First aid: Suggestions for immediate treatment of a suspected bone fracture include not moving the individual unless there is an immediate danger, especially in the case of a suspected fracture of the skull, spine, ribs, pelvis, or upper leg, due to the chances of nerve damage and signal cord injury or risking further injury to organs and blood vessels. It is best to attend to any bleeding wounds first. Healthcare professionals recommend stopping the bleeding by pressing firmly on the site with a clean dressing. If a bone is protruding, apply pressure around the edges of the wound. If bleeding is controlled, keep the wound covered with a clean dressing. Do not attempt to straighten broken bones. For limb fractures, provide support and comfort such as a pillow under the lower leg or forearm. However do not cause further pain or unnecessary movement of the broken bone.
Bone immobilization: Depending on the site of the fracture and the severity of the injury, bone immobilization treatment options may include splints, slings, braces, plaster cast, and traction. Surgically inserted metal rods or plates (to hold the bone pieces together) may also be used, along with medications for pain relief.
A splint may be needed to support the limb. A splint is a medical device for the immobilization of limbs or of the spine. Splints and casts support and protect injured bones and soft tissue, reducing pain, swelling, and muscle spasm.
A brace is a medical device that provides restraint and limits the motion of the affected area or joint, such as the knee. A brace permits weight bearing ambulation of the individual during healing of leg fractures or other traumas.
A sling for an arm may be needed to immobilize the area. A sling is a wrap (cotton or other material) placed around the neck and the arm for immobilization. If possible, elevate the fractured area and apply a cold pack to reduce swelling and pain. In an emergency, dial 911 for an ambulance.
Traction is the use of a pulling force to treat muscle and skeleton disorders, such as fractures. Traction is usually applied to the arms and legs, the neck, the backbone, or the pelvis. It is used to treat fractures, dislocations, and long-duration muscle spasms, and to prevent or correct deformities. Traction can either be short-term, as at an accident scene, or long-term, when it is used in a hospital setting. Traction serves several purposes: it aligns the ends of a fracture by pulling the limb into a straight position; it ends muscle spasm; it relieves pain; and it takes the pressure off the bone ends by relaxing the muscle.
The function of a cast is to rigidly protect an injured bone or joint. Casts are usually made of either plaster or fiberglass material. A cast serves to hold the broken bone in proper alignment to prevent it from moving while it heals. Casts may also be used to help rest a bone or joint to relieve pain that is caused by moving it (such as when a severe sprain occurs, but no broken bones). Different types of casts and splints are available, depending on the reason for the immobilization and/or the type of fracture.
A plaster cast is made from rolls or pieces of dry muslin that have starch or dextrose and calcium sulfate added. When the plaster gets wet, a chemical reaction happens (between the water and the calcium sulfate) that produces heat and eventually causes the plaster to set, or get hard, when it dries. A person can usually feel the cast getting warm on the skin from this chemical reaction as it sets. The temperature of the water used to wet the plaster affects the rate at which the cast sets. When colder water is used, it takes longer for the plaster to set, and a smaller amount of heat is produced from the chemical reaction. Plaster casts are usually smooth and white. The cast typically begins to feel hard about 10-15 minutes after it is put on, but it takes much longer to be fully dry and hard. It is especially important to be careful with the cast for the first one to two days because it can easily crack or break while it is drying and hardening. It can take up to 24-48 hours for the cast to completely harden.
Cast placement depends on the location and severity of the fracture. During surgery with a closed or simple fracture, the two ends of the broken bone are lined up and held in place. The limb is thoroughly bandaged then the wet plaster is applied. Sometimes, once the plaster is dry, the cast is split into two and the two halves are then re-bandaged on the outside. This allows room for any swelling that may occur. An open or compound fracture has to be thoroughly cleansed in the operating room to remove debris prior to being set because a broken bone exposed to the open air is at increased risk of infection. Long bones (such as the thigh, or femur bone), are difficult to keep aligned and, in adults, are generally treated by surgically inserted metal rods, pins, or plates.
Healthcare professionals recommend: until the cast has properly set, avoid direct heat such as hot water bottles (heat may cause the plaster not to harden); rest the limb as much as possible to promote healing; use the techniques directed by nursing staff to walk or manage day-to-day activities. The use of crutches incorrectly may result in further damage; and avoid any lifting or driving until the fracture has healed. If itching is experienced, do not put anything inside the cast between the cast and the limb,. Instead, use a hairdryer to blow cool air into the cast. Avoid getting the cast wet, as wet plaster becomes soft and does not provide the necessary support. Wet plaster can also cause skin irritation. When showering, wrap the cast in a plastic bag and tape it directly to the skin, keeping the area water-tight. Healthcare professionals recommend seeking immediate medical help if swelling, blueness or loss of movement of the fingers or toes, sensations of pins and needles in the affected area, numbness, or increased pain occur.
Long-term outlook: In most cases, the cast can be removed after a few weeks but the limb must be handled with care for at least the next month or so. Leg fractures will take several months to heal. Muscles may be diminished in size or strength due to lack of use and may need rehabilitation, including strengthening exercises to recover from their immobilization.
Surgery: Surgery on fractures are very much dependent on what bone is broken, where it is broken, and whether the orthopedic surgeon believes that the break is at risk for movement once the bone fragments have been aligned. If the surgeon is concerned that the bones will heal improperly, an operation will be needed. Sometimes bones that appear to be aligned normally are splinted, and at a recheck appointment, are found to be unstable and require surgery. Signs of poor bone healing may include pain and uneven or protruding bone surfaces at the point of healing.
Surgery can include closed reduction and casting, where the bones are manipulated under anesthesia so that alignment is restored. Reduction is a procedure to position bone and bone fragments into proper position. A plaster cast is placed to hold the bones after the alignment. A bone fracture may also need surgically inserted metal rods, pins, or plates. Open reduction means that, in the operating room, the skin is cut open and pins, plates, or rods are inserted into the bone to hold it in place until healing occurs. Depending on the fracture, some of these pieces of metal are permanent (never removed), and some are temporary until the healing of the bone is complete and surgically removed at a later time.
Surgical methods of treating fractures have their own risks and benefits, but usually surgery is done only if conservative treatment has failed or is very likely to fail. With some fractures, such as hip fractures, surgery is offered routinely because the complications of non-operative treatment include deep vein thrombosis (DVT, or blood clot in the legs) and pulmonary embolism (blood clot in the lungs. These complications may occur due to a stagnation of blood in the veins caused by prolonged immobility, which can promote blood clot formation in veins. When a joint surface is damaged by a fracture, surgery is also commonly recommended to make an accurate anatomical reduction and restore the smoothness of the joint. Prosthetic body parts, such as hip joints, may also be needed.
Pain control: Nonsteroidal anti-inflammatory drugs (NSAIDs) have been used to relieve pain and inflammation caused by musculoskeletal problems. Commonly used over-the-counter NSAIDs include ibuprofen (Advil® or Motrin®) and naproxen sodium (Aleve®). Higher doses of these drugs are also available by prescription. Commonly prescribed NSAIDs include diclofenac (Cataflam® or Voltaren®), nabumetone (Relafen®), and ketoprofen (Orudis®). NSAIDs may be taken by mouth, injected into a vein, or applied to the skin.
The frequency and severity of side effects from NSAIDs vary. The most common side effects include: nausea, vomiting, diarrhea, constipation, decreased appetite, rash, dizziness, headache, and drowsiness. The most serious side effects include: kidney failure, liver failure, ulcers, heart-related problems, and prolonged bleeding after an injury or surgery. About 15% of patients who receive long-term NSAID treatment develop ulcers in the stomach or duodenum.
Narcotic pain relievers, such as
acetaminophen/codeine (Tylenol with Codeine®), hydrocodone/acetaminophen (Lorcet®, Lortab®, or Vicodi®), or oxycodone (OxyContin® or Roxicodone®), may be prescribed to treat bone fracture pain. However, they do not reduce swelling. These medications are only used short-term to treat flare-ups. Common side effects include: constipation, drowsiness, dry mouth, and difficulty urinating. Narcotic pain relievers should be used cautiously because individuals may become addicted to them.
Strong scientific evidence
Calcium: Calcium is the nutrient consistently found to be the most important nutrient for attaining peak bone mass and preventing osteoporosis. Adequate vitamin D intake is required for optimal calcium absorption. Adequate calcium and vitamin D are deemed essential for the prevention of osteoporosis in general, including postmenopausal osteoporosis. It is best to take calcium supplements on an empty stomach to increase the absorption.
Although calcium and vitamin D alone are not recommended as the sole treatment of osteoporosis, they are necessary additions to pharmaceutical treatments. The vast majority of clinical trials investigating the efficacy of pharmaceutical treatments for osteoporosis have investigated these agents in combination with calcium and vitamin D. So, although calcium alone is unlikely to have an effect on the rate of bone loss following menopause, osteoporosis cannot be treated in the absence of calcium. Treatment of postmenopausal osteoporosis should only be done under the supervision of a qualified healthcare professional.
Multiple studies of calcium supplementation in the elderly and postmenopausal women have found that high calcium intake can help reduce the loss of bone density, especially in the ankles, hips, and spine.
Vitamin D: Vitamin D is found in numerous dietary sources such as fish, eggs, fortified milk, and cod liver oil. The sun is also a significant contributor to the daily production of vitamin D, and as little as 10 minutes of exposure is thought to be enough to prevent deficiencies. Vitamin D aids in the absorption of calcium, thus making strong, healthy bones.
In adults with severe vitamin D deficiency, bone mineral is lost ("hypomineralization") and results in bone pain and osteomalacia (soft bones). Osteomalacia may result from deficiency of vitamin D in elderly patients, decreased absorption of vitamin D, patients with chronic malabsorption syndrome secondary to jejunoileal bypass, patients with partial gastrectomy, aluminum-induced bone disease, chronic liver disease, or kidney disease with renal osteodystrophy. Treatment for osteomalacia depends on the underlying cause of the disease and often includes pain control and orthopedic surgical intervention, as well as vitamin D and phosphate binding agents.
Good scientific evidence
Vitamin D: Without sufficient vitamin D, calcium absorption cannot be maximized and the resulting elevation in parathyroid (PTH) secretion by the parathyroid glands results in increased bone resorption, which may weaken bones and increase the risk of fracture. Vitamin D supplementation has been demonstrated to slow bone loss and reduce fracture, particularly when taken with calcium.
Oral calcifediol or ergocalciferol may help manage hypocalcemia and prevent renal osteodystrophy in people with chronic renal failure undergoing dialysis. Renal osteodystrophy is a term that refers to all of the bone problems that occur in patients with chronic kidney failure.
Unclear or conflicting scientific evidence
Black tea: Black tea (Camellia sinensis) is from the same shrub as green tea and oolong tea. Each is processed differently. Preliminary research suggests that chronic use of black tea may improve bone mineral density (BMD) in older women. Better research is needed in this area before a conclusion can be drawn.
Caffeine is a stimulant of the central nervous system and may cause insomnia in adults, children, and infants (including nursing infants of mothers taking caffeine). Caffeine acts on the kidneys as a diuretic (increasing urine and urine sodium/potassium levels and potentially decreasing blood sodium/potassium levels) and may worsen incontinence. Caffeine-containing beverages may increase the production of stomach acid and may worsen ulcer symptoms. Tannin in tea can cause constipation. Caffeine in certain doses can increase heart rate and blood pressure, although people who consume caffeine regularly do not seem to experience these effects in the long-term. There are many drug interactions possible when using caffeinated beverages.
Boron: Boron is a trace mineral found in the global environment. Animal and preliminary human studies report that boron may play a role in certain metabolic functions, with effects on calcium, phosphorus, and vitamin D. However, research of bone mineral density in women taking boron supplements does not clearly demonstrate benefits in osteoporosis. Additional study is needed before a firm conclusion can be drawn.
Calcium: Calcium is the nutrient consistently found to be the most important for attaining peak bone mass and preventing osteoporosis. Adequate vitamin D intake is required for optimal calcium absorption. Adequate calcium and vitamin D are deemed essential for the prevention of osteoporosis in general, including postmenopausal osteoporosis.
Calcium supplementation in patients on long-term, high-dose inhaled steroids for asthma may reduce bone loss due to steroid intake. Treatment using the prescription drug pamidronate with calcium has been shown to be superior to calcium alone in the prevention of corticosteroid-induced osteoporosis. Inhaled steroids have been reported to disturb normal bone metabolism and they are associated with a decrease in bone mineral density. Results suggest that long-term administration of high-dose inhaled steroid induces bone loss that is preventable with calcium supplementation with or without the prescription drug etidronate. Long-term studies involving more patients should follow to confirm these preliminary findings.
Rickets (a softening of the bones in children potentially leading to fractures and deformity) and osteomalacia (bone softening) are commonly thought of as diseases due to vitamin D deficiency; however, calcium deficiency may also be another risk factor in sunny areas of the world where vitamin D deficiency would not be expected. Calcium gluconate is used as an adjuvant in the treatment of rickets and osteomalacia, as well as a single therapeutic agent in non-vitamin D deficient rickets. Research continues regarding the importance of calcium alone in the treatment and prevention of rickets and osteomalacia. Treatment of rickets and osteomalacia should only be done under the supervision of a qualified healthcare professional.
Copper: Copper is a mineral that occurs naturally in many foods, including vegetables, legumes, nuts, grains, and fruits, as well as shellfish, avocado, and beef (organs such as liver). Osteopenia and other abnormalities of bone development related to copper deficiency may occur in copper-deficient low-birth weight infants and young children. Supplementation with copper may be helpful in the treatment and/or prevention of osteoporosis, although early human evidence is conflicting. The effects of copper deficiency or copper supplementation on bone metabolism and age-related osteoporosis require further research before clear conclusions can be drawn.
DHEA: Laboratory studies have found that dehydroepiandosterone (DHEA) may improve bone mineral density. The ability of DHEA) to increase bone density in humans is under investigation. Effects are not clear at this time.
Few side effects are reported when DHEA supplements are taken by mouth in recommended doses. Side effects may include fatigue, nasal congestion, headache, acne, or rapid/irregular heartbeats. In women, the most common side effects are abnormal menses, emotional changes, headache, and insomnia. Individuals with a history of abnormal heart rhythms, blood clots or hypercoagulability, and those with a history of liver disease, should avoid DHEA supplements.
Gamma linolenic acid (GLA): Some evidence from a clinical trial as well as observations of clinicians and dieticians has suggested that gamma linolenic acid (GLA) and eicosapentaenoic acid (EPA) enhance the effects of calcium supplementation in elderly patients with osteoporosis. More clinical studies are required to produce results to determine the effectiveness in diverse elderly and middle-aged populations.
Horsetail: Silicon may be beneficial for bone strengthening. Because horsetail (Equisetum arvense) contains silicon, it has been suggested as a possible natural treatment for osteoporosis. Preliminary human study reports benefits, but more detailed research is needed before a firm recommendation can be made. People with osteoporosis should speak with a qualified healthcare provider about possible treatment with more proven therapies.
Physical therapy: Supervised or home-based physical therapy has been used in combination with resistance and endurance training in physically frail elderly women taking hormone replacement therapy to improve bone density. Long-term high-intensity weight-bearing exercise programs have also been used in rheumatoid arthritis patients with some success. Although early study is promising, more studies are needed in this area.
Red clover: It is not clear if red clover (Trifolium praetense) isoflavones have beneficial effects on bone density. Most studies of isoflavones in this area have looked at soy, which contains different amounts of isoflavones, as well as other non-isoflavone ingredients. More research is needed. Red clover extract may increase bleeding in sensitive individuals, including those taking blood-thinning medications, such as warfarin (Coumadin®).
Soy: It has been theorized that soy (Glycine max) "phytoestrogens" (plant-based compounds with weak estrogen-like properties) such as isoflavones may increase bone mineral density in post-menopausal women and reduce the risk of fractures. However, most studies have not been well designed or reported. Until better research is available, a firm conclusion cannot be drawn. Individuals at risk for osteoporosis should speak with a qualified healthcare provider about the therapeutic options for increasing bone mineral density.
Tai chi: Tai chi is a system of movements and positions believed to have developed in 12th Century China. Tai chi techniques aim to address the body and mind as an interconnected system and are traditionally believed to have mental and physical health benefits to improve posture, balance, flexibility, and strength. Preliminary research suggests that tai chi may be beneficial in delaying early bone loss in postmenopausal women. Additional evidence and long-term follow-up is needed to confirm these results.
Vitamin D: Some evidence implies that steroids may impair vitamin D metabolism, further contributing to the loss of bone and development of osteoporosis associated with steroid medications. There is limited evidence that vitamin D may be beneficial to bone strength in individuals taking long-term steroids.
Vitamin K: Vitamin K appears to prevent bone resorption, and adequate dietary intake is likely necessary to prevent excess bone loss. Elderly or institutionalized patients may be at particular risk and adequate intake of vitamin K-rich foods should be maintained. Unless patients have demonstrated vitamin K deficiency, there is no evidence that additional vitamin K supplementation is helpful. However, vitamin K may play a role in the prevention and treatment of glucocorticoid-induced bone loss. Further research is needed to confirm these results. Over-the-counter vitamin K1-containing multivitamin supplements may disrupt warfarin anticoagulation in vitamin K1-depleted patients. Vitamin K-depleted patients are sensitive to even small changes in vitamin K1 intake.
Fair negative scientific evidence
Selenium: Selenium is a trace mineral found in soil, water, and some foods. It is an essential element in several metabolic pathways. Kashin-Beck disease is an osteoarthropathy endemic in selenium- and iodine-deficient areas. Preliminary evidence suggests that selenium supplementation does not significantly improve this disease.
Traditional or theoretical uses lacking sufficient evidence
Integrative therapies used in bone fractures that have historical or theoretical uses but lack sufficient clinical evidence include: the Alexander technique, anise (Pimpinella anisum), applied kinesiology, arginine (L-arginine), black cohosh (Actaea racemosa), bovine colostrum, chelation (EDTA) therapy, dong quai (Angelica sinensis), folate (folic acid), glucosamine, green tea (Camellia sinensis), hops (Humulus lupulus), kudzu (Pueraria lobata), kundalini yoga, maca (Lepidium meyenii), magnet therapy, melatonin, mistletoe (Viscum album), octacosanol, omega-3 fatty acids (fish oil, alpha-linolenic acid), probiotics, resveratrol, rosemary (Rosmarinus officinalis), shiitake (Lentinula edodes), vitamin B12 (cyanocobalamin), vitamin C (ascorbic acid), and yoga.
Prevention of bone fractures and improvement in bone healing include measures to prevent osteoporosis or bone loss.
Smoking cessation: Smokers lose bone more rapidly than nonsmokers. Among 80 year olds, smokers have up to 10% lower bone mineral density, which translates into twice the risk of spinal fractures and a 50% increase in risk of hip fracture. Fractures heal slower in smokers, and are more apt to heal improperly. Stopping cigarette smoking can help to partially reverse many of the harmful effects of having been a smoker.
Alcohol in moderation: Excessive alcohol has been associated with osteoporosis due to the degenerative metabolic effects of alcohol. Alcohol excess may inhibit calcium absorption and bone formation.
Healthy body weight: Being underweight is a risk factor for osteoporosis. Staying within a healthy weight for an individual is important. Extreme thinness is a risk factor for osteoporosis. The potential impact of thinness on risk of osteoporosis development is of particular interest in developing countries, because of the high incidence of starvation, and in industrialized countries where slimness is promoted as ideal and dieting has been shown to be the most important risk factor for the development of anorexia, which leads to malnutrition. The onset of anorexia nervosa frequently occurs during puberty, the time of life when maximal bone mass accrual occurs, thereby putting adolescent girls with anorexia nervosa at high risk for reduced peak bone mass. Too much weight may also lead to an increase in fractures.
Sunlight: Healthcare professionals recommend sun exposure of 15 minutes a day to hands and face to help the body make vitamin D. Vitamin D helps calcium be absorbed and used by the body. Avoid overexposure to the sun, as it may lead to melanoma in sensitive individuals, particularly those with fair skin.
Diet: A high protein diet or high coffee consumption increases calcium loss. Fiber, oxalates (in rhubarb, spinach, beets, celery, greens, berries, nuts, tea, cocoa), and high zinc foods (such as oysters and red meats) decrease the absorption of calcium. The plant estrogens found in soy help maintain bone density and may reduce the risk of fractures, particularly in the first 10 years after menopause.
Exercise: The amount and type of exercise will vary depending on age and bone health. An exercise program should be individually tailored to the individual's needs and capabilities. Overall, most individuals should aim to exercise for 30-40 minutes three to four times each week, with some weight-bearing and resistance exercises in the program.
Although exercise is important in the prevention of osteoporosis, women and teenage girls who exercise to an extreme degree can develop amenorrhea (cessation of menstruation) due to estrogen deficiency. Estrogen deficiency in younger women contributes to bone loss. Exercise has been reported to lower estrogen levels due to decreasing the amount of fat. Women still make estrogen after menopause, although they make it in their fat cells instead of in their ovaries. A doctor can help an individual with decisions about exercise and bone health. Both male and female athletes who practice excessive exercise without adequate caloric intake are at heightened risk of osteoporosis. Athletes who train hard while trying to keep their weight below a certain level for competitive reasons are at particularly high risk.
There are a number of important preventive measures an athlete can take. It is recommended by healthcare professionals to avoid abrupt increases in overall training load and intensity. Adequate rest between workouts is important. Running shoes tend to lose their shock-absorbing capacity by 400 miles, so it is important to change them frequently. Expert advice is needed for correct choice of insoles and taping techniques to prevent bone injury, such as a fracture.
Eliminating fall hazards: If an individual has osteoporosis, it is important not only to help prevent further bone loss, but also to prevent a fracture. Eliminating hazards in the house that can increase the risk of falling is important. Removing loose wires or throw rugs, installing grab bars in the bathroom and non-skid mats near sinks and in the tub, and not walking in slick shoes or socks is recommended by healthcare professionals. Healthcare professionals also recommend caution when carrying or lifting items, as this could cause a spinal fracture. Wearing sturdy shoes is important. Using a cane or walker is recommended by healthcare professionals if the individual has balance problems or other difficulties walking.