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If an open wound is formed over the site of a bone fracture, that is, a violation of its anatomical integrity, then this is an open fracture, which, like a closed one, refers to injuries: according to ICD-10 class XIX, the code is S00-S99.
The size of the wound varies from a small puncture on the skin to a vast rupture of all layers of the skin and the gaping of the damaged soft tissues, often with their detachment and exposure of the bone fragments that enter the open wound cavity.
Causes of the open fracture
The causes of an open fracture are a strong external traumatic (deforming) effect of the residual energy of failure upon impact, fall, collision, accelerated compression, etc. Most of the specific situations in which all these effects manifest themselves are known to everyone and do not need to be listed: this is a fairly large list, including all accidents.
Regardless of how this happened, the pathogenesis of bone fracture of the skeleton is related to the fact that the force of the external action (specific surface energy) on a particular skeletal structure at the time of the fracture is much greater than the limit of the biomechanical strength of the bone - its ability to withstand the impact energy (which bone fabric absorbs just like any other material). Biomechanical resistance of bone is viscoelastic in character and, in addition, varies depending on the speed of application of forces: at high rates of mechanical action, bone tissues retain more energy, which leads to the destruction of their layered-crystalline structure.
The causes of any bone fractures are also seen in the fact that the structure of the bone is not uniform in the transverse and longitudinal directions, because of which the bone has different mechanical properties when loaded on different axes. And most fractures are the result of simultaneous impact on the bone in several directions.
So, stretching leads to a transverse fracture, with longitudinal impact of dynamic compression - oblique (diagonal) fracture. For example, an open fracture of the hip, as a rule, occurs when deformed to bend, when combined compressive and stretching forces acting towards each other are combined. But, since the bones are asymmetric, the compressive and tensile stresses can not be balanced, and the bone is broken.
Symptoms of the open fracture
The first signs of an open fracture of any localization are severe severe pain (up to the development of pain shock), deformity of the fractured limb, and bleeding due to vascular damage.
Rapidly manifested symptoms of an open fracture of any localization include the formation of edema (swelling and the nearby joint) and hematomas at the site of the fracture.
When there is an open fracture of the lower extremities (thighs, lower leg, ankles) or an open fracture of the pelvis, the person is in immobilized position and feels some numbness of the limb (due to nerve damage) and general weakness. Skin pale, chills begin. According to traumatologists, a characteristic feature of an open fracture of the tubular bones of the extremities is the mobility of bone fragments and a crunchy sound when palpation of the fracture site.
An open fracture of the skull is accompanied by the flow of cerebrospinal fluid from the subarachnoid space (through the ears and nose), loss of consciousness, bleeding from the venous collectors adjacent to the bones of the hard shell of the brain. If the temporal bone is broken, bleeding from the ear occurs and it ceases to hear. There is bleeding from the ears and nose, as well as liquorrhea (discharge from the nose of the cerebrospinal fluid) with open fractures of the occipital, latticed and wedge-shaped bones of the skull.
Distinguishing symptoms of an open fracture of the lower jaw: the inability to close the mouth, blood or bruises in the mouth, bloody saliva, teeth of the lower row can be broken. See also - Fracture of lower jaw
If there was an open fracture of the nose, then on the background of intense pain syndrome, nosebleeds are noted (mucous exudate can be isolated from the nasal passages), bruises in the bridge of the nose and sphenoid sinuses, swelling of the mucous nasal passages with a loss of the ability to breathe through the nose.
The classification of open fractures according to Kaplan-Markova determines the degree of tissue damage in case of violations of the integrity of tubular bones, highlighting categories (A, B and B) with subcategories (I, II, III, IV):
Category A - minor local injury: IA (wound size less than 1.5 cm), IIA (wound size from 2 to 9 cm), IIIA (wound size more than 10 cm);
Category B - bruised ragged wounds of soft tissues of medium severity: IB (wound size up to 1.5 cm), IIB (wound 2-9 cm), IIIB (more than 10 cm);
Category B - severe crushed and crushed injuries of soft tissues: IB (at a wound up to 1.5 cm), IIB (2-9 cm), IIIB (over 10 cm).
Categories АIV, БIV and ВIV - open fractures with crushing of bones, destruction of large areas of soft tissues and damage to large blood vessels.
The classification of open fractures by Gustilo-Anderson also determines the severity of the fracture of the limbs according to the size of the wound, the level of its contamination and the degree of soft tissue damage and the level of contamination:
- I type - simple transverse or oblique short fracture, wound <1 cm in diameter, practically clean, soft tissue injuries are minimal (without crushing);
- II type - wound size from 1 cm to 10 cm in length, moderately contaminated laceration without significant crushing of soft tissues;
- III type - open segmental fractures with extensive laceration> 10 cm, soft tissue injuries and degree of contamination of the wound are significant, blood vessels are also damaged;
- type IIIA - fractures with a contaminated wound, extensive crushing of soft tissues and a moderate exposure of the periosteum;
- type IIIB - fractures with a severely contaminated wound, extensive crushing of the soft tissues and a significant exposure of the periosteum; restoration of vessels is required to maintain the limb.
Regardless of the size of the wound, this classification of open fractures to type III automatically refers to an open segmental fracture with displacement, an open fracture from a gunshot wound, fractures of limbs in case of transport accidents and land-contaminated trauma in agricultural work. This includes traumatic amputations and open fractures that occurred 8 hours before seeking medical help.
It should be borne in mind that the appearance of a defect in the skin and soft tissues due to the same traumatic effect that led to bone fracture is defined in clinical trauma as a primary open fracture. And when the skin and soft tissues are damaged by bone fragments, an open fracture is called secondary, and in such cases a wound from the perforation is small (although this does not exclude its infection).
Localization of an open fracture
Injury of the musculoskeletal system - open limb fracture - may affect the peroneal, tibial and femoral tubular bones of the lower limbs; shoulder, elbow or radius of upper limbs.
An open fracture of the femur - the proximal end of the femur, the body (diaphysis) of the femur; supracondylar and supracondylar fractures; open fracture of the ankle (bones of the ankle joint).
An open fracture of the shoulder is a fracture of the diaphysis of the humerus or an epicondyloid fracture of the humerus.
An open fracture of the forearm is a lesion of the ulna or elbow epiphysis (terminal part of the bone); may be an open fracture of the radius. But with serious injuries both ulnar and radial bones are broken simultaneously.
An open fracture of the clavicle is very rare, and in most cases - due to a fall to the side or to the outstretched arms - the clavicle bone breaks in the middle third of the diaphysis.
An open fracture of the pelvis is diagnosed in cases of bone fractures of the pelvic ring - pubic, iliac, ischial, sacrum - if the fragments perforate the skin.
An open fracture of the skull is a fracture of the bones of the cranial vault (neurocranium); most often open fractures (with indentation of the bone fragments) are subject to more subtle temporal and parietal bones, the cranial bone, and also the region of the occipital opening near the base of the skull. And an open fracture of the jaw, a fracture of the eye socket and an open fracture of the nose are the most frequent open fractures of the facial bones of the skull.
Complications and consequences
What is dangerous open fracture? The main danger is that such trauma is accompanied by hemorrhage and internal hemorrhages, leading to significant loss of shelter. Also, with such complex fractures, a traumatic pain shock occurs, and the infection penetrates into the wound. Infection, in turn, is fraught with necrosis of soft tissues and development of gas gangrene and sepsis.
Any localization of an open fracture can have certain consequences and complications.
In the first place, complications include the displacement of bone fragments, which in the diagnosis is defined as an open fracture with displacement. The displacement relative to the physiological position of the bone can be longitudinal, lateral, at an angle, with rotation of bone fragments, and also combined. As a result of displacement of fragments, infringement or a rupture of muscles, tendons, vessels and nerve fibers occurs. In addition, there may be an avulsion - the detachment of a fragment of a broken bone (fragment) from the main mass of bone tissue.
Among the common negative consequences of open fractures, experts note a fatal closure of the lumen of the vessels of the lungs or the brain with particles of fat from the bone marrow of tubular bones (fat embolism)
Intracerebral hematoma and hemorrhages in the brain accompany open fractures of the skull bones.
Due to damage to the peripheral nerves, neurological complications of varying severity develop. For example, in cases of fracture in the occipital foramen, there is a disruption in the conductivity of the wandering, sublingual, and glossopharyngeal nerves, which causes speech, swallowing and breathing rhythm disturbances.
Because of a rupture of the femoral nerve with open fracture of the thigh, extension of the leg is blocked, and after an open fracture of the tibia it is often impossible to unbend the foot and lean on the heel while walking. And an open fracture of the radius can cause dysfunction of the radial nerve, and then there are problems with the extension of the hand and fingers.
Complications of an open fracture of the ankle may manifest as posttraumatic deforming osteoarthritis of the ankle, the formation of a false joint in the area of bone fusion, the development of habitual dislocation of the foot. An open fracture of the forearm can lead to splicing of the radius from the elbow.
An open fracture of the pelvis is fraught with the formation of hematomas in the retroperitoneal space, and can also cause complications such as rupture of the bladder, urethra or rectum; the consequence of a fracture of the ischial knee may be a shortening of the leg from the fracture and a significant limitation of its mobility in the hip joint.
Such consequences and complications, as the curvature of the nose or nasal septum, the violation of nasal breathing, inflammation of the trigeminal nerve, are characteristic of an open fracture of the nose. An open fracture with a shift of the lower jaw bone can disrupt the closing of the dentition and deform the bite.
In addition, for all open fractures, especially with displacement and avulsion, there is a threat of inflammation and necrosis of bone tissue - posttraumatic osteomyelitis.
Diagnostics of the open fracture
For traumatologists and surgeons injuries of this nature are obvious. And the diagnosis of an open fracture, which when the injured person arrives at the trauma center or in the department of traumatology begins with an examination, there are no difficulties.
However, it is only instrumental diagnostics that can be used to determine the degree of damage to bones and soft tissues, as well as to reveal the presence of displacements and fragments. It is the examination of the patient by fluoroscopy (the image is necessarily made in two projections), computed tomography, and fractures of the cranial bones - MRI.
Treatment of the open fracture
The first aid at an open fracture site is as follows:
- it is necessary to stop bleeding: with severe arterial bleeding, by applying a tourniquet above the fracture site and wound (indicating the time of its application), with minor bleeding, of a pressure bandage on the wound area;
- The wound over the fracture should be closed with a sterile bandage, while nothing can be touched at the wound itself;
- give the victim any painkiller.
First aid for an open fracture is carried out until the brigade of the ambulance service arrived. During this time, the victim with an open fracture of the hip, pelvis or skull move or move to another place is not recommended that bone fragments do not damage the larger areas of soft tissue.
To prevent displacement of bone fragments, correct transport immobilization is necessary with open fractures. For example, when the ray bone is broken, a tire is applied, which keeps not only the bones of the forearm in the stationary state, but also the joints - the elbow and the wrist. And with a shin fracture with the help of a tire from improvised materials, it is necessary to fix the knee and ankle joints.
If the victim has an open fracture of the pelvic bones, then it must be placed so that part of the body above the waist is slightly raised, and under the knees (to make them semi-bent), a slight elevation is necessary, which can be made from a rolled-up garment.
When the fracture of the lower jaw is open, transport immobilization is provided by tying the jaw over the head, and the injured person is taken lying down.
Considering the complexity of the trauma, treatment of open fractures is performed in a complex manner.
Treatment of the wound is necessary - see more details - Treatment of open wounds, anesthesia, anti-inflammatory therapy, reposition - anatomically accurate combining of bone fragments - and fixing them in the most appropriate way for each case.
It can be plaster or plastic longa - when an open fracture of the limbs without displacement. But in the presence of bias and bone fragments (in particular, with an open fracture of the thigh or lower leg), skeletal traction under traction is used, which ensures their stable position and thereby contributes to the normal fusion of the fracture.
In most cases, surgical treatment is necessary - in order to properly treat the wound, as well as to make the best possible alignment of the broken bones. After anatomical reposition, fixation is required, for which in the arsenal of surgeons-traumatologists there are special spokes, pins, staples, plates. The most famous apparatus with which external fixation of bone fragments is made is the apparatus of surgeon Ilizarov. Although the BDW pioneer is compression-distraction osteosynthesis (that is, the surgical repositioning of fragments with fixation constructs) - is the Belgian surgeon Albin Lambotte, who worked in the Netherlands, who used the first metal compression-distraction apparatus developed by him in the early 20th century - a simple unilateral external fixator of broken bone.
After the adhesion of the bone, the fixation structures are removed, and the soft tissues are sutured. Surgical treatment of open fractures also includes the removal of damage to the peripheral nerves, which can be carried out at a later date - within three months after the injury (after the detection of certain dysfunctions). These operations are performed by neurosurgeons.
Medicamentous treatment of open fractures
Medicamentous treatment of open fractures is carried out using antibacterial, analgesic, decongestants, immunostimulating, neuroprotective agents.
Applying antibiotics - Amoxiclav, Cefazolin, Ceftriaxone, Metronidazole (Flagil) and others - doctors prevent or significantly reduce inflammatory complications. Amoksiklav is injected into a vein of 1.2 g (children under 12 years of 0.03 g per kilogram of weight) at intervals of not more than 8 hours. A single dose of Cefazolin is 0.5-1 g (for adults), is administered similarly. The side effects of these drugs, common to all antibiotics, include nausea, diarrhea and enterocolitis; urticaria; changes in blood (anemia and leukopenia); increased levels of hepatic enzymes and nitrogen in the urine.
To stop pain injectively or orally, use drugs of the group of non-steroidal anti-inflammatory drugs (NSAIDs): Indomethacin, Ketoprofen, Ibuprofen, etc. Thus, Indomethacin can be administered intramuscularly for two weeks - once or twice a day (60 mg each), and then go to the reception of tablets - 25 mg twice a day, always after a meal. Among the side effects of NSAIDs are headache, gastrointestinal manifestations with pains in the stomach. Therefore, these funds are contraindicated in the presence of peptic ulcer diseases, as well as with bronchial asthma in the anamnesis.
Drugs that stabilize capillaries, for example, Methyl ethylpyridinol or L-lysine exciter, are used against edema. L-lysine is injected into the vein 5-10 ml once a day (with open TBT twice a day) for 3-7 days; The dose for children is calculated by body weight. This drug is not used for renal failure and concurrent with cephalosporin antibiotics; In rare cases, there may be side effects in the form of an allergic reaction.
In addition, with open fractures - the stimulation of tissue metabolism and the regeneration of damaged tissues - it is considered expedient to use the immunomodulating agent Timalin. Intramuscular injections of this drug (a one-time dose of 5 to 20 mg) are done once a day; the course of treatment lasts up to five days.
Calcium gluconate and calcium hydroxyapatite (Osteogenon) contribute to the restoration of bone tissue and fixation of calcium in it. Osteogenon after fractures is recommended to take twice a day (1-2 tablets) for 2.5-3 months. This remedy is contraindicated for problems with the kidneys and patients under 18 years of age.
The drug Gliatilin (Cereton) refers to neuroprotectors and is used to regenerate damaged peripheral nerves, especially with open fractures and other craniocerebral trauma: one capsule per day; In severe cases, the drug is administered parenterally (in droppers).
Rehabilitation after an open fracture
The length of the rehabilitation period, which begins after removal of the longi or compression-distraction apparatus, as well as the forecast of the further condition depends on the localization of the open fracture and the degree of its complexity.
A modern complex of rehabilitation measures that facilitate the return to the affected skeletal structures of their physiological functions includes various physiotherapy procedures, special therapeutic gymnastics, massage, as well as mechanotherapy or prolonged passive joint development - CPM therapy.
This method, the concept of which was created by the Canadian orthopedic surgeon Robert B. Salter (Robert B. Salter) in the 1970s, aims to develop joints after injuries with the help of special devices. CPM-machines cause the joints to bend to a predetermined degree without the involvement of the muscle strength of the patient. In this case, the degree of flexion of the joints increases as the rehabilitation proceeds after an open fracture, and the range of motion gradually expands.
Physicians-rehabilitologists advise you to eat right during the recovery period after an open fracture, using enough protein, vitamins A, C, D and Group B, as well as calcium-rich dairy products and products containing phosphorus (vegetable oils, beans, oats, almonds, nuts) .