Closed Fracture — বাংলায় সম্পূর্ণ ক্লিনিক্যাল নোট
Closed fracture হলো এমন হাড় ভাঙা যেখানে হাড়ের ধারাবাহিকতা ভেঙে যায়, কিন্তু উপরের skin intact থাকে; অর্থাৎ fracture site বাইরের পরিবেশের সঙ্গে যোগাযোগ করে না। তাই এটি open fracture নয় এবং routine antibiotic সাধারণত দরকার হয় না—যদি surgery না লাগে বা অন্য infection না থাকে।
NICE fracture guideline অনুযায়ী fracture management-এর প্রথম ধাপ হলো pain assessment, adequate analgesia এবং limb immobilisation; BOAST guidance অনুযায়ী fracture limb-এর vascular ও neurological status পরীক্ষা করে লিখে রাখা এবং reduction/splint-এর পর আবার পরীক্ষা করা জরুরি।
1. Definition / সংজ্ঞা
Closed fracture:
ত্বক না ফেটে বা ক্ষত না হয়ে হাড় ভেঙে গেলে তাকে closed fracture বলে।
Core meaning:
হাড় ভাঙবে, কিন্তু বাইরে কোনো open wound থাকবে না।
2. Causes / কারণসমূহ
Traumatic cause
- Fall / পড়ে যাওয়া: বয়স্কদের hip, wrist fracture বেশি হয়।
- Road traffic accident: femur, tibia, pelvis, ribs fracture হতে পারে।
- Sports injury: ankle, clavicle, wrist, metacarpal fracture।
- Direct blow / আঘাত: লাঠি, ভারী বস্তু, মারামারি, machinery injury।
- Twisting injury: ankle, tibia, spiral fracture।
Low-energy বা fragility fracture
- Osteoporosis: সামান্য পড়ে গিয়েও hip, vertebra, wrist fracture।
- Vitamin D deficiency / osteomalacia: bone weak হয়ে fracture tendency বাড়ে।
- Elderly age: bone density কমে যায়, fall risk বাড়ে।
Pathological fracture
- Bone tumor / metastasis
- Bone cyst
- Osteomyelitis
- Paget disease
- Long-term steroid use
Stress fracture
- repeated minor stress, যেমন: military training, athletes, long walking/running।
3. Symptoms / লক্ষণসমূহ
- তীব্র ব্যথা: injury site-এ sharp pain, নড়াচড়া করলে বাড়ে।
- Swelling: soft tissue injury ও bleeding-এর কারণে ফুলে যায়।
- Tenderness: fracture site চাপ দিলে ব্যথা।
- Deformity: limb বাঁকা/shortened/rotated দেখা যেতে পারে।
- Loss of function: হাত-পা ব্যবহার করতে না পারা; lower limb হলে weight bearing করতে না পারা।
- Bruising / ecchymosis: ভেতরে bleeding হলে নীলচে দাগ।
- Crepitus: fracture ends ঘষা লাগলে কড়কড় শব্দ/অনুভূতি—ইচ্ছা করে পরীক্ষা করা উচিত নয়।
- Abnormal mobility: যেখানে joint নেই সেখানে নড়াচড়া।
- Numbness/tingling: nerve compression/injury।
- Cold/pale limb বা absent pulse: vascular injury-এর warning sign।
- Pain out of proportion: খুব বেশি ব্যথা, passive stretch করলে ব্যথা বাড়া—compartment syndrome সন্দেহ।
4. Clinical Diagnosis / Clinically কীভাবে diagnosis করবেন
History
- Injury mechanism: fall/RTA/twist/direct blow।
- Time since injury।
- Pain severity, inability to bear weight।
- Previous fracture/osteoporosis/steroid use/cancer history।
- Anticoagulant use: warfarin, rivaroxaban, aspirin, clopidogrel।
Examination — specific points
- Look: swelling, deformity, bruise, skin condition, wound আছে কি না।
- Feel: tenderness, temperature, distal pulse।
- Move: active movement না করানো ভালো যদি fracture suspected হয়; joint above and below assess করতে হবে।
- Neurovascular examination:
- Pulse: dorsalis pedis/posterior tibial/radial/ulnar
- Capillary refill
- Sensation
- Motor function
- Skin colour and temperature
- Document before and after splint/reduction. BOAST guidance acute fracture limb-এর vascular ও neurological assessment repeat করার কথা বলে, বিশেষ করে reduction বা splint-এর পরে।
Red flag
- severe increasing pain
- pain with passive stretch
- numbness
- weak/absent pulse
- tense swollen compartment
- excessive swelling after cast
5. Investigations / পরীক্ষা-নিরীক্ষা
First-line imaging
- X-ray AP and lateral view: fracture diagnosis-এর প্রধান পরীক্ষা।
- Joint above and below include করবেন: long bone fracture হলে।
- Plain radiography usually first imaging; subtle/occult fracture X-ray-তে শুরুতে নাও দেখা যেতে পারে।
When CT করবেন
- intra-articular fracture
- pelvis/spine/calcaneum/complex fracture
- surgical planning
- X-ray unclear but clinical suspicion high
- occult fracture suspicion
When MRI করবেন
- occult fracture: hip/scaphoid/stress fracture
- ligament/meniscus/soft tissue injury suspicion
- bone marrow edema
- avascular necrosis suspicion
ACR criteria অনুযায়ী radiograph normal/equivocal হলে occult fracture বা soft tissue injury suspicion-এ CT/MRI useful।
Lab tests — সব closed fracture-এ লাগে না
Surgery বা suspected pathology থাকলে:
- CBC
- Blood grouping and crossmatch
- RBS
- Serum creatinine/electrolytes
- PT/INR, APTT
- Vitamin D, calcium, phosphate, ALP
- PTH/TSH if metabolic bone disease suspected
- ESR/CRP if infection/tumor suspected
- ECG/CXR for pre-operative assessment
Special tests
- CT angiography: absent pulse/vascular injury suspicion।
- Compartment pressure: diagnosis uncertain হলে; compartment syndrome mainly clinical, তবে ICP >30 mmHg supportive threshold হিসেবে ব্যবহৃত হয়।
- DEXA scan: elderly/fragility fracture/osteoporosis suspicion।
6. Differential Diagnosis
- severe sprain
- dislocation
- tendon rupture
- ligament injury
- muscle contusion
- bone bruise
- stress reaction
- osteomyelitis
- bone tumor/metastasis
- acute compartment syndrome
7. Complications / জটিলতা
Early complications
- Neurovascular injury: nerve damage হলে numbness/weakness; vessel injury হলে limb ischemia।
- Compartment syndrome: closed fascial compartment-এ pressure বেড়ে muscle/nerve ischemia করে; surgical emergency।
- Fat embolism syndrome: long bone fracture, especially femur; respiratory distress, confusion, petechial rash।
- DVT/PE: lower limb fracture, immobilization, surgery।
- Shock/bleeding: femur/pelvis fracture-এ internal blood loss হতে পারে।
- Cast complications: tight cast → pain, numbness, swelling, pressure sore।
Late complications
- Delayed union: fracture healing expected time-এর চেয়ে দেরি।
- Non-union: fracture unite না হওয়া।
- Malunion: ভুল alignment-এ জোড়া লাগা।
- Joint stiffness: immobilization দীর্ঘ হলে।
- Muscle wasting: disuse atrophy।
- Avascular necrosis: femoral neck/scaphoid/talus fracture।
- Post-traumatic arthritis: intra-articular fracture।
- Complex regional pain syndrome: disproportionate chronic pain, swelling, colour change।
- Osteomyelitis: closed fracture-এ কম, কিন্তু surgery/internal fixation থাকলে হতে পারে।
8. Non-pharmacological Treatment / মূল চিকিৎসা
Immediate management
- limb rest
- splint/back slab
- elevation
- ice pack: 15–20 min, দিনে কয়েকবার
- ring/watch tight clothing খুলে ফেলা
- neurovascular check
- pain control
Reduction
- displaced fracture হলে closed reduction করা হয়।
- reduction-এর আগে ও পরে pulse/sensation/motor লিখে রাখা জরুরি।
Immobilization
- splint/back slab initially
- swelling কমলে full cast
- functional brace কিছু fracture-এ
Surgical indications
- open fracture
- unstable/displaced fracture
- intra-articular fracture
- neurovascular compromise
- compartment syndrome
- femoral neck fracture
- failed closed reduction
- polytrauma
- pathological fracture
Surgery options
- ORIF: plate/screw
- intramedullary nail
- external fixation
- K-wire/CRPP
- hemiarthroplasty/arthroplasty: selected hip fracture
Rehabilitation
- physiotherapy
- range-of-motion exercise
- gradual weight bearing
- muscle strengthening
- follow-up X-ray
9. Pharmacological Treatment — Bangladesh Prescription-Oriented Drug List
নোট: নিচের dose adult, normal renal/hepatic function ধরে। Pregnancy, child, CKD, liver disease, ulcer, anticoagulant use, elderly—সব ক্ষেত্রে dose/choice change করতে হয়। Prescription ছাড়া opioid, injection, anticoagulant, antibiotic ব্যবহার করবেন না।
A. Pain control: Paracetamol
1. Generic name
Paracetamol / Acetaminophen
2. Therapeutic category
Analgesic, antipyretic
3. Pharmacological class
Para-aminophenol derivative; non-opioid analgesic
4. কেন used হয়
- mild to moderate fracture pain
- fever থাকলে
- NSAID contraindicated হলে safer first-line option
Dose and duration
- 500–1000 mg orally every 6 hours PRN
- Maximum: 4 g/day; liver disease/alcohol use হলে কম dose
- Duration: usually 3–7 days, pain অনুযায়ী
Bangladesh available brand examples
- Napa 500 mg — Paracetamol
- Ace 500 mg — Paracetamol
- Xpa 500 mg — Paracetamol
- Renova 500 mg — Paracetamol
- Reset 500 mg / Tamen 500 mg — Paracetamol
- IV form: Tamen IV 10 mg/ml, Paraciv IV 10 mg/ml
MedEx lists adult paracetamol dosing as 1–2 tablets every 4–6 hours up to maximum 4 g/day and lists multiple Bangladesh brands including Napa, Ace, Xpa, Renova, Reset, Tamen and IV products.
Side effects
- nausea
- rash/allergy
- overdose → severe hepatotoxicity
Interaction
- alcohol/liver disease → hepatotoxicity risk
- warfarin with repeated high-dose paracetamol → INR/bleeding risk may increase।
B. NSAIDs: inflammation + pain control
NSAIDs swelling/inflammatory pain কমায়, তবে prolonged/high-dose NSAID fracture healing নিয়ে evidence mixed; তাই fracture patient-এ lowest effective dose, short duration, high-risk patient-এ caution।
1. Ibuprofen
Generic name
Ibuprofen
Therapeutic category
Analgesic, anti-inflammatory
Pharmacological class
NSAID; propionic acid derivative
কেন used হয়
- mild–moderate fracture pain
- swelling/inflammation কমাতে
- paracetamol যথেষ্ট না হলে
Dose and duration
- 400 mg orally every 8 hours after food PRN
- OTC max often 1200 mg/day; physician-supervised dose higher হতে পারে
- Duration: 3–5 days preferred
Bangladesh brand examples
- Advel 400 mg
- Flamex 400 mg
- Profen 400 mg
- Reumafen 400 mg
- Inflam 400 mg
MedEx lists ibuprofen 200–400 mg 3–4 times daily with maximum 1200 mg/day and Bangladesh brands including Advel, Flamex, Profen, Reumafen and Inflam.
Side effects
- gastritis, dyspepsia
- GI bleeding/ulcer
- renal impairment
- BP increase/fluid retention
- bronchospasm in aspirin-sensitive asthma
Interaction
- warfarin/DOAC/aspirin/clopidogrel → bleeding risk
- steroid/SSRI → GI bleed risk
- ACEI/ARB + diuretic → acute kidney injury risk
- lithium/methotrexate → toxicity risk
2. Diclofenac sodium
Generic name
Diclofenac sodium
Therapeutic category
Analgesic, anti-inflammatory
Pharmacological class
NSAID; phenylacetic acid derivative
কেন used হয়
- moderate pain
- swelling and inflammatory pain
- acute musculoskeletal injury pain
Dose and duration
- 50 mg orally 2–3 times daily after food
- SR: 100 mg once daily
- Injection: 75 mg IM once daily, selected cases only
- Duration: 2–5 days preferred
Bangladesh brand examples
- Voltalin 50 mg / 75 mg injection / 100 mg SR
- Diclorex 50 mg / 75 mg/3 ml injection
- Difenac 50 mg
- Dilock 50 mg / 100 mg SR
- Rispain 50 mg / 100 mg SR
MedEx lists diclofenac Bangladesh brands and strengths including Voltalin, Diclorex, Difenac, Dilock and Rispain.
Side effects
- gastritis, ulcer, GI bleeding
- renal impairment
- edema, hypertension
- increased cardiovascular risk
- liver enzyme elevation
Interaction
- anticoagulants → bleeding
- ACEI/ARB/diuretics → renal risk
- lithium/digoxin levels may increase
- methotrexate/cyclosporine toxicity risk
MedEx notes diclofenac interactions with lithium, digoxin, anticoagulants, cyclosporine and methotrexate.
3. Naproxen
Generic name
Naproxen / Naproxen sodium
Therapeutic category
Analgesic, anti-inflammatory
Pharmacological class
NSAID; propionic acid derivative
কেন used হয়
- longer-acting pain control
- swelling/inflammation
- ankle/wrist/long-bone fracture pain after initial stabilization
Dose and duration
- 250–500 mg orally twice daily after food
- Duration: 3–5 days; avoid prolonged use unless specialist advises
Bangladesh brand examples
- Naprox 500 mg
- Naproxin 250/500 mg
- Napryn 250/500 mg
- Napsod 275/550 mg
- Naxo 500 mg
- Naspro 250 mg
MedEx lists naproxen brands and strengths including Naprox, Naproxin, Napryn, Napsod, Naxo and Naspro.
Side effects
- GI upset/bleeding
- renal impairment
- edema
- BP increase
Interaction
Same NSAID interactions: anticoagulants, antiplatelets, steroid, SSRI, ACEI/ARB/diuretic, lithium, methotrexate.
4. Ketorolac
Generic name
Ketorolac tromethamine
Therapeutic category
Short-term analgesic
Pharmacological class
Potent NSAID
কেন used হয়
- severe acute pain
- ED/post-operative short-term pain
- opioid-sparing analgesia
Dose and duration
- Oral: 10 mg every 6 hours PRN
- IM/IV: 30 mg IM/IV, selected cases
- Maximum duration: 5 days; ulcer/CKD/bleeding risk থাকলে avoid
Bangladesh brand examples
- Etorac 10 mg / 30 mg/ml / 60 mg/2 ml
- Ketorin 10 mg / 30 mg/ml
- Kelorac 10 mg / 30 mg/ml
- Kenodol 10 mg
- Todol 10 mg / 30 mg/ml
MedEx lists ketorolac brands and strengths including Etorac, Ketorin, Kelorac, Kenodol and Todol.
Side effects
- high GI bleed risk
- renal impairment
- bleeding tendency
- nausea, dyspepsia
Interaction
- anticoagulant/antiplatelet → bleeding
- other NSAIDs → toxicity
- ACEI/ARB/diuretic → renal injury
C. Opioid analgesic: moderate–severe pain
1. Tramadol
Generic name
Tramadol hydrochloride
Therapeutic category
Analgesic
Pharmacological class
Atypical opioid; μ-opioid agonist + serotonin/norepinephrine reuptake inhibition
কেন used হয়
- moderate–severe fracture pain
- NSAID/paracetamol inadequate হলে
- short course only
Dose and duration
- 50 mg orally every 6–8 hours PRN
- Severe pain: 50–100 mg every 6 hours
- Max: 400 mg/day
- Duration: 2–3 days usually; dependence risk আছে
Bangladesh brand examples
- Anadol 50 mg capsule / 100 mg SR
- Dolonil 50 mg capsule
- Other tramadol brands also available depending on market
MedEx lists tramadol usual oral dose 50–100 mg every 4–6 hours, max 400 mg/day, and Bangladesh brands including Anadol and Dolonil.
Side effects
- dizziness
- nausea/vomiting
- constipation
- drowsiness
- sweating
- dependence
- seizure risk
- serotonin syndrome risk
Interaction
- alcohol/benzodiazepine/sedatives → respiratory depression/sedation
- SSRI/SNRI/TCA/MAOI/linezolid → serotonin syndrome/seizure risk
- antiepileptic threshold-lowering drugs → seizure risk
MedEx and pharmacovigilance sources highlight tramadol interaction with CNS depressants and MAO inhibitors, and seizure/serotonin syndrome risk.
2. Morphine — hospital use
Generic name
Morphine sulfate
Therapeutic category
Strong analgesic
Pharmacological class
Opioid agonist
কেন used হয়
- severe fracture pain
- femur/pelvis/major trauma
- post-operative pain
- ED/inpatient setting
Dose
- IV titrated small doses under monitoring; outpatient self-use নয়।
- Hospital protocol অনুযায়ী দিতে হয়।
Bangladesh brand examples
- G-Morphine injection 15 mg/ml
- G-Morphine SR 15 mg
MedEx lists morphine sulfate for severe/intractable and post-operative pain with Bangladesh brands including G-Morphine.
Side effects
- respiratory depression
- hypotension
- constipation
- nausea/vomiting
- sedation
- dependence
Interaction
- alcohol/benzodiazepine/sedatives → fatal respiratory depression risk
- MAOI → serious reaction risk
- other opioids/CNS depressants → additive toxicity
D. Gastroprotection with NSAID
Esomeprazole
Generic name
Esomeprazole
Therapeutic category
Anti-ulcerant
Pharmacological class
Proton pump inhibitor, PPI
কেন used হয়
- NSAID-induced gastritis/ulcer prevention
- elderly, ulcer history, steroid/anticoagulant use, high-dose NSAID হলে
Dose and duration
- 20 mg once daily before breakfast
- High risk/severe gastritis: 40 mg once daily
- NSAID যতদিন, সাধারণত 5–14 days; long-term হলে review
Bangladesh brand examples
- Nexum 20/40 mg
- Esonix 20/40 mg
- Esoral 20/40 mg
- REMMO 20/40 mg MUPS
- DP 20/40 mg
MedEx lists esomeprazole 20/40 mg and IV 40 mg brands including Esonix, Esoral and REMMO.
Side effects
- headache
- diarrhea/constipation
- nausea
- long-term: low Mg, B12 deficiency, infection risk
Interaction
- clopidogrel effect may reduce
- warfarin/diazepam/phenytoin monitoring needed
- ketoconazole/itraconazole absorption may reduce
E. Antibiotic — routine closed fracture-এ নয়
Cefazolin — surgery prophylaxis
Generic name
Cefazolin sodium
Therapeutic category
Antibiotic
Pharmacological class
First-generation cephalosporin
কেন used হয়
- closed fracture with operative fixation হলে peri-operative prophylaxis
- routine closed fracture without surgery-তে antibiotic দরকার নেই
Dose and duration
- 1–2 g IV within 30–60 minutes before incision
- long surgery হলে repeat dose
- post-op usually ≤24 hours depending on protocol
MedEx lists perioperative cefazolin dose as 1 g IM/IV half to 1 hour before surgery, with intraoperative repeat for long procedures and 24-hour postoperative dosing.
Bangladesh brand examples
- Cefazol 500 mg/vial, 1 g/vial
- Cefalin 1 g/vial
- Zolibac 1 g/vial
- Cefazoline Panpharma 1 g/vial
Side effects
- allergy/rash/anaphylaxis
- diarrhea
- C. difficile colitis
- injection site pain
Interaction
- warfarin → INR/bleeding monitoring
- aminoglycoside/loop diuretic → renal risk
- probenecid → antibiotic level increase
F. VTE prophylaxis — selected lower-limb fracture/immobilization
Enoxaparin
Generic name
Enoxaparin sodium
Therapeutic category
Anticoagulant
Pharmacological class
Low molecular weight heparin, LMWH
কেন used হয়
- lower limb immobilization with high VTE risk
- hip/pelvis/femur fracture
- post-operative DVT/PE prevention
- prolonged bed rest
Dose and duration
- Common prophylactic adult dose: 40 mg SC once daily
- Renal impairment হলে adjust
- Duration: until mobile / 10–14 days / risk অনুযায়ী; NICE says lower limb immobilisation-এ VTE risk bleeding risk-এর চেয়ে বেশি হলে LMWH বা fondaparinux consider, এবং immobilisation 42 days ছাড়ালে prophylaxis stopping consider করতে হবে।
Bangladesh brand examples
- Enoject 4000 Anti-Xa IU/0.4 ml = 40 mg
- Enoma 4000 Anti-Xa IU/0.4 ml
- Enoparin 4000 Anti-Xa IU/0.4 ml
- Enorin 4000 Anti-Xa IU/0.4 ml
- Noxarin 4000 Anti-Xa IU/0.4 ml
- Parinox 8000 Anti-Xa IU/0.8 ml
MedEx notes enoxaparin 0.4 ml prefilled syringe contains 40 mg equivalent to 4000 anti-Xa IU and lists multiple Bangladesh brands.
Side effects
- bleeding
- injection site hematoma
- thrombocytopenia
- HIT, rare
- hyperkalemia, rare
Interaction
- NSAID/aspirin/clopidogrel/warfarin/DOAC → bleeding risk
- thrombolytics → severe bleeding risk
G. Bone health support
1. Calcium + Vitamin D3
Generic name
Calcium carbonate + Vitamin D3
Therapeutic category
Bone supplement
Pharmacological class
Mineral + vitamin preparation
কেন used হয়
- deficiency suspected হলে
- elderly/osteoporosis/fragility fracture
- low dietary calcium
- fracture healing support, but এটি painkiller নয়
Dose and duration
- Common: Calcium 500 mg + Vitamin D3 200 IU, 1 tablet twice daily after meal
- Or 600 mg + 400 IU twice daily
- Duration: 6–12 weeks or osteoporosis plan অনুযায়ী
Bangladesh brand examples
- Calbo-D 500 mg + 200 IU
- DP-CAL D 500 mg + 200 IU
- G-Cal D 500 mg + 200 IU
- Ipical DX 600 mg + 400 IU
- Eurocal-DX 600 mg + 400 IU
- Seacal-D 500 mg + 200 IU
MedEx lists calcium + vitamin D3 dosing as 500 mg + 200 IU twice daily or 600 mg + 400 IU twice daily, and Bangladesh brands including G-Cal D, Ipical DX, Eurocal-DX and Seacal-D/Seacal-DX.
Side effects
- constipation
- bloating
- hypercalcemia
- kidney stone risk
Interaction
- tetracycline/quinolone antibiotics absorption কমে
- levothyroxine absorption কমে
- iron absorption কমে
- bisphosphonate absorption কমে
Gap: calcium এসব drug থেকে 2–4 ঘণ্টা আলাদা করে খাওয়া ভালো।
2. Cholecalciferol / Vitamin D3
Generic name
Cholecalciferol
Therapeutic category
Vitamin D preparation
Pharmacological class
Fat-soluble vitamin
কেন used হয়
- vitamin D deficiency
- osteomalacia/osteoporosis
- fragility fracture prevention
Dose and duration
- Maintenance: 1000–2000 IU daily
- Deficiency: 20,000 IU weekly for 6–8 weeks or physician protocol
- Very high-dose injection/capsule only documented deficiency/doctor advice অনুযায়ী
Bangladesh brand examples
- D-Rise 2000 IU / 20000 IU / 40000 IU / 200000 IU/ml
- Aristo D3 2000 IU / 20000 IU / 40000 IU / 200000 IU/ml
- D-2000 / D-20000 / D-40000
- Hi-D 2000 IU / 200000 IU/ml
- Max D 1000 IU / 20000 IU
Side effects
- hypercalcemia
- nausea
- constipation
- polyuria
- kidney stone
Interaction
- thiazide diuretic → hypercalcemia risk
- digoxin → arrhythmia risk if hypercalcemia
- anticonvulsants/steroid → vitamin D level কমাতে পারে
3. Alendronic acid — osteoporosis/fragility fracture prevention
Generic name
Alendronic acid
Therapeutic category
Anti-osteoporotic drug
Pharmacological class
Bisphosphonate
কেন used হয়
- osteoporosis treatment
- fragility fracture prevention
- postmenopausal osteoporosis/men with osteoporosis
- acute traumatic fracture pain কমানোর drug নয়
Dose and duration
- 70 mg once weekly
- সকালে খালি পেটে full glass water দিয়ে
- খাওয়ার পর 30 মিনিট শোয়া যাবে না
- duration: long-term osteoporosis plan, usually years with periodic review
Bangladesh brand examples
- Alendon 70 mg
- Combination: Ostel-D 70 mg + 2800 IU Vitamin D3
- Bonemass D 70 mg + 2800 IU Vitamin D3
MedEx lists alendronic acid for osteoporosis and Bangladesh brands including Alendon 70 mg and combination products such as Ostel-D/Bonemass D.
Side effects
- esophagitis
- dyspepsia
- abdominal pain
- hypocalcemia
- rare: osteonecrosis jaw, atypical femur fracture
Interaction
- calcium/iron/antacid/food → absorption কমে
- NSAID → GI irritation বাড়তে পারে
10. Bangladesh Doctor-ra Prescription-e Commonly কী কী দেয়
Closed fracture-এ সাধারণত prescription pattern:
- Paracetamol 500 mg
- Pain control-এর base drug
- Example: Napa/Ace/Xpa 500 mg
- NSAID short course
- Ibuprofen 400 mg / Diclofenac 50 mg / Naproxen 500 mg
- swelling + inflammatory pain কমাতে
- gastritis/CKD/ulcer/anticoagulant থাকলে avoid
- PPI
- Esomeprazole 20/40 mg
- NSAID-induced gastritis prevent করতে
- Tramadol 50 mg
- severe pain হলে short course
- dizziness/sedation/dependence risk
- Cefazolin IV
- only operative fixation হলে prophylaxis
- simple closed fracture-এ routine antibiotic নয়
- Enoxaparin 40 mg SC daily
- lower limb immobilization/high VTE risk/hip-pelvis fracture/post-op patient
- Calcium + Vitamin D3
- elderly, osteoporosis, vitamin D deficiency, fragility fracture
- Alendronate 70 mg weekly
- osteoporosis confirmed/suspected fragility fracture prevention
11. Prevention / প্রতিরোধ
- fall prevention: bathroom grab bar, non-slip sandal, floor dry রাখা
- elderly vision/hearing check
- calcium-rich diet: milk, fish with bone, leafy vegetables
- vitamin D: sunlight exposure + deficiency treatment
- regular weight-bearing exercise
- smoking বন্ধ
- alcohol avoid
- osteoporosis screening: elderly/fragility fracture হলে DEXA
- road safety: helmet, seat belt, speed control
- sports safety: warm-up, proper shoes, protective gear
- workplace safety: PPE, machine guard
- long-term steroid ব্যবহার করলে bone protection plan
Overview / Summary
Closed fracture-এ skin intact থাকে। Diagnosis mainly clinical suspicion + X-ray; CT/MRI লাগে complex/occult/surgical planning-এ। Immediate management হলো analgesia, immobilization, elevation, neurovascular documentation এবং fracture reduction/fixation as needed। Routine antibiotic লাগে না, তবে surgery হলে cefazolin prophylaxis দেওয়া হয়। Pain control-এ paracetamol first-line, NSAID short course, severe pain-এ tramadol/morphine hospital setting। Lower limb immobilization/high-risk patient-এ VTE prophylaxis consider করা হয়।
Actionable Plan / Steps
- Suspected fracture হলে limb নাড়াচাড়া বন্ধ করে splint দিন।
- Pulse, capillary refill, sensation, motor function পরীক্ষা করে লিখুন।
- X-ray AP/lateral করুন; joint above and below include করুন।
- Pain control: paracetamol ± NSAID; severe pain হলে supervised opioid।
- Displaced/unstable fracture হলে orthopedic reduction/fixation।
- Red flag থাকলে emergency: increasing severe pain, numbness, cold limb, absent pulse, tight cast, dyspnea/confusion।
- Elderly/low-energy fracture হলে osteoporosis workup + calcium/vitamin D ± bisphosphonate plan।
- Lower limb immobilization হলে VTE risk assessment করুন।
Reference List
Textbook
- Rockwood and Green’s Fractures in Adults, 10th edition, Wolters Kluwer/LWW, 2024 — biomechanics, bone healing, adult fracture principles.
- Campbell’s Operative Orthopaedics, 15th edition, Elsevier, 2026 — operative fracture management principles.
- Apley & Solomon’s System of Orthopaedics and Trauma, 10th edition — general orthopaedics, fractures and joint injuries.
Guidelines
- NICE NG38: Fractures non-complex: assessment and management, 2016; last reviewed 2025.
- British Orthopaedic Association Standards for Trauma — BOAST, acute fracture neurovascular assessment and splinting principles.
- NICE NG89: Venous thromboembolism in over 16s, lower limb immobilisation prophylaxis recommendation.
- ACR Appropriateness Criteria, acute trauma imaging and occult fracture imaging principles.
Peer-reviewed DOI references
- Claes L, Recknagel S, Ignatius A. Fracture healing under healthy and inflammatory conditions. Nature Reviews Rheumatology. 2012;8:133–143. DOI: 10.1038/nrrheum.2012.1.
- Chuang P-Y, et al. Do NSAIDs affect bone healing rate, delay union, or cause non-union: systematic review and meta-analysis. Frontiers in Endocrinology. 2024. DOI: 10.3389/fendo.2024.1428240.
- Donaldson J, et al. The pathophysiology, diagnosis and current management of acute compartment syndrome. Open Orthopaedics Journal. 2014;8:185–193. DOI: 10.2174/1874325001408010185.
- Kim JY, et al. Diagnosis and Management of Acute Compartment Syndrome. Journal of the Korean Fracture Society. 2015;28(1):93–101. DOI: 10.12671/jkfs.2015.28.1.93.
Md.Rafiqul Islam Lipu,Date:-5-06-2026 Friday Time:-08-48-27 Am