Types of fractures
- Congenital fractures:
occurring in utero, due to underdevelopment of the fetal bone skeleton, and when force is used to remove the fetus during childbirth. - Acquired fractures:
those that occur during human life. They are distinguished into traumatic and pathological fractures. - Traumatic fractures:
occur under the influence of a mechanical force that exceeds the elasticity of normal bone. - Pathological fractures:
appear as a result of osteomyelitis, tuberculosis, syphilis, echinococcosis of bones and other pathological processes. They can occur with minor trauma or in the absence of any mechanical factors.
Most often, bone fractures occur during sudden movements, impacts, compression, lifting, falling from a height, twisting, twisting and eversion of the limbs.
Based on the presence or absence of damage to the skin, fractures are divided into closed and open. Open ones are considered more dangerous, as they can be accompanied by increased pain, heavy bleeding, infection of soft tissues and bones.
Fractures without displacement and with displacement of bone fragments are also distinguished.
According to location, fractures are divided into epiphyseal, metaphyseal and diaphyseal
- Epiphyseal
fractures are the most severe. They can lead to displacement of the articular surfaces and dislocations. If the bone is damaged within the joint capsule, then such fractures are called intra-articular. These fractures cause severe pain and dysfunction of the joint. - Metaphyseal
(periarticular) fractures are fixed by the common adhesion of one fragment to another, or impacted fractures.
According to the mechanism, fractures can be caused by compression, compression, twisting and avulsion.
According to the degree of damage, fractures can be complete - through the entire thickness of the bone - and incomplete, if there is a partial violation of the integrity of the bone.
Depending on the number, fractures are divided into single, if the fracture is in one bone, and multiple, if there are several fractures in one or more bones.
Open fracture
All open fractures are considered bacterially contaminated. Microbial invasion of a wound can cause a number of complications: anaerobic, putrefactive, purulent, as well as the development of tetanus. The likelihood of infectious complications increases with weakened immunity, local circulation disorders, the presence of non-viable tissue and extensive damage. Gunshot fractures are especially dangerous in this sense, since in such cases a significant array of non-viable tissue is always formed, there are foreign bodies in the wound, and the local blood supply deteriorates due to contusion.
The main method of instrumental diagnosis of open fractures is radiography of the damaged segment. In some cases, MRI may be additionally prescribed to assess the condition of soft tissue structures. With open fractures, there is a fairly high risk of compromising the integrity of nerves and blood vessels; if such damage is suspected, consultation with a neurosurgeon or vascular surgeon is necessary.
For open fractures, regardless of the size of the wound, surgical debridement is indicated. The optimal timing of surgical intervention is the first hours after injury. During the operation, the traumatologist removes all non-viable tissue, including contaminated small bone fragments, and uses special nippers to “bite off” the contaminated ends of large fragments. Loose clean fragments cannot be removed. The doctor washes the wound with antiseptics, sutures the skin and, if necessary, the muscles, without putting sutures on the fascia.
In case of significant skin defects, to prevent necrosis, before applying sutures, releasing incisions are made on the sides of the wound. In some cases, primary skin grafting is performed. After treatment is completed, drainage is installed in the wound. Contraindications for applying primary sutures are extensive contaminated and crushed wounds with detachment of soft tissue, as well as the presence of signs of local infection (swelling and hyperemia of the skin at the edges of the wound, purulent or serous discharge). If it is impossible to apply primary sutures, then primary delayed (after 3-5 days), early (after 7-14 days) or late (after 2 or more weeks) secondary sutures are applied to the wound. A prerequisite for delayed wound suturing is the patient’s satisfactory condition and the absence of signs of acute purulent inflammation.
The presence of a contaminated wound often significantly limits the traumatologist’s ability to immediately restore the normal relationship of fragments. Carrying out closed reduction is often difficult, since rough manipulations in the wound area are impossible. Holding fragments with a plaster cast also becomes problematic, since access to the wound for dressings must be provided for at least 10 days.
Treatment tactics are chosen taking into account the characteristics of the injury and the patient’s condition. Osteosynthesis using submersible metal structures is rarely used, since the presence of primary bacterial contamination sharply increases the likelihood of suppuration. Absolute contraindications to primary osteosynthesis are shock, intense bleeding, extensive, crushed and heavily contaminated wounds. If it is impossible to adequately compare the fragments, in such cases a temporary plaster cast or skeletal traction is applied, and subsequently, after the wound has healed and the patient’s condition has improved, delayed osteosynthesis is performed.
A promising method for treating open fractures is compression-distraction devices. The advantages of this method include the absence of metal structures in the fracture area (this reduces the risk of suppuration) and maintaining free access to the wound with reliable fixation of fragments. Along with surgical methods, conservative treatment methods are also widely used - skeletal traction and plaster casts. Both options have their advantages and disadvantages.
Skeletal traction makes it possible to maintain access to the wound and, if necessary, carry out additional correction of the position of the fragments. A significant “disadvantage” of this method is the long-term forced immobility of the patient, which is fraught with muscle atrophy and the development of post-traumatic contractures. In most cases, a plaster cast allows the patient to maintain a fairly high level of motor activity, but sometimes makes access to the wound difficult and immobilizes 2 or more joints of the affected limb.
Along with PSO and restoration of the normal position of fragments, treatment of open fractures necessarily includes antibiotic therapy, pain relief, physiotherapeutic procedures and exercise therapy. In the presence of traumatic shock, anti-shock measures are carried out at the initial stage, followed by correction of the condition of all organs and systems. During the rehabilitation period, patients are referred to exercise therapy and physiotherapy.
Treatment of an open fracture using a compression-distraction device
Signs of a fracture
A fracture can be diagnosed based on a number of signs:
- sharp, severe pain in the corresponding area;
- swelling of the tissue;
- swelling;
- clearly visible deformation of the damaged area;
- limited body movements or inability to do so;
- forced adoption of a certain posture to overcome severe pain;
- shortening of limbs;
- pain when tapping;
- sounds of bone fragments crunching under the surface of the skin.
How to distinguish a fracture from a dislocation
A fracture is a break in the integrity of the bone, while a dislocation is a rupture of the joint capsule and ligaments. This can lead, for example, to sprains. In this case, movements are completely blocked. At the same time, during a fracture, the damaged bones are quite mobile and therefore require immediate immobilization.
If a dislocation occurs, severe pain is felt in the joint, it swells, and a change in shape and unevenness of the surface are visually noticeable. Moreover, during a dislocation, the length of the limb and its shape never change, but the joints themselves are displaced. If a fracture occurs, the length of the bone, on the contrary, may change.
First aid for a closed fracture
If it is possible to call an ambulance, then do so. Then keep the injured limb immobile, for example, place it on a pillow and keep it at rest. Place something cold on the suspected fracture area. The victim himself can be given hot tea or a painkiller to drink.
If you have to transport the victim yourself, you must first apply a splint from any available materials (boards, skis, sticks, rods, umbrellas).
Any two solid objects are applied to the limb from opposite sides on top of clothing and secured securely, but not tightly (so as not to interfere with blood circulation) with a bandage or other suitable materials at hand (sash, belt, tape, rope).
It is necessary to fix two joints - above and below the fracture site. For example, in case of a tibia fracture, the ankle and knee joints are fixed, and in case of a hip fracture, all joints of the leg are fixed.
If there is absolutely nothing at hand, then the damaged limb should be bandaged to the healthy one (arm to the body, leg to the second leg).
A victim with a broken leg is transported in a lying position; it is advisable to elevate the injured limb.
Publications in the media
Fractures of the calvarial bones usually occur at the site of force. There are linear and depressed fractures. A LINEAR FRACTURE usually occurs as a result of a blow from a large area object. In itself, it does not have much clinical significance (with the exception of fractures of the squama of the temporal bone - see Epidural hematoma). Diastatic fracture is one of the types of linear fracture, characterized by the transition of the fracture line to one of the sutures of the skull (more often occurs in children). Diagnostics: craniography. The main distinguishing features of a linear fracture, vascular groove and cranial suture are as follows: • Linear fracture: color on the radiograph is almost black, the course is straight, there is no branching, the width is very narrow • The vascular groove: gray in color, the course is curved, usually branched, wider than the fracture line • Skull suture: gray in color, the stroke for each suture is standard, connects with other sutures, is of considerable width, has a jagged edge. No treatment is required , except in cases of a “growing fracture” (occurs in young children).
A DENTED FRACTURE occurs as a result of a blow to the head with a hard, small-area object (hammer, steel pipe, etc.). It is characterized by the introduction of bone fragment(s) into the cranial cavity, which can lead to local contusion, crushing of the brain, rupture of the membranes, and the formation of hematomas. Diagnostics . Craniography and CT Treatment . For an uncomplicated depressed fracture, conservative tactics are acceptable. In all other cases, surgical intervention is necessary - removal of bone fragments or their reposition. Indications for surgical treatment: depression of more than 8–10 mm or the thickness of the bone, focal neurological symptoms corresponding to the location of the fracture, signs of damage to the meninges (leakage of cerebrospinal fluid, cerebral detritus), open fracture. A relative contraindication is an asymptomatic closed depressed fracture in the area of the main sinuses of the dura mater. The prognosis depends on the volume of the affected area of the brain and its functional significance. Surgery to repair a depressed fracture does not affect the risk of developing late post-traumatic epilepsy. Note. In newborns and children of the first year of life, there is a specific depressed fracture of the bones of the calvarium of the “ping-pong ball” type. Treatment is indicated only for localization in cosmetically significant areas (for example, frontal). Synonym. Compression fractures of the skull
ICD-10. S02 Fracture of the skull and facial bones.