Fractures

Fractures - damage to the bone with a violation of its integrity. Traumatic fractures usually result from the sudden impact of considerable mechanical force on a healthy bone, for example, in road traffic accidents. Pathological (spontaneous) is called a fracture altered by any previous pathological process of bone with a relatively minor injury. Both parts of the disconnected bone are called fragments, and smaller fragments Damaged in the fracture zone of the bone are fragments. Traumatic fractures, depending on the condition of the integument (skin, mucous membranes) are divided into closed and open. With closed fractures, the integrity of the integument is not violated, although there may be abrasions. When an open fracture in its area, a wound is formed, through which the damaged bone and surrounding soft tissues can be infected.

A special group consists of gunshot fractures, which are among the most serious injuries. Depending on the type of wounding projectile, it can be bullet and fragmentation fractures, the nature of injury - through, blind and tangential.

There are transverse longitudinal, oblique, helical, T-shaped, Y-shaped, stellate and perforated fractures, as well as fractures with or without displacement of fragments. Fractures of the bones with the surviving periosteum (by the type of "green twig"), which are more common in children, are designated as subperiosteal. The fractured fracture is characterized by the insertion of one fragment into another, while the wedged fracture destroys and spreads the fragments of the latter. In the spongy bone, there may be so-called compression fractures (as a result of compression), in which structural destruction of the bone occurs.

Localization distinguishes diaphyseal, epiphyseal (intraarticular) and metaphyseal (periarticular) fractures. Fractures can be accompanied by mutual displacement of articular surfaces - dislocations or subluxations (for example, fracture of the ankles with subluxations of the foot). These fractures belong to the group of so-called fractures. Fractures with one or more fragments are considered to be comminuted. If the bone on a considerable extent turns into a mass of small and large fragments, the fracture is designated as broken. Fractures within one anatomo-functional formation are called isolated, in two or more anatomo-functional formations in one or more segments of the limb - multiple. Fractures with simultaneous damage to the internal organs are usually called combined, for example, fracture of the pelvic bones with damage to the bladder, fracture of the spine with damage to the spinal cord. Children have a special type of fracture - the so-called epiphiseolysis - the slippage (separation) of the bone epiphysis along the line of the neostegenous growth cartilage.

Clinical picture . The general condition of the victims in most fractures is satisfactory or of medium severity, less often severe. However, with multiple fractures, especially in the presence of open or combined injuries, as a rule, rapidly develops severe or extremely serious condition, and sometimes traumatic shock .

In the fracture region, swelling and bruising are usually noted. The limb function is in most cases broken. Active and passive movements are painful and limited. However, sometimes, for example, with nested fractures of the femoral neck, some patients continue to move even, which can lead to displacement of the fragments. Unconditional symptoms of fracture are deformity of the limb in combination with abnormal mobility in the fracture region, crepitation of fragments and shortening of the limb. With cracks, subperiosteal, punctured, intraarticular and periarticular fractures, some of these symptoms may be absent. With intraarticular fractures, hemarthrosis (hemorrhage into the joint cavity), rotational or lateral dislocations, as well as movements that normally occur in this joint do not occur.

When examining a patient, it is necessary to check the presence of a pulse below the fracture level. Particular care must be taken to assess the condition of victims who are unconscious or in heavy alcohol intoxication. Along with the fracture, they can have life-threatening injuries to the thoracic or abdominal organs, severe traumas of the brain and spinal cord, etc.

Particular attention deserves open fractures. Typically, microbial tissue contamination (and the likelihood of infection) with small wounds is less than with extensive deep and severe skin damage and underlying soft tissue. Often, the area of ​​soft tissue damage is much larger than the size of the cutaneous wound. A broken bone can be exposed on a larger or smaller extent or not at all. The more extensive, deeper and more significant the damage to the skin and underlying soft tissues, as well as bone with open fractures, the greater the likelihood of developing a serious infection - purulent, anaerobic or putrefactive. With open fractures, damage to the main vessels occurs much more often than in the case of closed fractures, as a result of which blood supply to the limb can be impaired, up to the development of gangrene.

In children, fractures occur more often in the elbow joint area: supra- and supra-lateral, detachable, fractures of the medial epicondyle, combined with a dislocation of the forearm bones, fractures of the block and head of the humerus, the neck of the radius and elbow, tearing fractures of the coronoid process. In newborns, fractures can occur during childbirth (see Birth trauma of newborns).

Fractures are a common trauma in elderly and elderly people. It contributes to involutive processes in the musculoskeletal system (osteoporosis, fragility and fragility of bones, loss of elasticity of the cartilage). Fractures of the neck of the femur and the vertex, the surgical neck of the humerus, the spine, the forearm in a typical place, and some others may occur in elderly people and with a relatively minor injury.

Complications . In patients with fractures, especially with multiple and combined injuries, with open fractures, pelvic or hip fractures, shock , fat embolism , traumatic toxicosis, anemia may develop. Fractures in the elderly are often complicated by pneumonia, and in persons with chronic alcoholism, acute psychosis. With open and gunshot fractures (especially with extensive damage to tissues), suppuration of the wound, osteomyelitis. Late complications include delayed fusion of bones and the formation of a false joint, incorrect fracture fusion, contractures, posttraumatic arthrosis, edema, etc.

The diagnosis . For diagnosis, a well-collected history, aimed at elucidating the conditions and mechanism of injury, is of great importance. Circumstances and the mechanism of the resulting fracture are often very typical. For example, compression fracture of the spine is often caused by a fall from the height to the gluteal region, fracture of the heel bones - a fall from height to foot, fracture of the pelvic bones and ribs - compression in the anteroposterior or lateral direction; Fracture of the neck of the femur and a vertebral fracture (especially in the elderly) - a fall on the side and a bruise in the area of ​​a large trochanter; Fractures of the bones of the foot and hand - the falling heavy objects on them; Fracture of the forearm in a typical place - by falling on an outstretched arm in the position of the rear bending of the hand. Some types of fractures are observed mainly in certain periods of the year. Thus, fractures of cervical vertebrae often occur in divers when swimming in unequipped water for this purpose, helical fractures of the shins of the shins - in winter skiers.

Of great importance in the diagnosis of fractures is an x-ray study, which allows not only to recognize a fracture with a displacement of fragments, but also to detect cracks, nailed and other fractures. Due to radiography, it is possible to determine the nature of the displacement of fragments, to observe the development of bone calluses, to monitor the results of treatment. In cases where there is a suspicion of damage to bone tissue, X-rays should be made in at least two mutually perpendicular projections. On the roentgenograms, not only damaged, but also adjacent healthy parts of bones should be displayed on a sufficient extent. The main radiographic evidence of bone integrity is the fracture line. A great diagnostic value is the displacement of fragments, the presence of which is an indisputable sign of a violation of bone integrity. In addition to conventional radiography, radionuclide and ultrasound methods of investigation, angiography, etc. are used.

Treatment should begin at the scene. The main tasks of first aid in case of an open fracture are to fight with shock, pain, bleeding, prevent secondary microbial contamination of the wound, immobilize the injured limb by means of transport tires and improvised means, prepare the victim for evacuation and carefully transport it to a medical institution. At the scene of the accident, a sterile bandage is applied to the wound. In cases of open fracture, it is not necessary to insert fragments of bone protruding into the wound through the damaged skin. The pressing cotton-gauze dressing applied to the wound not only protects the wound from contamination, but also, as a rule, allows to stop bleeding. The need for applying a hemostatic tourniquet occurs rarely. When immobilizing a damaged limb, two joints must be immobilized, located above and below the fracture. The first medical assistance to victims with a closed fracture is reduced mainly to temporary immobilization by a transport bus. With diaphyseal fractures of the hip, shoulder, both bones of the lower leg or forearm, a sharp deformation of the limb is possible as a result of angular displacement of the fragments. The paramedic can begin a complex of therapeutic measures aimed at fighting shock, including local anesthesia of the fracture zone. Anesthesia helps to remove the patient from shock and, by reducing muscle tension, facilitates reposition of fragments. Most often with fresh fractures apply local (in the fracture zone) introduction of 20-40 ml of 1-2% solution of novocaine.

The displaced fragments should be accurately compared, this provides anatomical restoration of the length, axis and shape of the limb, and also creates optimal conditions for fracture fusion and the most complete restoration of limb function. It is necessary that the juxtaposed fragments are in an immobilized state until the bone fusion.

The main methods of treatment of bone fractures are skeletal traction, gypsum dressing, external transosseous compression-distraction osteosynthesis with the help of various apparatuses, osteosynthesis by submerged (internal) fixators, endoprosthetics, for example, in fractures of the femoral neck in elderly people. The duration of immobilization depends on the location and type of fracture, as well as on the age of the patient. For fractures of the forearm bones in a typical place, a plaster bandage for adults is imposed for 4-5 weeks, diaphyseal fractures of the forearm bones for 2 to 3 months or more, ankle fractures for 6-12 weeks, fractures of the lower leg for 2-4 months. When punctured fractures of the surgical neck of the humerus, the duration of treatment after the application of the gypsum longus is 7-12 days. It should be borne in mind that after a one-stage reposition of fragments and the imposition of a cast bandage in connection with contraction of the muscles and reduction of the edema, a repeated displacement of bone fragments is possible. Therefore, 7 to 8 days after its application, it is necessary to make a control X-ray. Long-term gypsum immobilization, as a rule, leads to restriction of movements in immobilized joints. In a number of cases urgent surgical intervention is indicated.

In children with diaphyseal and metaphyseal fractures, preference should be given to conservative methods of treatment. In elderly weakened patients it is desirable to use simple, easily tolerated and relatively safe methods of treatment; Avoid treatment methods that force the patient to stay on bed for a long time or make it difficult to move. As a result of a fracture, severe functional disorders can occur that dramatically reduce the work capacity of the victims and often lead to disability. One of the reasons for this, in addition to the severity of the damage and excessively long immobilization, is the underestimation of the role of physiotherapy and physiotherapy in the overall complex of therapeutic measures aimed at restoring bone structure and preventing secondary function disorders (contractures, muscle hypotrophy, etc.).