
3.1
2.9
2.6
1.9
|
Lifetime risk men
|
50
60
70
80
|
20.7
14.7
11.4
9.6
|
2.9
2.0
1.4
1.1
|
3.1
3.1
3.3
3.7
|
1.2
1.1
1.0
0.8
|
10 year risk women
|
50
60
70
80
|
9.8
13.3
17.0
21.7
|
3.2
4.9
5.6
5.5
|
0.3
1.1
3.4
8.7
|
0.3
0.6
1.3
1.6
|
10 year risk men
|
50
60
70
80
|
7.1
5.7
6.2
8.0
|
1.1
0.9
0.9
0.9
|
0.2
0.4
1.4
2.9
|
0.2
0.3
0.5
0.7
|
According to table 1 showed lifetime risks of fracture among men and
women at 50 – 80 years of ages in UK. At 50 years of age, the remaining life
time risk of a fracture at any site was 53.2% among women and 20.7% among men.
These fractures fall to 28.6% at age 80 years of ages among women and 9.6% at
the same age among men. The specific lifetime risks of the site at 50 years of
age were: radius/ulna 16.6%, femur/hip 11.4% and vertebra body 3.1 in women,
but radius/ulna 2.9%, femur/hip 3.1%, and vertebra 1.2% in men. Lifetime risks
of clinical fractures 50 year old white women in US as follow:
1. Hip fracture of women was 17% lifetime risk and men was 6%
2. Wrist fracture of women was 16% lifetime risk and men was 3%
3. Vertebral fracture of women was 16% lifetime risk and men was 5%
4. Any fracture of women was > 50% lifetime risk, and men was 16%
5. Breast cancer was 15% lifetime risk
Table 1 also showed
10 years risks of fracture among men and women at 50 – 80 years of ages. At 50
years of age, the remaining 10 year risk of a fracture at any site was 9.8%
among women and 7.1% among men. These fractures increased to 21.7% at age 80
years of ages among women and 7.1% to 8.0% at the same age among men. The
specific 10 year risks of the site at 50 years of age were: radius/ulna 3.2%,
femur/hip 0.3% and vertebra body 0.3% in women, but radius/ulna 1.1%, femur/hip
0.2%, and vertebra 0.2% in men.
The epidemiology of osteoporotic fracture is 1.5
million fractures in US annually, 44 million individuals in US at risk for
fracture, at age 50 a woman lifetime risk of fracture exceeds combined risk of
breast, ovarian & uterine cancer and at age 50 a man’s lifetime risk of
fracture exceeds risk of prostate cancer.
The epidemiology of fractures are going to change
every year (1%) over the world because an improving social-economic and health
care delivery services can give a rise to the elderly population with an
increasing the number of fractures in both gender. In elderly women, the main
causal of fracture is mainly due to the osteoporosis. There will be further changes
in the fractures epidemiology caused by osteoporosis problems and also due to
increasing number of elderly, especially hip, proximal humerus and distal
radius fractures. (fig. 3 & 4)
Fig. 4. Estimated world population: 1990 and 2050
(Schwart AF)
Early detection, promotion, prevention and treatment
of osteoporosis are the primary policy in health care delivery to the community.
PATHOLOGY
Every bone fracture consists of soft tissue damage and
bone damage. It is important as a general practitioner and family medicine to
recognize these damages for the evaluation and management of the closed
fracture patient. Pathology of soft
tissue and bone damage is explained as below:
1. SOFT TISSUE DAMAGE
1. SOFT TISSUE DAMAGE
The soft tissue injury ranges from minor to massive,
for example crush injury. Tscherne classified the soft tissue injuries as: (1)
grade 0: it has negligible soft tissue injury. (2) Grade 1: it has superficial
abrasion or contusions of soft tissues overlying the fracture site. (3) Grade
2: it has significant contusions to muscle, contaminated skin abrasion, or both
type of injury. The bone is usually severe damaged. (4) Grade 3: it has severe
injury to soft tissues with significant degloving, crushing, compartment
syndrome, or vascular injury.
The soft tissues healing need oxygenation, functional
cellular activities, and clean wound without contamination or necrotic tissue.
The soft tissue healing is divided into four phases such as: coagulation,
inflammation, granulation and scar formation.
2.
BONE DAMAGE
The trauma can produce a discontinuation of bone
structures such as incomplete/complete fracture, displaced/undisplaced, stable/unstable,
comminuted/segmental, and so on. If the discontinuation of bone structure does not
complete is called INCOMPLETE FRACTURE. Transversal of the fracture line
usually is called STABLE FRACTURE (fig. 1) because after reduction the fracture
fragments undisplaced, but after reposition redisplaced is called UNSTABLE
FRACTURE for example oblique or spiral fracture lines. If trauma produces more
than2 fragments is called COMMINUTED FRACTURE (fig. 5) or there is a segment is
called segmental fracture.
Fracture healing is divided into inflammation phase,
callus response (bridging callus and medullary callus) and remodeling phase.
CROSS REFERENCE OF FRACTURE
PATIENTS IN INDONESIA
Illustration 3: cross reference of fracture patients
This illustration
above shows the patient referring system in Indonesia: (1) the fracture patient
refers from accident area to PUSKESMAS or (2) refers from accident area to RSUD
(3) or directly from accident area to RSUP/RSN. Some fracture patients consult
directly to private hospital or private clinic. At government delivery health
care center, the fracture patient request to be managed at private hospital or vice-versa
due to a specific reason. However, some
fracture patients prefers to be treated by traditional medicine (bone setter).
If there is no improvement they come to the hospital or GP/Family medicine the
in the neglected conditions. This is the problem of the epidemiology accuracy
in Indonesia because the unknown percentage of the fracture patients was
treated by bone setter.
“HOW DO THE GP OR FAMILY MEDICNE MANAGE THE CLOSED FRACTURE
PATIENT AT THE PUSKESMAS?”
PUSKESMAS CLOSED FRACTURE
MANAGEMENT
The goals of the closed
fracture patient are to normalize or to optimize function to the level of
before fracture condition. The specific aims are:
1.
Preserve life and
decrease mortality rate
2.
Preserve limb
3.
Preserve function,
and
4.
Prevent infection
Illustration 4: PUSKESMAS MANAGEMENT
INITIAL ASSESSMENT AND MANAGEMENT
A. LIFESAVING
The first GP or
family medicine should be able to assess AIRWAY, BREATHING, and CIRCULATION of
the closed fracture patient.
1.
The AIRWAY EVALUATION, GP or family medicine should
always protect the cervical spine by hard collar neck (fig. 6) to prevent
movement especially multiple trauma (head injury). Definitive airway must be
implemented during resuscitation.
2.
The BREATHING ASSESSMENT, GP or family medicine should
always check the ventilation of chest trauma in such condition for example, pneumothorax,
hemothorax and flail chest. The aim of the resuscitation is to achieve adequate
tissue oxygenation.
3.
CIRCULATION EVALUATION, GP or family medicine should
prevent the bleeding. The sign of hemorrhage during the initial assessment
include decreased of consciousness level, loss of skin color, and rapid pulse. The
physician should be able to estimate blood loss in fracture patients. The
estimated blood loss of long bone fracture is about 1.5 units or femur fracture
is about 3 units or pelvic fracture is about 3 units. Classification of shock
hemorrhagic as follow (table 2)
Table 2. Shock classification
Class
|
Blood
volume loss (%)
|
Treatment
|
I
|
until 15
|
Fluid
replacement
|
II
|
15-30
|
Fluid
replacement
|
III
|
30-40
|
Fluid replacement and blood replacement
|
IV
|
More
than 40
|
Fluid replacement and blood replacement
|
The bleeding must be controlled by general physician
or family medicine with immobilize the patient by splint. Fluid resuscitation
is done by two large-bore peripheral intravenous lines. Initially resuscitation
is 1 to 2 L of Lactated Ringer or normal saline for adult and 20 ml/kg for
children. Total replacement of fluid replacement is three times the estimated
blood loss and crystalloid solution should be given. The pattern response to fluid
replacement treatment can be seen on the table 3 below.
Table 3.
Initial fluid resuscitation response
Respon-se
|
Vital sign
|
Blood loss
|
Crystalloid
need
|
Blood need
|
Rapid
|
Return to
normal
|
Min. 10-20%
|
Low
|
Low
|
Transient
|
Improve transiently, recurrent of decreasing blood
pressure and increase heart rate
|
Moderate
and ongoing
|
High
|
Mode-rate to high
|
None
|
Remain abnormal
|
Severe
(> 40%)
|
High
|
Imme-diate
|
The favorable response to fluid replacement therapy is
increased urinary output and adequate urine output in adult which is 0.5
ml/kg/hr or 2.0 ml/kg/hr for in children. The patient has improving state of
consciousness, increased peripheral perfusion and change in vital signs such as
increased blood pressure and pulse pressure, and decreased pulse rate.
4.
DISABILITY EVALUATION, GP or family medicine should be
performed using Glasgow Coma scale calculation as below (table 4)
Table
4: Glasgow Coma Scale
Respose to assessment
|
Score
|
1.
Eye opening:
·
Spontaneous
·
To speech
·
To pain
·
None
|
4
3
2
1
|
2.
best motor response
·
Obeys commond
·
Localized pain
·
Normal withdrawal (flexion)
·
Abnormal withdrawal (flexion)-decorticate
·
Extension-decerebrate
·
None
|
6
5
4
3
2
1
|
3.
Verbal response
·
Oriented
·
Confused conversation
·
Inappropriate word
·
Incomprehensible
·
None
|
5
4
3
2
1
|
GCS is a useful scale but takes a long time to be assessed;
therefore AVPU is more simple and rapid method for evaluation of neurologic
status patient.
A means Alert
V means Response to vocal stimulus
P means Response to painful stimulus, and
U means Unresponsive
5.
The last is the EXPOSURE, GP or family medicine should
be able to assess the patient completely in undress for accurate evaluation but
after examination the patient should be covered by blanket to maintain the body
temperature (fig. 6).
B. LIMB
THREATENING
1.
GP and family medicine should be able to evaluate the neurovascular
of the distal fracture lesion to maintain the viability of the distal lesion. Example:
pulse, capillary refill test, skin color, the skin temperature.
2.
GP or family medicine should be able to realign the closed
fracture and immobilize by splinting (fig. 7), and then
Fig. 7 Left lower leg splinting/back slab
3.
GP or family medicine should always rechecking of the
neurovascular
4.
GP or family medicine should be able to prepare the
patient and the transportation to be referred to the RSUD or RSUP/RSN hospital
as soon as possible.
C. DEFINITIVE
TREATMENT
The aims of the non-surgical
management of soft tissues injuries and fractures include (a) protecting and
minimalizing the tissue damage, (b) controlling swelling, (c) reducing pain,
and (d) limiting of the loss of function. Because of that, GP or family
medicine should be able to facilitate the initial management by using
combination method: protecting, rest, ice, compression and elevation (PRICE).
GP or family
medicine should able to apply the non-surgical management include (1)
cryotherapy with using of cold is as initial management of choice for injuries
for minimizing secondary cell death from hypoxia and reducing of pain. Cooling
of tissue around the fracture site decreases the metabolic activity by reducing
the oxygen demand therefore allowing injured cells in that area to survive. (2)
Compression and elevation are more helpful in reducing initial swelling because
it can reduce the amount of space of fluid accumulation. (3) Thermotherapy such
as superficial heating, ultrasound and electrical stimulation are effective
tools in rehabilitation procedure. Thermotherapy can increase blood flow and
muscle temperature to stimulate analgesia, stimulating cellular metabolism to
increase the electricity of muscle, tendon, and ligamentous tissues, increasing
nutrition to cellular level and increasing lymphatic drainage for removing of
metabolites and others products of the inflammatory process. Thermotherapy can
be used during fracture repair.
GP or family
medicine should be able to manage soft tissues injures, incomplete and
undisplaced fractures in normal alignment by casting immobilization two joints
closed the fracture site (proximal and distal joint) until union is achieved for
adult patients (3 months for a long bone in adults or 6 weeks in children). The
union in children is more rapid compared to adult. Incomplete and undisplaced
fractures in children, the GP and family medicine should be able to pull to
normalize the alignment and then casting.
D. ANTIBIOTIC
OR SYMPTOMATIC/PALLIATIVE TREATMENT
GP or family
medicine should be able to prevent infection by giving prophylaxis antibiotic especially
patient with excoriation or skin abrasion around the fracture site (Tscherne
grade ≥ 1). Pain killer should be given to minimize suffering of the patient.
E. REHABILITATION
Rehabilitation is
the key to maximize recovery following factures management. The aims of
rehabilitation program are to restore the range of joint motion, to improve
muscle strength and coordination or to return to optimal function as soon as
possible. GP or family medicine should be able to instruct active exercises and
to guide passive training of the joint movement to prevent joint stiffness and
muscle atrophy. Therefore the basic type of rehabilitation at PUSKESMAS shows on
table 5
Table
5: Basic type rehabilitation at PUSKESMAS
(modified
from Green, 2001)
Excercise
|
Activity/Direction
|
1.
Stretching
|
Performed slowly and maintained for 20-39 seconds without
aggressiveness
|
2.
Active ROM
|
The patient performs the stretching or movement
|
3.
Passive
|
The physiotherapist or outside force is applied for
stretching or moving the joint
|
4.
Stretching
|
Performed at a slow, controlled rate through safe
parameters of patient’s ROM
|
·
There are three types of stretching procedures
in rehabilitation that include (1) isometric exercise which involves muscle
contraction while the muscles length remain constants. This method is useful
for initial rehabilitation. (2) Isotonic exercise is an increasing strength by
muscle shortening and lengthening throughout the full range of motion using a
constant load at variable speed. (3) Isokinetic exercise, performed with the
aid of machine, restricts the amount of force applied against a resistance.
·
GP or family medicine should be able to
understand balance exercise with assisted devices such as chair, railing,
table, wall especially during initial phase of rehabilitation
·
GP or family medicine should be able to
understand the walking aid devices using such as cane, crutch, walker and so on
Fig 8 Walking devices
·
GP or family medicine should be able to
understand the occupational therapy especially hand injury, the aquatic therapy
by reducing gravitational force for example rehabilitation in water.
·
GP or family medicine should be able to
understand the adverse outcomes of the rehabilitation for example
overaggressive exercises can caused tendinitis, tendon rupture, fracture,
surgical wound dehiscence, or failure of surgical therapy and others.
·
And also GP or family medicine should be able to
determine the referral system such as complex problem of rehabilitation, lack
of treatment progression or requirement for special equipment indicate referral
to physiotherapist. When ordering therapist for rehabilitation, GP or family
medicine should specify the type, duration and frequency of exercises
rehabilitation. The successful rehabilitation depend on GP or family medicine
guidance and seriousness of the rehabilitation exercise to the patient
F. HOME
CARE & FOLLOW UP
GP and family
medicine should be able to evaluate fracture patient after definitive
management at home or PUSKESMAS. He/she is able to determine the improvement of
outcome, simple rehabilitation (active and passive exercises), the needing of
the components of bone fracture and soft tissue healing, complications after
intervention, He/she is also be able to decide the fracture patient to follow
up to the Orthopaedic surgeon for a further recommendation change.
G. COMPLICATIONS
GP and family
medicine should be able to predict the immediate fractures complications for
example neurologic disturbances (loss of sensory and motor function or loss of
urinary/digestive tract function especially spine trauma), vascular injuries, deep
venous thrombosis/fat embolism for long bone fracture, hypovolemic shock cause
by bleeding for pelvic/femur/multiple fracture or crush injuries, infection in
open fracture, compartment syndrome, joint effusion in intraarticular
fractures.
GP and family
medicine should be able to decide the delay fracture complication for example
delayed union or nonunion (hypertrophic, atrophic, oligotrophic and infection
nonunion), malunion, osteomyelitis acute/chronic, reflex sympathetic dystrophy,
heterotophic ossification, and avascular necrosis.
GP and family
medicine should be able to refer immediately after initial emergency management
or refer to hospital directly.
H. END
OF LIVE CARE
Fig 9 Clinical
and radiologic pictures
Case scenario:
A-62-year female came to out-clinic of the Sardjito hospital with pathologic
fracture of the right femur cause by breast metastasis in late statge. She had
been treated by traditional medicine but no improvement. There were pelvic, the
proximal of the left femur, and lung metastasis. The pathology from needle biopsy
was adenocarcinoma.
Adenocarcinoma
is a malignant cancer that treatment is not helping may make the patient feels
lost and afraid. For this reason, GP and family medicine should be able to
communicate some questions of patient such as:
“What’s
going to happen to me? or What are my other option? or How much longer do I
have? or How much pain and suffering will I have? And so on”
When GP or
family medicine determines cancer diagnosed with late stage and serious or life
threatening illness as like this patient, the decision of selection option is a
difficulty because the influences are not only based on medical data
interpretation, risks, benefits and cost of management.
The patient and
his/her families will be a shock of hearing the cancer diagnosis and prognosis
of serious illness in decision of the best management. For this reason, GP and
family medicine should be able to explore what the patient/family expected and
helping of the patient decides which of the available therapy options are best
for her.
According to
Singer PA, et al (1999), the GP and family medicine has an obligation to
provide quality end–of-life care by: (1) adequate pain and distressing symptom
management; (2) avoiding in appropriate prolongation of dying; (3) achieving a
sense of control; (4) relieving unnecessary burdens; and (5) strengthening
relationship with loved ones and contribution to others and continued
participation and active involvement in social interaction. GP and family
medicine should also be able to apply the bioethics principles such as the
principle autonomy and self-determination and her importance in decision making.
The goal of the
end-of-life care is making patient comfort with specific aim such as; (1)
physical comfort; (2) mental and emotional needs; (3) spiritual issues, and (4)
practical task. Discomfort can come from pain, breathing problem, skin
irritation, digestive problem, temperature sensitivity, and fatigue.
INTERVENTION AND
END OF LIFE CARE MANAGEMENT
1.
The role of palliative care
GP and family medicine should be able to relieve the
patient suffering and improve the quality of living and dying. This strategy is
to assist GP and family medicine and other provider in helping the patient and
family physical, psychological, social, spiritual and practical issues, and the
associated expectations, needs, hopes and fears.
2.
CPR and other potentially life-sustaining treatment
GP and family medicine should be able to determine CPR
procedure to end of life patient by estimation of the benefit, the goals,
values and beliefs. For these reasons GP and family medicine is not obliged to
provide CPR that patient will not certainly benefit.
3.
Expected death at home
GP and family medicine should be able to decide
staying and dying at home if the patient is a manageable option, regular care
is able to provide and the provider health care team coverage in home care
4.
Euthanasia and assisted suicide
Euthanasia and assisted suicide is a criminal code in many
countries include Indonesia
I. CONCLUSION
The role of GP
and family medicine in closed fractures management at PUSKESMAS includes:
1.
GP and family medicine should be able to estimate shock
hypovolemic cause bleeding especially femur or pelvic fractures and to decide
neurovascular disturbances.
2.
GP and family medicine should be able to manage
lifesaving and limb threatening
3.
GP and family medicine should be able to perform
definitive treatment of incomplete or undisplaced closed fractures by casting
perfectly
4.
GP and family medicine should be able to follow up or
home care and perform a simple rehabilitation. GP and family medicine should
refer to orthopaedic surgeon to change strategies management or any
complications during follow up
5.
GP and family medicine should be able to manage end of
life care of closed pathologic fractures in a late stage at PUSKESMAS or home
care
J. REFERENCES
1.
Barnstein J editor (2003). Musculoskeletal Medicine. AAOS. Rosemeont
2.
Brinker MR edotor (2001). Review of Orthopaedic Trauma. WB Saunder Com. Philadelphia
3.
Court-Brown C and Caesar B (2006). Epidemiology of
adult fractures: A review. Injury, Int.J.
Care injured 37: 691-697
4.
Filiper O (2014). Epidemiology and social Buerden of
the femoral neck fracture. http://www.journel-Imab-bg.org
Septembre 2015.
5.
Green WB editor (2001). Essentials of Musculoskeletal Care. AAOS, Roesmemont
6.
Harveyw N, Earl S and Cooper C (2006). Epidemiology of
osteoporotic fractures in America Society
for Bone and Mineral Research 244-248
7.
Singer BR, McLauchlan GJ, Robinson CM, and Christie J
(1998). Epidemiology of fractures in 15.000 adults. The influence of Age and
Gender. JBJS 80B: 243-248
8.
van Staa TP, Denisson EM, Leufkens HGM, and Cooper C
(2001). Epidemiology of fractures in England and Wales. Bone 29: 517-522
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