Fractures: general information

Fractures (fractura) - mechanical damage to bones with a violation of their integrity. Repeated fractures in the same place are called refracture. Symptoms of fractures are pain, swelling, hemorrhage, crepitus, deformity and limb function. Complications of fractures include fat embolism, compartmental syndrome, nerve damage, infection. The diagnosis is based on clinical signs and in many cases on radiography data. Treatment includes anesthesia, immobilization, if necessary, surgical intervention.

In most cases, fracture is the result of a single significant force impact on normal, in general, bone. Pathological fractures are the result of an average or minimal force affecting the bone, weakened by an oncological or other disease. Stress fractures (for example, metatarsal bones fractures) are caused by a constantly repeated external impact on a specific area of bone tissue.

[1], [2]

Pathophysiology of fracture

At normal levels of Ca and vitamin D and healthy bone tissue, fractures heal within weeks or months by remodeling: a new tissue (bone callus) is formed within weeks, the bone acquires a new shape at different rates: during the first weeks or months. And, finally, for full bone remodeling, it is necessary to gradually restore normal movements of adjacent joints. However, remodeling can be disrupted, with external force or prematurely started movement in the joints, a second fracture is possible, usually requiring re-immobilization.

Severe complications are not typical. Damage to the arteries is possible in some cases with closed supracondylar fractures of the humerus and femur, but are rare in other closed fractures. Perhaps the development of compartmental syndrome or nerve damage. Open fractures predispose to infection of bone, difficult to treat. In fractures of long tubular bones, a sufficient amount of fat (and other components of the bone marrow) can be released and fat emboli can enter the veins into the lungs with the development of respiratory complications. Intra-articular fractures are accompanied by damage to the articular cartilage. Irregularities on the joint surface can be transformed into scars with the development of osteoarthritis and impaired mobility of the joint.

How are fractures manifested?

Pain is usually of medium severity. Within a few hours, edema develops. Both of these signs gradually weaken after 12-48 h. Strengthening pain later this period gives reason to think about the development of compartmental syndrome. Other symptoms may include bone pain during palpation, bruising, decreased or pathological mobility, crepitus and deformity.

A patient with signs of fracture is examined for ischemia, compartmental syndrome, nerve damage. If there is a wound of soft tissues next to the fracture, the fracture is considered open. Fracture is diagnosed with visualization methods, starting with direct radiography. If the fracture line is not obvious, examine the bone density, the structure of the trabeculae and cortical plate for the presence of small signs of fracture. If, with serious suspicions of a fracture on the radiograph, it is not visible, or additional details are needed to select the treatment, perform MRI or KG. Some experts recommend to explore and joints distal and proximal fracture.

Radiographic manifestations of fractures can be accurately described by five definitions:

• type of fracture line;
• its localization;
• angle;
• bias;
• open or closed fractures.
  

On localization, fractures are divided into head fractures (possibly involving the articular surface), cervical spines and diaphyseal fractures (proximal, middle and distal third).

Classification of fractures

A working classification has been adopted: fractures, which includes several positions.

1. By origin, fractures are divided into traumatic fractures, formed when a force is applied that exceeds the strength of the bone; and pathological, arising when small loads are applied to degenerate bone (for bone tumors, osteomyelitis, cystic dysplasia, etc.).
2. According to the state of skin, they are divided into closed, when the skin is not damaged or there are skin abrasions; and open, when there is a wound in the area of the fracture.
3. The level of fracture is distinguished: epiphyseal (intra-articular); metaphyseal (in the humus part); and diaphyseal fractures.
4. On the line of the fracture, they are divided into transverse (occur with a direct impact, so they are also called bumper); Skew (due to a fracture at one of the fixed ends of the limb); spiral (the break occurs at a fixed end of the segment, more often the foot, with the rotation of the body along the axis); longitudinal (when falling from a height of up to 3 m on the straightened limb); "T" -shaped (when falling from a higher height, when not only the longitudinal splitting of the bone occurs, but also a transverse fracture); linear (with fractures of flat bones, for example, skull, sternum); dents (with fractures of the skull bones with the introduction of a fragment into the cavity of the skull); compression (for vertebral fractures with wedge deformation), and others, including "author's" (Malgenia, LeFore, Potta, etc.);
5. By the type of displacement fragments. With the correct axis of the bone and the distance between the bone fragments to 5 mm, the fracture is considered unbiased (since this is the ideal distance for adhesion). In the absence of these conditions, four types of displacement can be noted (more often they are combined): along the length, in width, at an angle along the axis (rotational).
6. In count. Fractures are divided into isolated in the region of one segment of the body and multiple - in several segments of the body (for example, the thigh and the shin, pelvis and spine, etc.). In relation to one bone, fractures can be: single, double, triple and multiple (they are regarded as fractured fracture).
7. For complications, fractures are divided into uncomplicated, occurring as a local process, and complicated. To complications of fractures are: shock, blood loss (for example, with a fracture of the hip or pelvis, blood loss is 1-2 liters with the formation of retroperitoneal hematoma), open fractures, lesions of the neurovascular trunk with rupture or infringement in the area of bone fragments, multiple and combined fractures, damage to internal organs, combined injuries, fracture.
8. Children can form two specific forms of fractures that develop as a result of incomplete formation and flexibility of the bone.

Subperiosteal fractures (such as the "green twig") without anatomical disturbances of the periosteum - belong to the category of the lungs, since they grow together in 2-3 weeks.

Osteoepiphyolysis - fractures with a detachment in the growth zone (more often the shoulder and forearm in the elbow joint area) are the most severe fractures, as the head of the bone is aseptically necrotic and the growth in the growth zone ceases. Clinic and diagnosis of fractures

Pathological fractures caused by malignant tumors are painless, with all other symptoms.

For fractures, as well as for other injuries, the main symptoms are: pain (but it is very sharp), increasing when trying to move or load; which determines the development of pain contracture (violation of the function of the limb) and the symptom of reduction (the injured involuntarily tries to limit movement, pressing the injured segment to the trunk or other intact limb); edema and bruising (but their severity is greater than with other closed injuries).

For fractures, the following specific symptoms are characteristic: vicious limb position, pathological mobility, bone crepitation during palpation of the fracture zone. Especially these symptoms do not cause due to the possibility of development of complications, shock, aggressive reaction of the victim. But if they are visible by eye or determined by careful palpation, the diagnosis is unquestionable.

Only in doubtful cases can be used methods: traction (careful stretching of the injured segment) or compression (easy squeezing of the limb segment along the axis of the bone). A sharp increase in pain is a sign of a possible fracture. For fractures of the spine and pelvis is a symptom of the stitched heel (the victim can not tear his leg off the bed). For rib fractures, chest lag in the act of breathing, pain and difficulty in coughing are characteristic.

Victims with an obvious clinic of fractures or in doubtful cases should be taken to the admissions offices of the hospitals or fully equipped trauma centers (recently the trauma centers located in the adapted premises and unable to provide emergency care to trauma patients at the proper level have been transferred to the rehabilitation regime of the victims).

At the hospital level, a traumatologist must necessarily have the following activities; anesthesia fracture, X-ray diagnosis and documentation, reposition and therapeutic immobilization.

[3], [4], [5]

Some types of fractures

Stress fracture

Small fractures that arise as a result of repeated force. Most often they are observed in the metatarsal bones (usually runners), less often in the peroneal and tibial bones. Symptoms include the gradual development of intermittent pain, the intensity of which increases along with the load and eventually becomes permanent. Sometimes swelling is possible. On examination, local bone pain is found. Perform radiography, but at the beginning the result can be false-negative. Many such fractures are treated presumably, and radiography is repeated after 1-2 weeks, when the callus can become visible. Treatment includes rest, elevated limb position, analgesics and in some cases immobilization. MRI or CT scan is rare.

Epiphysiolysis

Bone tissue grows in length due to growth zones or the growth plate (epiphysis), which is limited by the metaphysis (proximal) and the epiphysis (distally). Age, when the growth zone closes and bone growth stops, varies depending on the type of bone, but the growth plate in all bones disappears with the end of puberty.

The growth zone represents the weakest part of the bone and, in the case of force, usually breaks first. The fractures of the growth zone are classified according to the Salter-Harris system. Impairment of growth in the future is characteristic of types III, IV and V and is not typical of types I and II.

Type I is a complete separation of the growth plate from the metaphysis with or without bias. Type II occurs most often, the line of fracture of the growth plate passes to the metaphysis of the bone with the formation of a metaphyseal spine, sometimes very small. Type III - intra-articular fracture of the epiphysis. Type IV - a combination of intra-articular fracture of the epiphysis with a fracture of the metaphyseal bone. Type V occurs less frequently than other types, is a compression fracture of the growth plate.

Fracture of the growth plate should be suspected in the child with local soreness in this zone. These fractures are clinically distinct from bruises with a circular character of pain. With fractures I and V types, radiographs can be normal. In this case, such fractures can sometimes be differentiated by the mechanism of injury (a break in the direction of the longitudinal axis of the bone or compression). For types I and II, closed treatment is usually used; III and IV types often need OVF. Patients with type V epiphysiolysis should be under the supervision of a pediatric orthopedist, since these lesions almost always lead to growth disorders.

[6], [7], [8], [9]

X-ray diagnosis of fractures

With obvious signs of fracture, and in doubtful cases, radiology, the study should be carried out without fail, as the roentgenogram is a legal document confirming the presence of a fracture.

To determine the type of displacement of bone fragments, radiography should be performed in at least two projections. In cases of fractures of segments with small bones (wrist, wrist joint, foot and ankle joint, cervical spine), radiography is performed in three projections. Radiographs in the presence of a fracture are given to the victim's hands or stored for life in the archives of the health facility.

Description of the radiographs are carried out according to a certain scheme:

• the date of radiography and the number of radiographs (to document the dynamics of the studies, as each victim is usually conducted 4-6 studies to monitor the standing of fragments and the process of fracture fusion);
• the anatomical segment reflected on the roentgenogram is indicated, and the number of projections;
• in the presence of a fracture: indicate its location and type - level, fracture line, displacement of bone fragments;
• give an x-ray diagnosis of the diagnosis;
• during the process of fracture fusion, an assessment is made of the standing of bone fragments and the state of bone callus.

Treatment of a fracture

Immediate treatment includes anesthesia and, if suspected of instability or fracture of long bones, splinting. When an open fracture is necessary, a sterile bandage, tetanus prophylaxis and broad-spectrum antibiotics are required (for example, a combination of second generation cephalosporins and aminoglycosides).

With rotational and / or angular displacement and deformation, the reposition is shown. The exception is diaphyseal fractures in children, in which remodeling gradually corrects some types of angular displacements, and the comparison of end-to-end bone fragments can stimulate bone growth, which can then become redundant.

Surgical treatment can consist in the fixation of bone fragments with metal structures [open reposition and internal fixation (ORVF)]. The OVFF is shown at:

• intra-articular fractures with displacement (for an exact comparison of articular surfaces);
• with certain fractures, when more reliable fixation of bone fragments is needed;
• if the closed repository is not effective;
• if the fracture line passes through the tumor (there will be no normal bone healing in this zone).

Since OVVF provides structural stabilization immediately after implementation, which facilitates early mobilization of the patient, the method is indicated in clinical cases when prolonged immobilization, necessary for the formation of callus and remodeling, is undesirable (for example, femoral neck fracture). Surgical treatment is necessary in case of suspected damage to large vessels (to restore them), with open fractures (for washing, sanitation and infection prevention) or after an unsuccessful attempt at closed reposition (for open reposition and, in some cases, internal fixation).

Regardless of whether a repositioning and / or surgery is required or not, it is usually immobilized with the capture of proximally and distally located joints from it. Usually the cast remains for weeks or months, but you can also use tires, especially if the fractures heal faster in the early mobilization. Treatment at home includes such supportive measures as rest, cold, pressing bandage and elevated limb position.

The patient is explained the need to immediately seek help when there are signs of compartment syndrome.

Rehabilitation therapy

Restorative treatment of fractures (rehabilitation), after repositioning and immobilization can be carried out by a surgeon. It should start as soon as possible. With qualitative repositioning, the main direction of rehabilitation measures includes: accumulation of calcium salts in the fracture zone (administration of calcium preparations, as well as the means stimulating its assimilation: methandrostenolone and methyluracil; locally calcium chloride electrophoresis can be used); and improvement in this zone of microcirculation using microwave therapy or magnetotherapy. In the presence of concomitant diseases Vessels of limbs must necessarily undergo their complex treatment, as the trauma in itself causes their exacerbation, and the decrease in blood flow leads to a slowing of the fracture fusion.

After removal of immobilization, the joints must be developed and the muscle tissue restored. This is done by the method of passive and active therapeutic physical training, massage, the development of movements in the joint "through pain and tears." It is much easier to develop in warm water with salt (1 tablespoon per cup of water). Effective baths with different salts, preferably sea, hydromassage from the fingertips to the center, the use of mud; better than brine with iodine, sulfur or radon, magnetotherapy. In the absence of metal structures, microwave therapy and electrophoresis with potassium iodide, lidase or ronidase can be used. With contractures, phonophoresis of hyaluronidase preparations can be used, but with great caution, since prsulus ultrasound and other methods of physiotherapy are contraindicated for half a year. Only complete restoration of the function of the limb is an indication for the closure of the sick leave sheet. With the development of complications or inefficiency of rehabilitation measures, the victim is registered for disability.