If a bone fracture occurs in old age...

Each of us had major or minor injuries during our lives, but after each fall we got up and moved on because there were no fractures. However, in older people, a fracture can occur as a result of minor trauma (for example, tripping) or even without it. Why do people break bones more and more often as they get older?

To better understand why older people can experience fractures even without serious injury, we first need to understand what osteoporosis is.

Osteoporosis is a chronic and progressive disease characterized by a decrease in bone mass, i.e. bone mineral density, and changes in bone structure, resulting in decreased bone strength and a significantly increased risk of fractures.

Reduced bone mineral density is a major risk factor for bone fractures. But bones also become more fragile for other reasons, for example, due to a sedentary lifestyle or a previous fracture, the use of glucocorticosteroids in connection with treatment, for example, rheumatoid arthritis. Risk factors for osteoporosis are divided into two groups.

Risk factors that cannot be influenced:

fractures in first-degree relatives (for example, parents) as a result of osteoporosis;
age;
female.

Risk factors that can be influenced and changed:

alcohol consumption;
smoking;
insufficient intake of calcium and vitamin D;
insufficient sun exposure;
early menopause (menstruation ends before age 45);
low body weight (body mass index less than 18–19 kg/m2);
sedentary lifestyle;
increased risk of falls.

Scientists have discovered that the risk of bone fractures increases as a person ages. The older a person is, the greater the risk of fractures, even if there is no significant trauma (for example, a fall from a great height or a car accident). With severe osteoporosis, a fracture of the forearm bones can occur even if a person simply leans on this arm to get out of bed! Often people don't even realize they have osteoporosis until the first fracture occurs.

Loss of bone mineral density occurs most rapidly in women after menopause (on average, after age 50). However, it should be taken into account that osteoporosis is not only a “women’s” disease; As men age (usually after 70 years of age), their bones also become more fragile, and as a result, the risk of fractures increases.

Every year in Europe, more than 2 million fractures occur due to osteoporosis! Every second woman and every fourth man after the age of 50 may have a fracture due to osteoporosis! According to the International Osteoporosis Foundation, an osteoporotic fracture occurs every 3 seconds!

Data from the United States Osteoporosis Risk Assessment Study indicate that the risk of osteoporotic fractures increases after menopause. If a woman has had a fracture of the radius (the largest bone of the forearm) after menopause, then in the next 3 years there is a high risk of breaking any other bone due to osteoporosis, even if the results of bone mineral density measurements on osteodensitometry were normal and there are no risk factors osteoporosis.

If the fracture occurred after the age of 50, you should remember that:

the fracture may be due to loss of bone mineral density, i.e. due to osteoporosis;
If the fracture was due to osteoporosis, then the risk of hip fracture increases significantly, i.e. femur;
In the case of osteoporosis, there is treatment that must be started immediately after the fracture has occurred!

If a fracture does occur, a traumatologist will handle the treatment. To understand the treatment of fractures, it is necessary to understand what a bone fracture is.

A bone fracture is a soft tissue injury that disrupts the integrity of the bone. Osteoporosis most often results in fractures of the radius (one of the bones of the forearm), humerus, vertebrae (these fractures occur most often), and the femoral neck.

Most often, as a result of a fall, one of the bones of the forearm is injured - the radius. Why this particular bone? When falling, for the purpose of self-defense, a person straightens his arms straight in front of him as a support. As a result, the radius bone breaks approximately 2.5 cm above the wrist joint. Of course, the fracture line may be in another place, the wrist joint may be affected, and the fracture may also consist of several small pieces, or fragments, of bone.

What complaints will there be with a fracture?

The most common complaints with a fracture are pain, limited movement in the affected area, swelling, and there may also be subcutaneous hemorrhage. The patient himself often notices the deformation of the injured area (see Fig. 1).

Rice. 1. Deformation of the right forearm as a result of a fracture of the radius

If you break your arm, remember the following:

remove all jewelry from the injured hand;
apply cold to the area where it hurts;
relieve your hand by hanging it in a triangular scarf!

Duration of bone healing after a fracture

Those who are interested in how quickly bones heal after a fracture need to know that the healing process depends on many factors. It can occur differently in all people, and even an experienced doctor cannot always say exactly how long it will take for bone function to be fully restored.

Here are some important factors that influence fusion time:

Age. In young people, regeneration occurs much faster than in older people. In childhood, complete recovery may take even less time and undesirable consequences are usually not observed at a young age.
Type of injury. With a closed fracture, the bones will heal faster than with an open one. During an open fracture, an infection often enters the human body, which will slow down the recovery process or complicate it with additional problems. If ligaments and muscles were damaged during an open fracture, regeneration will take a long time.
Structure and size of bones. Spongy bones (for example, carpal bones) grow together much faster than tubular and flat bones. Smaller bones will heal faster than larger ones.
The presence of inflammatory processes or multiple injuries. With extensive damage, the body quickly uses up energy and cannot quickly cope with a heavy load. If several fractures occur at the same time, each bone will heal more slowly than in the case of a single injury.
Providing first aid. If a person consults a specialist some time after the injury, additional damage is possible, and therefore healing will take longer. If care is provided incorrectly, hemorrhages and injuries are possible, which negatively affects the fusion process and disrupts blood circulation in the damaged bone.
Poor metabolism and weight problems. Exhaustion of the body or excess body weight negatively affects bone healing. Impaired metabolism also slows down regeneration.

All these factors must be taken into account, and in order for the fracture to heal faster, you can take simple actions that have a positive effect on the healing process.

What happens in a hospital emergency room or emergency room?

Upon arrival at the medical facility, the traumatologist on duty will talk with the patient and an x-ray of the injured arm will be taken. Taking into account the results of the examination, a decision will be made on further treatment tactics or on the necessary additional examinations. Since a fracture of the radius most often occurs, in continuation of the article we will talk about the treatment of just such a fracture.

Rice. 2. Fracture of the bones of the right hand with displacement of parts of the bone, i.e. with dislocation

The doctor on duty, having seen on the x-ray a fracture of the radius with displacement of bone fragments, i.e. with dislocation (see Fig. 2), under local anesthesia he will perform a manipulation to restore the anatomical structure of the bone, i.e. closed reduction. To ensure that the bone fragments do not move again and the bone can heal, a plaster splint is applied. that is, gypsum. After applying the plaster splint, a repeat radiograph is taken to ensure that the displacement of the bone fragments has been corrected (see Fig. 3).

Rice. 3. Fracture after reduction and application of a plaster splint

A plaster splint is applied so that the injured arm can move in the elbow joint and in all finger joints. In the first days, finger movements may be painful, but then the pain will decrease. If severe pain occurs when moving your fingers, then these movements are performed using your healthy hand. Once the displacement of the fracture bone is corrected and the anatomy of the wrist joint is restored, the patient can go home and continue treatment as an outpatient. The plaster splint must be worn for up to 6 weeks.

If the doctor was unable to restore the anatomical structures of the bone by performing a closed reposition manipulation, then surgery is necessary. In this case, the patient must remain in the hospital or be given instructions when to report for surgery. The final decision - whether to agree to surgery or not - is made by the patient himself; the doctor only recommends the best treatment option.

Bone Regeneration: Basics

Reparative regeneration is the restoration of damaged or lost tissue. The degree and quality of the regenerative process in different tissues is different. The higher the differentiation of the tissue (nervous, muscle), the less ability it has to restore its structure. Therefore, anatomical restoration of the damaged area occurs by replacing the defect with connective tissue - a scar. Damaged bone tissue is able to go through a number of stages of the reparative process and restore its anatomical shape, histological structure and functional suitability.

A bone fracture is accompanied by damage to adjacent soft tissues and causes a stressful situation, which is accompanied by local and general reactions of the body. During the process of bone tissue restoration, complex general and local biological and biochemical changes occur, which depend on the blood supply to the bone, the age of the patient, the general condition of the body, and the quality of treatment.

What should you do after receiving help?

As a result of the fracture, swelling of the surrounding tissues occurs, which persists even after the application of a plaster splint. To avoid increasing swelling, the injured arm should be kept elevated. This is best done with a triangular scarf.

In the first 48 hours after injury, cold compresses can be applied to the injured wrist joint for 15 minutes every hour. Cold compresses must be applied very carefully so as not to wet or otherwise damage the plaster splint. If there is pain, it is recommended to take painkillers (non-steroidal painkillers) according to the manufacturer's instructions.

To ensure that after 6 weeks there are no difficulties moving the injured arm in the shoulder, elbow and finger joints, it is important to do exercises for all of these joints several times a day!

After 5–7 days, you need to visit a traumatologist and take an x-ray of the injured arm again - this can also be done in a clinic. Taking into account the results of the x-ray, the traumatologist will set a date for the next visit (usually in 5–7 days). If the bone heals well, the last visit to the doctor will be in 2-3 weeks, when the plaster splint is removed.

important to remember! If, while at home, after applying a plaster splint, you experience severe pain in your hand (more severe than before the injury), significant swelling has formed, it is difficult to move the fingers of the injured hand, or numbness in your fingers has appeared, you should immediately consult a doctor!

If during the first or second visit the traumatologist discovers that a repeated shift has occurred, he will offer you treatment for the fracture during surgery. And in this case, the decision to continue treatment is made by the patient himself.

Sources of regeneration

Restoration of bone integrity occurs through the proliferation of cells of the osteogenic layer of the periosteum, endosteum, insufficiently differentiated pluripotent cells of the bone marrow, as well as due to metaplasia of giaraosseous tissues.

Modern ideas about the processes of bone tissue regeneration combine the concepts of neoplastic and metaplastic theories. Preosteogenic cells are considered osteoblasts, fibroblasts, osteocytes, pericytes, histiocytes, lymphoid, fat and endothelial cells, cells of the myeloid and erythrocyte series.

During the fusion of broken bones, a staged pattern of reparative osteogenesis has been established, which is conditional. The division into stages is not of fundamental importance, since they overlap in dynamics.

Even with ideal reposition and fixation of fragments, differentiation of various cells occurs simultaneously, and therefore the stages of the reparative process are difficult to distinguish. But to choose the optimal treatment tactics for patients, you need to have an idea of the patterns of reparative osteogenesis.

What should you do when the plaster splint is removed?

After removing the plaster splint, you need to develop movements in the wrist joint of the injured hand - first passive movements (when movements are made with the help of a healthy hand), then active (when movements are made by the injured hand). The time to restore movement is individual for each patient.

In order to promote the development of movements, paraffin applications, chamomile baths or pine buds are recommended. Physiotherapy (for example, magnetic therapy), which is recommended by a traumatologist or rehabilitation specialist, is also possible. If necessary, a consultation with a physiotherapist, rehabilitation specialist or occupational therapist will be scheduled to help restore movement in the wrist joint. On average, within two or three months after removal of the plaster splint, a gradual restoration of movements occurs, provided that the patient follows the instructions of the attending physician, orthopedic traumatologist, physiotherapist, rehabilitation specialist or occupational therapist.

Remember!

Fractures occur more often among older people!
In older people, fractures can be due to minor trauma or even without it, and most often the radius, femoral neck, and vertebrae are fractured.
If a fracture occurs in an elderly patient, you need to remember about osteoporosis!

Assistive devices and additional activities

Simple additional remedies that can be used at home will help increase the patient’s comfort during recovery after a broken leg:

Orthopedic insoles. They help not to overload the injured limb, relieve stress from bones and joints.
Belt. Special straps are attached to the bed, so the patient receives additional support when sitting down or standing up. Patients with a hip fracture especially need such a device.
Crutches or cane. Depending on the severity of the injury, in the early recovery period the patient may require assistance while walking. Auxiliary supports will relieve excessive stress from the limbs and give the patient confidence during movements.

Rehabilitation measures provide for a uniform increase in the load on the body. Initially, the doctor prescribes simple breathing exercises to the patient, which help saturate the body with oxygen and develop the respiratory system. Afterwards, exercise is added, which is aimed at developing general body mobility. After about a month, physical exercises are expanded and divided into two groups:

general – aimed at improving the health of the whole body;
special ones - restore the damaged area.

Properly selected gymnastics and a course of physical therapy restore blood circulation, strengthen muscles, resume motor activity and prevent complications.

X-RAY DIAGNOSIS OF SKELETAL FRACTURES

Traumatology

- this is the field of dramatic medicine, the field of stressful conditions, where there is a struggle between the living and the dead, from the cell to the whole organism, where the fate of a person and the quality of his subsequent life are decided.

In this work, we would like to recall some important concepts for practice regarding the most common traumatic injuries of the skeleton, clarify the terms accepted in trauma institutions, and help practitioners in the ability to recognize and describe the most common traumatic injuries of bones.

Introduction

So, a few general rules:

All parts of the skeleton (with rare exceptions) should be photographed in two mutually perpendicular projections.
To avoid missing dislocations in injuries, photographs of long tubular bones should be taken with the capture of the nearby joint, and in case of fractures of the forearm and tibia - of the entire segment of the limb with the capture of the corresponding joints.
The size of the cassette and the magnitude of the irradiated field must correspond to the object of interest. Focal length - 60-100 cm, depending on the size of the object being photographed and whether a screening raster is used or not.
An important indicator of the correct choice of placement during radiography of the joint is the identification of the joint space.
With the development of osteosclerosis and massive callus, it is necessary to additionally take hard and superexposed images, and to identify early cloud-like callus, “soft” images are advisable.
If juvenile epiphysiolysis is suspected, a Lunstein photograph should be taken. This projection allows us to better identify the posterior displacement of the femoral head, which is characteristic of such fractures.
It is advisable to perform an X-ray examination of the thoracic spine using zonography techniques.

The main radiological symptoms of fractures are the line (plane) of the fracture and bone deformation caused by displacement of fragments. In the spongy substance, the fracture line appears as a band of clearing and a break in the trabecular pattern. The fracture line is more clearly identified in the break of the compact substance. The contours of the fracture line are usually uneven, finely toothed, and zigzag. The trabeculae of adjacent fragments are interrupted and protrude freely into the transparent strip of the fracture line. The fracture line visible on the x-ray is a reflection of the fracture plane, the nature of the image of which depends on its shape and on the direction of the x-ray beam. If the fracture plane runs perpendicular to the film, it appears on the radiograph as a light stripe. If the fracture plane has a complex spatial orientation, then the destroyed areas of one half-cylinder are projectively layered onto areas of the preserved bone of the other half-cylinder, as a result of which the fracture line is poorly visible on the radiograph. In such cases, it can only be visible in the cortical region.

With impacted fractures without displacement, the fracture line does not look like a clearing, but a compaction, and only after a week, when the bone trabeculae in the fracture area are partially reabsorbed, the fracture plane appears as a clearing strip.

Fractures can be complete or incomplete. Incomplete fractures are called fissures. In such cases, the fracture plane does not pass through the entire bone mass, but extends only to part of it. On an x-ray, the crack is visible as a thin line, which is gradually lost in the unchanged bone structure.

Both ends of the separated bone in the fracture area are called fragments; smaller fragments in the fracture zone are called splinters.

Based on localization, they are divided into diaphyseal, epiphyseal (intra-articular), metaphyseal (periarticular).

Depending on the mechanism of action, fractures are divided into:

to the sides (offset in width);
longitudinal (displacement along the length with the passage of fragments one after another, with divergence and wedging, impacted, compression;
flexion (bending), displacement of fragments at an angle to each other;
torsion (displacement along the periphery, rotation of fragments around the longitudinal axis of the limb;
avulsion (stretching), most often observed avulsion of the condyles;
like a green (willow) twig (subperiosteal);
"banana" fractures;
epiphysiolysis (displacement of the epiphyses of bones along the line of non-ossified growth cartilage);
depressed fractures of the calvarial bones;
chronic fractures (Loozero zone of restructuring).

Angular misalignment is the most common type of misalignment.

If there are two fragments - proximal and distal - they speak of a simple fracture. If there are two or more large segmental fragments along the bone, they speak of a multiple (double, triple, etc.) fracture. Fractures with one or more fragments are considered comminuted. If a bone, as a result of injury, turns into a mass of small and large fragments, the fracture is called comminuted. Fractures with simultaneous damage to internal organs are usually called combined.

Fractures can be combined with dislocations or subluxations. In these cases they are called fracture-dislocations.

After manual reposition, secondary displacement of fragments often occurs, regardless of the method of fixation, which leads to unsatisfactory treatment results.

Secondary displacement can be especially pronounced in patients with well-developed muscles due to the traction effect of muscles on bone fragments.

Of particular interest are fractures in deforming osteodystrophy (Paget's disease). Despite the increase in thickness and density of bone tissue, with this disease the bones lose mechanical strength. S. Reinberg believes that the incidence of fractures in Paget's disease reaches 30-40%. The X-ray picture of a bone fracture in Paget's disease is characteristic: a violation of the integrity of the bone does not occur in typical places, as in normal bones, but is usually observed in the area of the diaphysis of a long tubular bone. The fracture line runs strictly transversely, that is, the fracture plane is perpendicular to the long axis of the bone. The edges of the bone fragments are smooth, and the jaggedness characteristic of other fractures is absent. A Paget's disease fracture can be compared to a banana fracture, which is why it is called a "banana" fracture. Healing of a fracture in Paget's disease usually occurs within normal periods.

Healing of fractures

Fracture healing occurs mainly due to periosteal granulation tissue, from which the so-called callus is formed. The endosteal reaction also plays a role in callus formation to some extent.

Callus formation goes through three stages: connective tissue, osteoid and bone. Blood leaking from the ruptured vessels forms a hematoma in the fracture area. Already in the first hours after the injury, a huge number of young connective tissue elements - fibroblasts - rush into the resulting fibrinous-bloody clot from the bone marrow and periosteum. During the first 7-10 days, a nodule of proliferating connective tissue forms in the area of the fracture. Then, over approximately the same time, the metaplastic transformation of immature connective tissue into osteoid occurs. Lime is deposited into the resulting osteoid substance, thus forming a callus.

The process of bone regeneration goes through the stage of compaction of the fracture line. This dark fracture line is called a bone suture. In adults, the first tender, cloud-like foci of calcification appear on x-ray images no earlier than 3-4 weeks on average. At the same time or several days earlier, the ends of the fragments become somewhat dull, the contours of the cortical fragments in the area of the callus become uneven and blurred. Subsequently, the shadow of the callus becomes more intense and takes on a focal granular character. Then the individual sections merge, and with complete calcification, the callus takes on the appearance of a circular homogeneous coupling. Gradually, the shadow of the callus thickens, and bone consolidation occurs. The fracture line disappears between the 4th and 8th month. The timing of callus formation depends on many reasons: the location of the fracture, the age and general condition of the patient, the presence of concomitant diseases, infection, the degree of fixation of fragments, etc.

Pronounced clinical healing of fractures of various bones occurs at different times: phalangeal bones - 2.5 weeks; metacarpal, metatarsal bones and ribs - 3 weeks; collarbone - 3.5-4 weeks; bones of the forearm, ankle - 7-8 weeks; shoulder diaphysis - 6-7 weeks; tibial diaphysis, humeral neck - 8-9 weeks; both bones of the lower leg - 10 weeks; vertebrae - 16-18 weeks; pelvis - 10 weeks. Of course, these terms should be considered conditional, approximate, since the process of bone repair depends on many conditions. The process of bone structure restructuring lasts about a year. The fracture line disappears between 4 and 8 months.

Relatively stable fractures require only minimal callus formation. Stable internal fixation of the perfused bone fully activates the “healing potential”, resulting in the “welding” of well-matched and stably fixed fragments, and then direct healing of the fracture without callus formation. By analogy with wound healing, this type of restoration of bone integrity is called primary or direct healing.

The timing of callus formation depends on many reasons: the location of the fracture, the age and general condition of the patient, the presence of concomitant diseases, infection, the degree of fixation of fragments and other reasons.

In some cases, for various reasons, the healing process of the fracture is interrupted. Fibrous or cartilaginous tissue forms between the main fragments of the fracture, which prevents the consolidation of the fragments. Pseudarthrosis develops. Most often this occurs after conservative treatment of a fracture. The causes of pseudarthrosis are varied: impaired blood supply and reduced ability to regenerate, poor reposition, too much distraction of bone fragments and lack of their sufficient contact, insufficient fixation of fragments, loss of bone substance, early application of physical activity. When fragments are displaced, muscles, blood vessels, and nerves may be pinched between them (soft tissue interposition). Their untimely release can cause paralysis, impaired circulation in the limb, and nonunion of fragments.

With poor reposition due to constant irritation and injury to the bone ends in the fracture area, excessive bone formation occurs, which does not lead to consolidation of the fragments. The touching ends of the fragments are shortened and smoothed, all jagged edges and irregularities in the fracture line disappear. In a false joint with close contact of bone fragments, their ends are connected by fibrous tissue. In old cases of non-union of a fracture, after 6-8 months something resembling a “new joint” develops with all the elements of a normal joint. One of the fragments expands in a saucer-like manner, taking the shape of a glenoid cavity, the other is rounded, taking on the appearance of a head. Both are covered with hyaline or fibrous cartilage, and the surrounding fibrous tissue takes on the appearance of a joint capsule. The bone marrow canals of adjacent bone fragments are closed by thick plates of compact bone substance; X-ray photographs show an overdeveloped callus and a wide gap in the newly formed pathological joint. With significant bone diastasis, a so-called dangling false joint develops. The ends of the fragments in these cases are sharply atrophied, acquiring an irregularly pointed shape, sometimes with spikes at the ends.

A pathological fracture is a violation of the integrity of the bone due to a previous pathological process accompanied by destruction. The most common causes of pathological fracture are fibrous osteodystrophy and new bone formations (primary or secondary).

Scull

Fractures of the calvarium are divided into linear, depressed, comminuted and perforated. Linear fractures and cracks are sometimes difficult to recognize. Sometimes they are visible only on special styling. For fractures of the base of the skull, survey films are ineffective. Therefore, negative data from conventional radiography in standard projections have no value.

In flat bones of the calvarium, the fracture line may have a zigzag appearance and be difficult to distinguish because the fracture lines of the outer and inner plates may intersect.

There is a problem of overestimation of indications for traditional X-ray examination of the skull. This applies to headaches and skull injuries. Numerous studies have shown that life-threatening factors are brain damage - concussion, shock, general or local cerebral edema, intra- or extracerebral hematomas, subarachnoid or ventricular hemorrhages, and not skull fractures. It has been shown that, although skull fractures are often combined with brain injuries, almost every case of a serious intracranial complication is manifested by clinical symptoms sufficient to make a correct diagnosis.

Thus, we see that conventional radiography of the skull in traumatological practice does not solve diagnostic problems and is associated with high radiation exposure and significant economic costs. These findings motivated the development of criteria that would increase the likelihood of identifying skull fractures. Such criteria are loss of consciousness, vomiting, penetrating wounds to the skull, discharge from the ear or nose, blood in the middle ear, “spectacles” symptom, coma or stupor, focal neurological symptoms, etc.

It is for this reason that the World Health Organization, in its report (“Effective selection of diagnostic images in clinical practice.” Report of the WHO scientific group. Series of technical reports 795. Geneva, 1992), when making decisions regarding therapeutic measures for head injuries, recommends focusing more on the neurological status than radiographic data.

Reparative processes for skull fractures are very weakly expressed, periosteal callus practically does not develop.

In case of traumatic injuries of the facial skeleton, only fractures of the lower jaw are easily diagnosed.

Spine

A compression fracture of the spine is typical. The lower thoracic and upper lumbar parts of the spinal column are most often affected. The first places in terms of frequency of damage are occupied by Th12 and L1.

With a compression fracture, the anterior part of the vertebral body is usually flattened, resulting in a wedge-shaped appearance on a lateral radiograph. An important difference between traumatic compression and metastatic vertebral destruction is the preservation of the arches and intervertebral joints. Sometimes the body of the damaged vertebra protrudes beyond the anterior contour of the spinal column. The density of the vertebra increases.

With luxation fractures, in addition to a fracture of the vertebral body, damage to the arches and processes, primarily articular ones, and displacement in the form of a bayonet-shaped deformity of the spinal column often occur.

In case of injuries to the cervical vertebrae, it is advisable to take photographs of the upper cervical vertebrae through the mouth to exclude rotational subluxation of C1.

Dislocations and subluxations of the cervical vertebrae

Displacement during dislocations of the cervical vertebrae occurs between the articular surfaces of the lower articular process of the overlying vertebra and the upper articular process of the underlying vertebra. The overlying vertebra is considered dislocated. Dislocations occur during sudden rotation, sudden flexion and extension. Especially often, dislocations of the cervical vertebrae occur when falling on the head, when divers hit their heads on the bottom, or in car accidents.

Traumatic spondylitis (Kümmel's disease)

The essence of the disease has not been definitively established. It occurs mainly in those engaged in heavy physical labor.

S. Reinberg distinguishes three stages in the course of this disease. The first is the acute injury stage. The second is the stage of imaginary well-being, the light period lasts from several weeks to several months, the patient forgets about the trauma he suffered. The third is the stage of relapse: pain appears in the bruised area of the spine, most often in the lumbar region. Radiographs reveal a compression fracture pattern. The body of one of the vertebrae decreases in height, mainly in the anterior section, the intervertebral spaces retain normal height, and angular deformation of the spine appears.

The formal radiological picture of Kümmel lesion of the spine resembles tuberculous spondylitis. However, unlike tuberculosis, with traumatic Kümmel spondylitis there is no leaky abscess, and there is no damage to adjacent vertebrae characteristic of tuberculosis.

Spatula

Fractures of the scapula are relatively rare and occur when falling on the back or as a result of a direct blow. Transverse fractures of the scapula below its spine are more common, fractures of the neck and processes are less common, and longitudinal fractures are extremely rare. Radiologists often make mistakes in interpreting the relationship of the bones of the acromioclavicular joint.

Normally, the upper surface of the clavicle is located above the acromion process of the scapula, which is often perceived as a subluxation. You should focus on the lower surface of the head of the clavicle and the acromion process, which normally form a straight line. A step-like deformation of the lower contour of the joint indicates the presence of a dislocation.

Shoulder

When examining the shoulder, radiography is usually performed in two standard projections. Due to severe pain and the danger of secondary displacement of fragments, an axial photograph of the shoulder joint should not be taken. In such cases, in order to exclude dislocation of the head of the humerus, it is recommended to perform an x-ray of the shoulder joint in a lateral projection through the chest from the uninjured side (the beam is directed through the armpit).

Forearm

A typical (classical) fracture is the distal metaepiphysis of the radius. It accounts for about 70% of forearm fractures. The fracture line passes at a distance of 1.5-2 cm from the articular surface. Often combined with avulsion of the styloid process. Typically this fracture is intra-articular with a T-shaped fracture line. An extra-articular extensor fracture of the radius in a typical location is called a Collis fracture, and a flexion fracture in the same location is called a Smith fracture. The purpose of the reposition is to eliminate the angular displacement of the distal fragment, since this is of great importance for restoring hand function.

An isolated fracture of the radial shaft with dislocation of the radioulnar joint is called a Galeasi fracture. An isolated fracture of the radial diaphysis may be accompanied by dislocation of the head of the ulna, posterior dislocation of the ulna in the elbow joint with separation of the coronoid process. These features of forearm bone fractures should be taken into account during radiography: radiographs of the forearm should include the elbow and wrist joints.

A fracture of the head of the radius is always intra-articular, since the articular capsule is attached along the edge of the articular cartilage of the head.

Subluxation of the radial head is often observed in children, but diagnosing it presents significant difficulties due to the presence of several points of ossification. Traumatologists use the following rule: the axis of the proximal end of the radius (above the level of the tuberosity), extended to the head of the capitate eminence of the humerus, divides it into two equal parts. This rule is valid for photographs in any projection. When the head of the radial bone is displaced, the axis divides the capitate eminence into two unequal parts.

A typical Monteggia fracture-dislocation is a forearm injury. It is characterized by a fracture of the ulna diaphysis at the border of the proximal and middle thirds with significant angular displacement and dislocation of the radial head. Timely identification of this fracture in its entirety is of great importance for proper treatment and outcome. Unfortunately, radiologists, surgeons and traumatologists often make mistakes in diagnosing this type of fracture. Dislocation of the radial head is especially common. An overlooked and unreduced dislocation of the head of the radial bone leads to severe limitation of the function of the joint, which subsequently develops deformity of the elbow joint and forearm. In advanced cases, treatment with conservative methods is impossible.

Let us give one example typical for this situation. An 8-year-old girl fell from a swing, injuring her forearm. At the emergency room, the x-ray technician took a methodologically correct picture. The surgeon on duty saw in the image an obvious fracture of the radius with a typical angular displacement, but due to ignorance, did not recognize the dislocation of the radius. He put on a plaster cast, sent the girl home, and the next day did not consult the victim with a traumatologist. In violation of all the rules, the radiologist did not take part in the diagnostic process, did not look at the radiograph and did not record its description in the medical history. A month and a half after removing the plaster cast, dysfunction of the elbow joint was discovered - it did not work. According to the stereotype, it was recommended to “develop” the joint. Did not help. And only then was a control photograph taken, which revealed a dislocation of the radius in the elbow joint. It was necessary to perform an osteotomy of the healed fracture of the ulna, apply metal pins and surgically reduce the dislocation of the radius. After six months of ordeal and suffering for the child and parents, the function of the joint was restored at the Central Institute of Traumatology and Orthopedics.

Unfortunately, situations like this are typical. Thousands of people become disabled due to illiteracy, great arrogance and carelessness of doctors who so irresponsibly decide the fate of the patient. The staff of the institution where this happened strongly defended the hapless colleague. Criminal negligence was completely dismissed, the case was regarded as a diagnostic error, and we are not punished for this.

Brush

The hand consists of the metacarpus and wrist. Fractures of the bones of this part of the skeleton occur for various reasons: a fall, a direct blow, etc. In the wrist, the scaphoid bone is most often broken, less commonly the lunate and triquetrum.

A typical fracture of the base of the first metacarpal bone (Bennett's fracture), which usually proceeds quite favorably. This fracture is often accompanied by dislocation of the distal fragment.

Pelvis

Injuries to the pelvic bones are divided into two main groups: 1) isolated fractures of individual bones without violating the integrity of the pelvic ring; 2) fractures with disruption of the integrity of the pelvic ring. The first group includes avulsions of bone fragments at muscle attachment sites, fractures of the iliac wing and sacrum. It should be remembered that fractures of the coccyx practically do not occur, but subluxations and dislocations are possible.

For fractures of the second type, one should be guided by the “donut rule”, which always breaks in at least two places. In accordance with this rule, if you find a fracture on one side of the pelvic half-ring, you should look for a fracture on the opposite side.

Hip

When radiography is performed in a direct projection, dislocation of the femoral head upwards and downwards is easily recognized. However, photographs in direct projection cannot indicate the absence of displacement of the femoral head posteriorly or anteriorly. It should be borne in mind that dislocation or subluxation of the head posteriorly, as a rule, is accompanied by a fracture of the posterior edge of the acetabulum. In this case, an additional photograph should be taken in the lateral projection - with the patient positioned on the injured side with the opposite side tilted to the plane of the table by 25-30o.

The femur most often breaks at the head and neck of the femur.

Femoral neck fractures most often occur in older people, who already have static-dynamic disturbances and reduced reparative abilities.

Typical fractures of the upper third of the femur are: fracture of the femoral head, medial or subcapital fracture of the femoral neck, lateral or intertrochanteric fracture of the femoral neck, pertrochanteric fracture, subtrochanteric fracture.

The closer the fracture plane is to the head, the less likely it is to heal. Due to poor blood supply and poorly developed periosteum, a subcapital fracture usually does not heal.

Intertrochanteric fracture (lateral neck fracture) is the most common fracture of the upper third of the femur. The fracture line passes through the intertrochanteric ridge and the intertrochanteric line. This is a partially intra-articular fracture. In a pertrochanteric fracture, the greater trochanter, neck, and head of the femur remain in a single unit. It is difficult to distinguish a pertrochanteric fracture from an intertrochanteric one, so in difficult cases it is better to talk about an intertrochanteric-pertrochanteric fracture. Intertrochanteric and pertrochanteric fractures are often impacted, are not accompanied by large displacement of fragments, and most often proceed favorably and end in consolidation.

A subtrochanteric fracture is easily recognized.

In the distal femur, supracondylar fractures are typical.

A hip fracture is a tragedy for an elderly person with reduced skeletal regenerative capacity. It is often accompanied by complete immobility of a person. The only treatment option is often endoprosthetics surgery, the outcomes of which are difficult to predict.

Shin

Condylar fractures are intra-articular fractures or T- and Y-shaped fractures of the upper end of the tibia. The intercondylar eminence is torn off along with the anterior cruciate ligament.

In the distal tibia, a supramalleolar Malgaigne fracture is typical. The fracture line passes through the metaphysis of the tibia. In adolescence, the fracture plane involves the medial part of the growth cartilage. The fibula usually breaks higher, at the border with the middle third of the diaphysis. This fracture is extra-articular. As a rule, there is a significant displacement of the distal fragments along with the foot outward.

A transmalleolar (dimalleolar) Dupuytren's fracture is also typical. The fracture line of the medial malleolus lies at the level of the main joint space, and the fracture of the fibula is located slightly higher. There is usually significant outward subluxation of the foot. Often there is a tear of the posterior labrum (posterior malleolus) of the tibia. In such cases, the fracture is called a trimalleolar fracture. A fracture of the posterior ankle causes posterior subluxation of the foot.

Fractures of the diaphysis are most often helical (spiral-shaped). In oblique and spiral fractures of the tibial shaft, a fracture of the proximal end of the fibula usually occurs; therefore, for such fractures, radiography of the tibia is necessary, including the knee joint.

Foot

In the talus, a transverse fracture of the neck is most often observed, separating the body of the bone from its head. A similar fracture often occurs when falling from a height with emphasis on the legs.

An isolated fracture of the posterior process of the talus should be differentiated from an accessory triangular bone that arises as a result of non-fusion of the posterior process of the talus with its body. In this case, the accessory bone, unlike a fracture, has a clearly defined compact plate along its entire perimeter.

Loozero perestroika zones

Loozer zones are a kind of restructuring of bone tissue, expressed in the form of areas of rarefaction of the bone structure. Loozer zones can be called a chronic fracture, since they develop, as a rule, at points of greatest overload. Thus, the “marching foot” or “marching fracture”, the fracture of recruits, is well known. This condition causes severe pain in the foot. At first, no changes are detected on radiographs. After a few weeks, a band of clearing several millimeters wide appears in the bone, penetrating the cortical and spongy substance over the entire width of the bone. A reactive ossifying periostitis, which is a bone callus, develops around the Loozero zone of restructuring. In the vast majority of cases, the second metatarsal bone is affected.

In rare cases, zones of restructuring appear in other bones (most often the tibia and femur) in the form of marginal surface defects of the cortical substance, surrounded by a zone of periosteal reaction. Unloading the limb in combination with conservative therapy leads to complete recovery.

Fractures in children

Pediatric traumatology has its own characteristics associated with the anatomical and physiological characteristics of the growing bone. The presence of radiolucent zones and additional ossification nuclei often poses significant difficulties in interpreting the X-ray picture and is the cause of diagnostic errors.

A child's bones are thinner and less strong than those of adults, but they are more elastic and flexible. In young children, an incomplete “willow twig” type fracture is often observed, and in older children, subperiosteal fractures are often observed, often with angular curvature. Displacement of fragments in children is less common than in adults. If there is no displacement of the fragments, then the only sign of a subperiosteal fracture is deformation of the cortical layer, which is not always detected on radiographs. Most often, subperiosteal fractures are observed with fractures of the forearm bones.

Fractures of one of the bones of the forearm with displacement or overlap of one fragment after another are almost always combined with dislocation or subluxation in one of the radioulnar joints.

Another feature of childhood fractures is traumatic osteoepiphysiolysis. In children, the metaphyseal zone is weaker than in adults, so fractures occur here, in the subchondral zone. Most often, traumatic epiphysiolysis is observed in the area of the wrist joint.

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Unfortunately, the length of a newspaper article does not allow us to present a description of all the diverse options for traumatic injuries to the skeleton, so we limited ourselves to presenting the semiotics of the most typical and common traumatic injuries to the skeleton.

Pavel VLASOV, professor.

Department of Radiation Diagnostics, Institute of Advanced Studies

Federal Department of Medical, Biological and Extreme Problems of the Ministry of Health of the Russian Federation.

Olga NECHVOLODOVA, professor.

Central Research Institute of Traumatology and Orthopedics named after. N.N. Priorova.

Overbone osteosynthesis with plates

Bone osteosynthesis is performed using plates of various lengths, widths, shapes and thicknesses, in which holes are made. Through the holes, the plate is connected to the bone using screws. For external osteosynthesis, wire (wrapped wire sutures) and other fixatives are also used.

The latest advancement in bone osteosynthesis is the angular stable plate (LCP). In addition to the threads on the screw, with which it is screwed into the bone and fixed in it, there are threads in the holes of the plate and in the screw head, due to which the head of each screw is firmly fixed in the plate. This method of fixing screws in the plate significantly increases the stability of osteosynthesis.

Plates with angular stability were created for each of the segments of all long tubular bones, having a shape corresponding to the shape and surface of the segment.

Plates for the proximal and distal humerus

Bony osteosynthesis allows for open reduction and perfectly accurate comparison of fragments (directly under visual control at the time of surgery). Therefore, it is the method of choice for osteosynthesis of intra-articular and periarticular fractures, since it is necessary to restore the anatomy of the articular surfaces so that there are no mechanical obstacles to movement in the joint.