Distal Interphalangeal (DIP) Joint Dislocation

• Dorsal dislocations – results from PIPJ hyperextension with longitudinal compression (i.e. ball-striking fingertip) leads to tearing of the collateral ligaments and shearing of the volar plate off of the base of the middle phalanx commonly seen with a small avulsion fracture of the base of the middle phalanx
• Volar dislocations – simple  dislocation without rotation results from rupture of the central slip, rotatory dislocation with rotation results from rupture of one collateral ligament, with the other remaining intact one of the proximal phalangeal condyles, buttonholes between the central slip and lateral band
• Lateral dislocations – results from rupture of one collateral ligament and at least partial avulsion of the volar plate from the middle phalanx
• Simple – hyperextension deformity middle phalanx remains in contact with condyles of proximal phalanx
• Complex – bayonet deformity base of middle phalanx not in contact with the condyle of proximal phalanx volar plate can act as a block to reduction with longitudinal traction

Causes of Distal Interphalangeal (DIP) Joint Dislocation

Finger dislocations can involve the MCP, PIP, or DIP joints and should occur within the dorsal, volar, or lateral planes. Dislocations are consistent with the position of the distal bone relative to the more proximal bone.

Hyperextension or high-energy axial loads at the MCP joint may result in dislocation. MCP joint dislocation occurs due to the protection against hyperextension by the volar plate, radial, ulnar deviation by the collateral ligaments the foremost common MCP joint dislocation is the index. MCP joint dislocation of the center finger occurs more frequently when it’s subjected to ulnar stress while in hyperextension. The commonest MCP joints dislocate dorsally the standard presentation of MCP joint dislocation is with the IP joint in flexion and therefore the MCP joint in extension.

PIP joint dislocations are the foremost common dislocation thanks to sports and also are referred to as “coach’s finger.” the standard presentation of PIP joint dislocation is a deformity, decreased range of motion, and pain. PIP joint dislocations may classify into dorsal, volar, and lateral dislocations. PIP joint dislocation is most ordinarily dorsal, volar dislocation correlates with a better rate of complications and harder reductions. Dorsal dislocation from longitudinal compression and hyperextension is commonly by a ball hitting, catching a cricket ball, boxing the fingertip.

Dorsal PIP joint dislocation most ordinarily occurs at the center finger and is related to the volar plate, collateral ligament, and dorsal joint capsule injury. Swan neck deformity most frequently occurs in dorsal dislocations and results from volar plate injury. Trapping of the volar plate inside the joint may occur, causing malalignment and oblique rotation resulting in challenging reductions. Volar dislocation of the PIP joint may occur with and without rotation of the intermediate phalanx. Volar dislocation is related to injury to the central slip of the extensor tendon. Untreated rupture of the central slip after PIP joint dislocation is related to pseudo-boutonniere (PIP flexion contracture). Pseudo-boutonniere may be a chronic PIP joint flexion with the absence of DIP extension.

Lateral PIP dislocation also can occur and involves disruption of the collateral ligaments. The patient presents with joint instability and therefore the widening of the joint on radiographs. Finally, rotary volar dislocations may occur when the phalanx displaces and rotates around one collateral ligament, allowing the proximal phalanx to wedge itself between the lateral band and extensor tendon. The classic lateral radiographic finding has the outline of a Chinese finger-trap.

DIP joint dislocations occur with deformity at the fingertip and dorsal, lateral, and volar DIP joint dislocations are all possible. Dorsal DIP joint dislocations occur frequently and are related to fractures and skin injuries they’re not always related to flexor tendon avulsions but may have an interposed volar plate causing a non-reducible dislocation. Volar DIP joint dislocations are dorsal PIP joint dislocations therein both are related to extensor tendon injuries. The lateral DIP joint is more likely to possess post-reduction instability than volar or dorsal dislocations. Isolated DIP joint dislocation without related injuries like soft tissue, bone, or fractures is rare and is usually managed with closed reduction and splinting within the emergency departments.

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.[rx][rx] 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 tools[rx] and fracture typically displaces anteriorly for the pull of these muscles. [rx]

Symptoms of Distal Interphalangeal (DIP) Joint Dislocation

Symptoms of Distal Interphalangeal (DIP) Joint Dislocation are 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 Distal Interphalangeal (DIP) Joint Dislocation

The diagnosis of Distal Interphalangeal (DIP) Joint Dislocation 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 [rx]. 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

• CBC, ESR test
• Random blood sugar, glucose, and routine diabetes test if the patient has diabetes mellitus.
• Microscopic urine examination test and stool test.
• ECG, EKG test for heart abnormality is present
• Ultrasonography test in some cases.
• Normalized hemoglobin, hematocrit test
• Coagulation profile with bleeding time and coagulation time test, prothrombin time (PT) test for surgery if needed,
• Thromboplastin time and platelet counts will be required for operative intervention.
• Serum creatinine test,
• Serum lipid profile
• Serum uric acid test
•  If the patient is older specially 50year or more hormonal imbalance tests may be included such as

• • Hyperthyroidism test
  • Hypothyroidism, test  
  • Hypogonadism,
  • Thyroid-stimulating hormone,
  • Parathyroid hormone (PTH) test
  • Albumin Test
  • Liver function tests
  • Renal function test and
  • Urine protein electrophoresis 

• Laboratory tests for the diagnosis of osteoporosis if the patient is 50 are:
  • Vitamin D deficiency test
  • Serum total calcium level test
  • Serum Ionized calcium level test
  • Serum phosphate level test
  • Serum alkaline phosphatase level
  • Serum 25-(OH)-vitamin D level
  • calcium, phosphorus, urinary calcium,

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.[rx][rx]
• 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 Distal Interphalangeal (DIP) Joint Dislocation

Non-pharmacological and initial treatments of Distal Interphalangeal (DIP) Joint Dislocation are includes

• 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

• Antibiotic and booster tetanus – Cefuroxime or Azithromycin, Flucloxacillin or any other cephalosporin/quinolone, meropenem antibiotic must be used to prevent infection or clotted blood removal from preventing further swelling, inflammation, and edema. [rx] Antibiotics should be administered as soon as possible within the prehospital setting or emergency department if antibiotics got within 66 minutes of injury, the infection rate was 0%, but increased to 17% if antibiotics were delayed beyond this point frame.[rx] Tetanus booster and antihelmintic drugs such as albendazole must be used if the fracture is open or complicated for immunization to get fracture healing more quickly. [rx]
• NSAIDs – Prescription-strength drugs that reduce both pain and inflammation. Pain medicines and anti-inflammatory drugs help relieve pain and stiffness, allowing for increased mobility and exercise. There are many common over-the-counter medicines called non-steroidal anti-inflammatory drugs (NSAIDs). They include first choice NSAIDs is Ketorolac, then Etoricoxib, then Aceclofenac, naproxen. As you are taking pain medication or NSAIDs, your doctor must prescribe a standard anti-ulcer drug, such as omeprazole, pantoprazole, esomeprazole, rabeprazole, dexlansoprazole, etc.
• Muscle Relaxants –  These medications relieve spinal muscle spasms and spasticity. Muscle relaxants, such as baclofen, tolperisone, eperisone, methocarbamol, carisoprodol, dantrolene sodium, and cyclobenzaprine, may be prescribed to control postoperative muscle spasms, spasticity, stiffness, contracture. If any muscular abnormality is present or older age patient then take this medicine, otherwise not.
• Calcium & vitamin D3 and Calcitonin– To improve bone health, blood clotting, helping muscles contract, regulating heart rhythms, nerve functions, and healing fractures. As a general rule, too absorbed more minerals for men and women aged 50 and older should consume 1,200 milligrams of calcium and 600 mg international units of vitamin D a day to heal back pain, fractures, and osteoarthritis. Bisphosphonates are first-line drugs and other agents include raloxifene, a selective estrogen receptor modulator, strontium ranelate, which may be considered for treatment for bone fractures in osteoporotic and osteopenic bone disease. [rx] Serum 25-OH vitamin D level to the normal range of 30 to 80 ng/dL than patients can take a repletion dose of 50,000 IU ergocalciferol weekly.[rx], [rx]
• Neuropathic Agents – Drugs(pregabalin & gabapentin) address neuropathic—or nerve-related—pain. This includes burning, numbness, tingling sensation, and paresthesia. and if any nerves are injured, then take this medicine, otherwise not, 
• Glucosamine & Diacerein, Chondroitin sulfate – To tighten the loose tendon, cartilage, ligament, and cartilage, ligament regenerates cartilage or inhabits the further degeneration of cartilage, ligament. The dosage of glucosamine is 15oo mg per day in divided dosage and chondroitin sulfate is approximately 500mg per day in different dosages. Diacerein minimum of 50 mg per day may be taken if the patient suffers from osteoarthritis, rheumatoid arthritis, and any degenerative joint disease.[rx] If any tendon, cartilage, the ligament is injured, then take this medicine, otherwise not, 
• Topical Medications and essential oil – These prescription-strength creams, gels, ointments, patches, essential oil, and sprays help relieve pain and inflammation in acute trauma, pain, swelling, and tenderness through the skin. If the fracture is closed and not open, you can use this item. If the fractures are closed, and skin and soft tissue lacerations are not present, then take this medicine, otherwise not.
•  Antidepressants – A drug that blocks pain messages from your brain and boosts the effects of endorphins in your body’s natural painkillers. It also helps in neuropathic pain, anxiety, tension, and proper sleep.
• Corticosteroids – Also known as oral steroids, these medications reduce inflammation. To heal the nerve inflammation and clotted blood in the joints. Corticosteroid your doctor can use in a low dosage and not extend more than 14 days, or more.
• Type II collagen – It is the basis for articular cartilage and hyaline cartilage, formed by homotrimers of lumbar vertebral disease collagen, type II, alpha 1 chains can be taken. It makes up and fulfills 50% of all protein in cartilage and 85–90% of collagen of articular cartilage. Type II collagen does form fibrils that are an essential element in cartilage regenerator. This fibrillar network of collagen allows cartilage to remove nerve entrap the proteoglycan in fracture aggregate as well as provide tensile and overall strength to the tissue in fracture reason. Oral administration of native type II collagen induces oral tolerance to pathological immune responses and may be useful in fracture of the bone, degenerative joint disease, and all kinds of arthritis.^[rx][rx]
• Dietary supplement – To eradicate the healing process from fracture, your body needs a considerable amount of vitamin C and vitamin E. From your dietary supplement, you can get it, and also need to remove general weaknesses & improve your health.
• Cough Syrup – If your doctor finds any chest congestion or fracture-related injury in your chest, dyspnoea, or post-surgical breathing problem, then advise you to take bronchodilator cough syrup. If feel any chest pain, bronchial congestion, or pain during coughing, then take this medicine, otherwise not.
• Teriparatide – Teriparatide may be a recombinant human parathormone (PTH) that stimulates osteoblasts to grow new bone cells when given intermittently. Use in treatment for osteoporosis, osteoarthritis, and all kinds of fractures are successful results.  Teriparatide increases the number of osteoblasts bone cells by both stimulating formations and preventing apoptosis, to increase bone density, cortical thickness, and bone strength as well as reduce fracture risk.[rx]The medication was administered once daily as a subcutaneous injection of 20 μg to 100 μg of PTH for about a month or more[rx] [rx] If any hormonal abnormality is present or older age patient then take this medicine, otherwise not.

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.[rx,rx,rx]
• 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.

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.

• Broken bones or fractures need abundant minerals (calcium, phosphorus, magnesium, boron, zinc, selenium, omega-3) and protein to become strong and healthy again. Plenty of mineral water, cow milk, meat, egg, chicken, vitamin C, and vitamin E containing green leave vegetables.
• Excellent sources of minerals/protein include dairy products, tofu, beans, broccoli, tomato, cucumber, carrot, cabbage, pomegranate, apple, citrus fruits, green vegetables, especially taro leaf, green banana, coconut water, nuts, seeds, date, honey, sardines, sea fish, catfish, and salmon.
• Essential vitamins that are needed for bone healing include vitamin C (needed to make collagen that your important body element for healing open fractures), vitamin D (crucial for mineral absorption, or machine for mineral absorber from your food by small, and large intestine), and vitamin K (binds calcium to bones and triggers more quickly collagen formation).
• Conversely, don’t consume food or drink that is known to impair bone/tissue healing, such as alcoholic beverages, cold drinks, sodas, heavy oily food, constipation formation food, fried fast food, most fast food items, sugar, and foods made with lots of factory refined sugars and preservatives food.

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