Fracture- This medical term, which denotes a broken bone. Fractures are a fairly common problem, and statistically the average person will have two fractures in their lifetime. A bone fracture occurs when physical strength, affecting the bone, turns out to be stronger than the bone itself. Fractures are most often caused by falls, blows, or other injuries.
Risk of fracture is largely related to a person’s age. Fractures often occur in childhood, although fractures in children are usually not as complex as those in adults. With age, bones become more fragile, and fractures usually occur after falls, even those that would not have caused any negative consequences at a younger age.
2. Types of fractures
There are many different types of fractures, but most often Fractures are classified into fractures with displacement and without displacement, open and closed. The division of fractures into displaced and non-displaced fractures is based on the way the bone breaks.
At displaced fracture the bone is broken into two or more pieces that are arranged so that their ends do not form a single line. If a bone is broken into many parts, it is called comminuted fracture. During non-displaced fracture the bone breaks or may develop a crack, but the bone still remains straight and retains the ability to move.
Closed fracture is a fracture in which the bone breaks, but there is no open wound or puncture on the surface of the skin. During an open fracture, the bone may pierce the skin. Sometimes, with an open fracture, the bone may break the skin, but then return to its original position and not be visible upon superficial examination. An additional danger of an open fracture is the risk of infection of the wound and bone.
There are some other types of fractures:
- Incomplete fracture, in which the bone bends but does not break. This type of fracture most often occurs in children.
- Transverse fracture– fracture at right angles to the axis of the bone;
- Oblique fracture– fracture along a curved or inclined line;
- Fracture with multiple fragments and bone fragments;
- Pathological fracture– caused by a disease that weakens the bones. Pathological fractures can be caused by cancer or, more commonly, osteoporosis. The most common fractures that occur due to osteoporosis are the hip, wrist, and spine.
- Compression fracture, which occurs from strong compression.
Fractures are also classified depending on which bone was broken. The most common are leg fracture, hip fracture, arm fracture, spine fracture, femoral neck fracture, finger fracture, ankle fracture, collarbone fracture, rib fracture, and jaw fracture.
3. Signs of a bone fracture
Signs and symptoms of a bone fracture may include:
- Swelling and bruising;
- Deformation of an arm or leg;
- Pain in the damaged area, which intensifies with movement or pressure;
- Loss of function of the damaged area;
- In an open fracture, there is bone protruding from the skin.
The severity of the fracture depends on its location and how much damage to the bone and soft tissue located next to it. Serious fractures without timely treatment dangerous for their complications. This may include damage to blood vessels or nerves, infection of the bone (osteomyelitis) or surrounding tissue.
Recovery time after a fracture depends on the age and health of the patient, as well as the type of fracture. Small fractures in children heal within a few weeks. A serious fracture in an elderly person will require several months of treatment.
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Fracture shin is a fairly common injury, both in adults and children. This fracture can be relatively mild or severe, depending on the number of bone fragments and their relative position, as well as the degree of damage to the surrounding soft tissue. Treatment of a tibia fracture is carried out only by a traumatologist or surgeon on the basis of long-term immobilization (immobilization) of the limb in the knee and ankle joints, necessary for bone fusion. Before immobilization, the bone fragments are compared to their normal position, which is fixed with knitting needles, bolts, plaster, pins and other devices for treating fractures. Treatment of a tibia fracture ends with a period of rehabilitation necessary for the complete restoration of all functions of the leg.Fracture of the leg - definition and general characteristics
The shin is the part of the leg from the knee to the ankle joint. A tibial fracture is a violation of the integrity of any part of the bones that make up a given part of a person’s leg. Since the human shin consists of two bones - the tibia and tibia, a fracture of either one of them or both at once is possible. In principle, most often only a fracture of the tibia is recorded while maintaining the integrity of the fibula. However, there is also a simultaneous fracture of both tibia bones of the leg. A fracture of only the fibula with preservation of the integrity of the tibia is extremely rare.Tibia fractures can vary in severity, depending on how much of the bone is broken, how the bone fragments are located, how much damage there is to soft tissue, blood vessels and joints, and whether there are complications. Therefore, it is impossible to call all tibia fractures relatively mild or severe. The severity of each fracture must be assessed individually, based on the listed signs.
Mild fractures are usually isolated fractures of the tibia, obtained in a fall on the street, skating rink or in another place, and not combined with other injuries to bones and soft tissues. Severe fractures of the tibia occur when performing complex movements, falls from a height, car accidents, etc.
Causes
The main cause of tibia fractures is the impact of a large force on a small area of the bone. The bone cannot withstand very strong pressure and breaks. Most often, great pressure occurs when you fall on a leg that is bent or fixed in an awkward position, for example, in a ski boot, skates, between some objects, etc. Less commonly, a fracture occurs with a direct and very strong influence on the leg, for example, a fall of a heavy object, an impact, etc.Photos of shin fractures
This photograph shows the appearance of a leg with a closed, non-displaced tibia fracture.
This photograph shows the appearance of a leg with an open tibia fracture.
This photograph shows a view of a leg with a closed displaced fracture.
Classification of tibia fractures and brief characteristics of varieties
Currently, there are several classifications of tibia fractures based on the site of injury, the nature, number and location of bone fragments, as well as the degree of damage to soft tissues and joints.Single and multiple fractures of the tibia. Depending on the number of bone fragments formed, tibia fractures are divided into single and multiple. With a single fracture of the tibia, the integrity of the bone is broken in only one place. And in this place there are two free ends of the broken bone (fragment). With multiple fractures, the integrity of the bone is broken in several places simultaneously, resulting in the formation of more than two bone fragments.
Straight, oblique and spiral fractures. Depending on the nature of the fracture line, they are divided into straight, oblique and spiral. If the bone breaks exactly across, then it is a direct fracture. If it breaks diagonally, then it is an oblique fracture. If the fracture line is uneven, resembling a spiral, then this is, accordingly, a spiral fracture.
Smooth and comminuted fractures. In addition, depending on the shape of the edge of the fragment, fractures are divided into even and comminuted. Straight fractures have the same fracture line, which appears to have been neatly filed. Comminuted fractures are uneven breaks that form teeth on the broken bone various shapes and size.
Fractures of the tibia with and without displacement. Depending on the location of the bone fragments, fractures with displacement and without displacement are distinguished. Fractures without displacement are characterized by the normal position of bone fragments relative to each other. If such fragments are simply combined, they form a bone. Displaced fractures are characterized by a change in the position of bone fragments relative to each other. If such fragments are compared with each other, they do not form normal bone. You first need to return them to their normal position and only then compare them. The displacement can be rotational, angular, etc.
Open and closed fracture of the tibia. Depending on the presence or absence of soft tissue damage, tibia fractures are divided into open and closed. Accordingly, open fractures are those in which, in addition to bone damage, there is an open wound formed by torn muscles and skin. One of the ends of the broken bone may stick out in the lumen of this open wound. Closed fractures are those in which the skin remains intact and the muscles are minimally damaged, as a result of which bone fragments remain in the thickness of the tissue.
Extra-articular and intra-articular fractures of the tibia. In addition, depending on the presence of damage to the knee or ankle joints, tibia fractures can be intra-articular or extra-articular. If the fracture involves joint structures, it is called intra-articular and is considered severe. If only the tibia is broken, but the joints remain intact, then the fracture is called extra-articular.
Fractures of one or both bones of the leg, as well as their upper, middle and lower thirds. In addition, there is a classification of tibia fractures based on which part of the bone was damaged. In order to have a good understanding of this classification, you need to know the structure of the tibia and fibula. So, both bones consist of a long main part, which at both ends turns into rounded and wide formations. The main long part of the bone, enclosed between the two thickened ends, is called diaphysis. The terminal thickenings are called epiphyses. It is the epiphyses of the tibia that participate in the formation of the knee and ankle joints. The part of the diaphysis and epiphysis located closer to the knee are called proximal, and those closer to the foot are called distal. The proximal epiphysis has two projections called condyles, which are necessary for the formation of the knee joint and the attachment of ligaments.
Depending on which part of the leg was damaged, its fractures are classified into the following three types:
1.
Proximal tibia fractures
(upper third of the tibia and fibula). These include fractures of the condyles and tuberosities of the tibia or the head and neck of the fibula;
2.
Mid-tibia fractures
(middle third of the tibia). These include fractures of the diaphysis of the tibia and fibula;
3.
Fractures of the distal tibia
(lower third of the tibia). These include ankle fractures.
Fractures of the distal and proximal parts of the legs almost always involve damage to the knee or ankle joint, which makes the injury severe.
Severity
Currently, the severity of a tibia fracture is determined by its belonging to one of three types - A, B or C. Mild fractures are classified as type A, moderate severity- to B and heavy ones - to N. B general view we can say that they are considered easy closed fractures without displacement and with minimal trauma to soft tissues. Moderate fractures can be open or closed with injury to soft tissues, but without damage to joints or nerves. Severe fractures are those that damage joints, nerves and blood vessels.Symptoms of a tibia fracture
The symptoms of tibia fractures differ somewhat depending on the location of the injury, but there are also common Clinical signs. So, with any location of the fracture, severe pain, swelling and discoloration of the skin appear. When you try to move a limb or feel it, you can hear the crunch of bone fragments rubbing against each other. It is impossible to lean on a broken leg. It is also impossible to make any active movement of the lower leg. Externally, shortening or lengthening of the leg, or bone fragments protruding from the wound may be visible. If the broken bone has injured the peroneal nerve, the foot begins to droop and cannot be bent. If bone fragments have injured blood vessels, the skin of the lower leg becomes pale or bluish.
The above symptoms are common to all tibia fractures. Below we will consider specific symptoms characteristic of fractures of various locations.
Proximal tibia fractures characterized by a forced slightly bent position of the leg at the knee joint. The shin is displaced outward or inward. With strong displacement of the broken condyles directly under the knee joints, severe swelling and deformation are formed. When palpating the knee joint, shin and the site of injury, following signs fracture:
- Pain at the site of injury that does not spread to other areas of the leg;
- The noise of bone fragments rubbing against each other;
- Patella mobility;
- Mobility in the knee of the aligned leg;
- An attempt to make an active movement of the lower leg is impossible.
To clarify the diagnosis of a fracture, it is necessary to perform an x-ray, computed tomography or magnetic resonance imaging.
Diaphyseal fractures characterized by severe pain, swelling and cyanosis of the skin of the leg. The lower leg is deformed, the foot is deviated outward, and the crunching of bones can be heard in the thickness of the tissue. With fractures of the tibia, a person cannot bear even minimal weight on his leg. And if only the fibula is fractured, supporting the leg is quite possible.
Distal tibia fractures (ankle fractures) characterized by very severe pain and swelling. The foot may be turned inward or outward, and support on the leg is impossible.
Treatment
General principles of treatment of tibial fractures
To treat different types of tibia fractures, various modifications of the same techniques are used, which lead to recovery and fusion of bones in the shortest possible time. However general sequence actions in the treatment of any fracture of the tibia are exactly the same, and therefore they can be considered the principles of treatment for this injury.So, treatment of any fracture of the tibia is carried out by sequentially applying the following actions:
1.
Reposition of bone fragments, which consists in giving pieces of bone a normal position necessary for subsequent proper fusion. Reposition can be carried out by the surgeon's hands simultaneously under local anesthesia, using a skeletal traction system, or during surgery. The operation is performed either for open fractures or for unsuccessful reduction by hand or by skeletal traction.
2.
Fixation of bone fragments in a normal position using various devices, such as Kirschner wires, side loops, bolts, plates, Ilizarov, Kostyuk, Kalnberz, Tkachenko, Hoffmann devices, etc.
3.
Immobilization of the limb by applying a plaster splint or installing compression-distraction devices (for example, Ilizarov, Kostyuk, Kalnberz, Tkachenko, Hoffman, etc.) for several weeks or months until a callus forms and the fracture heals.
In each specific case, the methods and materials used for reposition, fixation of bone fragments and immobilization of the limb may be different, and their choice is made by a surgeon or traumatologist based on the specifics and characteristics of the fracture. If some methods are ineffective, they can be replaced by others in the process of treating a fracture. Let's consider the features of treatment of fractures of various parts of the leg and the optimal methods for this.
Treatment of proximal tibia fractures
Immediately after the patient is admitted to the hospital, an anesthetic drug (Novocaine, Lidocaine, etc.) is injected into the area of injury, the joint is punctured and the blood accumulated in it is removed. If the fracture is closed and without displacement, then immediately after pain relief a plaster cast is applied to the leg for 1 month. After a month, the plaster is removed and prescribed rehabilitation measures. You can fully put weight on your leg 2 months after the injury. If the fracture is displaced, then after pain relief the fragments are repositioned and then fixed with simultaneous immobilization by applying a plaster splint for 6 to 7 weeks. If it is impossible to compare the fragments with your hands, then reposition is carried out using the method of skeletal traction for 4 to 8 weeks. After traction, depending on the thickness of the callus, either a tight bandage or a plaster splint is applied to the leg, leaving it until the bones are completely fused. You can fully put weight on your leg 3 months after the fracture.
Currently, the application of a plaster splint is often replaced by the installation of an Ilizarov apparatus with the preliminary introduction of special screws and plates into the tissue, which hold bone fragments in the correct position after reposition. In this case, healing of the fracture occurs without applying plaster.
Treatment of diaphysis fractures
In case of displaced fractures of the tibia or both bones of the leg, it is necessary to make a reduction under local anesthesia. After this, a plaster cast is applied from the middle of the thigh to the fingertips for 2.5 - 3 months. However, the consequence long-term wearing A plaster splint causes stiffness of the knee and ankle joints, therefore, if possible, doctors prefer to immobilize the limb using rod compression-distraction devices such as Kostyuk, Ilizarov, SKID, Hoffman, etc.Oblique, spiral, splinter and other fractures of the diaphysis of the tibia bones, which tend to secondary displacement of fragments, must be treated using a skeletal traction system. That is, after repositioning the fragments, the person was placed on a skeletal traction system for 3–4 weeks, after which a plaster splint was applied from the middle third of the thigh to the fingertips for another 1.5–2.5 months.
Full recovery from injury occurs after 5–6 months, and you can begin walking without crutches and a cane after 4–4.5 months.
Treatment of ankle fractures
Ankle fractures are severe because they always involve damage to the ankle joint. Therefore, reposition of bone fragments is most often performed during surgery. The fragments are fixed with knitting needles, bolts or plates, after which a B-shaped plaster cast is applied from the middle of the lower leg to the beginning of the toes. The cast is applied for 3 to 7 weeks, depending on the volume of surface formed by the bone fracture.If, after repositioning bone fragments, there is very large swelling on the leg, then the lower leg is placed on a Beler splint on a skeletal traction system until the swelling decreases. Only after the swelling has subsided is a plaster cast applied to the leg.
If a fracture of the head of the tibia occurs, then reduction by hand is impossible, and it is carried out during surgery, after which the person is placed on a double skeletal traction system for 3 to 4 weeks. Then a plaster boot is placed on the leg for 3 - 3.5 months. If skeletal traction is not performed, the bones will heal incorrectly, and the foot will acquire a deformed shape that can only be corrected by repeated surgery.
Complete healing of an ankle fracture occurs 6 to 7 months after the injury, but for the best rehabilitation it is recommended to wear an arch support for a year after removing the cast.
Operations for tibia fracture
Operations for a fractured leg are performed if there are the following indications:
- Fractures in which it is impossible to reposition the fragments using conservative methods;
- Double fractures of the tibia with severe displacement;
- Change in the normal position of soft tissues;
- Danger of skin rupture, compression of nerves or blood vessels with bone fragments;
- Open fracture.
When the bones of the leg are fractured, two types of operations are performed to reposition the fragments and restore the integrity of the soft tissues:
1.
Reposition with fixation of fragments with metal structures (plates, knitting needles, screws, etc.) followed by fixation with a plaster splint.
2.
Reposition of fragments with simultaneous fixation by applying a compression-distraction device.
Repositioning of fragments with a metal plate is used to treat nonunion or pseudarthrosis of the tibia. In all other cases, it is preferable to treat fractures by applying compression-distraction devices, for example, Ilizarov, Kalnberz, Tkachenko, Hoffmann, etc.
After a broken leg
After a broken leg, a person should direct all his physical and mental strength to recover from the injury. It is necessary to understand that a fracture is a serious injury that violates not only the integrity of bones, but also soft tissues. And during the period of immobilization of the limb, necessary for the fusion of bone fragments, atrophic changes in the muscles and congestion are added due to impaired blood and lymph circulation in the compressed soft tissues. However, with due persistence, all these violations are reversible, that is, they are completely eliminated.Understanding the possibility of complete recovery after an injury, you need to know and imagine that this process is long, difficult, sometimes excruciating and very painful. After all, you will actually have to re-learn how to perform the simplest movements that were previously done automatically, without even thinking about them. You cannot feel sorry for yourself, indulge in your reluctance to walk and do exercises that may cause pain, because the more time passes after the injury, the more difficult the process of restoring functions will be. Also, for successful rehabilitation, it is very important to put aside the fear of breaking a leg again, which literally fetters many people who have experienced such an injury. Remember that the only factor making it impossible full recovery functions of the leg after a fracture is insufficient perseverance in achieving the goal. If you don’t give up and work hard on your leg every day, then after a while its functions will be completely restored.
Tibia fracture - rehabilitation
The process of rehabilitation of a tibia fracture is a set of measures aimed at the speedy and durable fusion of bone fragments, as well as the complete restoration of all functions of the limb. Rehabilitation is aimed at achieving the following specific goals: - Elimination of atrophy of the muscles of the lower leg and thigh;
- Normalization of tone and elasticity of the lower leg muscles;
- Normalization of blood circulation in the muscles and tendons of the lower leg;
- Normalization of mobility of the knee and ankle joints;
- Elimination of congestion in the soft tissues of the lower leg;
- Normalization motor activity legs.
To achieve all these goals in the rehabilitation process, the following four main methods are used:
1.
Physiotherapy. A person performs daily physical exercise with dosed and selected loads, which help restore muscle structure, normalize blood circulation, eliminate stagnation and inflammation, and also prevent muscle atrophy and joint contractures;
2.
Massages and rubbing. Performing daily massages and rubbing is necessary to prevent joint stiffness, degeneration of the lower leg muscles and scar formation in soft tissues;
3.
Physiotherapeutic procedures aimed at reducing inflammatory process, improving healing and restoration of tissue structure, intensifying metabolism and blood flow in the vessels of the leg;
4.
Diet, which includes foods rich in calcium, vitamins, iron and other microelements.
The listed techniques in various combinations are used throughout the entire rehabilitation period, which lasts 2–4 months. However, since different stages recovery requires the implementation of various activities aimed at achieving strictly defined goals, then three main periods of rehabilitation can be distinguished:
1.
The first stage of rehabilitation lasts 2–3 weeks from the moment the plaster is removed;
2.
The second stage of rehabilitation lasts for 2 – 3 months and begins immediately after the first;
3.
The third rehabilitation period continues for a month after completion of the second.
At the first stage of rehabilitation You should definitely massage and rub the skin and muscles of the lower leg with your hands and using special creams containing substances that promote tissue restoration, such as cedar oil, Collagen Plus, Chondroxide, etc. In addition, in addition to massages, it is recommended to take baths with sea salt , wax and ozokerite wraps, as well as magnetic therapy sessions. At the first stage of rehabilitation, you should not load the limb with exercises, as this can provoke severe pain. It is recommended to simply gently move your foot in different directions, raise and lower your leg, bending it at the knee joint, and also strain and relax your calf muscles.
At the second stage of rehabilitation it is necessary to restore all functions of the leg. To do this, they continue to do massages and warm baths, after which they begin active exercises. A set of exercises for developing and restoring leg functions after a tibia fracture consists of the following movements:
- swing to the sides, forward and backward from a standing position;
- alternately rising on your toes and lowering on your heels from standing and sitting positions;
- walking as much as possible and sustainably;
- crossing the legs in a “scissors” fashion while lying down;
- rotation of the raised leg with the foot in different directions.
At the third stage of rehabilitation it is necessary to attend physical therapy courses and engage in various programs aimed at strengthening the leg muscles.
In addition, for successful rehabilitation after a tibia fracture, it is necessary to create a diet in such a way that it includes foods containing large amounts of silicon and calcium, such as milk, cottage cheese, fish, soybeans, hazelnuts, bran bread, sesame seeds, beans , persimmon, cauliflower, raspberries, pears, radishes, currants, etc. It is also recommended to take vitamins E, C and D, which promote rapid healing of the fracture and better absorption of calcium and silicon.
Special mention should be made of physiotherapy in rehabilitation after a tibia fracture. At different stages of rehabilitation, it is recommended to resort to different physiotherapeutic techniques to improve especially necessary functions.
In the first ten days after a fracture, the following physiotherapeutic procedures are recommended:
- Interference currents (promote the resorption of hematomas, the convergence of swelling and the relief of pain);
- Ultraviolet irradiation (destroys pathogenic bacteria, preventing wound infection);
- Bromine electrophoresis for severe pain.
- Interference currents (normalize metabolism and accelerate tissue healing and bone fusion);
- UHF therapy (improves blood flow, strengthens the immune system and accelerates the restoration of tissue structure);
- Ultraviolet irradiation;
- Massotherapy.
Exercises for a broken leg
Exercises for a broken leg are aimed at recovery normal functioning legs, increasing muscle strength and gaining full range of motion. After removing the plaster or various external structures such as the Ilizarov apparatus, it is recommended to perform the following exercises to develop the leg after a tibia fracture:
- Walking on level and uneven surfaces in shoes and barefoot with support on the injured leg. You need to try to walk as much and as often as possible.
- Standing on one leg, make rotational movements with the foot of the injured leg.
- While sitting on a chair or other surface, make rotational movements with the foot of the injured leg.
- Swinging movements with legs in different directions. To perform them, you need to stand on both legs and rest your hands on the back of the chair. From this position, you should slowly and carefully lift the injured leg up and hold it suspended for a few seconds, then lower it to the floor. 10 repetitions must be performed on each leg. In addition to swinging your legs forward, it is recommended to also swing them backwards and to the sides.
- Stand up straight, leaning on both legs and resting your hands on the table, back of a chair, window sill or any other stable object. Slowly rise onto your toes and transfer your body weight back to your heels. Do at least 30 repetitions.
- Lie on your back and start swinging your legs in different directions.
First aid for a broken leg
The general sequence of first aid for a broken leg is as follows:- Give painkillers;
- Remove shoes from the injured foot;
- Stop the bleeding and treat the edges of the wound;
- Secure the leg using a splint or any available materials.
Anesthesia
First of all, in case of a tibia fracture, if possible, the pain syndrome should be relieved. To do this, you can give a person a tablet of any painkiller (for example, Analgin, Nimesulide, Pentalgin, Sedalgin, MIG, etc.) or inject a solution intramuscularly local anesthetic(Novocaine, Lidocaine, Ultracaine, etc.). The anesthetic solution should be injected as close as possible to the site of the bone fracture.Then it is necessary to remove the shoes from the person’s feet, since the rapidly increasing traumatic swelling will provoke severe compression of the tissues, which will cause increased pain syndrome. You should move your leg carefully, supporting it by the knee and ankle joints with both hands (Figure 1). If it is necessary to change the position of the injured leg, it should always be moved in this way.
Picture 1– Rules for moving the leg when the tibia is fractured.
Treating the wound and stopping bleeding
After this, carefully cut or tear the clothing on the leg and inspect the surface of the skin of the lower leg. If there is an open and bleeding wound, then you should determine whether the bleeding is dangerous. If blood flows out in a stream, the bleeding is dangerous because a large blood vessel has been damaged by bone fragments. In this case, you should stop the bleeding by tamponade the wound with any piece of clean cloth, bandage, cotton wool, gauze, etc. To do this, fabric or cotton wool is carefully pushed into the wound, compacting each layer with a finger or some other instrument. A loose regular bandage is applied over the tamponade. It is not recommended to stop bleeding by applying a tourniquet, since in a complex fracture, tightening the muscles can lead to the displacement of bone fragments, which will rupture the vessel in another place, which will aggravate the situation.If blood is simply oozing from the wound, then there is no need to pack the wound. In this case, you should simply treat the edges of the wound with any antiseptic at hand (potassium permanganate, Chlorhexidine, hydrogen peroxide, iodine, brilliant green, any alcohol-containing liquid, etc.), without pouring it into the wound opening.
Tibia fracture splint
After bandaging the wound and stopping the bleeding, the most important stage of first aid for a fracture of the leg begins, which consists of immobilizing the leg (immobilization), which is necessary to fix the current position of soft tissues and bones in order to avoid their movement, during which they can rupture blood vessels, nerves, and muscles. and ligaments, thereby aggravating and aggravating the injury.It is necessary to apply a splint to the injured leg in such a way that the knee and ankle joints are immobilized (see Figure 2). To do this, you need to take any two (stick, umbrella, etc.) available straight and relatively long objects (at least half a meter) and apply them to the injured leg from the outside and inside so that one end is at the level of the heel, and the second reached mid-thigh. Then these items are tightly bandaged to the leg in several places using any available means - laces, ties, bandages, pieces of fabric, etc. Before tying a long object to your leg, it is advisable to wrap it in a soft cloth.
The anatomical features of the structure of the skeletal system of children and its physiological properties determine the occurrence of certain types of fractures that are characteristic only of this age. It is known that children younger age often fall during outdoor games, but they rarely have bone fractures. This is explained by the child’s lower body weight and well-developed soft tissue cover, and therefore by a weakening of the impact force during a fall. Children's bones are thinner and less strong, but they are more elastic than adult bones. Elasticity and flexibility depend on less mineral salts in the bones of the child, as well as on the structure of the periosteum, which in children is thicker and abundantly supplied with blood. The periosteum forms a kind of sheath around the bone, which gives it greater flexibility and protects it from injury. The preservation of bone integrity is facilitated by the presence of epiphyses at the ends of the tubular bones, connected to the metaphyses by wide elastic growth cartilage, which weakens the force of impact. These anatomical features, on the one hand, prevent the occurrence of a bone fracture, on the other hand, in addition to the usual fractures observed in adults, they cause the following skeletal injuries typical for childhood: fractures, subperiosteal fractures, epiphysiolysis, osteoepiphysiolysis and apophysiolysis.
Breaks and fractures like a green branch or a willow twig are explained by the flexibility of bones in children. This type of fracture is observed especially often when the diaphysis of the forearm is damaged. In this case, the bone is slightly bent, on the convex side the outer layers are subject to fracture, and on the concave side they retain their normal structure. Subperiosteal fractures are characterized by the fact that the broken bone remains covered by the periosteum, the integrity of which is preserved. These injuries occur when force is applied along the longitudinal axis of the bone. Most often, subperiosteal fractures are observed on the forearm and lower leg; In such cases, bone displacement is absent or very insignificant.
Epiphysiolysis and osteoepiphysiolysis are traumatic separation and displacement of the epiphysis from the metaphysis or with part of the metaphysis along the line of the germinal epiphyseal cartilage. They occur only in children and adolescents until the end of the ossification process (Fig. 14.1).
Epiphysiolysis occurs more often as a result of the direct action of force on the epiphysis and, according to the mechanism of injury, is similar to dislocations in adults, which are rarely observed in children. This is explained anatomical features bones and ligamentous apparatus of the joints, and the place of attachment of the articular capsule to the articular ends of the bone is essential. Epiphyseolysis and osteoepiphysiolysis are observed where the joint capsule is attached to the epiphyseal cartilage of the bone: for example, the wrist and ankle joints, the distal epiphysis femur. In places where the bursa is attached to the metaphysis so that the growth cartilage is covered by it and does not serve as a place for its attachment (for example, the hip joint), epiphysiolysis does not occur. This position is confirmed by the example of the knee joint. Here, during injury, epiphysiolysis of the femur occurs, but there is no displacement of the proximal epiphysis of the tibia along the epiphyseal cartilage. Apophysiolysis is the separation of the apophysis along the line of the growth cartilage.
Apophyses, unlike epiphyses, are located outside the joints, have a rough surface and serve for attachment of muscles and ligaments. An example of this type of injury is displacement of the medial or lateral epicondyle of the humeral csti. At complete fractures limb bones with displacement of bone fragments, the clinical manifestations are practically no different from those in adults. At the same time, with fractures, subperiosteal fractures, epiphysiolysis and osteoepiphysiolysis without displacement, movements can be preserved to a certain extent, pathological mobility is absent, the contours of the injured limb that the child is sparing remain unchanged and only upon palpation is pain determined in a limited area corresponding to the fracture site. In such cases, only x-ray examination helps to make the correct diagnosis.
A feature of bone fractures in a child is an increase in body temperature in the first days after injury from 37 to 38°C, which is associated with absorption of the contents of the hematoma.
In children, it is difficult to diagnose subperiosteal fractures, epiphysiolysis and osteoepiphysiolysis without displacement. Difficulty in establishing a diagnosis also arises with epiphysiolysis in newborns and children. infancy, since even radiography does not always provide clarity due to the absence of ossification nuclei in the epiphyses. In young children, most of the epiphysis consists of cartilage and is passable for x-rays, and the ossification nucleus gives a shadow in the form of a small dot. Only when compared with a healthy limb on radiographs in two projections is it possible to establish the displacement of the ossification nucleus in relation to the diaphysis of the bone. Similar difficulties arise during birth epiphysiolysis of the heads of the humerus and femur, the distal epiphysis humerus etc. At the same time, in older children, osteoepiphysiolysis without displacement is easier to diagnose, since radiographs show separation of a bone fragment of the metaphysis of the tubular bone. Errors in diagnosis are more often observed with fractures in young children. Insufficient medical history, well-defined subcutaneous tissue making palpation difficult, and the absence of displacement of fragments in subperiosteal fractures make recognition difficult. Often, in the presence of a fracture, a bruise is diagnosed. As a result of improper treatment in such cases, curvature of the limb and impairment of its function are observed. In some cases, a repeat X-ray examination performed on days 7-10 after injury helps clarify the diagnosis, which becomes possible due to the appearance of initial signs of fracture consolidation.
The leading principle is a conservative method of treatment (94%). In most cases, a fixing bandage is applied. Immobilization is carried out with a plaster splint, usually in the average physiological position, covering 2/3 of the circumference of the limb and fixing two adjacent joints. A circular plaster cast is not used for fresh fractures in children, since there is a risk of circulatory disorders due to increasing edema with all the ensuing consequences (Volkmann’s ischemic contracture, bedsores and even necrosis of the limb).
During treatment, periodic x-ray monitoring (once a week) of the position of bone fragments is necessary, since secondary displacement of bone fragments is possible. Traction is used for fractures of the humerus, shin bones and mainly for fractures of the femur. Depending on the age, location and nature of the fracture, adhesive plaster or skeletal traction is used. The latter is used in children over 3 years of age. Thanks to traction, displacement of the fragments is eliminated, gradual reposition is carried out and the bone fragments are held in the reduced position.
For bone fractures with displacement of fragments, one-stage closed reduction is recommended as early as possible after the injury. In particularly difficult cases, reposition is performed under periodic X-ray control with radiation protection of the patient and medical personnel. Maximum shielding and minimal exposure allows for repositioning under visual control.
The choice of pain relief method is of no small importance. Good anesthesia creates favorable conditions for reposition, since the comparison of fragments should be done in a gentle way with minimal tissue trauma. These requirements are met by anesthesia, which is widely used in hospital settings. In outpatient practice, reposition is performed under local or regional anesthesia. Anesthesia is carried out by injecting a 1% or 2% novocaine solution into the hematoma at the fracture site (at the rate of 1 ml per one year of the child’s life). When choosing a treatment method for children and establishing indications for repeated closed or open reduction, the possibility of self-correction of some types of remaining displacements during growth is taken into account. The degree of correction of the damaged limb segment depends both on the age of the child and on the location of the fracture, the degree and type of displacement of the fragments. At the same time, if the growth zone is damaged (during epiphysiolysis), as the child grows, a deformation may appear that was not there during the treatment period, which should always be remembered when assessing the prognosis (Fig. 14.2). Spontaneous correction of the remaining deformity occurs the better, the younger the patient is. The leveling of displaced bone fragments in newborns is especially pronounced. In children under 7 years of age, displacements for diaphyseal fractures are allowed in the length range from 1 to 2 cm, in width - almost the diameter of the bone and at an angle of no more than 10°. At the same time, rotational displacements cannot be corrected during growth and should be eliminated. In children of the older age group, more accurate adaptation of bone fragments is necessary and it is necessary to eliminate deflections and rotational displacements. In case of intra- and periarticular fractures of the bones of the extremities, accurate reduction with the elimination of all types of displacements is required, since unresolved displacement of even a small bone fragment during an intra-articular fracture can lead to blockade of the joint or cause varus or valgus deviation of the limb axis.
Surgical intervention for bone fractures in children is indicated in following cases: 1) for intra- and periarticular fractures with displacement and rotation of the bone fragment; 2) with two or three attempts at closed reduction, if the remaining displacement is classified as unacceptable; 3) with interposition of soft tissues between fragments; 4) with open fractures with significant damage to soft tissues; 5) in case of improperly healed fractures, if the remaining displacement threatens permanent deformation, curvature or stiffness of the joint; 6) for pathological fractures.
Open reduction is performed with special care, gentle surgical access, with minimal trauma to soft tissues and bone fragments and is completed mainly by simple methods of osteosynthesis. Complex metal structures are rarely used in pediatric traumatology. Most often, a Kirschner wire is used for osteosynthesis, which, even when carried out transepiphyseally, does not have a significant effect on bone growth in length. The Bogdanov rod, CITO, Sokolov nails can damage the epiphyseal growth cartilage and therefore are used for osteosynthesis for diaphyseal fractures of large bones.
For incorrectly fused and improperly fused bone fractures, false joints of post-traumatic etiology, compression-distraction devices of Ilizarov, Volkov-Oganesyan, Kalnberz, etc. are widely used.
The time frame for consolidation of fractures in healthy children is shorter than in adults. In weakened children suffering from rickets, hypovitaminosis, tuberculosis, as well as open damage the immobilization period is lengthened, since reparative processes in these cases are slowed down (Table 14.1).
With insufficient duration of fixation and early loading, secondary displacement of bone fragments and re-fracture are possible. Ununited fractures and false joints in childhood are an exception and proper treatment usually not found. Delayed consolidation of the fracture area can be observed with insufficient contact between fragments, interposition of soft tissues, and with repeated fractures at the same level.
After the onset of consolidation and removal of the plaster splint, functional and physiotherapeutic treatment is indicated mainly for children with intra- and periarticular fractures, especially when movement in the elbow joint is limited. Physical therapy should be moderate, gentle and painless. Massage near the fracture site, especially with intra- and periarticular injuries, is contraindicated, since this procedure promotes the formation of excess callus and can lead to myositis ossificans and partial ossification of the joint capsule. Children who have suffered injury near the epimetaphyseal zone require long-term follow-up (up to 1.5-2 years), since injury does not exclude the possibility of damage to the growth zone, which can subsequently lead to limb deformity (post-traumatic deformity of the Madelung type, varus or valgus deviation of the limb axis, segment shortening, etc.).
Birth damage
Birth trauma includes injuries sustained during birth act, as well as when providing manual assistance and reviving a child born with asphyxia. More often, newborns experience fractures of the collarbone, fractures of the femur and humerus, and damage to the skull and brain. Fractures of the bones of the forearm and lower leg are extremely rare.
Clavicle fracture. In newborns, clavicle fracture occurs most often and is usually caused by pathological childbirth. Damage is possible during spontaneous birth in cephalic presentation, narrow pelvis, early rupture of water, etc. The fracture, as a rule, is localized in the middle third of the diaphysis and can be complete or incomplete (subperiosteal). In the area of the fracture there is slight swelling due to edema, hematoma, displacement of fragments and pathological mobility. In case of complete fractures, the child holds the arm in a forced position and does not move it, which gives rise to an erroneous diagnosis of Erb's palsy due to damage to the brachial plexus. The most consistent sign of a clavicle fracture in newborns is crepitus of the fragments. With subperiosteal fractures, the diagnosis is often made at the end of the 1st week of the child’s life, when a large callus appears in the clavicle area.
Fractures of the humerus and femur. Such fractures are a consequence of obstetric care for foot or pelvic presentation of the fetus. Typical location- in the middle third of the diaphysis of the tubular bone; along the plane, the fracture runs in a transverse or oblique direction. Traumatic epiphysiolysis of the proximal and distal ends of the humerus and femur are rare. This circumstance, as well as the fact that X-ray diagnostics are difficult due to the absence of ossification nuclei, often lead to untimely diagnosis of these injuries. In diaphyseal fractures of the humerus and femur with complete displacement of bone fragments, pathological mobility at the level of the fracture, deformation, traumatic swelling and crepitus are noted. Any manipulation causes pain to the child. Fractures of the femur are characterized by a number of features: the leg is in a position of flexion at the knee and hip joints and is brought to the abdomen due to physiological hypertension of the flexor muscles. Radiography clarifies the diagnosis.
There are several treatment options for newborns with diaphyseal fractures of the humerus and femur. In case of a fracture of the humerus, the limb is immobilized for a period of 10-14 days. The arm is fixed with a plaster splint from the edge of the healthy scapula to the hand in the average physiological position or with a cardboard U-shaped splint in the position of shoulder abduction to 90°. After immobilization, movement in the injured limb is restored in the near future without additional procedures and manipulations. For femur fractures in newborns, Schede traction is most effective. The immobilization period is the same. When monitoring the position of fragments, one should take into account the degree of permissible displacement of bone fragments (displacement in length up to 2-3 cm, in width - by the full diameter of the bone, at an angle - no more than 25-30°), since self-correction and leveling will occur as they grow remaining offset; rotational displacements are not eliminated.
Traumatic epiphysiolysis in newborns has a typical picture and is more pronounced the more the fragments are displaced. Generic epiphysiolysis of the distal end of the humerus is often accompanied by paresis of the radial or median nerve. X-ray diagnostics is practically impossible due to the lack bone tissue in the area of the epiphyses, and only by the end of the 7-10th day on repeated radiographs can you see the callus and retrospectively resolve the issue of the nature former fracture. Most typical mistake with this pathology, a traumatic dislocation of the forearm bones is diagnosed and a reduction is attempted, which, naturally, is doomed to failure. Treatment consists of one-stage closed reposition “by eye” followed by fixation in a light plaster splint in an average physiological position. At follow-up, a varus deviation of the forearm axis may be noted due to internal rotation of the humeral condyle that was not eliminated during treatment.
When epiphysiolysis of the proximal end of the femur is performed differential diagnosis with congenital hip dislocation. The injury is characterized by swelling, significant pain when moving, and possible bruising. Good results in the treatment of newborns with this injury are obtained by using a spacer splint. Immobilization period -. 4 weeks With epiphysiolysis of the distal end of the femur in newborns, severe swelling and deformation in the knee joint are observed. During the examination it is determined characteristic symptom"click". X-ray reveals a displacement of the ossification nucleus of the distal epiphysis of the femur, which facilitates diagnosis and allows the position of fragments to be monitored after reposition. The timing of clinical observation of children who have suffered a birth injury depends on the severity and location of the injury, but by the end of the first year of life it is possible, in principle, to resolve the issue of the outcome of the injury received at birth.
Clavicle fractures
Clavicle fractures are one of the most common bone injuries in childhood and account for about 15% of extremity bone fractures, second in frequency only to fractures of the forearm and humerus. In children, a clavicle fracture is caused by indirect trauma from a fall on an outstretched arm, on the shoulder or elbow joint. Less commonly, the cause of a clavicle fracture is direct trauma - a direct blow to the collarbone. More than 30% of all clavicle fractures occur between the ages of 2 and 4 years.
With incomplete clavicle fractures, deformation and displacement are minimal. The function of the arm is preserved, only its abduction above the level of the shoulder girdle is limited. Subjective complaints of pain are minor, so such fractures are sometimes not identified and the diagnosis is made only after 7-14 days, when a callus is detected in the form of a thickening on the collarbone. For fractures with complete displacement of fragments, the diagnosis is not difficult. Clavicle fractures heal well, and function is fully restored with any treatment method, but the anatomical result may vary. Angular curvature and excess callus under the influence of growth disappear over time almost without a trace. In most cases, a Deso-type bandage is sufficient to fix fragments for the entire period of treatment. For fully displaced fractures in older children, stronger fixation is required with the shoulder retracted and the external clavicle fragment elevated. This is achieved using an eight-shaped fixing bandage or a Kuzminsky-Karpenko crutch-plaster bandage.
Surgical treatment is used extremely rarely and is indicated only when there is a threat of perforation by a skin fragment, trauma to the neurovascular bundle and interposition of soft tissues.
Scapula fractures
Scapula fractures are very rare in children. They arise as a result of direct trauma (falling on your back, blow, car injury, etc.). The most common fracture is the neck of the scapula, then the body and acromion. Fractures glenoid cavity, the angle of the scapula and the coracoid process are an exception. There is almost no displacement of fragments.
Characteristic feature scapula fractures is a swelling, clearly demarcated, repeating the shape of the scapula (Comolli’s “triangular pillow” symptom). This is caused by subfascial hemorrhage over the body of the scapula as a result of damage to the vessels supplying the scapula. Multiaxial radiography clarifies the diagnosis. Treatment consists of immobilization in a Deso-type bandage.
Rib fractures
Due to the high elasticity of the rib frame, rib fractures are not common in children. They are observed when the traumatic agent is of significant force (fall from a height, transport injury, etc.).
The diagnosis is made on the basis of clinical manifestations and X-ray data. The child accurately indicates the location of the injury. Careless movements increase the pain. Slight cyanosis is noted skin, shortness of breath, shallow breathing due to fear of increased pain. Compression of the chest during the examination also causes pain to the child, so you should not resort to palpation if the patient reacts negatively.
Treatment of patients with uncomplicated rib fractures consists of an intercostal novocaine block along the paravertebral line on the affected side, anesthesia of the fracture with a 1-2% novocaine solution and injection of a 1% pantopon solution in an age-specific dosage (0.1 ml per year of the child’s life, but not more than 1 ml ).
In case of severe symptoms of pleuropulmonary shock, it is advisable to perform a vagosympathetic blockade on the affected side according to Vishnevsky. Immobilization is not required, since tight bandaging of the chest limits the excursion of the lungs, which negatively affects the recovery period (complications such as pleurisy and pneumonia are possible).
With a direct and strong impact on the chest, multiple rib fractures may occur in combination with damage internal organs. Significant ruptures of lung tissue and damage to blood vessels are accompanied by severe bleeding into the pleural cavity, which leads to death. Damage to the bronchi, causing tension pneumothorax, is also dangerous. The continued flow of air into the pleural cavity collapses the lung, displaces the mediastinum, and mediastinal emphysema develops. Bulau drainage or active aspiration are advisable for minor injuries to the lungs and bronchi. In case of bronchial ruptures, increasing hemopneumothorax, or open injury, urgent surgical intervention is indicated.
Sternum fractures
Sternal fractures in children are rare. They are possible with a direct blow to the sternum area. The most common site of injury is the junction of the manubrium of the sternum with the body. When fragments are displaced, sharp pain can cause pleuropulmonary shock. X-ray examination of the chest only in a strictly lateral projection allows us to identify the location of the fracture and the degree of displacement of the bone fragment. Local anesthesia of the damaged area is effective, and in cases of pleuropulmonary shock - vagosympathetic blockade according to Vishnevsky. If there is a significant displacement of bone fragments, a closed reduction is performed or, according to indications, surgical intervention with fixation of the fragments with suture material.
Humerus fractures
Depending on the location, there are fractures of the humerus in the area of the proximal metaepiphysis, diaphyseal fractures and in the area of the distal metaepiphysis.
Typical types of damage to the proximal end of the humerus in children are fractures in the area of the surgical neck, osteoepiphysiolysis and epiphysiolysis, with typical displacement of the distal fragment outward with an angle open inward. In fractures with displacement of bone fragments, the clinical picture is typical: the arm hangs along the body and the abduction of the limb is sharply limited; pain in the shoulder joint, swelling, tension in the deltoid muscle; with significant displacement (abduction fracture), a peripheral fragment is palpated in the axillary fossa. X-rays are performed in two (!) projections.
When indicated, reposition is usually performed in a hospital setting under general anesthesia and periodic monitoring of an X-ray screen. After reduction for abduction fractures, the arm is fixed in the average physiological position. In case of an adduction fracture with displacement of fragments, it is not always possible to compare bone fragments using conventional reposition, and therefore it is advisable to use the method developed by Whitman and M.V. Gromov. During the reposition process, one of the assistants fixes the shoulder girdle, and the other carries out constant traction along the length of the limb, moving the arm upward as much as possible. At this time, the surgeon places the fragments in the correct position, pressing on their ends (be careful - the neurovascular bundle!).
The arm is fixed with a plaster splint, which goes onto the torso, in the position in which the correct position of the fragments was achieved (Fig. 14.3). The duration of fixation in a plaster splint is 2 weeks (the time required for the formation of primary callus). On the 14-15th day, the thoracobrachial bandage is removed, the arm is transferred to the mid-physiological position and a plaster splint is again applied for 2 weeks (a total immobilization period of 28 days). Against the background of physical therapy and physiotherapy, movement in shoulder joint will be restored in the next 2-3 weeks. In case of epiphysiolysis and osteoepiphysiolysis with significant damage to the growth zone in the long term, impaired bone growth in length can be caused. Dispensary observation is carried out for 1.5-2 years.
Humeral shaft fractures are uncommon in children. The clinical picture is typical. Fractures in the middle third of the humerus are dangerous due to possible damage to the radial nerve, which bends around the humerus at this level. Displacement of fragments can cause traumatic paresis or, in severe cases, disruption of the integrity of the nerve. In this regard, all manipulations for a fracture in the middle third of the diaphysis of the humerus must be performed with extreme caution. The method of one-stage closed reduction followed by fixation in a plaster splint or the method of skeletal traction of the proximal metaphysis is used. ulna which gives better results. If, during subsequent X-ray monitoring, secondary displacement of the fragments is detected, then it is eliminated by applying corrective rods. Pay attention to the correctness of the axis of the humerus, because displacement of bone fragments along the length of up to 2 cm is well compensated, while angular deformations during growth are not eliminated. Fractures of the distal humerus are common in children. They account for 64% of all humerus fractures. For diagnosing injuries in the area of the distal metaepiphysis of the humerus, the most convenient is the classification proposed by G. A. Bairov in 1960 (Fig. 14.4).
Trans- and supracondylar fractures of the humerus in children are not uncommon. The fracture plane in transcondylar injuries passes through the joint and is accompanied by rupture of the articular capsule and capsular-ligamentous apparatus (95% of all injuries). In supracondylar fractures, the fracture plane passes through the distal metaphysis of the humerus and does not penetrate the joint cavity (5%). The mechanism of injury is typical - a fall on an arm extended or bent at the elbow joint. Displacement of the distal fragment of the humerus can be in three planes: anteriorly (with a flexion trans- or supracondylar fracture), posteriorly (with an extension fracture), outward - to the radial side or inward - to the ulnar side; rotation of the fragment around its axis is also noted. With significant displacement, disruption of innervation may occur as a result of injury to the ulnar, radial, transcondylar fractures of the humerus or median nerve.
It is important to promptly identify peripheral circulatory disorders. The pulse in the radial and ulnar arteries may be absent for 4 reasons: due to post-traumatic spasm of arterial vessels, compression of the arterial vessel by a bone fragment or increasing edema and hematoma, and rupture of the neurovascular bundle (the most serious complication). For trans- and supracondylar fractures of the humerus with displacement, conservative treatment is used in the vast majority of cases. Closed reduction is performed under general anesthesia and periodic X-ray monitoring. The introduction of novocaine into the fracture area does not provide sufficient anesthesia and muscle relaxation, which makes it difficult to manipulate the fragments and keep them in the reduced position. After a good comparison of bone fragments, monitoring the pulse is mandatory, since compression of the brachial artery by edematous soft tissue is possible. After reposition, a deep posterior plaster splint is applied in the position of the arm in which it was possible to fix the bone fragments.
In case of significant swelling and failure of one-stage closed reduction, it is advisable to use the method of skeletal traction for the proximal metaphysis of the ulna with a load of 2 to 3 kg. If the fracture is unstable (more often observed with an oblique plane), you can use percutaneous fixation of bone fragments according to K. Papp (diafixation) or percutaneous osteosynthesis with crossed Kirschner wires according to the Judet technique. In case of failure conservative treatment and unacceptable displacement of fragments may require open reduction. The operation is performed in extreme cases: with repeated unsuccessful attempts at closed reduction, with interposition of the neurovascular bundle between fragments with the threat of the formation of Volkmann’s ischemic contracture, with open and improperly healing fractures. Among the complications that are possible with this type of fracture, it should be noted myositis ossificans and ossification of the joint capsule. They are observed in children who undergo repeated closed reductions, accompanied by the destruction of granulations and primary callus. According to N.G. Damier, ossification of the joint capsule most often develops in children with a tendency to form keloid scars.
If internal rotation and inward displacement of the distal fragment of the humerus are not corrected during treatment, they lead to varus deformity of the elbow joint. When the forearm axis deviates by 15° in girls and 20° in boys, a corrective transcondylar wedge osteotomy of the humerus is indicated. It is performed no earlier than 1-2 years after the injury using the Bairov-Ulrich method (Fig. 14.5). Preliminary calculation of the volume of proposed bone resection is important. X-rays of two elbow joints are taken in strictly symmetrical projections.
The axis of the humerus and the axis of the forearm bones are drawn. Determine the value of the resulting angle a. Measure the degree physiological abnormality the axis of the forearm on the healthy arm is angle /3, add its value to the value of angle a and thus determine the angle of the proposed bone resection. The angle on the contourogram is plotted in the area of the distal metaphysis of the humerus at the level or slightly below the apex of the olecranon fossa. The sides of the wedge should be as close to each other as possible. The stages of surgical intervention are presented in Fig. 14.6.
Fractures of the epicondyles of the humerus are typical injuries for childhood (most common in children from 8 to 14 years old). They belong to apophyseolysis, since in most cases the fracture plane passes through the apophyseal cartilaginous zone. The most common avulsion of the medial epicondyle of the humerus occurs. Its displacement is associated with tension on the medial collateral ligament and contraction of a large group of muscles attached to the epicondyle. Often, separation of this epicondyle in children is combined with dislocation of the bones of the forearm in the elbow joint. When the capsular-ligamentous apparatus is ruptured, a displaced bone fragment can penetrate into the cavity of the elbow joint. In such a case, the apophysis is pinched in the humeroulnar joint; paresis possible ulnar nerve. The consequences of untimely diagnosis of a torn medial epicondyle embedded in the joint cavity can be severe: impaired articulation in the joint, stiffness, wasting of the muscles of the forearm and shoulder due to partial loss of arm function.
There are four ways to extract an osteochondral fragment from the joint cavity: 1) using a single-tooth hook (according to N. G. Damier); 2) reproducing the dislocation of the forearm bones with subsequent re-reduction (during manipulation, the fragment can be removed from the joint and reduced); 3) during surgery; 4) according to the method of V. A. Andrianov. The method of closed extraction of the restrained medial epicondyle of the humerus from the cavity of the elbow joint according to Andrianov is as follows. Under general anesthesia, the injured arm is held in an extended position and valgused at the elbow joint, which leads to widening of the joint space on the medial side. The hand is retracted to the radial side to stretch the forearm extensors. With light rocking movements of the forearm and jerk-like pressure along the longitudinal axis of the limb, the medial epicondyle is pushed out of the joint, after which reposition is performed. If conservative reduction fails, open reduction with fixation of the medial epicondyle is indicated. Fracture capitate eminence humerus (epiphysiolysis, osteoepiphysiolysis, epiphysis fracture) is an intra-articular fracture and most often occurs in children aged 4 to 10 years. The damage is accompanied by rupture of the capsular-ligamentous apparatus, and the displacement of the bone fragment occurs outward and downward; Rotation of the capitate eminence up to 90° and even 180° is often observed. In the latter case, the bone fragment with its cartilaginous surface faces the fracture plane of the humerus. Such a significant rotation of a bone fragment depends, firstly, on the direction of the impact force and, secondly, on the traction of a large group of extensor muscles attached to the lateral epicondyle.
When treating children with a fracture of the capitate eminence of the humerus, one must strive for ideal adaptation of bone fragments. Uncorrected displacement of the bone fragment disrupts articulation in the brachioradial joint, leading to the development of pseudarthrosis and contracture of the elbow joint. In case of epiphysiolysis and osteoepiphysiolysis of the capitate eminence with slight displacement and rotation of the bone fragment up to 45-60°, an attempt is made at conservative reduction. During reposition (to open the joint space), the elbow joint is given a varus position, after which reduction is performed by applying pressure on the bone fragment from the bottom up and from the outside inwards. If reposition is unsuccessful, and the remaining displacement threatens to cause permanent deformity and contracture, the need for surgical intervention arises. Open reduction is also indicated when the bone fragment is displaced and rotated by more than 60°, since an attempt at reduction in such cases is almost always unsuccessful. In addition, during unnecessary manipulations, existing damage to the capsular-ligamentous apparatus and adjacent muscles is aggravated, and the epiphysis and articular surfaces of the bones forming the elbow joint are unnecessarily injured. Convenient surgical access to the elbow joint according to Kocher. After reposition, the bone fragments are fixed with two crossed Kirschner wires. A good result is achieved using a compression device proposed by V. P. Kiselev and E. F. Samoilovich. Children who have suffered this injury are subject to dispensary observation within 2 years, since damage to the growth zone with the formation of deformation in the later stages is possible.
Traumatology and orthopedics
Edited by corresponding member. RAMS
Yu. G. Shaposhnikova
– this is a complete or partial violation of the integrity of the bone resulting from an impact that exceeds the strength characteristics of bone tissue. Signs of a fracture include abnormal mobility, crepitus (bone crunch), external deformity, swelling, limited function and severe pain, while one or more symptoms may be absent. The diagnosis is made on the basis of anamnesis, complaints, examination data and X-ray results. Treatment can be conservative or surgical, involving immobilization using plaster casts or skeletal traction, or fixation by installing metal structures.
ICD-10
S42 S52 S72 S82
General information
A fracture is a violation of the integrity of a bone as a result of traumatic impact. Is a widespread injury. Most people experience one or more fractures during their lifetime. About 80% of total number injuries are fractures of tubular bones. Along with the bone, surrounding tissues also suffer during injury. More often there is a violation of the integrity of nearby muscles, less often compression or rupture of nerves and blood vessels occurs.
Fractures can be single or multiple, complicated or uncomplicated by damage to various anatomical structures and internal organs. There are certain combinations of injuries that are frequently encountered in clinical traumatology. Thus, with fractures of the ribs, damage to the pleura and lungs is often observed with the development of hemothorax or pneumothorax; if the integrity of the skull bones is violated, the formation of an intracerebral hematoma, damage to the meninges and substance of the brain, etc. Treatment of fractures is carried out by orthopedic traumatologists.
Causes of fracture
Violation of bone integrity occurs with intense direct or indirect exposure. The immediate cause of a fracture can be a direct blow, a fall, car accident, industrial accident, criminal incident, etc. There are typical mechanisms of fractures of various bones that cause the occurrence of certain injuries.
Classification
Depending on the initial structure of the bone, all fractures are divided into two large groups: traumatic and pathological. Traumatic fractures occur on a healthy, unchanged bone, while pathological fractures occur on a bone affected by some pathological process and, as a result, partially lost its strength. To form a traumatic fracture, a significant impact is necessary: a strong blow, a fall from a fairly high height, etc. Pathological fractures develop with minor impacts: a small impact, a fall from a height of one’s own height, muscle strain, or even turning over in bed.
Taking into account the presence or absence of communication between the damage area and external environment all fractures are divided into closed (without damage to the skin and mucous membranes) and open (with a violation of the integrity of the skin or mucous membranes). Simply put, with open fractures there is a wound on the skin or mucous membrane, but with closed fractures there is no wound. Open fractures, in turn, are divided into primary open, in which the wound occurs at the time of traumatic impact, and secondary open, in which the wound is formed some time after the injury as a result of secondary displacement and damage to the skin by one of the fragments.
Depending on the level of damage, the following fractures are distinguished:
- Epiphyseal(intra-articular) - accompanied by damage to the articular surfaces, rupture of the capsule and ligaments of the joint. Sometimes they are combined with dislocation or subluxation - in this case they speak of fracture-dislocation.
- Metaphyseal(periarticular) - occur in the area between the epiphysis and diaphysis. They are often impacted (the distal fragment is embedded in the proximal one). As a rule, there is no displacement of fragments.
- Diaphyseal– are formed in the middle part of the bone. The most common. They are distinguished by the greatest variety - from relatively simple to severe multi-fragmented injuries. Usually accompanied by displacement of fragments. The direction and degree of displacement are determined by the vector of the traumatic impact, the traction of the muscles attached to the fragments, the weight of the peripheral part of the limb and some other factors.
Taking into account the nature of the fracture, there are transverse, oblique, longitudinal, helical, splintered, polyfocal, crushed, compression, impacted and avulsion fractures. V- and T-shaped injuries occur more often in the metaphyseal and epiphyseal zones. When the integrity of the cancellous bone is violated, the penetration of one fragment into another and compression of the bone tissue are usually observed, in which the bone substance is destroyed and crushed. In simple fractures, the bone is divided into two fragments: distal (peripheral) and proximal (central). With polyfocal (double, triple, etc.) injuries, two or more large fragments form along the bone.
All fractures are accompanied by more or less pronounced destruction of soft tissue, which is caused both by direct traumatic effects and by displacement of bone fragments. Typically, hemorrhages, soft tissue bruises, local muscle tears and ruptures occur in the area of injury. small vessels. All of the above in combination with bleeding from bone fragments causes the formation of a hematoma. In some cases, displaced bone fragments damage nerves and great vessels. Compression of nerves, blood vessels and muscles between fragments is also possible.
Symptoms of a fracture
There are absolute and relative signs of a violation of bone integrity. Absolute signs are deformation of the limb, crepitus (bone crunch, which can be distinguished by the ear or determined under the doctor’s fingers during palpation), pathological mobility, and in open injuries - bone fragments visible in the wound. To the number relative characteristics includes pain, swelling, hematoma, dysfunction and hemarthrosis (only for intra-articular fractures). The pain intensifies with attempted movements and axial load. Swelling and hematoma usually occur some time after the injury and gradually increase. Dysfunction is expressed in limited mobility, impossibility or difficulty in support. Depending on the location and type of damage, some of the absolute or relative signs may be absent.
Along with local symptoms, large and multiple fractures are characterized by general manifestations caused by traumatic shock and blood loss due to bleeding from bone fragments and damaged nearby vessels. At the initial stage, there is excitement, underestimation of the severity of one’s own condition, tachycardia, tachypnea, pallor, cold sticky sweat. Depending on the predominance of certain factors, blood pressure may be reduced, or less often, slightly increased. Subsequently, the patient becomes lethargic, lethargic, blood pressure decreases, the amount of urine excreted decreases, thirst and dry mouth are observed, and in severe cases, loss of consciousness and respiratory disorders are possible.
Complications
Early complications include skin necrosis due to direct damage or pressure from bone fragments from the inside. When blood accumulates in the subfascial space, subfascial inflammation occurs hypertension syndrome, caused by compression of the neurovascular bundle and accompanied by impaired blood supply and innervation of the peripheral parts of the limb. In some cases, as a result of this syndrome or concomitant damage to the main artery, insufficient blood supply to the limb, gangrene of the limb, and thrombosis of the arteries and veins may develop. Damage or compression of the nerve can lead to paresis or paralysis. Very rarely, closed bone injuries are complicated by suppuration of the hematoma. Most common early complications open fractures are wound suppuration and osteomyelitis. With multiple and combined injuries, fat embolism is possible.
Late complications of fractures are improper and delayed fusion of fragments, lack of fusion and pseudarthrosis. With intra-articular and periarticular injuries, heterotopic para-articular ossifications often form, and post-traumatic arthrosis develops. Post-traumatic contractures can form with all types of fractures, both intra- and extra-articular. Their cause is prolonged immobilization of the limb or incongruence of the articular surfaces due to improper fusion of fragments.
Diagnostics
Since the clinical picture of such injuries is very diverse, and some signs are absent in some cases, when making a diagnosis, much attention is paid not only clinical picture, but also to clarify the circumstances of the traumatic impact. Most fractures are characterized by a typical mechanism, for example, when falling with emphasis on the palm, a fracture of the radius often occurs in a typical place, when twisting a leg - a fracture of the ankles, when falling on the legs or buttocks from a height - a compression fracture of the vertebrae.
The patient's examination includes a thorough examination for possible complications. If the bones of the extremities are damaged, the pulse and sensitivity in the distal parts must be checked; in case of fractures of the spine and skull, reflexes and skin sensitivity, if the ribs are damaged, auscultation of the lungs is performed, etc. Particular attention is paid to patients who are unconscious or in a state of severe alcohol intoxication. If a complicated fracture is suspected, consultations with relevant specialists (neurosurgeon, vascular surgeon) and additional research(for example, angiography or echoEG).
The final diagnosis is made on the basis of radiography. X-ray signs of a fracture include a line of clearing in the area of damage, displacement of fragments, a break in the cortical layer, bone deformations and changes in bone structure (clearing with displacement of fragments of flat bones, compaction with compression and impacted fractures). In children, in addition to the listed radiological symptoms, with epiphysiolysis, deformation of the cartilaginous plate of the growth zone may be observed, and with greenstick fractures, limited protrusion of the cortical layer.
Fracture treatment
Treatment can be carried out in an emergency room or in a trauma department, and can be conservative or surgical. The goal of treatment is the most accurate comparison of fragments for subsequent adequate fusion and restoration of function of the damaged segment. Along with this, in case of shock, measures are taken to normalize the activity of all organs and systems; in case of damage to internal organs or important anatomical formations, operations or manipulations are carried out to restore their integrity and normal function.
At the first aid stage, pain relief and temporary immobilization are carried out using special splints or improvised objects (for example, boards). For open fractures, remove contamination around the wound if possible, and cover the wound with a sterile bandage. In case of intense bleeding, apply a tourniquet. Measures are taken to combat shock and blood loss. Upon admission to the hospital, a blockade of the injury site is performed, reposition is carried out under local anesthesia or general anesthesia. Reposition can be closed or open, that is, through the surgical incision. Then the fragments are fixed using plaster casts, skeletal traction, as well as external or internal metal structures: plates, pins, screws, knitting needles, staples and compression-distraction devices.
Conservative treatment methods are divided into immobilization, functional and traction. Immobilization techniques (plaster casts) are usually used for non-displaced or slightly displaced fractures. In some cases, plaster is also used for complex injuries at the final stage, after removal of skeletal traction or surgical treatment. Functional techniques are indicated mainly for vertebral compression fractures. Skeletal traction is usually used in the treatment of unstable fractures: comminuted, helical, oblique, etc.
Along with conservative methods, there is great amount surgical methods for treating fractures. Absolute indications before surgery there is a significant discrepancy between the fragments, excluding the possibility of fusion (for example, a fracture of the patella or olecranon); nerve damage and great vessels; interposition of a fragment into the joint cavity during intra-articular fractures; the threat of a secondary open fracture when closed damage. Relative indications include interposition of soft tissues, secondary displacement of bone fragments, the possibility of early activation of the patient, reducing treatment time and facilitating patient care.
As additional methods Treatments widely use exercise therapy and physiotherapy. At the initial stage, to combat pain, improve blood circulation and reduce swelling, UHF is prescribed to remove the plaster cast; measures are taken to restore complexly coordinated movements, muscle strength and joint mobility.
When using functional methods (for example, for compression fractures of the spine), exercise therapy is the leading therapeutic technique. The patient is taught special exercises, aimed at strengthening the muscle corset, decompressing the spine and developing motor patterns that prevent aggravation of the injury. First, the exercises are performed lying down, then on your knees, and then in a standing position.
In addition, for all types of fractures, massage is used to improve blood circulation and activate metabolic processes in the area of damage. At the final stage, patients are sent to sanatorium-resort treatment, prescribed iodine-bromine, radon, sodium chloride, pine-salt and pine medicinal baths, and also carry out rehabilitation measures in specialized rehabilitation centers.
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