Fractures: general information

Fractures (fracture) are mechanical damage to bones with a violation of their integrity. Repeated fractures in the same place are called refracture. Symptoms of fractures include pain, swelling, hemorrhage, crepitus, deformation and dysfunction of the limb. Complications of fractures include fat embolism, compartment syndrome, nerve damage, infection. Diagnosis is based on clinical signs and, in many cases, on X-ray data. Treatment includes pain relief, immobilization, and, if necessary, surgery.

In most cases, a fracture is the result of a single, significant force on an otherwise normal bone. Pathological fractures are the result of moderate or minimal force on a bone weakened by cancer or another disease. Stress fractures (such as metatarsal fractures) occur due to repeated external force on a specific area of bone tissue.

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Pathophysiology of fracture

With normal levels of Ca and vitamin D and healthy bone tissue, fractures heal within weeks or months by remodeling: 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 complete bone remodeling, gradual restoration of normal movements of adjacent joints is necessary. However, remodeling can be disrupted, with external force or premature movement in the joints, a re-fracture is possible, usually requiring repeated immobilization.

Severe complications are uncommon. Arterial damage may occur in some cases of closed supracondylar fractures of the humerus and femur, but is rare in other closed fractures. Compartment syndrome or nerve damage may develop. Open fractures predispose to bone infection, which is difficult to treat. In fractures of long tubular bones, a sufficient amount of fat (and other bone marrow components) may be released and fat emboli may travel through the veins to the lungs, causing respiratory complications. Intra-articular fractures are accompanied by damage to the articular cartilage. Irregularities on the articular surface may transform into scars, leading to osteoarthritis and impaired joint mobility.

How do fractures manifest themselves?

The pain is usually of moderate intensity. Swelling increases over several hours. Both of these signs gradually subside after 12-48 hours. An increase in pain after this period of time gives reason to think about the development of compartment syndrome. Other symptoms may include bone tenderness on palpation, bruising, decreased or abnormal mobility, crepitus and deformation.

A patient with signs of a fracture is examined for ischemia, compartment syndrome, and nerve damage. If there is a soft tissue wound near the fracture, the fracture is considered open. The fracture is diagnosed using imaging techniques, starting with direct radiography. If the fracture line is not obvious, bone density, trabecular structure, and cortical plate are examined for small signs of a fracture. If a fracture is strongly suspected but is not visible on radiography or if additional details are needed to select a treatment, an MRI or CG is performed. Some experts recommend examining the joints distal and proximal to the fracture as well.

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

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

According to location, fractures are divided into fractures of the head (possibly involving the articular surface), neck, and diaphyseal fractures (proximal, middle, and distal thirds).

Classification of fractures

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

1. By origin, fractures are divided into traumatic, which occur when a force exceeds the strength of the bone is applied; and pathological, which occur when minor loads are applied to a degeneratively altered bone (with bone tumors, osteomyelitis, cystic dysplasia, etc.).
2. Depending on the condition of the 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. According to the fracture level, the following are distinguished: epiphyseal (intra-articular); metaphyseal (in the humous part); and diaphyseal fractures.
4. According to the fracture line, they are divided into transverse (occur with a direct blow, which is why they are also called bumper); oblique (due to a fracture at one of the fixed ends of the limb); spiral (a fracture occurs at a fixed end of a segment, most often the foot, with a rotation of the body along the axis); longitudinal (when falling from a height of up to 3 m onto a straightened limb); "T"-shaped (when falling from a greater height, when not only a longitudinal splitting of the bone occurs, but also a transverse fracture); linear (with fractures of flat bones, such as the skull, sternum); depressed (with fractures of the bones of the skull with the introduction of a fragment into the cranial cavity); compression (with fractures of the vertebrae with wedge-shaped deformation) and others, including "author's" (Malgenya; LeFort, Pott, etc.);
5. By type of displacement of fragments. If the bone axis is correct and the distance between bone fragments is up to 5 mm, the fracture is considered non-displaced (since this is the ideal distance for fusion). In the absence of these conditions, four types of displacement can be observed (they are often combined): lengthwise, widthwise, at an angle along the axis (rotational).
6. By quantity. Fractures are divided into isolated ones in the area of one segment of the body and multiple ones - in several segments of the body (for example, the femur and shin, pelvis and spine, etc.). In relation to one bone, fractures can be: single, double, triple and multiple (they are considered as a comminuted fracture).
7. According to complications, fractures are divided into uncomplicated, occurring as a local process, and complicated. Complications of fractures include: shock, blood loss (for example, with a hip or pelvic fracture, blood loss is 1-2 liters with the formation of a retroperitoneal hematoma), open fractures, damage to the neurovascular trunk with rupture or strangulation in the area of bone fragments, multiple and combined fractures, damage to internal organs, combined injuries, fracture dislocation.
8. Children may develop two specific forms of fractures that develop as a result of incomplete formation and flexibility of the bone.

Subperiosteal fractures (of the "greenstick" type) without anatomical disruption of the periosteum are classified as the easiest, as they heal in 2-3 weeks.

Osteoepiphysiolysis - fractures with avulsion in the growth zone (usually the shoulder and forearm in the elbow joint area) - the most severe fractures, since aseptic necrosis of the bone head occurs and growth in the growth zone stops. Clinic and diagnostics of fractures

Pathological fractures caused by malignant tumors are painless, in the presence of all other symptoms.

Fractures, like other injuries, are characterized by the following main symptoms: pain (but it is very sharp), which intensifies when trying to move or exert weight; which determines the development of pain contracture (impaired limb function) and the adduction symptom (the victim involuntarily tries to limit movement by pressing the injured segment to the body or another undamaged limb); swelling and bruising (but their severity is more significant than with other closed injuries).

The following specific symptoms are characteristic of fractures: abnormal position of the limb, abnormal mobility, bone crepitus when palpating the fracture zone. These symptoms are not specifically called for due to the possibility of complications, shock, and aggressive reaction of the victim. But if they are visible to the eye or determined by careful palpation, the diagnosis is certain.

Only in doubtful cases can the following methods be used: traction (gently stretching the injured segment) or compression (lightly squeezing the limb segment along the bone axis). A sharp increase in pain is a sign of a probable fracture. Fractures of the spine and pelvis are characterized by the symptom of a stuck heel (the victim cannot lift his foot off the bed). Rib fractures are characterized by a lag in the chest in the act of breathing, pain and difficulty in coughing.

Victims with obvious clinical signs of fractures or in questionable cases should be taken to hospital emergency departments or fully equipped trauma centers (recently, trauma centers located in adapted premises and not having the ability to provide emergency care to trauma patients at the proper level have been transferred to a rehabilitation mode for victims).

At the hospital level, the traumatologist must perform the following measures: fracture anesthesia, radiographic diagnostics and documentation, repositioning and therapeutic immobilization.

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Some types of fractures

Stress fracture

Small fractures resulting from repeated force. They are most common in the metatarsals (usually in runners), and less commonly in the fibula and tibia. Symptoms include gradual onset of intermittent pain that increases in intensity with force and eventually becomes constant. Swelling may occasionally occur. Physical examination reveals localized bone pain. X-rays are taken but may be false negative initially. Many of these fractures are treated presumptively, with x-rays repeated after 1 to 2 weeks, when the callus may become visible. Treatment includes rest, elevation, analgesics, and sometimes immobilization. MRI or CT scans are rarely indicated.

Epiphyseolysis

Bone tissue grows in length through growth plates or growth plates (epiphysis), which are bounded by the metaphysis (proximally) and the epiphysis (distally). The age at which the growth plate closes and bone growth ceases varies depending on the type of bone, but the growth plate disappears in all bones by the end of puberty.

The growth plate is the weakest part of the bone and is usually the first to break when subjected to force. Growth plate fractures are classified using the Salter-Harris system. Future growth impairment is typical for growth types III, IV, and V and is not typical for growth types I and II.

Type I is a complete rupture of the growth plate from the metaphysis with or without displacement. Type II is the most common, the fracture line of the growth plate goes to the metaphysis of the bone with the formation of a metaphyseal splint, sometimes very small. Type III is an intra-articular fracture of the epiphysis. Type IV is a combination of an intra-articular fracture of the epiphysis with a fracture of the metaphyseal part of the bone. Type V is less common than other types, it is a compression fracture of the growth plate.

A growth plate fracture should be suspected in a child with localized pain in this area. These fractures are clinically different from contusions with a circular nature of pain. In fractures of types I and V, radiographs may be normal. In this case, such fractures can sometimes be differentiated by the mechanism of injury (rupture in the direction of the longitudinal axis of the bone or compression). For types I and II, closed treatment is usually used; types III and IV often require ORVF. Patients with type V slipped epiphysiolysis should be under the supervision of a pediatric orthopedist, since these injuries almost always lead to growth disorders.

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X-ray diagnostics of fractures

In case of obvious signs of a fracture, and in doubtful cases, an X-ray examination must be carried out without fail, since an X-ray 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 (hand, wrist, foot and ankle, cervical spine), radiography is performed in three projections. Radiographs in the presence of a fracture are given to the victim or stored in the archive of the medical institution for life.

The description of radiographs is carried out according to a specific scheme:

• date of radiography and radiograph number (to document the dynamics of the studies, since each victim usually undergoes 4-6 studies, to monitor the position of the fragments and the process of fracture healing);
• the anatomical segment reflected on the radiograph and the number of projections are indicated;
• if there is a fracture: its location and type are indicated - level, fracture line, displacement of bone fragments;
• provide an X-ray conclusion about the diagnosis;
• During the process of fracture healing, an assessment is made of the position of the bone fragments and the condition of the bone callus.

Treatment of fracture

Immediate treatment includes pain relief and, if instability or fracture of a long bone is suspected, splinting. An open fracture requires sterile dressing, tetanus prophylaxis, and broad-spectrum antibiotics (eg, a combination of a second-generation cephalosporin and an aminoglycoside).

In cases of rotational and/or angular displacement and deformation, repositioning is indicated. The exception is diaphyseal fractures in children, where remodeling gradually corrects some types of angular displacement, and end-to-end alignment of bone fragments can stimulate bone growth, which may then become excessive.

Surgical treatment may involve fixation of bone fragments with metal structures [open reduction and internal fixation (ORIF)]. ORIF is indicated for:

• intra-articular fractures with displacement (for precise alignment of articular surfaces);
• for certain fractures when more reliable fixation of bone fragments is required;
• if closed reposition is ineffective;
• if the fracture line passes through the tumor (there will be no normal healing of the bone in this area).

Since ORVF provides structural stabilization immediately after its implementation, thereby facilitating early mobilization of the patient, the method is indicated in clinical situations where prolonged immobilization necessary for callus formation and remodeling is undesirable (e.g., femoral neck fracture). Surgical treatment is necessary when major vascular injury is suspected (for their reconstruction), in open fractures (for irrigation, debridement, and infection prevention), or after an unsuccessful attempt at closed reduction (for open reduction and, in some cases, internal fixation).

Whether or not a fracture requires reduction and/or surgery, it is usually immobilized with the joints proximal and distal to it. A plaster cast is usually left in place for weeks or months, but splints may be used, especially for fractures that heal more quickly with early mobilization. Home treatment includes supportive measures such as rest, ice, compression, and elevation.

The patient is advised of the need to seek immediate help if signs of compartment syndrome appear.

Rehabilitation therapy

Restorative treatment of fractures (rehabilitation), after repositioning and immobilization, can also be performed by a surgeon. It should begin as early as possible. With high-quality repositioning, the main direction of rehabilitation measures includes: accumulation of calcium salts in the fracture zone (prescription of calcium preparations, as well as agents stimulating its absorption: methandrostenolone and methyluracil; locally, calcium chloride electrophoresis can be used); and improvement of microcirculation in this zone by using microwave therapy or magnetic therapy. In the presence of concomitant diseases of the vessels of the extremities, their complex treatment must be carried out without fail, since the injury itself causes their aggravation, and a decrease in blood flow leads to a slowdown in fracture healing.

After immobilization is removed, joints should be developed and muscle trophism should be restored. This is done using passive and active therapeutic exercise, massage, and developing joint movements "through pain and tears." Development in warm water with salt (1 tablespoon per glass of water) is significantly easier. Baths with various salts, preferably sea salts, hydromassage from the fingertips to the center, the use of mud (preferably brine with iodine, sulfur or radon), and magnetotherapy are effective. In the absence of metal structures, microwave therapy and electrophoresis with potassium iodide, lidase or ronidase can be used. In case of contractures, phonophoresis of hyaluronidase preparations can be used, but with great caution, since other physiotherapy methods are contraindicated for six months after ultrasound. Only complete restoration of limb function is an indication for closing the sick leave. If complications develop or rehabilitation measures prove ineffective, the victim is declared disabled.