Bone fractures These occur when there is a break in the continuity of the bone. This happens either as a result of violence or because the bone is unhealthy and unable to withstand normal stresses.
SIMPLE FRACTURES Fractures where the skin remains intact or merely grazed. COMPOUND FRACTURES have at least one wound which is in communication with the fracture, meaning that bacteria can enter the fracture site and cause infection. A compound fracture is also more serious than a simple fracture because there is greater potential for blood loss. Compound fractures usually need hospital admission, antibiotics and careful reduction of the fracture. Debridement (cleaning and excising dead tissue) in a sterile theatre may also be necessary.
The type of fracture depends on the force which has caused it. Direct violence occurs when an object hits the bone, often causing a transverse break – which means the break runs horizontally across the bone. Indirect violence occurs when a twisting injury to the ankle, for example, breaks the calf-bone (the tibia) higher up. The break may be more oblique. A fall on the outstretched hand may cause a break at the wrist, in the humerus or at the collar-bone depending on the force of impact and age of the person. FATIGUE FRACTURES These occur after the bone has been under recurrent stress. A typical example is the march fracture of the second toe, from which army recruits suffer after long marches. PATHOLOGICAL FRACTURES These occur in bone which is already diseased – for example, by osteoporosis (see below) in post-menopausal women. Such fractures are typically crush fractures of the vertebrae, fractures of the neck of the femur, and COLLES’ FRACTURE (of the wrist). Pathological fractures also occur in bone which has secondary-tumour deposits. GREENSTICK FRACTURES These occur in young children whose bones are soft and bend, rather than break, in response to stress. The bone tends to buckle on the side opposite to the force. Greenstick fractures heal quickly but still need any deformity corrected and plaster of Paris to maintain the correction. COMPLICATED FRACTURES These involve damage to important soft tissue such as nerves, blood vessels or internal organs. In these cases the soft-tissue damage needs as much attention as the fracture site. COMMINUTED FRACTURES A fracture with more than two fragments. It usually means that the injury was more violent and that there is more risk of damage to vessels and nerves. These fractures are unstable and take longer to unite. Rehabilitation tends to be protracted. DEPRESSED FRACTURES Most commonly found in skull fractures. A fragment of bone is forced inwards so that it lies lower than the level of the bone surrounding it. It may damage the brain beneath it.
HAIR-LINE FRACTURES These occur when the bone is broken but the force has not been severe enough to cause visible displacement. These fractures may be easily missed. Symptoms and signs The fracture site is usually painful, swollen and deformed. There is asymmetry of contour between limbs. The limb is held uselessly. If the fracture is in the upper
limb, the arm is usually supported by the patient; if it is in the lower limb then the patient is not able to bear weight on it. The limb may appear short because of muscle spasm.
Examination may reveal crepitus – a bony grating – at the fracture site. The diagnosis is con?rmed by radiography.
Treatment Healing of fractures (union) begins with the bruise around the fracture being resorbed and new bone-producing cells and blood vessels migrating into the area. Within a couple of days they form a bridge of primitive bone across the fracture. This is called callus.
The callus is replaced by woven bone which gradually matures as the new bone remodels itself. Treatment of fractures is designed to ensure that this process occurs with minimal residual deformity to the bone involved.
Treatment is initially to relieve pain and may involve temporary splinting of the fracture site. Reducing the fracture means restoring the bones to their normal position; this is particularly important at the site of joints where any small displacement may limit movement considerably.
with plaster of Paris. If closed traction does not work, then open reduction of the fracture may
be needed. This may involve ?xing the fracture with internal-?xation methods, using metal plates, wires or screws to hold the fracture site in a rigid position with the two ends closely opposed. This allows early mobilisation after fractures and speeds return to normal use.
External ?xators are usually metal devices applied to the outside of the limb to support the fracture site. They are useful in compound fractures where internal ?xators are at risk of becoming infected.
Consolidation of a fracture means that repair is complete. The time taken for this depends on the age of the patient, the bone and the type of fracture. A wrist fracture may take six weeks, a femoral fracture three to six months in an adult.
Complications of fractures are fairly common. In non-union, the fracture does not unite
– usually because there has been too much mobility around the fracture site. Treatment may involve internal ?xation (see above). Malunion means that the bone has healed with a persistent deformity and the adjacent joint may then develop early osteoarthritis.
Myositis ossi?cans may occur at the elbow after a fracture. A big mass of calci?ed material develops around the fracture site which restricts elbow movements. Late surgical removal (after 6–12 months) is recommended.
Fractured neck of FEMUR typically affects elderly women after a trivial injury. The bone is usually osteoporotic. The leg appears short and is rotated outwards. Usually the patient is unable to put any weight on the affected leg and is in extreme pain. The fractures are classi?ed according to where they occur:
subcapital where the neck joins the head of the femur.
intertrochanteric through the trochanter.
subtrochanteric transversely through the upper end of the femur (rare). Most of these fractures of the neck of femur
need ?xing by metal plates or hip replacements, as immobility in this age group has a mortality of nearly 100 per cent. Fractures of the femur shaft are usually the result of severe trauma such as a road accident. Treatment may be conservative or operative.
In fractures of the SPINAL COLUMN, mere damage to the bone – as in the case of the so-called compression fracture, in which there is no damage to the spinal cord – is not necessarily serious. If, however, the spinal cord is damaged, as in the so-called fracture dislocation, the accident may be a very serious one, the usual result being paralysis of the parts of the body below the level of the injury. Therefore the higher up the spine is fractured, the more serious the consequences. The injured person should not be moved until skilled assistance is at hand; or, if he or she must be removed, this should be done on a rigid shutter or door, not on a canvas stretcher or rug, and there should be no lifting which necessitates bending of the back. In such an injury an operation designed to remove a displaced piece of bone and free the spinal cord from pressure is often necessary and successful in relieving the paralysis. DISLOCATIONS or SUBLUXATION of the spine are not uncommon in certain sports, particularly rugby. Anyone who has had such an injury in the cervical spine (i.e. in the neck) should be strongly advised not to return to any form of body-contact or vehicular sport.
Simple ?ssured fractures and depressed fractures of the skull often follow blows or falls on the head, and may not be serious, though there is always a risk of damage which is potentially serious to the brain at the same time.
Compound fractures may result in infection within the skull, and if the skull is extensively broken and depressed, surgery is usually required to check any intercranial bleeding or to relieve pressure on the brain.
The lower jaw is often fractured by a blow on the face. There is generally bleeding from the mouth, the gum being torn. Also there are pain and grating sensations on chewing, and unevenness in the line of the teeth. The treatment is simple, the line of teeth in the upper jaw forming a splint against which the lower jaw is bound, with the mouth closed.
Congenital diseases These are rare but may produce certain types of dwar?sm or a susceptibility to fractures (osteogenesis imperfecta).
Infection of bone (osteomyelitis) may occur after an open fracture, or in newborn babies with SEPTICAEMIA. Once established it is very di?cult to eradicate. The bacteria appear capable of lying dormant in the bone and are not easily destroyed with antibiotics so that prolonged treatment is required, as might be surgical drainage, exploration or removal of dead bone. The infection may become chronic or recur.
Osteomalacia (rickets) is the loss of mineralisation of the bone rather than simple loss of bone mass. It is caused by vitamin D de?ciency and is probably the most important bone disease in the developing world. In sunlight the skin can synthesise vitamin D (see APPENDIX 5: VITAMINS), but normally rickets is caused by a poor diet, or by a failure to absorb food normally (malabsorbtion). In rare cases vitamin D cannot be converted to its active state due to the congenital lack of the speci?c enzymes and the rickets will fail to respond to treatment with vitamin D. Malfunction of the parathyroid gland or of the kidneys can disturb the dynamic equilibrium of calcium and phosphate in the body and severely deplete the bone of its stores of both calcium and phosphate.
Osteoporosis A metabolic bone disease resulting from low bone mass (osteopenia) due to excessive bone resorption. Su?erers are prone to bone fractures from relatively minor trauma. With bone densitometry it is now possible to determine individuals’ risk of osteoporosis and monitor their response to treatment.
By the age of 90 one in two women and one in six men are likely to sustain an osteoporosis-related fracture. The incidence of fractures is increasing more than would be expected from the ageing of the population, which may re?ect changing patterns of exercise or diet.
Osteoporosis may be classi?ed as primary or secondary. Primary consists of type 1 osteoporosis, due to accelerated trabecular bone loss, probably as a result of OESTROGENS de?ciency. This typically leads to crush fractures of vertebral bodies and fractures of the distal forearm in women in their 60s and 70s. Type 2 osteoporosis, by contrast, results from the slower age-related cortical and travecular bone loss that occurs in both sexes. It typically leads to fractures of the proximal femur in elderly people.
Secondary osteoporosis accounts for about 20 per cent of cases in women and 40 per cent of cases in men. Subgroups include endocrine (thyrotoxicosis – see under THYROID GLAND, DISEASES OF, primary HYPERPARATHYROIDISM, CUSHING’S SYNDROME and HYPOGONADISM); gastrointestinal (malabsorption syndrome, e.g. COELIAC DISEASE, or liver disease, e.g. primary biliary CIRRHOSIS); rheumatological (RHEUMATOID ARTHRITIS or ANKYLOSING SPONDYLITIS); malignancy (multiple MYELOMA or metastatic CARCINOMA); and drugs (CORTICOSTEROIDS, HEPARIN). Additional risk factors for osteoporosis include smoking, high alcohol intake, physical inactivity, thin body-type and heredity.
Individuals at risk of osteopenia, or with an osteoporosis-related fracture, need investigation with spinal radiography and bone densitometry. A small fall in bone density results in a large increase in the risk of fracture, which has important implications for preventing and treating osteoporosis.
Treatment Antiresorptive drugs: hormone replacement therapy – also valuable in treating menopausal symptoms; treatment for at least ?ve years is necessary, and prolonged use may increase risk of breast cancer. Cyclical oral administration of disodium etidronate – one of the bisphosphonate group of drugs – with calcium carbonate is also used (poor absorption means the etidronate must be taken on an empty stomach). Calcitonin – currently available as a subcutaneous injection; a nasal preparation with better tolerance is being developed. Calcium (1,000 mg daily) seems useful in older patients, although probably ine?ective in perimenopausal women, and it is a safe preparation. Vitamin D and calcium – recent evidence suggests value for elderly patients. Anabolic steroids, though androgenic side-effects (masculinisation) make these unacceptable for most women.
With established osteoporosis, the aim of treatment is to relieve pain (with analgesics and physical measures, e.g. lumbar support) and reduce the risk of further fractures: improvement of bone mass, the prevention of falls, and general physiotherapy, encouraging a healthier lifestyle with more daily exercise.
Further information is available from the National Osteoporosis Society.
Paget’s disease (see also separate entry) is a common disease of bone in the elderly, caused by overactivity of the osteoclasts (cells concerned with removal of old bone, before new bone is laid down by osteoblasts). The bone affected thickens and bows and may become painful. Treatment with calcitonin and bisphosphonates may slow down the osteoclasts, and so hinder the course of the disease, but there is no cure.
If bone loses its blood supply (avascular necrosis) it eventually fractures or collapses. If the blood supply does not return, bone’s normal capacity for healing is severely impaired.
For the following diseases see separate articles: RICKETS; ACROMEGALY; OSTEOMALACIA; OSTEOGENESIS IMPERFECTA.
Tumours of bone These can be benign (non-cancerous) or malignant (cancerous). Primary bone tumours are rare, but secondaries from carcinoma of the breast, prostate and kidneys are relatively common. They may form cavities in a bone, weakening it until it breaks under normal load (a pathological fracture). The bone eroded away by the tumour may also cause problems by causing high levels of calcium in the plasma.
EWING’S TUMOUR is a malignant growth affecting long bones, particularly the tibia (calfbone). The presenting symptoms are a throbbing pain in the limb and a high temperature. Treatment is combined surgery, radiotherapy and chemotherapy.
MYELOMA is a generalised malignant disease of blood cells which produces tumours in bones which have red bone marrow, such as the skull and trunk bones. These tumours can cause pathological fractures.
OSTEOID OSTEOMA is a harmless small growth which can occur in any bone. Its pain is typically removed by aspirin.
OSTEOSARCOMA is a malignant tumour of bone with a peak incidence between the ages of ten and 20. It typically involves the knees, causing a warm tender swelling. Removal of the growth with bone conservation techniques can often replace amputation as the de?nitive treatment. Chemotherapy can improve long-term survival.... bone, disorders of
When the discharge is yellow, indicating pus, an infection is suspected which may develop into an abscess. Herbal treatment can be effective but if, after a week, the condition has not improved surgical exploration may be necessary to remove the affected duct.
Alternatives. Clivers, Goldenseal, Fenugreek, Marigold, Poke root, Queen’s Delight, Wild Indigo. Taken as tea, powder, liquid extract or decoction.
Tea. Formula. Equal parts: Red Clover, Clivers, Gotu Kola. 2 teaspoons to each cup boiling water; infuse 15 minutes. Half-1 cup thrice daily.
Powders. Formula. Wild Indigo 1; Echinacea 2; Poke root 1. Dose: 500mg (two 00 capsules or one-third teaspoon) thrice daily.
Tinctures. Formula. Echinacea 2; Goldenseal 1; Poke root 1. Dose: 30-60 drops thrice daily.
Topical – for sore nipples. Wheatgerm oil, Evening Primrose oil. Lotions: Goldenseal, Marigold, distilled extract of Witch Hazel. Nipples to be washed before a child is again put to the breast. Cracked nipples: Comfrey – pulp from fresh plant, or equal parts powder and milk as a paste.
Minerals: magnesium, zinc. ... breasts, nipples, discharge
Internal: Echinacea. Acid tincture of Lobelia (10-20 drops). Wounds may be severe enough to require surgical exploration, herbal antibiotic therapy or tetanus prophylaxis. Pain control is essential (Black Willow, Black Cohosh) as pain may be intense and patient restless from respiratory and cardiac distress. Wash with strong spirit (methylated, whiskey, etc). ... jelly fish sting
Symptoms: bleeding, with alteration of bowel habit. Common in diverticular disease where large polyps may be undetected. Early detection by flexible sigmoidoscopy at hospital is essential to accurate diagnosis. Sudden episodes of unexplained diarrhoea and constipation.
The term refers to cancers of the ascending colon, caecum, transverse colon, hepatic flexure, descending colon, splenic flexure, sigmoid colon and rectum. The large bowel tumours are almost wholly adeno-carcinoma.
Common causes: ulcerative colitis, Crohn’s disease, necrotic changes in polyps. The colon is at risk from cancer on a diet high in protein, fat and alcohol and which is low in fibre. An exception is the average diet in Finland where a high fat intake is present with a low incidence of cancer. Strong evidence advanced, includes the heavy consumption of yoghurt (acidophylus lacto bacillus) by the population.
A study of 8006 Japanese men living in Hawaii revealed the close relationship between cancer of the rectum and alcohol consumption. A family history of pernicious anaemia predisposes.
A 19-year prospective study of middle-aged men employed by a Chicago electric company reveals a strong correlation between colorectal cancer and Vitamin D and calcium deficiency. Results “support the suggestion that Vitamin D and calcium may reduce the risk of colorectal cancer”. (Lancet, 1985, Feb 9, i, 307)
Patients with ulcerative colitis of more than 10 years standing carry the increased risk of developing colorectal cancer. There is evidence that malignancy in the bowel may be reduced by saponins. Alternatives of possible value. Inoperable lesions may respond to: Bayberry, Goldenseal, Echinacea, Wild Yam, Stone root, Black root, Mistletoe, Clivers, Marshmallow root, Violet leaves, Chickweed, Red Clover, Thuja.
Tea. Equal parts: Red Clover, Gotu Kola, Violet leaves. 2-3 teaspoons to each cup boiling water; infuse 15 minutes. Freely, as tolerated.
Tablets/capsules. Echinacea, Goldenseal, Wild Yam.
Formula. Echinacea 2; Bayberry 1; Wild Yam 1; Stone root 1; Goldenseal half; Liquorice quarter. Mix. Dose: Powders: 500mg (two 00 capsules or one-third teaspoon). Liquid extracts: 1 teaspoon. Tinctures: 2 teaspoons. Thrice daily and at bedtime.
Mistletoe: Injections of fresh plant (Iscador). (Dr Rudolph Steiner Institute, Switzerland)
Violet leaves: Daily irrigations of strong infusion.
Chickweed: Bathe rectum with strong infusion. Follow with Chickweed ointment.
Chinese Herbalism. (1) Tea – Pan-chih-lien (Scutellaria barbarta), 2 liang. (2) Tea. Feng-wei ts’ao (Pteris multifida) 1 liang, and po-chi (water chestnut) 2 liang. (3) Concoction of suitable amount of ts’ang-erh ts’ao, for bathing affected area. (Barefoot Doctor’s Manual)
Diagnosis. Exploration of proctosigmoidoscope to confirm.
Diet. Special emphasis on yoghurt which is conducive to bowel health; orally and by enema. A vegan uncooked raw food diet has been shown to reduce the body’s production of toxins linked with colon cancer. A switch from conventional Western cooked diet to an uncooked vegan diet reduced harmful enzymes produced by gut bacteria. (Journal of Nutrition)
A substance has been found in fish oil believed to prevent cancer of the colon. Mackerel, herring and sardines are among fish with this ingredient. Bowel cancer and additives. See: CROHN’S DISEASE (Note).
Preventive care. All 55-year-olds with this predisposing condition should be screened by sigmoidoscopy. Regular faecal occult blood tests advised.
Regular exercise helps prevent development of bowel cancer. (Nottingham University researchers) Treatment by general medical practitioner or oncologist. ... cancer-colorectal
FAMILY: Myrtaceae
SYNONYMS: New Zealand tea tree, kahikatoa, red manuka, manex.
GENERAL DESCRIPTION: The Manuka plant is an elegant, bushy evergreen shrub with deep green small spiky leaves that bears small flowers of white to pink in colour. The blossom is produced from September to February and most profusely in the later months. Its size ranges from a creeping plant to a small tree – trees can reach heights of up to 8 metres, especially when found within dense woodland. The leaves and flowers are strongly aromatic.
DISTRIBUTION: Manuka is the only Leptospermum species native to New Zealand, where it is widely distributed in various climatic and altitudinal zones. The physical characteristics, such as flower and leaf colour, leaf size and shape, branching habit, and foliage density vary considerably among populations. The plant can now be found in Australia where it seems to acclimatize well to varied terrain from marshland to dry mountain slopes. The essential oil is generally harvested from wild plants, as little farming of Manuka is currently undertaken.
OTHER SPECIES: The family Myrtaceae yields many valuable essential oils including eucalyptus, myrtle and tea tree. Another native tree of New Zealand called kanuka (Kunzea ericoides), sometimes called white or tree manuka, although superficially similar to L. scoparium in that both are collectively known as ‘tea trees’, is actually genetically a very distinct species. Kanuka in its typical form can grow into a tree up to 30 metres tall. It is also used to produce an essential oil.
HERBAL/FOLK TRADITION: For centuries, New Zealand Maori have used manuka to treat a wide range of complaints. Early New Zealand records indicate that the plant’s bark, leaves, sap and seed capsules were used in beverages and medicinal preparations. A decoction of the leaves was drunk for urinary complaints and as a febrifuge. The steam from leaves boiled in water was inhaled for head colds. A decoction was prepared from the leaves and bark and the warm liquid was rubbed on stiff muscles and aching joints. The emollient white gum, called ‘pai manuka’, was given to nursing babies and also used to treat scalds and burns. Chewing the bark is said to have a relaxing effect and enhance sleep. It is said that Captain James Cook used the leaves of the plant as a tea to combat scurvy during long explorations of the southern hemisphere; later, early European settlers of New Zealand adopted Captain Cook’s use of the plant as a tea.
Recently, scientists have confirmed that manuka oil is up to 33 times stronger than tea tree essential oil for protecting against specific strains of bacteria; it is also effective against the MRSA (Methicillin-Resistant Staph. Aureus) bacteria, which is resistant to normal antibiotics.
ACTIONS: Analgesic, antibacterial, antibiotic, antifungal, antihistamine, anti-inflammatory, anti-infectious, antimicrobial, antiseptic, astringent, deodorant, digestive, expectorant, immune stimulant, insecticide, sedative, vulnerary.
EXTRACTION: Steam distilled from the leaves, twigs and branches.
CHARACTERISTICS: A mobile liquid with a distinctive fresh, spicy, herbaceous aroma with a honey-like sweetness. It blends well with bay leaf, bergamot, black pepper, cajuput, cedarwood atlas, cinnamon, clove bud, elemi, ginger, juniper, lavender, nutmeg, peppermint, rose, rosemary, sandalwood, thyme, vetiver and ylang ylang.
PRINCIPAL CONSTITUENTS: The main active constituents of manuka oil are isoleptospermone, ?-pinene, ?-pinene, myrcene, ?-cymene, 1,8-cineole, linalol, methylcinnamate, ?-farnesine, isoleptospermone, leptospermone, sesquiterpenes such as cadina-3, 5-diene and ?-amorphene, and triketones. However, within the species of manuka there are at least nine different chemotypes: oil which contains high levels of triketones, found in the East Cape area of North Island in New Zealand appears to possess the greatest antimicrobial potential. Other chemotypes however are thought to reveal greater anti-inflammatory and analgesic tendencies. It is important to be aware of these various chemotypes when selecting an oil for therapeutic purposes.
SAFETY DATA: Generally it is thought to be non-sensitizing, non-toxic, and non-irritant. It can in some individuals, produce mild irritation but has a low irritancy compared to Australian tea tree oil. Avoid use during pregnancy because of spasmolytic activity.
AROMATHERAPY/HOME: USE
Skin care: Acne, abscesses, athlete’s foot skin, bed sores, blisters, boils, burns, carbuncles, cold sores, cracked skin, dandruff, dermatitis, eczema, fungal infections, insect bites and stings, lice, nail infections, oily skin, pimples, ringworm, sores, sunburn, tinea and ulcers.
Circulation, muscles and joints: Aches and pains, muscular tension, sprains and stiffness in joints, rheumatism.
Respiratory system: Coughs, cold, ’flu congestion, as well as asthma and hayfever.
Immune system: Tonic
Nervous system: Nervous debility.
OTHER USES: The essential oil is much used in phyto-cosmetic and pharmaceutical preparations mainly for its potent antimicrobial properties. Commercial development of the essential oil has led to a range of products for the topical treatment of various conditions including joint pain, eczema and psoriasis. The oil is also used in perfumes and soaps. The scented flowers of the shrub attract bees, which are used for making the popular manuka honey.... manuka