Humeral Head Fracture

Humeral head fracture is an irregular hemisphere shape one of three types of shoulder fractures and refers to an injury, dislocation, or break involving the area surrounding the humeral head, which is commonly known as the ball of the shoulders. The humeral head is the articular surface of the upper extremity, located at the top of the humerus (upper arm bone). A proximal humerus fracture can greatly affect the shoulder joint and upper arm movement develop inferior pseudo subluxation from decreased muscle tone.

The head (caput humeri), is nearly hemispherical in the form, directed upward, medial ward, and a little backward, as well as articulates with the glenoid cavity of the scapula to form the glenohumeral joint or shoulder joint consisting of the glenoid cavity of the scapula and the head of the humerus. The circumference of its articular surface is slightly constricted and is termed the anatomical neck, then a few centimeters below the tubercles called the surgical neck. The diameter of the humeral head is generally larger in men than in women. The shoulder is an extremely mobile joint that is stabilized by surrounding soft tissues such as the joint capsule, muscles, tendon, cartilage, and ligaments. The greater and lesser tuberosities’ bony prominent areas are bony landmarks of the proximal humerus and serve as attachment sites for musculature.

Depending upon the mechanism, pattern, and severity of the injury, a range of other fractures i.e. greater tuberosity fracture, humeral shaft fracture, coracoid fracture, humeral neck fracture, and avulsion types fractures of the anterior glenoid rim are possible. The anatomical neck is the part between the head, and the tuberosities, and the surgical neck is the part between the tuberosities and the shaft. The greater tuberosity is located lateral side of the head.

Mechanism of Fracture

Most of the fracture mechanism in the upper limb is caused by repetitive avulsion strain from activities valgus stress on the elbow, wrist, direct blow to the elbow such as falling on an outstretched hand, through throwing, wrestling, frequent loaded gripping, forearm pronation, and/or wrist flexion associated with shoulder, elbow, wrist dislocations. In case of anterior, posterior, inferior dislocation in the upper limb transmitting force to the medial epicondyle via the ulnar collateral ligament fall on an outstretched hand with the elbow in full extension, direct blow (rare) resulting in sudden traction on the flexor-pronator muscle group of the forearm muscle, tendon. The intense, vigorous valgus forces during the late cocking and acceleration phases of throwing time or the late phases of the golf swing, cricket balling just before and during contact with the cricket ball contribute to athletes. Although it is often associated with athletes, the pull of the attachments at the muscle, and tendon during valgus stress the ulnar ligament, and flexor-pronator mass condition is also seen in the general population, commonly seen in carpenters, and utility workers. Upper limb fracture is often precipitated by poor body mechanics, improper techniques, and/or inadequate equipment or toolsand fracture typically displaces anteriorly for the pull of these muscles.

Causes of Humeral Head Fracture

Causes of Humeral Head Fracture are following

  • The repetitive impact – on the lower limb bone with weight-bearing exercises occupational work cause microfractures, which consolidate to stress and avulsion fractures. [rx] Injury can occur through hyperextension of the wrist in combination with eccentric contraction of the flexor carpi ulnaris (FCU) can result in osteochondral or avulsion fractures or dislocation of the pisiform [], axial force applied to the wrist is hyperextended in a fall from hitting the heel of the hand on a hard surface following a fall onto an outstretched hand, impaction of the hand bone after a fall on an outstretched hand or by avulsion of attached ligaments.  subluxations, higher energy trauma such as a punch delivering a blow, direct trauma to the bone, longitudinal axial loading, clenched fist injuries, axial load via direct trauma to a clenched fist transfers energy to the upper limb bone,
  • Heavy influence – The force of a jump or fall from height can result in a broken knee. It can happen in foot bone fractures even if you jump from a high altitude, lift accident in a big shopping mall, or multilevel apartment. Falling on an extended, displacement of each fracture pattern can be angulated, translated, rotated, or shortened, an impact onto a clenched fist, direct blow, rotational movement, displacement of each fracture pattern can be angulated, translated, rotated, shortened, segmental fractures, 
  • Missteps – Frequently falling from outstretches hand can cause a fracture of the upper extremity if you put your foot, and knee down awkwardly abnormally. Your ankle might twist, suddenly change direction, sprint, kick, leap, or roll your foot joint to the side as you put weight on it. It can also happen in stare up or stare down unconscious.
  • Sports – High-impact sports such as football, cricket, hockey, volley boll involve intense movements that place stress on the joints, including knee bone fracture examples of high-impact sports include cricket, racing of the bike, soccer, football, horseback riding, hockey, skiing snowboarding, in-line skating, jumping on a trampoline, basketball, and hitting, as in a boxer or a defensive lineman in a football game hitting an offensive lineman to protect the quarterback. Impacts on the upper limb bone with forced hyperextension deviation by a direct blow over the hypothenar eminence in sports where a firm grip is an upper limb such as tennis, baseball, golf, racket, club, bat, volleyball, baseball catchers, golfers, karate, carpenters, polishers, builders, strong dorsopalmar compression
  • In a Race – The injuries are occurring mostly in competitive sports with hitting, running, and sudden direction changes in sprinting, steeplechase, sudden direction-changing sportive activities, sudden accelerating, and decelerating activities, uncontrolled football hitting, repetitive hip movements, and repetitive loads, in high sporting activities in fully grown athletes, dance, soccer, or kicking a soccer ball, football training season, hockey, rugby, cricket, football playing, skating, playing baseball, running or kicking a ball, tennis, fencing, basketball, gymnastics, the excessive passive elongation of the musculotendinous unit during gymnastic movements.
  • Daily collisions accident – The sudden, heavy impact of a car accident, or bike accident can cause knee bone fractures. Often, these types of injuries need surgical repair. boxer playing, catching the ball when playing cricket, or a defensive wicket-keeper, goalkeeper in a football game, hitting, gunshot wound, sudden fall in outstretch hand, crush injury, projectile, sudden acceleration of the bike accelerator or clas, opening cran bottle, door entrapment of hand, ligamentous laxity predisposes to hyper-extension, poor muscle attachment, osteoporosis, abnormal hormonal imbalance, may be associated with concomitant carpal fractures and dislocations, axial carpal instability, etc. The crushing injuries common in car accidents may cause breaks that require surgical repair.
  • Falls from height – Tripping and falling when walking on uneven surfaces can break bones in knee bone fractures, as can landing on your feet after jumping down from just a slight height, sudden landings from the plane in the war field, downhill, violent trauma, etc. Crush injury, ceiling fan accident sudden uprighting hand, heavy impact of a car accident, bike accident, hitting hammer in the workshop.
  • Driving and compressing in the break – It is one of the significant causes of hip microtrauma for the driver of the car, motorbike, truck, bus, bicycle runner, suddenly accelerating (getting faster), and suddenly decelerating (going slower). During driving, such a kind of vehicle frequently has to compress breaks to maintain the car’s speed. Repeated compression causes microtrauma, tendon, cartilage, ligament degeneration in the elbow, wrist, and weakness that may lead to injury in the upper extremity bone fracture.
  • Missteps – Sometimes, just putting your foot down the wrong way can result in a twisting injury that can cause a broken bone. Fracture also occurs when stairs up or stairs down, especially in older people.
  • Unconsciously Toilet Use – A widespread and daily increasing incidence of rupture of the hip, knee joint, foot bone, exceptionally high comodo using time frequently fall by slapping on the floor and causes fracture from abnormal fall.
  • High hell Use – It is the most common cause of fracture in the knee, ankle, foot, lower limb fracture, especially for women, abnormal arch, foot angle, the lake of the flat foot, abnormal sole of your footwear, muscle, tendon, cartilage, ligament weakness in the knee, ankle joints cause fracture and dislocation.
  • Soldier, armies on the battlefield – With the increasing technology of nuclear weapons on the battlefield, one country is involved in the war from one country to another country. On the battlefield, millions of armies and general people are falling into injury.
  • Have osteoporosis – a disease of your bone that weakens your bones gradually due to inadequate intake of calcium or vitamin D, less exposure to sunlight may lead to fracture of the bone in older age.
  • Weak low muscle mass or poor muscle strength – Lack of agility or older age muscle strength, mass, power, endurance becomes weak, and poor balance conditions make you more likely to fall and cause a fracture.
  • Walk or do other activities in the snow or on the ice – Especially north region of the world maximum time is low temperature. That frequent water turns into snow and activities that require a lot of forwarding momenta, such as in-line skating and skiing, snowboarding, in-line skating, Jumping, and playing lead to fracture of the bone in the upper limb.
  • Insufficient vitamin D and sunlight – Insufficient vitamin D and sunlight decrease the intestinal absorption of calcium, leading to abnormal regulation of parathyroid hormone (PTH). Vitamin D also works to upregulate the transcription of genes involved in neovascularization in areas of endochondral ossification, such as a healing fracture site. Vitamin D deficiency is typically characterized as a serum level of 25-hydroxyvitamin D3 of less than 20 ng/mL, and sufficiency is between 20 and 31 ng/mL.[rx]
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Symptoms of Humeral Head Fracture

Symptoms of  Humeral Head Fracture include

  • A fracture means intense pain, bleeding, swelling, tenderness, limited range of motion are the first symptoms
  • May present with pain, swelling, tenderness, and hematoma directly over the hip in athletes. Construction workers may present various pain and swell with paresthesia
  • Pain may be referred to the shoulder, arms, wrist joint, and thumb in the web space between the thumb and index finger
  • Inability to grasp or weakness of grasp between your upper extremity
  • Tenderness to the touch along the phalanges, carpal, and metacarpal bone.
  • Blue or black discoloration of the skin over the thumb
  • Pain with or after regular activity or a noticeable abnormality, such as a bent elbow, arm, or wrist
  • Pain that goes away when resting time and then returns when standing, walking, or during activity respective joint
  • Pinpoint pain at the site of the fracture when touched
  • Swelling but no bruising may be present if it becomes microtrauma
  • Bruising or discoloration that extends to nearby parts of the fractured bones.
  • Pain may decrease with rest but increases again with activity or movement
  • Pain at the fracture site, which in some cases can extend from the upper extremity
  • Blisters, change in color appearance, and bruising may occur over the fracture site after some days.
  • Warmth, bruising, numbness in the forearm or wrist, or radiating pain through
  • This pain may occur or feel in the setting of acute trauma or repetitive microtrauma over weeks to months. One should be suspicious of stress fracture with discomfort or pain of worsening quality or duration over time.
  • Arm pain that gets worse with wrist or elbow movement

Diagnosis of Humeral Head Fracture

Diagnosis of Humeral Head Fracture are following

History

Your doctor in the emergency department may ask the following questions about your fracture

  • How –  How was the fracture created, and, if chronic, why is it still open? Have any underlying etiology including constitutional systems (fever, chills, night sweats, anorexia, changes in weight, fatigue).
  • When – How long has this fracture been present? If not emergency stage or after 24 hours of fracture, or(e.g., regular less than one month acute, more than six months chronic)
  • What – What anatomy and structure do it involve? (e.g., epidermis, dermis, subcutaneous tissue, fascia, muscle, tendon, bone, arteries, nerves). What comorbidities, economic or social factors do the patient have which might affect their ability to heal the fracture?
  • Where – Where on the body parts is fracture and pain location and intensity, quality, onset, precipitating factors, alleviating factors? Is it difficult to offload, complicated, or keep clean? Is it in an area of high skin tension? Is it near any vital organ and structures such as a major artery, or low muscle attachment?
  • What is your Past – Has your previous medical history of fracture, if have? Are you suffering from any chronic disease, such as hypertension, stroke, blood pressure, diabetes mellitus, or previous major surgery? What kind of medicine did you take? What are your food habits, occupation, alcohol, tea, coffee consumption habit, betel leave and betel nut, anabolic steroid uses for athletes, etc.?
  • Past Medical History – It is important to know the patient’s previous medical history, as this could clue into the reason for osteoporosis symptoms, degenerative arthritis, rheumatoid arthritis, chronic heart, and lung disease.
  • Medications history – What kind of medication do patients take some medications can cause reversible fracture healing The patient had properly full dosage vaccinated, covid 19 vaccine condition, had taken any helminthic drugs, tetanus vaccine.
  • Social History – It is vital to know living conditions, geographic location, patients living in big cities, industrial areas or villages, chemical exposures, use of alcohol, tobacco, recreational drugs, seafood, pets, animal exposures, recent traveling from one place to another.
  • Sexual History – It is important to know the number of sexual partners, wives, girls friends, sexually active with males, females, or both; use of any contraceptive protection, history of sexually transmitted infections, tumors, malignancy, and partners with known sexually transmitted infections.
  • Surgical History – Inquire must be done in case of elder patients, if have any previous heart, liver, lung surgeries and when they occurred, how soon they occurred, had any bioabsorbable plates, intramedullary bioabsorbable rod fixation, heart valve, and coronary heart surgery.

Physical Examination

Physical examination is done by your doctor, consisting of palpation of the fracture site, eliciting boney tenderness, edema, swelling, bleeding, and contamination of infection. If the fracture is in the dept of a joint, the joint motion, and normal movement will aggravate the pain.

  • Inspection – Your doctor also checks superficial tissue skin color, involving not only the epidermal layer or Partial-thickness affects the epidermis and extends into the dermis, but full-thickness also extends through the dermis and into the adipose tissues or full-thickness spreads through the dermis. Adipose exposes muscle to bone and evaluates and measures the fracture’s depth, length, and width, bony landmark, and more or less muscle attachment, tendon, and ligament origin or insertion area. Access surrounding skin tissue, fracture margins for tunneling, rolled, undermining fibrotic changes, and if unattached, evaluate for signs and symptoms of infection warm, pain, and delayed healing.
  • Palpation – Physical examination may reveal tenderness to palpation, swelling, edema, tenderness, worm, temperature, open fracture, closed fracture, open, spiral, oblique, multiple bone fractures, microtrauma, a palpable gap, visible deformation, decreased range of motion, gross motion, active or passive range of motion, local tenderness, discomfort, guarding, weakness, bruising, inability to bear weight, mild limitation of activity, sudden loss of function, ligament integrity, comparison of laxity, block to motion, muscle fraction, weakness, crepitus, ecchymosis at the site of fracture. Condition of the surrounding skin and soft tissue, quality of vascular perfusion, loss of tissue planes, a non-concentric joint, widened joint space, or effusion pulses, and the integrity of nerve function. When palpating a fracture, one must remember the location, size, firmness, and pain.
  • Motor function – Your doctor may ask the patient to move the injured parts to assist in assessing muscle, ligament, and tendon function. The ability to move the joint means that the muscles and tendons work correctly and do not guarantee bone integrity or stability. The concept that it can’t be fractured because you can move it is incorrect. The jerk and manual tests are also performed to investigate the motor function.
  • Sensory examination – assesses sensations such as light touch, worm, paresthesia, itching, tingling sensation, numbness, and pinprick sensations, in its fracture side. Sensation and distal arms pulses rate should be assessed manually. A systematically performed neurological examination, and manual test for specific muscles, and joints are necessary to find out any neurological injury in the affected extremity. 
  • Range of motion – A range of motion examination either active, active-assisted, or active resisted exercise of the fracture associate joint and its surrounding joint may help assess the muscle, tendon, ligament, condyle, bone tuberosity, and cartilage stability. Active assisted, actively resisted exercises are performed around the communal injured area and associate joints.
  • Blood pressure and pulse check – Blood pressure is the fundamental term used to describe the strength of blood with which your blood pushes on the sides of your arteries as it’s pumped around your body. An examination of the circulatory system, feeling for pulses, blood pressure, and assessing how quickly blood returns to the tip of a toe to the heart. It is pressed, and the toe turns white (capillary refill).
  • Rotational alignment –  Any degree of malrotation, fracture pattern, rotational alignment is a crucial component of the physical exam. Alignment can be assessed correctly by examining the arm, the hand with the MCP and PCP joints in flexion, and DIP joints extended. If fracture lines are drawn along the digits and extended distally, normally aligned digits will show these lines. Malrotation can also be detected by examining the shoulder, arms, and hand with the MCPs flexed, and PCPs and DIPs extended.
  • Vital signs – Temperature, Blood pressure, heart rate, respiratory rate, and oxygen saturation are all of significance to help determine the fracture if the patient is hemodynamically stable. Heart, lung, kidneys, a major artery, nerve, lymphatic are associated with this fracture, or not.
  • A head-to-toe exam – It must to conducted including an inspection of the head, ears, nose, throat, and thyroid gland. Auscultation of lungs, heart sound, and palpation with an associated injury area. A thorough inspection should be done of the skin, palpating when necessary, and looking for rashes, lesions, lacerations,s, and nodules.

Lab Test

Laboratory tests should be done as an adjunct to the overall medical status for surgical treatment. If major surgery is needed for an open fracture, multiple organs, bone fracture your doctor may consider prescribing the following test

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Imaging Test

  • X-Ray  – It is a universal and available imaging technology around the world. Your orthopedic doctor decides how what view of x-ray will be done. X-rays basically indicate the fractured bone, fracture pattern, angulation,  bone lesions, bone fragments, and when a fracture occurs radiographic evaluation is selected, three radiographic views should be obtained consistent with the American College of Radiology guidelines: anteroposterior (AP), lateral, and all views, anonymously perfect view to find out the fracture, that depends on a radiologist and your doctors
  • CT Scan –  Given these findings, computerized tomography (CT) is the gold standard for diagnosis, though only 91% of fractures were properly evaluated with a CT scan at a top-level trauma center. CT scans are more enhanced types of imaging technology to investigate, tendon, cartilage, ligament, soft tissue injury with fracture pattern, angulation, bone lesion, osteophyte formation, joint synovial fluid, etc.
  • MRI – It is a more advanced stage diagnostic procedure of magnetic resonance imaging (MRI) to evaluate any incongruity, trapped osteochondral fragment, chondral damage, soft tissue integrity, malalignment, and even small incisional fractures.
  • Multi-Detector computerized tomography (MDCT) – Is a terminal stage imaging test that has both higher sensibility and specificity than radiography. CT images are often more easily interpreted even when anatomical relations are subverted. MPR images should be performed along the anatomical axes. MDCT evaluation with MPR and VRT reconstruction is recommended to best assess fracture(s), anatomical relationship, degree of comminution, fracture angle, and eventual intraarticular loose bodies. CT is additionally needed to guide management decisions and for surgical planning.
  • Ultrasound Test – Ultrasonography is a procedure that uses high-frequency sound waves to create an image inside the body’s internal organs, associated with a fracture of another organ, bone, or multiple fractures, blood vessel, nervous system, or muscle. An ultrasound is an imaging test that uses sound waves to create a 2D picture of organs, tissues, and other structures inside the body.
  • Bone Scintigraphy-  It is known as a gamma scan is a diagnostic test in the nuclear medicine department, where radioisotopes radioactive materials called radiotracers are injected into the blood vessels that travel to a specific organ or tissue is taken internally and the emitted gamma radiation is captured by external detectors (gamma cameras) to form two-dimensional images. In another contrast, single-photon emission computed tomography (SPECT), and positron emission tomography (PET) form 3-dimensional images and are therefore classified as separate techniques from scintigraphy, although they also use gamma cameras to detect internal radiation. The radiotracer travels through the area being examined and gives off radiation in the form of gamma rays which are detected by a special gamma camera and a computer to create fracture images of your bones.

Treatment of Humeral Head Fracture

Initial Treatment Includes for Humeral Head Fracture is following

  • Get medical help immediately – If you fall on an outstretched leg, play cricket, get into a car accident, or are hit while playing a sport and feel intense pain in your, then get medical care immediately. Cause significant pain in your shoulder, elbow, wrist, carpal, metacarpal bone, and joint. If the accident is substantial, you keep your hand at the same heart position and then clean and treat any wounds on the skin of the injured upper extremities. Aggressive fracture care is essential for patients to reach a safe place with the proper ventilation to straighten the head and neck to lye and the patient needed to save contaminated any infection from the germ. Injured are clear with disinfectant material as quickly as possible and take steps to stop bleeding[rx]
  • ICE  apply – Apply ice in the fracture area, and it helps to prevent swelling and edema by constricting the blood vessel.
  • Rest – Sometimes, rest is all that is needed to treat a traumatic fracture of your shoulder, elbow, wrist, carpal, metacarpal bone, and joint. Sometimes rest is the only treatment required to eradicate the healing of a stress or traumatic fracture of the upper extremities bone fracture.
  • Compression – It is best for an elastocrape bandage will limit swelling edema and help to stop bleeding from fracturing the joint. A tubular compression bandage is frequently used but should be removed at night by easing it off gradually. Please put it on again before you are out of bed in the morning. Mild to moderate pressure that is not too uncomfortable or too tight, and stops blood flow. Depending on the amount of swelling, pain, and edema, you may be advised to remove the bandage for good after 48 hours.
  • Elevation – Elevation initially aims to limit and reduce any swelling, or bleeding. For example, keep the hand upright on a chair or pillow to at least heart level when sitting. When you are in bed, put your hand on a pillow. 
  • Taping – If the fracture is a closed fracture your doctor is commonly used as an adjunct or temporary technique. Athletes often make use of taping as a protective mechanism in the presence of an existing injury. Some of the goals of taping are to restrict the movement of injured joints, and soft tissue compression to reduce swelling. The benefits of taping will depend on your injury. Your physiotherapists will aim to encourage some of the following benefits: Protection of injured soft tissue structures (ligaments, tendons, fascia), Injury prevention, Encouraging normal movement, quicker return to sport or work, pain reduction, improves the stability of a joint, reduces the risk of re-injury, and reduces swelling.
  • Splinting – Splints immobilize the fractured bone(s) to promote healing and reduce pain and swelling by ensuring the bone to protect and maintain in the proper alignment as it begins to heal. The hand may be fitted with a splint to keep the fracture in a fixed position. Splints are used for minor breaks in children’s hands. Splints support the broken bone on one side and immobilize the injured area to promote healing bone and maintain alignment. Splints are basically used in emergency situations to hold a joint in a right steady position during transportation to a medical facility.
  • Traction and Closed reduction – It helps to correct broken or dislocated bones into proper position by using a gentle and steady pulling force motion in a specific direction to stretch muscles and tendons around the broken bone in a closed fracture. This allows the bone ends to right align and heal, and in some cases, it reduces painful muscle spasms, spasticity, and joint stiffness. Closed reduction is a non-surgical procedure used to reduce pain, swelling, and set the fracture. Using a local anesthetic typically given through an intravenous in the arm, your doctor realigns the bone fragments from outside the body and holds them in right place with a cast or splint.
  • Avoid the offending activity – Because fractures result from repetitive stress trauma, it is essential to avoid the movement that lead to the rupture more seriously. Crutches, a wheelchair, or other types of supporting splint are sometimes required to offload weight to give it time to heal.
  • Casting or rigid – A cast made from plaster of Paris, plastic, or resin. Slings, triangular bandage, cervical collar, and cuff, high sling. A proper casting or form of immobilization may be used to protect the fractured bone while it is healing. A short arm cast is applied below the shoulder, elbow to the hand used after forearm or wrist joints fractures; also used to hold the shoulder, forearm, or wrist muscles and tendons in right place after surgery. A long arm cast is applied from the upper arm to the hand and is used after the shoulder, upper arm, elbow, or forearm fractures; also used to hold the arm or elbow muscles and tendons in place after surgery. Arm cylinder cast applied from the upper arm to the wrist holds the elbow muscles, ligament, and tendons in place after a dislocation or surgery.
  • Stretching the hand– If you’ve been diagnosed with a stress fracture, avulsion fracture avoiding the activity that caused pain is essential for healing. Stretching keeps the muscles flexible, muscles long, lean, strong, healthy, and flexible to maintain a range of motion in the joints. Lake of proper muscles stretching, muscle become shortens and tight. Then, when you call on the muscles for activity, they are weak and unable to extend the hand, which causes joint pain, strains, and muscle damage.

    Do no HARM for 72 hours after injury.

    • Heat – Heat applied to fracture and injured side by hot baths, electric heat, saunas, heat packs, etc, has the opposite effect on the blood flow. Heat may cause more fluid accumulation in the fracture joints by encouraging dilating blood vessels. Heat should be avoided when inflammation is developing in the acute stage or the first 72 hours from the injury time. However, after about 72 hours, no further inflammation is likely to create, and warmth and gentle isometric exercise can be done to soothe pain and prevent joint stiffness, muscle spasm, and spasticity formation.
    • Alcohol – It stimulates the central nervous system, can increase bleeding and swelling, decrease healing, and also causes drugs to drugs interaction.
    • Running and movement – Running and walking, or any kind of movement in fractured joint, associated soft tissue may cause further damage, dislocation, and causes healing delay.
    • Massage – A massage also may increase bleeding and swelling. However, 72 hours later of your fracture, you can take a simple message, isometric, active assisted, strengthening exercise, and applying heat may soothe the pain.

    Medication

    Your doctor may consider the following medications to relieve acute and immediate pain, long term treatment

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    The hormone that helps to heal fractures of the bone is following

    • Parathyroid hormone – Works on Kidney and bone and Stimulates 1,25 Vitamin D formation and osteoclastic activity; increases circulating calcium concentrations.
    • Calcitonin – Work on Osteoclasts and Inhibits action of osteoclasts; lowers circulating calcium concentrations in blood
    • Vitamin D (1,25D) – Works on Osteoblasts and Stimulates collagen, osteopontin, and osteocalcin synthesis; stimulates differentiation; increases circulating calcium concentrations. Bone osteoclasts, Stimulate activity of osteoclasts, Kidney Stimulates calcium retention, Intestine Stimulates calcium absorption,
    • Estrogen – Works on Bone, Stimulates formation of calcitonin receptors, inhibiting resorption
    • Prostaglandins – Works on Osteoclasts, Stimulates resorption and formation of new bone.
    • Bone morphogenetic protein – Work on Mesenchyme, Stimulates cartilage protein and bone matrix formation; stimulates replication.
    • TGF-B (transforming growth factor) – Works on Osteoblasts, chondrocytes, Stimulate differentiation
    • IL-1, IL-3, IL-6, IL-11( IL = interleukin) – Works on Marrow, osteoclasts, Stimulate osteoclast formation
    • TNFa(TNF = tumor necrosis factor), GMCSF(GMCSF = granulocyte-macrophage colony-stimulating factor) – Work on Osteoclasts, Stimulates bone resorption
    • Leukemia inhibitory factor – Works on 0steoblasts, osteoclasts, Stimulates osteoblast and osteoclast formation marrow

    What To Eat and What to avoid

    Eat Nutritiously During Your Recovery

    All bones and tissues in the body need certain micronutrients to heal appropriately and promptly. Eating a nutritious and balanced diet that includes lots of minerals and vitamins is proven to help heal broken bones and all types of fractures. Therefore, focus on eating lots of fresh food (fruits and veggies), whole grains, cereal, beans, lean meats, seafood, and fish to give your body the building collagen needed to repair your fracture correctly. In addition, drink plenty of purified water, milk, and other dairy-based non-alcoholic beverages to augment what you eat.

    Surgery

    Surgically treatment depends on the individual fracture characteristics, pattern, the size of fractures, the degree of displacement, dislocation, previous fracture at the same place, bone ridge, poor muscle attachment, low blood vessel supply, the location, comminution, the condition of integrity of the soft tissues of the joint, the presence of associate bones, multiple fractures, tendon, ligament injuries on the knee joint, comorbidities, and overall functional movement status or your doctor’s decision. [rx]

    • Internal fixation (ORIF) –  It uses steel screws, rods, plates, pins, grid plates, headless compression screws, or K-wires to hold the broken bones in the correct position. Bioabsorbable plates, intramedullary bioabsorbable rod fixation, are another plate that uses in order to avoid another operation for hardware removal and its potential-associated risks such as refracture, infection, and soft tissue injury.[,,]
    • External Fixation –  It is done by attaching a metal framework outside the limb to hold the fractured bone in the right position and includes the bone reduction forceps, fragment excision, the Ilizarov method,  X-frame, and a self-reinforced poly-L-lactide (SR-PLLA) absorbable rod.

    Physiotherapy

    Your doctor may advise you to take physiotherapy from the first day of the injury and fracture to prevent postoperative joint stiffness, muscle contracture, muscle wasting, muscle spasm, and to maintain flexibility, the elasticity of tendon, cartilage, and ligament.

    • Phase 1: Isometric muscle exercises by yourself or a physiotherapist, and weight protection are essential from the fractured day (week 1). Auto-assisted range of movement exercises by physiotherapists where the muscles complete the movement within the available range and then additional pressure is applied to achieve a few extra degrees. Gravity-assisted range of movement exercises where the movement is done by muscle activation in a position where gravity can assist pull the weight of the limb to the end of the joint’s available range.
    • Phase 2: Passive motion period in which another person or another body part completes the full movement without muscle activation power. Patients are advised to move without weight-bearing or with partial weight-bearing (weeks 2–4).
    • Phase 3: Active motion, range of motion, strengthening exercise, isokinetic exercises, and active joint movements including against gravity (weeks 4–6). Range of movement exercises within the water or sandbag can be advised by the physiotherapist as warm water can help to relax the tissues and increase the extensibility of the tissues increasing the achievable range.
    • Phase 4: Resistance exercises or active resistance exercises to improve muscle strength regularly(weeks 6–9).
    • Phase 5: Final period to prepare the patients for a normal life. Isokinetic dynamometry may be used to aid the decision to allow competition, or working life (after week 9).[rx]

    References