Bone Fractures and Analgesia: Figures from the Orthopedic Emergency

Introduction: Accidental injuries are part of human life and present in a variety of styles ranging from soft tissue damage to complexed bone fractures. We observed the emergency presentations of the orthopedic patients with different body part injuries. The nature of injury and associated damage was assessed by clinical and radiological tools. Analgesia and fracture management was done according to nature of trauma using general and local anesthesia as needed. Methodology: Both genders presenting with any sort of trauma at any age were included and non-traumatic non orthopedic emergencies were excluded. Centre for study was liaquat university of medical and health sciences orthopedic section of the emergency department. X-rays were obtained for ruling out fractures and soft tissue injuries. Name, age, gender and other biodata were collected from patients or attendants as found convenient. Sample size was taken 99 and sampling technique was non probability, purposive sampling. Data Analysis: i nformation received from subjects was analyzed in terms of frequency, percentage, mean age was also calculated. Results: A figure of 42(42.42%) was found with bony fracture while 57(57.5%) had no bone injury. 16(16.16%) were female 04(4.04%) out of them had fractures while 12(12.12%) were having soft tissue injuries, 83(83.83%) were male 38(38.38%) had fractures while 45(45.45%) had their bones saved. NSAIDs were mostly used analgesics with tramadol as alternative other techniques were not in common practice here. Conclusion: Male were the predominant subjects to trauma and the same gender was more prone to have bone fractures as compared to female with lower limb at more risk and NSAIDs still remain the first choice as analgesia.


Introduction
Bones are the pillars of the building of the human body giving a beautiful structure to what would have been a heave of flash. The commonest reason for morbidity and mortality in pediatric, adults, men and women population is trauma. Fractures place strong impact over the society along with the patients and their families through utilizing financial and human resources. All age groups are commonly affected by these mishaps trauma being a commonest factor responsible for morbidity as well as mortality in children second to acute infections [1]. The prevalence of femoral fractures in children was declared 2% in mid 90s (1994) [2]. The young population is more prone to femoral fractures (neck-shaft) owing to over speeding accidents along with height falls.
The incidence is between 2.5% to 9% for the femoral neckshaft fracture of the same side and the same is increasing with time [3][4][5]. Osteonecrosis of femoral head, acomplication of femoral neck fracture can be reduced with early fixation that also enhances the union chances [6]. Distal tibial Pilon fracture accounts for 3%-10% of tibial fractures and 1% of all fractures of lower limb with a ranging 11.4%-54% complication rate [7]. Pilon fracture are characterized by severe soft tissue injuries, articular cartilage damage and metaphyseal compression resulting from axial load and shear stress due to sports or traffic accidents [8][9][10]. Distal radius fractures were thought to be 1/6 of the total fractures presenting to the emergency and it was considered as the fracture of elderly but now a day's all age groups are seen to be affected. Elderly people are at more risk of fractures due to osteoporosis, reduced BMD, menopause [11].
About 2 million fractures occurs in united states due to osteoporosis annually consuming 17 billion dollars specially in elderly postmenopausal women and the incidence of the same is supposed to rise three times by 2040 [12]. Symptomatic arthritis of posttraumatic origin occurs following a healing with more than 2mm articular congruity after intra-articular radius fractures [13]. Road traffic crash (RTC) is one of the main causes of injury responsible for approximately 50 million injuries, per year, worldwide [14]. Pain is the predominant complaint of emergency room trauma patients and its management is a challenge with reported low patient satisfaction [15]. NSAIDs (Celecoxib, Rofecoxib Ibuprofen, Diclofenac, Ketoprofen, Flurbiprofen), Opioids analgesics (Morphine, Codeine, Methadone, Pethidine, tramadol) and ketamine (a dissociative anesthetic) are the recommended drugs for moderate to severe pain along with the regional block and all are successful treatment options for analgesia [15,16]. The present survey was planned to evaluate the frequency and percentage of bone fractures in patients presenting to the orthopedic emergency with the history of trauma and the preferred use of analgesics and their routes of administration.

Methodology
Patients visiting the orthopedic emergency were evaluated for required parameters and biodata was collected. Patients with age range >5 years, having history of trauma by fall or accident were included in the survey through non probability, purposive sampling. Patients with chronic previously operated fractures, fracture of skull and thoracic trauma requiring ICU set were also excluded.

Data Analysis
Frequency and percentage was calculated for gender, fracture and soft tissue injuries and presented in table and charts.

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Orthopedics and Rheumatology Open Access Journal

Fractures of the Lower Limb
Soft tissue with poor circulation and high risk of different complications make Pilon fracture difficult to treat with a poor prognosis. Its previously used surgical therapies include open reduction and internal fixation (ORIF) and external fixation (Open fractures) combined with limited internal fixation (closed fractures). Proximal or distal tibial fractures are treated with butter's plate while shaft fractures are handled by interlocking nails used. In past, these fractures have been treated through different modalities. Historically these fractures were managed conservatively in cast by applying hip spica, which in return produces acceptable results [4]. Such method of treatment produces too much physical and mental stress on patient and his/her family [5]. Femur neck fractures need cancellous screws but in IT (Intertrochanteric) fractures we use DHS (Dynamic hip screws) and DCS (Dynamic compression screw). While in open fractures we use external fixator Titanium elastic nailing (TEN) has gained popularity over the last two decades and is now being most widely performed procedure for femur shaft fractures in children aged 6 and above [6]. Elastic intramedullary nailing provide stable fixation and allow rapid postoperative functional recovery in 6-10 years of age group [17]. Current study found majority of fractures of tibia and fibula that is consistent to previous reports [18].

Fractures of the Upper Limb
Neck fractures are managed with K-Wires (Stable fractures I, II), Head replacement (Type IV) according to neer's classification while shaft with Interlocking nails (recommended) but most of the surgeons use plating as the bones are thinner and the medullary cavity is narrow however external fixator in case of open wound. Wrist fractures are best handled by plating of butters T and L shape but if the bone quality is poor LCDCP (Low contact dynamic compression plates) is suggested. For clavicle conservative therapy is the best but recon plate may also be used. Our results did not found accordance with Billy T.H 2011 who showed majority of the fractures probably due to sample size difference that was 250 for his study [18].

Analgesia
Our study showed the majority of the patients were given NSAIDs and opioids were rarely used where the pain was not tolerable. Most frequently used NSAID was diclofenac Sodium while tramadol was the available alternative for severe pain. Our results were consistent with Belli TH et al. [18] who also reported diclofenac sodium to be most commonly used analgesic how he did not reported any opioid use [18]. NSAIDs mediate their analgesic effects through reducing the synthesis of prostaglandins [19]. Opioids have multiple mechanisms including substance P and u receptors reducing the pain perception as well as increasing the pain threshold at the levels of spinal cord with best use in intense pain parentral [20].

Conclusion
Male were more affected by fractures in comparison to females, lower limb injuries were higher then the upper limb, NSAIDs were the most commonly used analgesics, parentral