Treatment of radius fractures

Knee surgery // Epiphysiolysis - fractures in the area of ​​the growth plate of the bone

The growth zone of bone is an area of ​​developing cartilage tissue at the ends of long bones. The growth plate regulates and determines the length and shape of mature bone.

Bones grow from the growth plate zone. After the body matures, the growth zone closes and bone growth stops. The growth plate is located between the metaphysis

(extension at the end of the bone) and
the epiphysis
of the bone.

location of the growth plate at the end of the femur

Statistics

Epiphysiolysis accounts for 15 to 30% of all childhood fractures. These fractures are a medical emergency because they can cause bending and differences in limb length.

Fracture healing occurs faster in children than in adults.

A pediatric orthopedic surgeon who performs the appropriate examination will help determine the nature of the growth plate injury, select the appropriate treatment method, and schedule follow-up to evaluate the recovery process.

Fractures in the area of ​​the growth plate are common, but they usually do not pose a serious problem. Bone deformation accompanies epiphysiolysis only in 1-10% of cases.

Volkmann's ischemic contracture

Ischemic contracture develops as a result of prolonged (measured in hours) and significant (but not complete) disruption of arterial blood flow in the limb. This complication occurs after injury to the extremities and can be caused by impaired blood flow at any level of the artery. The most common forms of ischemic contracture complicate trauma to the upper limb and are predominantly found in childhood. Typically, ischemic contracture develops with supracondylar and condylar fractures of the humerus and with fractures of the bones of the forearm. In most cases, ischemic contracture is observed with tightly applied circular plaster casts, leading to disruption of the blood supply to the limb. Compression of the neurovascular bundle can occur even with a correctly applied plaster cast, but with a subsequent increase in edema. This applies to those cases when observation of patients was insufficient: the plaster cast was not cut in a timely manner and was not loosened. Volkmann's contracture can be the result of a bruise, kinking or compression of the artery by displaced fragments, the result of spasm, thrombosis, embolism, partial or complete damage to the artery, the formation of an aneurysm, etc. Primary changes occur in the muscles (primarily the deep flexor of the digitorum), sensitive and motor nerves of the forearm (median, ulnar and anterior interosseous nerves of the forearm). Insufficient blood supply to the limb with any disturbance of blood flow is enhanced by a reflex spasm of the arteries and collaterals. The developing venous and capillary stasis contributes to increased swelling, pressure and tension in the soft tissues under the deep fascia of the shoulder and forearm, which further impairs the blood supply to the muscles and nerves.

Symptoms and recognition. The most important thing is that the diagnosis of developing ischemic contracture be made within the first 1-2 hours. The main signs are pain in the flexor muscles of the forearm, despite good reduction of the fragments. Usually, if there are no complications, pain after reduction decreases or disappears completely. An important symptom is pallor or cyanosis of the fingers. Constant signs are the disappearance of the pulse in the radial artery, increasing swelling and coldness of the limb. The sensitivity and movement of the fingers are gradually impaired, they take a flexion position. Any attempt to actively or passively straighten the fingers causes excruciating pain.

Treatment. If the symptoms mentioned above are present, immediate action must be taken. A delay of 2-3 hours can lead to irreversible changes. The plaster cast must be immediately cut along its entire length and removed, despite the fact that this may involve repeated displacement of the fragments. The forearm should be extended to PO-120° and a plaster splint fixed with a simple bandage should be applied, or the arm should be suspended using cutaneous traction in the same position. A case blockade according to Vishnevsky in the upper part of the shoulder is shown. The elbow and forearm are covered with ice packs. If in the next 1-2 hours the symptoms of circulatory disorders remain persistent or increase, you should proceed with the operation without unnecessary hesitation. A delay of 3-4 hours may be an irreparable mistake and lead to irreversible impairment of limb function.

An S-shaped incision is made in the elbow bend (Fig. 62), which begins at the inner edge of the biceps muscle and continues on the forearm to the wrist joint. The fascia and fibrous bridge are dissected. The biceps muscle is retracted outward, and the brachial artery and median nerve are examined. The hematoma is removed. Sometimes this is enough to improve blood supply to the limb. If the brachial artery is severely injured and noticeably narrowed, then the narrowed part over 3-4 cm should be resected, and the proximal and distal ends of the artery should be ligated. This is usually

relieves spasm of collateral vessels. Additionally, both superficial and deep fascia are dissected on the forearm and the intermuscular septa are pulled apart. Then only the skin is sutured. After conservative treatment, as well as after surgery, if the fragments have re-displaced, reposition begins no earlier than 2-3 weeks later.

Rice. 62. Surgery for developing Volkmann's contracture.

A – skin incision; b – dissection of the fibrous bridge in the elbow bend and dissection of the fascia “a” of the forearm; c – exposure of the brachial artery and median nerve – muscle separation.

Treatment of persistent ischemic contracture should be carried out comprehensively, including medication and physiotherapeutic measures, as well as therapeutic exercises both in the preoperative and postoperative periods. Among the surgical interventions, depending on the indications, transplants of the superficial flexors according to Kausch-Epstein-Rosov to the deep flexor tendons, neurolysis, removal of the proximal row of carpal bones, arthrodesis of the wrist joint, etc. are used.

Risk group

The risk group for developing epiphysiolysis includes:

• Fractures in the growth plate are twice as common in boys as in girls.
• Actively growing children. The peak incidence of epiphysiolysis is observed in adolescents.
• A third of all cases of epiphysis occur in sports such as football, basketball and gymnastics.
• In 20% of cases, fractures in the area of ​​the growth plate occur during recreational physical activity: cycling
• sledding, skateboarding, skiing or skating

Classification of epiphysiolysis

Currently, several classification systems have been developed. The most common system is probably the Salter-Harris classification.

Treatment

Type I fractures

• May interfere with bone growth.
• Many fractures of this type are treated with plaster immobilization, but surgery may also be required. The surgery usually involves placing an intramedullary (inside the bone) pin, which holds the fragments in place and recreates the normal axis of the bone.

Type II fractures

• These fractures usually heal well, but may require surgical treatment. They are the most common type of fractures in the growth zone of bones.
• Most fractures of this type are treated using plaster immobilization.

Type III fractures

• Type III fractures are most common in older children. Due to the beginning ossification of the growth plate, the fracture line does not pass through the entire bone, but bends, which is accompanied by the breaking off of a section of the epiphysis.
• Fractures of this type require surgical treatment and internal fixation, which restores the normal anatomy of the growth plate and articular surfaces.

Type IV fractures

• These fractures usually stop bone growth completely.
• They require surgical treatment with internal fixation.

Humerus fractures

When indicated, reposition is usually performed in a hospital setting under general anesthesia and periodic monitoring of an X-ray screen. After reduction for abduction fractures, the arm is fixed in the average physiological position. In case of an adduction fracture with displacement of fragments, it is not always possible to compare bone fragments using conventional reposition, and therefore it is advisable to use the method developed by Whitman and M.V. Gromov. During the reposition process, one of the assistants fixes the shoulder girdle, and the other carries out constant traction along the length of the limb, moving the arm upward as much as possible. At this time, the surgeon places the fragments in the correct position, pressing on their ends (be careful - the neurovascular bundle!). The arm is fixed with a plaster cast, which goes onto the body, in the position in which the correct position of the fragments has been achieved. The duration of fixation in a plaster splint is 2 weeks (the time required for the formation of primary callus). On the 14-15th day, the thoracobrachial bandage is removed, the arm is transferred to the mid-physiological position and a plaster splint is again applied for 2 weeks (a total immobilization period of 28 days). Against the background of physical therapy and physiotherapy, movements in the shoulder joint are restored in the next 2-3 weeks.

In case of epiphysiolysis and osteoepiphysiolysis with significant damage to the growth zone in the long term, impaired bone growth in length can be caused. Dispensary observation is carried out for 1.5-2 years.

Humeral shaft fractures are uncommon in children. The clinical picture is typical. Fractures in the middle third of the humerus are dangerous due to possible damage to the radial nerve, which bends around the humerus at this level. Displacement of fragments can cause traumatic paresis or, in severe cases, disruption of the integrity of the nerve. In this regard, all manipulations for a fracture in the middle third of the diaphysis of the humerus must be performed with extreme caution. The method of one-stage closed reduction followed by fixation in a plaster splint or the method of skeletal traction of the proximal metaphysis of the ulna is used, which gives the best result. If, during subsequent X-ray monitoring, secondary displacement of the fragments is detected, then it is eliminated by applying corrective rods. Pay attention to the correctness of the axis of the humerus, because displacement of bone fragments along the length of up to 2 cm is well compensated, while angular deformations during growth are not eliminated.

Fractures of the distal humerus are common in children. They account for 64% of all humerus fractures. For diagnosing injuries in the area of ​​the distal metaepiphysis of the humerus, the most convenient is the classification proposed by G. A. Bairov in 1960.

Transcondylar and supracondylar fractures of the humerus are not uncommon in children. The fracture plane in transcondylar injuries passes through the joint and is accompanied by rupture of the articular capsule and capsular-ligamentous apparatus (95% of all injuries). In supracondylar fractures, the fracture plane passes through the distal metaphysis of the humerus and does not penetrate the joint cavity (5%). The mechanism of injury is typical - a fall on an arm extended or bent at the elbow joint. Displacement of the distal fragment of the humerus can be in three planes: anteriorly (with a flexion trans- or supracondylar fracture), posteriorly (with an extension fracture), outward - to the radial side or inward - to the ulnar side; rotation of the fragment around its axis is also noted. If the displacement is significant, disruption of innervation may occur as a result of injury to the ulnar, radial or median nerve. It is important to promptly identify peripheral circulatory disorders. The pulse in the radial and ulnar arteries may be absent for 4 reasons: due to post-traumatic spasm of arterial vessels, compression of the arterial vessel by a bone fragment or increasing edema and hematoma, and rupture of the neurovascular bundle (the most serious complication).

For trans- and supracondylar fractures of the humerus with displacement, conservative treatment is used in the vast majority of cases. Closed reduction is performed under general anesthesia and periodic X-ray monitoring. The introduction of novocaine into the fracture area does not provide sufficient anesthesia and muscle relaxation, which makes it difficult to manipulate the fragments and keep them in the reduced position. After a good comparison of bone fragments, monitoring the pulse is mandatory, since compression of the brachial artery by edematous soft tissue is possible. After reposition, a deep posterior plaster splint is applied in the position of the arm in which it was possible to fix the bone fragments.

In case of significant swelling and failure of one-stage closed reduction, it is advisable to use the method of skeletal traction for the proximal metaphysis of the ulna with a load of 2 to 3 kg. If the fracture is unstable (more often observed with an oblique plane), you can use percutaneous fixation of bone fragments according to K. Papp (diafixation) or percutaneous osteosynthesis with crossed Kirschner wires according to the Judet technique. If conservative treatment fails and there is unacceptable displacement of the fragments, open reduction may be necessary. The operation is performed in extreme cases: with repeated unsuccessful attempts at closed reduction, with interposition of the neurovascular bundle between fragments with the threat of the formation of Volkmann's ischemic contracture, with open and improperly healing fractures.

Among the complications that are possible with this type of fracture, it should be noted myositis ossificans and ossification of the joint capsule. They are observed in children who undergo repeated closed reductions, accompanied by the destruction of granulations and primary callus. According to N.G. Damier, ossification of the joint capsule most often develops in children with a tendency to form keloid scars.

If internal rotation and inward displacement of the distal fragment of the humerus are not corrected during treatment, they lead to varus deformity of the elbow joint. When the forearm axis deviates by 15° in girls and 20° in boys, a corrective transcondylar wedge osteotomy of the humerus is indicated.

It is performed no earlier than 1 to 2 years after the injury using the Bairov-Ulrich method. Preliminary calculation of the volume of proposed bone resection is important. X-rays of two elbow joints are taken in strictly symmetrical projections. The axis of the humerus and the axis of the forearm bones are drawn. Determine the value of the resulting angle a. The degree of physiological deviation of the forearm axis on the healthy arm is measured - angle /3, its value is added to the value of angle a and thus the angle of the proposed bone resection is determined. The angle on the contourogram is plotted in the area of ​​the distal metaphysis of the humerus at the level or slightly below the apex of the olecranon fossa. The sides of the wedge should be as close to each other as possible.

Fractures of the epicondyles of the humerus are typical injuries for childhood (most common in children from 8 to 14 years old). They belong to apophyseolysis, since in most cases the fracture plane passes through the apophyseal cartilaginous zone. The most common avulsion of the medial supracondyle of the humerus occurs. Its displacement is associated with tension on the medial collateral ligament and contraction of a large group of muscles attached to the epicondyle. Often, separation of this epicondyle in children is combined with dislocation of the bones of the forearm in the elbow joint. When the capsular-ligamentous apparatus is ruptured, a displaced bone fragment can penetrate into the cavity of the elbow joint. In such a case, the apophysis is pinched in the humeroulnar joint; possible ulnar nerve paresis. The consequences of untimely diagnosis of a torn medial epicondyle embedded in the joint cavity can be severe: impaired articulation in the joint, stiffness, wasting of the muscles of the forearm and shoulder due to partial loss of arm function.