Fractures of bones and their types. Fracture of various parts of the spine

Remember as a child: “Don't run! Look under your feet! Fall and break something!" And there were also such “heroes” who, despite all the warnings, still managed to either leg, and then proudly come to school with a cast, enthusiastically telling and desperately lying, of course, how it all happened in reality.

Nevertheless, if we discard the peculiar “heroism” of adolescents, we understand that there is nothing funny or funny in injuries of this kind, and that they are quite fragile, and a fracture, say, of a limb can permanently change our habitual way of life.

Realizing the seriousness of the consequences, we sometimes even fall slightly, listen to ourselves with fear, trying to dissuade ourselves and denying in turn all the signs of a fracture.

So, first of all, it should be noted that a fracture is a violation of the integrity of the bone, which, as a rule, occurs as a result of various kinds of injuries.

In turn, the influence of the traumatic factor can be of two types: direct (impact) and indirect (high axial load on the bone).

Most often, the severity of the injury directly depends on which is affected.

Recall, by the way, that all bones can be divided into spongy and tubular. They have a different structure, and, therefore, differ from each other in their properties. Here, for example, (the lower and upper limbs of a person) are able to withstand much greater loads, but at the same time they are less elastic compared to spongy ones.

Types and signs of bone fracture:

Fractures are of several types, among them, for example, transverse and spiral fractures are often found, but multidirectional fractures resulting from comminuted injuries are considered the most dangerous.

The latter type is most often the result of a fall from a height or traffic accidents.

Some fractures occur without axis displacement, but sometimes, in more severe cases, several lines of fractures appear, and the fragments are significantly displaced. The latter type leads to deformation of the body part.

Often, the sharp edge of a bone fragment injures nearby vessels, as a result of which fractures are also complicated by heavy bleeding. In some cases, fragments can also injure the nerve trunks during fractures. spinal cord, the brain - with severe craniocerebral injuries, and injuries of the lungs and pleura are signs

There are two main criteria that report the likelihood of a fracture - relative and absolute.

Relative signs of a fracture:

Pain that gradually increases significantly at the site of injury.

After some time, a hematoma appears in the fracture area. If it also pulsates, this may indicate that intense bleeding continues inside the damaged area.

The shape of the limb changes.

The damaged limb loses its inherent functions, for example, its mobility or the ability to withstand previously permissible loads is limited.

Edema occurs in the area of ​​injury.

Absolute signs of a fracture:

When in the wound, bone fragments can be seen.

The presence of a kind of crunch, called crepitus. This crunch can be heard by attaching an ear to the damaged area, and sometimes it is felt just at hand.

The position of the limb is unnatural.

Abnormal mobility, i.e. the limb becomes mobile in the place where there is no joint.

Clinically, the symptoms of a fracture can be divided into reliable and probable. The former include: a sensation of a crunch of bone fragments at the fracture site and the occurrence of pathological mobility. The second - pain, hematoma, deformity, bruising, dysfunction and swelling.

It is always worth paying close attention to the color of the skin directly near the injured area, as well as in the area of ​​​​the hand and foot. If you notice a strong blanching of the skin, a bluish tint without any movement, this may indicate damage to large vessels. Violation of the sensitivity of the skin, unpleasant burning sensation, lack of pulse in the damaged area, feeling of "goosebumps", tingling can also indicate serious damage.

In all of the above cases, you should immediately seek help from a doctor.

fracture is a medical term for a broken bone. Fractures are a fairly common problem, and according to statistics, the average person has two fractures in a lifetime. A bone fracture occurs when the physical force acting on the bone is stronger than the bone itself. Most often, fractures are caused by falls, blows, or other injuries.

fracture risk largely related to the age of the person. Fractures often occur in childhood, although fractures in children are usually not as complex as those in adults. Bones become more fragile with age, and fractures usually occur after falls, even those that would not entail any negative consequences at a younger age.

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2. Types of fractures

There are many different fracture types, 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 how the bone breaks.

At displaced fracture the bone breaks into two or more pieces, which are arranged in such a way that their ends do not form a single line. When a bone breaks into many pieces, it is called comminuted fracture. During fracture without displacement the bone breaks, or a crack may form on it, but still the bone 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 can 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 on superficial examination. An additional danger of an open fracture is the risk of infection of the wound and bone.

There are other types of fractures:

• incomplete fracture where the bone bends but does not break. This type of fracture is most common in children.
• transverse fracture- fracture at a right angle to the axis of the bone;
• oblique fracture- fracture along a curved or inclined line;
• Fracture with many fragments and fragments of bone;
• pathological fracture Caused by a disease that weakens the bones. Cancer or, more commonly, osteoporosis can lead to pathological fractures. Fractures of the hip, wrist, and spine are most common due to osteoporosis.
• Compression fracture, which arises from strong squeezing.

Classify fractures and depending on which bone was broken. The most common are leg fracture, hip fracture, arm fracture, spinal fracture, hip fracture, finger fracture, ankle fracture, clavicle fracture, rib fracture, jaw fracture.

3. Signs of a broken bone

Signs and symptoms of a broken bone may include:

• swelling and bruising;
• Deformity of the arm or leg;
• Pain in the injured area, which increases with movement or pressure;
• Loss of functioning of the damaged area;
• In an open fracture, the bone protrudes from the skin.

The severity of the fracture depends on its location and how badly the bone and soft tissues located next to it have been damaged. Serious fractures without timely treatment are dangerous for their complications. This may be damage to the blood vessels or nerves, infection of the bone (osteomyelitis) or surrounding tissues.

The 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.

Bone fractures have been a notable problem throughout the medical community throughout human history. Even at the dawn of human civilization, people faced this phenomenon and tried to deal with the consequences. Not a single person is immune from this misfortune - it always happens unexpectedly and brings a lot of suffering and inconvenience.

Fractures of bones for a long time take a person out of their usual way of life and partially deprive them of their ability to work. Based on this alone, accelerating the recovery of the body and returning a person to a normal state is becoming an important task for orthopedists around the world.

Essence of a broken bone

In its essence, a bone fracture is a complete or partial destruction of the bone, i.e. loss of integrity of bone tissue when a force is applied that exceeds the tensile strength of the substance. This phenomenon may result from the direct application of an excessive load or be a consequence of a reduction in strength. bone structure during certain diseases.

In general, bone is made up of mineral (calcium, phosphorus and trace elements) and organic (collagen) ingredients. The mineral component provides the necessary strength, and the organic composition provides the elasticity of the structure.

Any fracture is accompanied by damage to blood vessels, nerve processes and surrounding tissues, incl. muscles, joints, ligaments, tendons. The most typical is a fracture with a displacement of the destroyed bone, which is due to the direction of the load and the reflexive reaction of the muscles. The human body provides independent repair of damaged tissues. An active process of fusion of the bone structure begins with the formation of a new tissue, the so-called bone callus. The duration of bone restoration depends on the individual characteristics of the person (state of health, age, etc.) and the type of damage. Fractures in children heal much faster than in adults. The mechanism of formation of a new bone composition is based on the cell division of the periosteum, endosteum, bone marrow and vascular adventitia.

Classification of pathologies

The classification of bone fractures is made according to several main parameters. The main types of pathologies are traumatic and pathological. Traumatic is caused by the impact of extreme load on a normally formed skeletal system. Pathological is characterized by a decrease in the strength of bone tissue as a result of internal processes, which causes fracture of the bone under a small load.

According to the degree of damage, complete and incomplete (partial) fractures are distinguished. In turn, complete destruction is subdivided into a fracture without displacement and with displacement of fragments. Incomplete types include partial fractures and cracks in the bone.

Taking into account the direction and type of destruction, the following types of fractures are classified:

1. Transverse type: the direction of destruction is perpendicular to the bone axis.
2. Longitudinal type: the fracture is directed along the bone body.
3. Oblique variety: the fracture is directed at an acute angle to the bone axis.
4. Helical variety: the load had torque, as a result of which the bone fragments are displaced in a circle relative to their usual location.
5. Comminuted type: a clear fracture line is not traced - the bone is simply crushed.
6. Wedge-shaped type: a wedge-shaped deformity occurs as a result of indentation of one bone into another (most often, a fracture of the spine).
7. Impacted variant: fragments of a broken bone are displaced along the bone axis.

Types of bone fractures

The following main types are distinguished: closed and open. Closed damages are isolated from the external environment, i.e. do not cause destruction of the skin. Such injuries can be single (only one segment of the support system is destroyed) and multiple. The open version implies a violation of the integrity of the skin and the presence of direct contact of the site of destruction with air. Among such processes, combined fractures are distinguished, which are accompanied by damage internal organs.

Taking into account the localization of the process, it is customary to distinguish between such fractures:

1. Epiphyseal fracture: belongs to the intra-articular variety, causes destruction of the ligaments, joint, capsule, as well as displacement of bones and damage to the surface of the joints: most common in children.
2. Metaphyseal type (periarticular): manifests itself in the region of the cortical layer; a characteristic representative is the impacted type; displacement of debris is not observed.
3. Diaphyseal fracture: The most common type of fracture in a bone, it occurs in the middle part of the bone body.

According to the severity of the manifestation, uncomplicated (typical) and complicated fractures are noted. The main complicating factors include: pain shock, damage to internal organs, profuse hemorrhage, fat embolism, concomitant infection, the presence of osteomyelitis and seasis.

Among the injuries of various parts of the skeleton, fractures most often manifest themselves in the following elements: fractures of the bones of the extremities - lower and upper (including the radius, tibia, foot), spine, femoral neck, coccyx, collarbone, shoulder region, jaw, nose , pelvis, skull, tibia.

Causes of fractures

The etiology of fractures is divided into two groups - traumatic and pathological factors. Traumatic fracture occurs under the influence of excessive mechanical load of a static or kinetic nature. Most often, the destruction of the bone occurs as a result of extreme kinetic (moving) load applied perpendicular or at an angle to the bone axis. This load occurs when strong blow, fall, unsuccessful jump. One of the most common causes of our time is an accident. Longitudinal rupture of the bone is less common and is usually caused by pinching of the limb under the action of axial force. Static loading is shown, for example, at blockages.

The pathological factor reduces the strength of the tissue to such an extent that the bone is destroyed when small loads- a sharp rise from a chair, squatting, and even when walking. The main diseases leading to such consequences are tissue tumors, osteoporosis, osteomyelitis. It is because of the weakening of the bone structure that the risk of fractures in the elderly increases with ice.

The main signs of fractures

Bone fractures have characteristic symptoms, which allow you to identify the pathology when it occurs, which is very important to exclude complications. The following main relative signs of a fracture can be distinguished:

1. Pain syndrome: sharp pain with broken bones and It's a dull pain in the future, moreover, increasing with a longitudinal load or its imitation.
2. Swelling: Swelling in the affected area develops gradually.
3. Hematoma: different sizes on the affected area; in this case, a hematoma with a pulsation indicates continued bleeding.

The absolute sign of a fracture occurs as a result of the direct destruction of the bone and indicates the completion of the process. These signs of a fracture are:

1. A characteristic crunch (crepitus): occurs when the bone tissue is ruptured, later it is heard with a phonendoscope due to the friction of the fragments.
2. Unnatural direction of a limb or other bone.
3. Increased mobility with joint rupture.
4. Fragments of the bone are visible visually.
5. Shortening of the limb when the fragments are displaced, protrusion of a broken bone.

Some signs of a non-displaced or incomplete fracture may not appear, making diagnosis difficult. The symptoms of a fracture are unambiguously determined by radiography - localization, type and degree of destruction are recorded.

Regeneration process

The fusion of bone tissue and the restoration of the entire structure is a natural reflexive process that usually proceeds according to the chondroblastic scenario (due to the activation of chondroblasts). The regeneration process is divided into the following stages:

1. Catabolic phase: duration 8-10 days; all symptoms are manifested in fractures, develops inflammatory response, profuse bleeding, blood supply to tissues is disturbed, intoxication of the body occurs; cellular enzymes are activated in the rupture zone, necrosis develops on the surface of the site, fusion does not yet occur.
2. Differential phase: 15-30 days after fracture; there is a process of the appearance of new cells, which leads to the formation of calluses on a fibrous-cartilaginous basis; synthesis of glycosamiglycans develops; the basic basis of callus begins to form - metrics; collagen production is activated.
3. Primary accumulative phase: 15-40 days; gradually formed vascular system from small capillaries; chondroitin sulfate combines with phosphate and calcium ions to form bone tissue; synthesis of calcium phosphate is activated; with the participation of silicon and magnesium ions, primary callus is formed.
4. Mineralization phase: up to 4 months; crystalline hydroxyapatite is formed; their complex with collagen appears; crystallization nuclei are formed - primary mineralization; intercrystalline bonds are created that complete the secondary mineralization of callus.

Fracture treatment

When fractures are fixed, treatment must be urgently started with first aid, and then immobilization, anesthesia, conservative and restorative therapy, other methods of treating fractures are applied, and if necessary, surgical treatment is performed.

In order to accurately understand the nature of the injury, an x-ray is required.

First aid. The main task in rendering before the arrival of the doctor is to relieve pain shock, provide peace to the victim, maximally exclude damage to soft tissues, and ensure the immobility of the damaged area.

With an open fracture, it is necessary to stop the bleeding by applying a bandage. For anesthesia, analgin or promedol is used. Immobilization for fractures is carried out by fixing a homemade splint.

immobilization measures. Main principle treatment of fractures - complete immobilization of the damaged area. Immobilization is provided by layer-by-layer application of bandages impregnated with gypsum or modern synthetic compounds. A plaster splint has a different number of layers depending on the location of the fracture (for example, shoulder - 6, lower leg - up to 10, thigh - 12 layers). Before applying the splint, the damaged area is treated with an antiseptic and lined with cotton wool to prevent bedsores.

Recovery activities. Restoration of the damaged area is a rather lengthy process. Exercise therapy is widely used for fractures, in addition, physiotherapy is used for full functional rehabilitation, massotherapy, CRM-therapy, treatment of bone fractures with folk remedies. In the event that for some reason there is an incorrectly fused fracture, the resulting callus is carefully destroyed and re-immobilized; more often, surgery is used to correct an improperly healed fracture.

Gelatin is an effective remedy. It is used when home treatment by ingestion and as a compress. Of the other folk remedies, mummy in various combinations is the most popular. Folk remedies are also used from comfrey root or in the form of mixtures of rose hips and currants, budra and plantain, lemon and spinach, and many other folk recipes.

Fractures may be traumatic and pathological(non-traumatic). Pathological fractures occur in acute and chronic osteomyelitis, osteogenesis imperfecta, hyperparathyroid osteodystrophy, bone cysts, benign and malignant bone tumors, with bone metastases (tumors of the mammary glands, kidneys, prostate, lungs, stomach, etc., metastasize to the bone more often than others) .

Allocate fractures open and closed. The skin over the fracture and other soft tissues with an open fracture can be damaged by the traumatic force that breaks the bone - these are primary open fractures; if the soft tissues and skin are perforated from the inside by the sharp end of the fragment, this is a secondary open fracture. With a secondary open fracture, the wound is usually small, equal to the diameter of the end of the fragment that perforates the bone. Both with a primary open and a secondary open fracture, there is primary microbial contamination of the fracture zone, therefore, with both fractures, suppuration and osteomyelitis are possible.

Closed fractures may be complete or incomplete. With incomplete fractures, the integrity of the entire bone is not broken. These are marginal fractures, separations of tubercles of bones.

Fractures are classified according to location. diaphyseal, metaphyseal and epiphyseal. Violations of the integrity of the bone in children and adolescents along the growth zone are called epiphyseolysis. Epiphyseal fractures are usually intraarticular. Metaphyseal fractures are also called periarticular. Depending on the height of the location, fractures are distinguished in the lower third of the bone, the middle third and the upper third.

It is necessary to distinguish between the concepts of "fragment" and "splinter". The fragment contains all the constituent parts of the bone, i.e. if it is a fragment with a diaphyseal fracture, then it certainly has a bone canal. There are two fragments (with a single fracture), three (with a double fracture), four (with a triple fracture). Allocate multi-comminuted, as well as large-comminuted fractures.

In the direction of the fracture plane, fractures are distinguished transverse, oblique, helical, longitudinal.

Fractures occur without displacement of fragments and with displacement of fragments. Displacement can be primary: it occurs at the time of a fracture under the influence of a traumatic force and secondary: it occurs under the influence of muscle contraction (retraction); X-rays usually show secondary displacement of fragments.

There are displacements of fragments along the length, width, at an angle to the axis and rotational. Angular displacement of a bone in a segment with two long bones (forearm, lower leg) is also called axial displacement. Unlike the angular one, it is difficult to remove with closed reposition.

FROM clinical point vision, it is important to distinguish between fractures stable and unstable. Stable fractures have a transverse fracture line. With unstable fractures (oblique, helical), due to the increasing muscle retraction after injury, a secondary displacement necessarily appears.

Fractures can be driven in when the end face or the sharp edge of the end face of one fragment is introduced into the end face of another fragment. A classic example of an impacted fracture is an abduction fracture of the neck. femur. With such a fracture, the retraction of the muscles surrounding the hip joint enhances the adhesion (impacting) of the fragments, eliminating the possibility of their displacement. Impacted fractures also occur with a fracture of the trochanteric region. In the elderly and old age this impaction should not be eliminated, since it contributes to a more rapid union of the fracture. The damaging force at the fracture determines the nature of the fracture and the direction of the fracture line.

According to the x-ray, seeing the direction of the fracture line, the shape of the fragments, one can imagine the mechanogenesis of the fracture. A flexion fracture is characterized by a rupture of the bone on the side of its tension (the side opposite to the direction of the forces that bend and break the bone) and a triangular fragment is punctured on the side of the compression of the bone. A shear fracture occurs when one bone, resting against another, under the influence of increasing external forces exceeding the strength of the bone, breaks, shifts it.

Shear fractures occur in ankle joint:

• a fracture of the medial malleolus with a supination mechanism of injury to the ankle joint (the ankle is shifted by the talus resting against it, the fracture line approaches the vertical);
• a fracture of the posterior edge of the tibia with excessive plantar flexion of the foot (the talus rests against the posterior edge of the tibia and shifts it);
• a fracture of the anterior edge of the tibia with excessive dorsiflexion of the foot (the talus rests against the anterior edge of the tibia and shifts it);
• fracture of the outer edge of the tibia (in the area of ​​the lower tibiofibular syndesmosis) with a pronation mechanism of injury to the ankle joint (the outer edge of the tibia is shifted by the talus resting against it).

An avulsion fracture is opposite to a shift, when a section of the bone opens with sharply contracted muscles or ligaments during excessive movement in the joint. This is an avulsion fracture of the medial malleolus with a pronation mechanism of injury - the deltoid ligament tears off the medial malleolus; the fracture line is always horizontal and often at the level of the joint space. This is an avulsion fracture of the lateral malleolus with a supination mechanism of injury, when the calcaneal-fibular ligament tears off the top of the lateral malleolus; fracture line is horizontal. With avulsion fractures, the periosteum is often torn not at the same level with the fracture line, tucking itself into an “apron” between the fragments, excluding the possibility of their complete reposition.

Compression fractures arise under the influence of destructive forces along the longitudinal axis of the bone. These are often fractures of the vertebral bodies when falling from a height, fractures of the calcaneus, radius when falling on a bent or unbent hand.

Rotation fractures result from indirect action couples of twisting forces. These are more often fractures of the bones of the lower leg when a person falls, when the foot is fixed, and the body rotates along with the lower leg around the foot. Spiral fractures of the tibia occur. The fibula also breaks below at the level of the tibiofibular syndesmosis or above under the head.

Fracture-dislocations occur in joints when, along with a dislocation, there is a fracture of the bone that forms the joint: for example, fracture-dislocations in the ankle joint, fracture-dislocations in the hip joint, fracture-dislocations of the vertebrae, fracture-dislocations in the knee joint, elbow joint, shoulder joint. Dislocation and fracture within the same segment of the limb occur when the traumatic force breaks the diaphysis of the bone (for example, from excessive flexion) and dislocates one of the articular ends of this bone or dislocates the head of another bone in case of damage to the forearm. Fracture and dislocation of the femur occurs in car accidents, when the victim receives a blow to the knee by the instrument panel of the car: the thigh breaks at the level of the diaphysis and the femoral head is dislocated backwards. An example of a fracture and dislocation within the same segment would be injuries to the forearm of Galeazzi and Monteggia. In the first case, the radius breaks from bending in the lower third of the forearm and dislocation occurs in the distal radioulnar joint; in the second case, the ulna in the upper or middle third of the forearm breaks and the head of the radius is dislocated.

Symptoms of bone fractures

Without taking into account clinical manifestations, cases of X-ray overdiagnosis are possible, and, conversely, the possibility of the X-ray method often remains unused to the full extent. It is advisable to divide the clinical signs of fractures into reliable (unconditional) and probable. Reliable signs include shortening of the damaged segment, pathological mobility at the fracture site, and crepitus of bone fragments.

It should be noted that the crepitation of fragments should be checked only in extreme cases, since this attempt can cause increased pain. Reliable signs of a fracture are detected more often with diaphyseal fractures of long tubular bones, fractures of the clavicle and ribs. In fractures of short tubular bones, metaepiphyseal fractures, incomplete fractures, reliable signs are incomparably less important or absent. Moreover, the search "by all means" for reliable signs can harm the patient. Therefore, it is important to identify likely signs: deformity at the fracture site, local tenderness on palpation, pain at the fracture site with axial load, characteristic position of the limb.

For example, a noticeable shortening of the leg and external rotation of the foot (its outer edge lies on the bed) make one suspect a fracture of the neck or trochanteric region of the femur; hallux valgus feet, swelling of the ankle joint area are characteristic of pronation fracture-dislocation in the ankle joint. Of great importance is such a symptom as pain at the fracture site during palpation of the bone.

With a fracture of the ribs, especially costal cartilage, this symptom may be the only sign of a fracture. In the case of a helical fracture of the tibia, the fibula is almost always broken, but on the radiograph, only the site of the fracture of the tibia is not visible. Pain on palpation under the head or just above the syndesmosis gives grounds to diagnose a fracture.

Tissue edema in a fracture is not a reliable sign, but the smoothness of the lumbar groove is an important symptom of a spinal fracture. The diagnosis is confirmed by palpation, which determines the protrusion of the spinous process of the damaged vertebra. Of great importance is the study of the nature of hemorrhage in the tissue (hematoma, bruising). The rapid appearance after injury of a significantly widespread hemorrhage usually indicates a fracture with a large area of ​​\u200b\u200bdamage (for example, a rapidly growing perineal hematoma makes it possible to diagnose a severe fracture of the pelvic bones). Hemorrhage over the mastoid process (behind the ear) is characteristic of a temporal bone fracture and allows the diagnosis of a skull base fracture. It must be remembered that the fracture site can be located at a distance from the hemorrhage zone - the blood spreads through the interfascial fissures. Therefore, with a fracture of the clavicle, hemorrhage may appear on the anterior surface of the chest, with fractures of the neck of the shoulder - in the area of ​​the elbow joint.

An important symptom of a fracture- deformation of the damaged segment. It can be caused by displacement of fragments and hemorrhage into soft tissues. Severe deformation occurs when fragments are displaced, especially with angular displacement and displacement along the length. With oblique and helical fractures and a relatively small displacement along the length, there may be a pronounced displacement along the periphery. The injured segment should always be carefully compared with the healthy segment, using measurement to detect small shortenings, rotational deviations, and axial deviations in periarticular and intraarticular fractures.

When examining the victim pay attention to the position of the limbs. Distinguish position active, passive and forced. By the nature of the passive position, it is possible with a high degree of probability to put correct diagnosis. For example, a passively hanging hand indicates damage to the radial nerve. Forced position can be caused by pain or dislocation in the joint. For example, adduction of the hip with internal rotation and slight flexion at the knee joint is characteristic of a posterior dislocation in the hip joint. With diaphyseal fractures, when many signs of a violation of the integrity of the bone are present, dysfunction (cannot raise a leg above the bed, cannot stand on it) is taken for granted. The poorer the symptomatology of the fracture, the more important this symptom becomes as a "distress" signal and obliges to a thorough search for damage.

The symptom of dysfunction is especially important in the diagnosis of fracture-related injuries of the nerve trunks. With closed fractures of the humerus, especially fractures in the lower third of it, the radial nerve can be damaged. For fractures surgical neck shoulder, the axillary nerve is usually damaged: after the fracture has healed, the patient cannot withdraw his arm, atrophy of the deltoid muscle increases. A subcapitate fracture of the fibula (this fracture often accompanies a fracture of the tibia) is accompanied by damage to the common peroneal nerve, which runs in close proximity to this bone, behind its head and neck. Characterized by sagging of the foot, the impossibility of dorsiflexion of it, the lack of sensitivity on the back of the foot and in the first interdigital space.

Of particular importance are the symptoms of damage to the main arteries in closed fractures. Rupture of an artery with the formation of a hematoma, tense or pulsating, when the diagnosis of damage to the artery is clear, is rare. More often, at the time of the primary displacement (in case of injury), as a result of overstretching of the artery, its intima is torn and thrombosis occurs at the site of injury. The most dangerous in relation to damage to the arteries are dislocations in the knee joint, anterior hip dislocation (the head presses the femoral artery from behind), low fractures of the femur and high fractures of the tibia, dislocations in the shoulder and elbow joints. The probability of violation of the main arterial blood flow in case of closed fractures and dislocations significantly increases in elderly and senile people, in whom atherosclerotic plaque breaks during the primary displacement of fragments due to bending of the calcified artery. It closes the lumen of the artery - thrombosis joins.

Early symptoms of arterial obstruction are pain in the distal limb, aggravated by placing it on a splint for traction; coldness of the foot or hand, clearly noticeable when compared with the temperature of an uninjured limb; the absence of a pulse in the arteries distal to the fracture or dislocation (compare with a healthy limb); pallor of the skin and retraction of the saphenous veins. If these symptoms are detected, urgent help from a vascular surgeon is necessary, otherwise ischemia may become irreversible. Then there are "late" signs of it: the absence of active movements in the joints of the foot and hand, muscle contracture, impaired sensitivity of the distal sections.

Complications of fractures

One of the complications of a closed fracture is blood loss. Bleeding from a broken bone lasts up to 3-5 days. For some reason, many surgeons associate bleeding and blood loss only with damage to the main vessel and external bleeding or bleeding into the cavity.

Bleeding always occurs with a closed fracture. Blood loss in case of a fracture of the posterior half-ring of the pelvis can reach 2-3 liters, the anterior half-ring of the pelvis - 0.8 liters, the femur - 0.5-2.5 liters, the lower leg - 0.5-1.0 liters. Especially dangerous is bleeding in elderly and senile patients with fractures of the ilium and sacrum, subtrochanteric and pertrochanteric fractures of the femur, high fractures of the tibia. In patients with multiple fractures, blood loss can be 2-3 liters or more.

Fat embolism is a rare but severe complication of fractures. It occurs more often in those victims who have not been diagnosed with shock and therefore have not received antishock therapy. It is believed that fat embolism develops as a result of impaired tissue circulation during shock. Pathological deposition of blood in the capillaries, acidosis as a result of hypoxia, impaired blood chemistry are links in the pathogenetic chain. In the clinic, a mixed form of embolism is more often observed - both cerebral and pulmonary.

Clinically, fat embolism manifests itself sudden deterioration the patient's condition ("light interval" from several hours to 2 days). The first symptom is a change in the consciousness of the victim due to increasing hypoxia of the brain up to loss of consciousness. Important signs of fat embolism are increased respiration, cyanosis of the skin and mucous membranes (hypoxia!), an increase in body temperature to 39 ° C and above (obviously, of central origin). There are scattered symptoms of damage to the cerebral cortex, subcortical formations and the trunk: smoothness of the nasolabial fold, tongue deviation, swallowing disorder, meningeal symptoms. On radiographs of the lungs, symptoms of edema are noted - a picture of a "snow blizzard".

It is very important to differentiate a fat embolism from a growing intracranial hematoma, since in both cases there is a "light gap". With a hematoma, focal symptoms of damage to one hemisphere are more pronounced, symptoms of damage to the subcortical regions and the brain stem are less pronounced. Hematoma is also characterized by bradycardia, there is no such shortness of breath and hypoxia as with embolism. Special research methods help: a picture of a "snow blizzard" on x-rays of the lungs, a shift in the midline structures of the brain on echoencephalograms with a hematoma, an increase in the pressure of the cerebrospinal fluid and blood in the cerebrospinal fluid with a hematoma. Of great importance is the study of the fundus: drops of fat can be seen in the capillaries of the fundus during embolism; varicose veins and smoothness of the contours of the optic nerve with hematoma.

Along with common complications closed fractures may be local complications. First of all, they should include an internal bedsore, which often occurs with a complete displacement of fragments of the tibia. Internal decubitus significantly complicates the use of many methods of treatment.

Diagnosis of bone fractures

Typical fractures are complaints of pain at the fracture site and the inability to use the injured limb. These symptoms are especially pronounced in diaphyseal fractures and the absence of immobilization of the injured limb. They may be indistinct in impacted periarticular fractures. Pain as a symptom of a fracture may be absent in a victim with severe combined or multiple fractures, when the severity of the condition is due to other, more severe injuries or complications of the injury: bleeding, pneumothorax, shock, damage to the hollow abdominal organs, requiring treatment for life reasons. Therefore, fractures that do not have clear clinical manifestations are often diagnosed with a delay (after an acute period of injury): fractures of the spine, impacted fractures of the neck of the humerus.

Anamnesis damage is essential in the diagnosis of a fracture. It is necessary to find out the circumstances of the injury, if possible, the mechanism of damage, which will make it possible to establish a certain type of fracture.

Loss of consciousness at the time of injury indicates brain damage. The story of the victim about bleeding from the nose and ears helps to suspect a fracture of the base of the skull. An indication of chest compression during an injury during further examination makes it possible to exclude the possibility of a sharp increase in pressure in the system of the superior vena cava, i.e. chest compression syndrome. Compression or impact at the level of the abdomen and pelvis requires a mandatory thorough examination, excluding the possibility of damage to the hollow or parenchymal organs of the abdomen, kidneys, bladder, urethra.

Of great importance are information about previous diseases, indications of bone disease (osteomyelitis, dystrophic processes, tumors, etc.) to clarify pathological fractures. It is also necessary to find out the frequency and amount of alcohol consumed by the victim and the possibility of alcohol addiction; the possibility of an anaphylactic reaction to novocaine, antibiotics and other drugs.

Palpation allows you to determine the fracture of the coccyx, sacrum, ischial bones, ankles, bones of the forearm, shoulder and lower leg.

In most closed fractures, radiodiagnosis is of paramount importance. This study is necessary not only to confirm the diagnosis of a fracture and its documentation. It is very important for the traumatologist, on the basis of radiographs, to get an idea of ​​the nature of the displacement of fragments, the direction of the fracture lines and the presence of additional cracks, indicating splitting of the fragment. This information is needed to determine the treatment tactics, the choice of the type of osteosynthesis. X-ray examination important in the course of treatment. It determines the completeness of the reposition, the correct position of the fixing structure, the absence of secondary displacement (by the subsidence of edema), the appearance and formation of callus. The surgeon and traumatologist must follow the rules for performing radiographs for fractures.

First rule: take a picture of the entire damaged segment, and not just the place of an obvious fracture, i.e., not only the diaphysis, but also the upper and lower ends of the bone should be visible on the picture. In metatarsal fractures, a full x-ray of the entire foot must be taken, then dislocations of these bones in the tarsal-metatarsal joint are visible (due to large edema and hematoma, clinical examination does not allow this diagnosis to be made).

The second strict rule of X-ray diagnostics: The photograph must be taken in two projections. According to the radiograph in one projection, it is often impossible to make a diagnosis of a fracture in general, and even more so to judge the degree of displacement of the fragments. This rule must be observed at any localization of the fracture, otherwise gross errors in diagnosis and treatment are possible. For example, when treating a subtrochanteric fracture of the femur by traction and performing radiographs only in anteroposterior projections (it is often difficult to obtain images in lateral projections), the doctor sees a complete or almost complete comparison of fragments on such radiographs and, being satisfied with this, continues traction. On the radiograph performed later in the lateral projection, a posterior tipping of the end of the central fragment is detected, i.e., there is a complete displacement, and traction treatment without radical correction is unsuccessful. Osteosynthesis of a fracture of the femoral neck, if it is possible to perform an X-ray image only in direct projection on the operating table, is unacceptable, since the correct position of the nail in the head and neck in such an image may be a mistake. On the radiograph in the lateral projection, performed after the operation, it is found that the nail passed by the head - in front or behind it.

The traumatologist often waives the rule of two projections if it is difficult to perform a large radiograph. For example, in case of a fracture of the neck of the humerus, laying involves the imposition of a cassette on the shoulder girdle and the direction of x-ray radiation from the side of the armpit with the arm abducted. However, it is impossible to remove a broken arm, so the radiologist, radiologist and traumatologist are content with a direct projection. It is convenient to obtain a radiograph of the upper end of the humerus in the lateral projection if the patient is placed sideways, with the injured shoulder to the cassette, and the beam is directed through the chest with a healthy arm thrown back over the head.

In addition to the standard two projections - direct and lateral, if necessary, perform radiographs with an oblique beam direction. They are especially indicated in the detection of foci of aseptic necrosis of the femoral head, fractures of the articular ends of the bones.

Third rule: radiographs should document major periods of fracture healing. Pictures must be taken immediately after reposition and dressing; after 8-12 days, after the edema has subsided, since an early secondary displacement is possible; 30 days after reposition, as a later shift is possible. At this time, it is still possible to correct the situation by repositioning or by another method; after removing the plaster cast and then, as necessary, to control the completeness of the union. In traction treatment, second scans should be taken in the first 2-3 days to confirm complete reposition, then after correction of traction. After 14 days, it is necessary to confirm the correct standing of the fragments, as well as after the cessation of traction and the application of a plaster cast. In the treatment of fractures of the shin bones by traction, it is necessary to take, if possible, pictures of the entire segment, and not just the fracture site, since small angular displacements are poorly visible on small radiographs, in particular, valgus deformity of the tibia, which inevitably occurs due to the peculiarities of the anatomical structure of the shin and if traction carried out without moving the block of the horizontal frame of the tire to the medial side.

Treatment of bone fractures

The main objectives of the treatment of the victim with a fracture are to save the life of the victim and preserve the limb, restore the integrity of the bone and anatomically shaped joint, the function of the injured limb and the work capacity of the victim.

The victim with a closed fracture is examined in a specialized department. In the emergency room of the hospital, it should be possible to carefully examine the victim (warm room, good lighting) and perform special studies(ECG, echoencephalography). First of all, the traumatologist assesses the general condition of the patient: whether he is conscious or unconscious, whether there are respiratory disorders (respiration rate per minute), pulse rate and quality, blood pressure level, signs of blood loss. The victim is in serious condition due to compression of the brain by a hematoma, internal bleeding in the chest or abdomen in case of damage to the hollow organs of the abdomen, injuries of the main arteries accompanying a closed fracture, they are immediately transferred to the intensive care unit or to the operating room, where, in parallel with anti-shock and resuscitation measures, a detailed examination is completed and a medical history is taken. If not threatening state- an isolated uncomplicated fracture, then the examination of the patient and the recording of the medical history are completed in the emergency room. With an isolated fracture and dislocation, the local status record should be completed with a description of the state of pulsation of the main arteries below the injury site.

In the case of polytrauma (car accident, fall from a height) in the case history, the description of the "norm" excludes all possible damage to the skeleton and internal organs. Unfortunately, sometimes a traumatologist sees a clear injury, such as a diaphyseal fracture, and does not pay attention to some "minor" injuries, which then become leading and determine the fate of the patient.

Every patient in the emergency room should have an electrocardiogram. Patients with concomitant therapeutic diseases, senile age and centenarians in the emergency room should be examined by a therapist.

Hypothermia of the patient in the emergency room and during intrahospital transportation, in the X-ray room is unacceptable. Therefore, the victim must be laid on a gurney with a mattress and covered with a blanket.

Patients with polytrauma (multiple and combined injuries), fractures of the femur and lower leg, spine and pelvis, in order to exclude additional injuries in the emergency room, are transferred from the ambulance stretcher to a special wooden shield with a mattress, sheets, a blanket, a pillow. The shield is installed on a gurney and the patient is transported to the x-ray room, then to the operating room for skeletal traction or surgery; on the same shield, the patient is laid on the bed. The dimensions of the shield are such that it fits on a gurney, on dressing and operating tables, and does not get stuck in doors and elevators.

Reposition of fragments at a fracture. Important conditions for the treatment of a fracture are complete reposition of fragments and their reliable fixation, which allows a functional load on the limb until the completion of the process of consolidation of fragments. Undoubtedly, the role of reposition and fixation of bone fragments in the elimination of post-traumatic changes in soft tissues, restoration of blood circulation and trophism of the damaged segment and the entire limb. Reduction and fixation of fragments should be performed immediately after hospitalization of the victim, if there are no contraindications to this: shock, unreplenished blood loss, the need for surgical treatment for intracranial hematoma, damage to the organs of the chest, abdomen and pelvis. Even with listed states under anesthesia at the beginning of the operation (or after stabilization of hemodynamic parameters in the treatment of shock and blood loss), dislocations in the joints and displacement of fragments in diaphyseal fractures must be eliminated without fail.

In case of contraindications to simultaneous reposition and fixation of fragments for the period of removal of the victim from serious condition(sometimes it takes 2-3 days or more), temporary therapeutic immobilization of fractures is carried out, designed to immobilize the damaged segment. For temporary immobilization of the forearm, shoulder and lower leg, a deep gypsum splint is used, an apparatus for transosseous osteosynthesis, in the simplest version of two rings. Temporary therapeutic immobilization of the femur in case of fractures of the femur and tibia of one leg, both hips can be carried out on the Beler splint with plaster casts according to Mityunin. Frame rod devices for extrafocal transosseous osteosynthesis and pin devices for the same osteosynthesis are also convenient, since after the patient's condition improves, gradual reposition and final immobilization can be completed with the same devices.

Reposition of fragments in bone fractures can be carried out simultaneously or as soon as possible.

Simultaneous reposition can be performed manually, with the help of special devices or promptly. Reposition is gradual, produced either by skeletal traction or by devices for extrafocal transosseous osteosynthesis.

The choice of reposition method is determined by the nature of the fracture, the time elapsed since the injury, the condition of the soft tissues and the general condition of the victim.

One-stage closed reposition usually ends with the imposition of a plaster cast. It is widely used in the treatment of dislocation fractures in the ankle joint, with fractures of the lower metaepiphysis of the radius.

Important conditions for the successful completion of manual reposition are complete anesthesia of the fracture zone and relaxation of the surrounding muscles. The best in this regard is anesthesia. Complete anesthesia and good relaxation provides intravenous anesthesia. It is convenient for reduction in the shoulder, elbow, hip and knee joints. When repositioning fracture-dislocations in the ankle joint, fractures of the radius in typical place intravenous anesthesia is not entirely convenient, since short-term anesthesia does not allow you to reliably keep the fragments in the reduced state at the time of applying the plaster bandage and until it hardens. In these cases, it is better to use conduction anesthesia.

Closed simultaneous reduction with the help of devices is performed for fractures of the radius in a typical place (Ivanov, Sokolovsky devices). The disadvantage of these industrial devices is that traction is carried out by fingers II-III-IV and V, while successful reposition requires traction by finger I, which is a continuation of the axis of the radius. The device for repositioning fractures of the radius in a typical place of Voronin is deprived of this shortcoming. Traction is carried out by two cuffs: one is put on the I finger, the second - on the II and III fingers.

Simultaneous fracture reduction not indicated for a painful condition of the skin (blisters, bedsores, dermatitis) and a sharp swelling of the limb.

Depending on the method of fixation of fragments after reposition, there are four main methods of treating fractures:

• constant stretching method;
• treatment with plaster bandages;
• method of intrafocal osteosynthesis, when the structure passes through the fracture site;
• a method of extrafocal transosseous osteosynthesis, when the devices that fix the fracture do not pass through the fracture site.

Fracture treatment skeletal traction method. Traction is one of the oldest healing methods. Hippocrates also described several stretching techniques. It was carried out simultaneously by belt loops on devices operating with the help of blocks, levers, gates.

Permanent traction is one of the four main treatments for fractures. Traction is indicated for closed and open diaphyseal, near and intra-articular fractures as independent method treatment, and in preparation for osteosynthesis. It is difficult to draw a clear line between indications for permanent traction and surgical treatment. These indications are determined by many conditions: localization of the fracture; the nature of the fracture: with a smaller fracture plane (transverse fractures), an operation is indicated; the provision of the department with the necessary tools and fixators, the level of operational training of the traumatologist. The main thing in determining indications is that one should not oppose conservative and operational methods treatment. They should complement each other in the interests of the patient.

The continuous pull method has its advantages and disadvantages.

The positive aspects include ease of implementation, training and equipment; the availability of monitoring the injured limb and the possibility of performing special studies, functional treatment and physiotherapy; availability of use if other methods are contraindicated.

Disadvantages of permanent traction: the possibility of infection of the tissues around the wires, trophic skin disorders when using adhesive plaster and adhesive traction, incomplete immobilization of fragments, forced long-term non-physiological position in bed, hypodynamia and hypokinesia of the patient, bulky equipment, limitation of patient transportation even within the same medical institution, laboriousness maintenance of a patient who is on bed rest, the difficulty of physiological functions and a hygienic toilet.

Skeletal traction is contraindicated in severe counted and multiple injuries requiring anti-shock and resuscitation measures; with a large zone of muscle damage (labor-intensive comparison of fragments due to uneven stretching of the muscle antagonists, the possibility of overstretching of blood vessels and nerves), non-critical behavior of the patient (mental illness, acute psychosis, senile insanity, intoxication), inflammation in the fracture zone and the site of the spokes; in diseases leading to abrupt changes in muscle tone (paresis, paralysis, convulsions, myopathy, etc.); with fat embolism.

When treating fractures with skeletal traction, 5 principles should be observed.

First principle- traction should be carried out in the mid-physiological position of the limb.

Second principle- traction should be carried out in a position of absolute physiological rest.

It is impossible to eliminate tension in the muscles of one segment of the limb if the muscles of other segments are not relaxed. Consequently, in order to restore the full balance of all the muscles of any limb, i.e., to eliminate tension in all muscles, it is necessary to put all the joints in a middle position and create a stable resting position for the limb.

In other words, the position in which a general and complete relaxation of the muscles is achieved in the limb is a half-bent position in all joints, provided that gravity is completely eliminated. This position is called the position of absolute physiological rest.

Experimental and clinical studies have shown the shortcomings of roller blocks and cotton cord hangers commonly used in traction systems. Due to friction in the systems, the loss of traction force at rest is 60% of the value of the load, and when trying to give the load a uniform upward movement (correcting the position of the limb, doing physical therapy), the traction force increases by 240-600%. The resulting fluctuations in the traction force are many times higher than the threshold for stretching the striated muscle, and therefore disturb the rest of the muscles and the comparison of fragments.

Third principle- the principle of anti-traction. Since the traction is carried out by the peripheral fragment, the countertraction must be carried out by the patient's body weight. Therefore, in many guidelines on traumatology, for the implementation of countertraction, it is recommended to raise the foot end of the bed, depending on the size of the load, by 30-70 cm. However, the position of the patient in bed with legs raised and the torso and head lowered in relation to them surgeons resort to operations on the organs of the abdomen and pelvis. The non-physiological nature of this position is manifested by difficulty in the outflow of venous blood from the brain to the heart, an increase in central venous pressure, overload of the right heart, displacement of the intestines to the diaphragm, elevation of the diaphragm and a decrease in pulmonary ventilation. The first symptom of trouble in patients on traction is a disorder of consciousness, and the most common complication- pneumonia. Raising the foot end of the bed for countertraction is unacceptable in the treatment of elderly patients and the elderly, as well as patients with combined injuries of the brain, chest and abdomen. When using damper skeletal traction, reposition can be achieved with small loads (3-6 kg).

Fourth principle- the principle of opposition of fragments. This principle is carried out by establishing a peripheral fragment along the central axis (for this, typical displacements of fragments during fractures must be taken into account).

To eliminate the angular displacement of fragments and displacements in width, since the time of Bardengeyer, lateral repositioning loops and pressure pads have been used. However, loops and pads compress soft tissues, so there may be disorders of the lymphatic and venous outflow, the possibility of vein thrombosis and embolism increases. For this reason, it is impossible to apply large loads on the reducing loops, act on short fragments and eliminate displacements in case of stale fractures.

Significant advantages have a constant lateral skeletal traction. It is simple and convenient to carry out with bayonet-shaped knitting needles using the Block method. 4-5 cm above and below the fracture line, Kirschner wires are passed through the ends of the fragments. At the end of the needle, opposite to the direction of extension, a bayonet-like bend 3-4 mm high is made with crampon tongs or circular pliers. Behind the other end of the spoke, a bayonet-like bend is placed on the bone. It passes freely through soft tissues, so no additional incisions are needed. The end of the needle, opposite to the direction of extension, is shortened so that it is under the skin. With lateral skeletal traction, soft tissues are not compressed, therefore, large loads can be used for stale fractures and impact on short fragments. Lateral skeletal traction is especially indicated for central fracture-dislocations and subtrochanteric fractures of the femur.

Fifth principle- Gradual loading. There are several techniques for repositioning fragments by constant traction. The most widespread in our country is the method of gradual reduction of an increasing load with a decrease in it after reposition. The load is gradually increased by 0.5-1.0 kg. On the 2nd day from the start of treatment, a control radiograph should be performed, if necessary, correction of traction should be made and reposition achieved by the end of 3 days - the repositioning phase of treatment ends. The maximum load is held for 2 weeks. At this time, maximum rest of the injured limb should be ensured. The remaining matching of fragments should be confirmed radiographically 2 weeks after the start of treatment. By the end of the 2nd phase, the load is gradually reduced to the initial one. Then follows the 3rd phase - from the first signs of callus to sufficient consolidation. Clinically, this is confirmed by the fact that the patient can raise the injured limb. Skeletal traction is stopped and the limb is fixed with a plaster bandage that captures the joints located next to the damaged segment. This is the so-called combined method of treatment. Fixation with a plaster bandage continues for about 2 months, then the bandage is removed and the development of movements in the joints begins.

More progressive functional treatment fractures. After the traction is completed, a plaster cast is applied like a splint to the damaged segment or a plaster boot (for fractures of the lower leg). An increase in the load on the limb and restoration of function occur in parallel with the completion of fusion, which reduces the period of disability by 1.5–2 months.

In case of fractures of the trochanteric region of the femur, low oblique fractures of the tibia, intra-articular fractures of the femur and tibia, high fractures of the tibia, it is advisable, after the end of skeletal traction, to establish loop traction for the ankle joint on a splint with ball-bearing blocks and begin intensive development of movements in the joints of the injured limb. After 4-5 weeks, loop traction is stopped and the patient begins to walk with crutches, gradually increasing the load on the leg.

Unification techniques of permanent skeletal traction. The purpose of unification is to reduce the number of devices and devices for traction, eliminate skin traction, simplify traction systems, and make them more aesthetic.

To create any traction system, you need spokes for traction and a drill for pulling the spokes, staples for tensioning the spokes, dampers (cylindrical steel springs), fishing line, suspension for Arenberg weights, weights 0.5; 1 and 2 kg, splint with ball bearing blocks for the treatment of fractures of the lower limb, bed frame, telescopic brackets with ball bearing blocks designed by the Minsk Research Institute of Traumatology and Orthopedics, abduction splint for the treatment of fractures of the humerus. Traction for olecranon the ulna is conveniently carried out with the help of a bayonet-shaped needle.

Treatment of fractures with plaster bandages. A plaster bandage for the treatment of fractures was first used in 1851 by the Dutch doctors Mathyssen and Vanderloo. In 1854, N. I. Pirogov published the experience of using plaster bandages when assisting the wounded with gunshot fractures. 90 years after the introduction of plaster casts in traumatology, S. S. Yudin once again emphasized the role of plaster casts in the treatment of fractures: “In medicine, it often happens that a forgotten or updated method of treatment with improved technique or specified indications begins to give results that were previously possible was only a dream." About 50 years have passed, but even now plaster bandages have not lost their leading role in the treatment of fractures.

The plaster bandage has a number of positive properties: it evenly and tightly adheres to the body, quickly hardens, and can be easily removed. A properly applied plaster bandage holds the matched fragments well.

Gypsum - calcium sulfate dried at a temperature of 100-130 ° C. Dried gypsum is easily ground into a fine white powder. Gypsum has hydrophilic properties, so it must be stored in tightly sealed metal boxes or glass jars.

The best is gypsum brand M400, which hardens at a water temperature of 15 ° C in 10 minutes, and at 40 ° C - in 4 minutes. A number of samples are used to check the quality of gypsum. To the touch, gypsum powder should be finely ground evenly, without lumps and grains; when mixed with water, there should be no smell of rotten eggs (hydrogen sulfide).

Test for hardening. Mix equal amounts of gypsum and water, spread the creamy gruel on a plate thin layer. After 5-6 minutes, the gypsum should harden and make a sound when tapped solid body. The plate removed from the plate should not crumble and deform when pressed.

To speed up the setting of gypsum, take hot water(40-50°C) or lime milk is added. To slow down the hardening of gypsum, cold water is used, adding half a tablespoon of table salt, milk, starch paste or liquid wood glue to it.

It is convenient to use factory plaster bandages, hermetically packed. Can cook plaster bandages from chopped gauze, from which the edge is cut off. The length of the gauze bandage should not exceed 3 m. Bandages are prepared in three sizes: from a piece of gauze cut into three parts, a wide bandage (23 cm) is obtained, into 4 parts - medium (17 cm), into 6 parts - narrow (10-11 cm).

There are 2 types of plaster bandages - a plaster bandage with cotton-gauze, flannel or knitted padding and an unlined plaster bandage. A plaster bandage with a cotton-gauze pad has a number of disadvantages: cotton wool can stray and put pressure on the body; in addition, poor fixation of bone fragments is often observed when using lining bandages. Knitted bandage and knitted stocking, which protect the skin from abrasions and at the same time have all the advantages of an unlined plaster bandage, are most widely used as a lining.

An unlined plaster cast is applied directly to the skin, which is not lubricated with anything, the hair is not shaved. When applying plaster casts, it is important to protect the most protruding parts of the body from pressure.

Disadvantages of a plaster cast: the possibility of secondary displacement of fragments after the subsidence of edema, especially with oblique fractures; the possibility of compression of the soft tissues of the limb with an increase in edema.

Therefore, it is impossible to impose a deaf plaster bandage on a fresh fracture; the possibility of thrombosis of superficial and deep veins, especially in patients suffering from varicose veins veins. Subsequently, post-traumatic edema may develop, and in the worst case, thromboembolism; increasing muscle atrophy and joint stiffness, requiring further long-term rehabilitation therapy; unreliability of fixation in high fractures of the lower leg, fractures of the bones of the forearm, since due to the soft tissues of the thigh in the first case and the shoulder in the second, mobility in the knee and elbow joints is maintained. It is difficult to perform immobilization with a plaster cast for fractures of the clavicle, humerus, femoral neck and subtrochanteric fractures of the femur.

We must always remember these shortcomings and find ways to prevent them.

Most dangerous complication- the possibility of compression of the limb in a plaster cast by increasing edema. The veins are squeezed, worsens even more venous return, the blood supply to the nerve trunks and muscles is disturbed - Zudeck's syndrome or Volkmann's ischemic contracture is further formed, even irreversible limb ischemia may develop. To prevent these complications, traumatologists and surgeons should know that it is impossible to apply a blind plaster bandage to a fresh fracture, that a plaster bandage fixed with a bandage is the same blind bandage. Therefore, after hardening of the splint (1-2 hours), the bandage is cut longitudinally throughout the splint, the edges of the bandage are somewhat parted and the splint is bandaged tightly again. The patient is warned that the limb should be in an elevated position (above the level of the heart); in case of increasing edema and compression in the bandage, the bandages fixing it should be dissected.

To combat the growing edema, suspension of the limb on springs to the bedside frame is highly effective. To prevent venous thrombosis, patients should receive anticoagulants ( acetylsalicylic acid- 0.25 g 3 times a day), drugs that improve blood rheology.

To prevent vein thrombosis, fingers should not be plastered when applying a plaster cast on the lower limb to victims with fractures of the metatarsal bones, damage to the ankle joint, lower leg and thigh. By bending the fingers, the patient can strain the muscles of the lower leg. This prevents muscle atrophy and stiffness in the joints.

Muscle atrophy, stiffness in the joints and osteoporosis are prevented by providing an early load on the limb in a plaster cast. To do this, a heel or stirrup is plastered to the sole at the level of the arch. The patient begins to load the leg with crutches. The load is increased as the pain disappears in response to the load at the fracture site and is brought to full (the patient walks without additional support) by the time the bandage is removed.

To prevent secondary displacement of fragments in a plaster cast, it must be applied very carefully: in case of damage to the ankle joint - up to the lower third of the thigh, lower leg - up to the upper third of the thigh; in case of damage to the knee joint, the bandage should be with a pelvic girdle, the same bandage is applied for fractures of the femur. In case of subtrochanteric fractures, the bandage should be coxite, i.e., it should also cover the thigh up to the knee joint on the healthy side. To prevent secondary displacement, according to indications, it is advisable to fix fragments after reposition with percutaneous pins (for example, in the treatment of fractures of the radius in a typical location and in the treatment of fracture-dislocations in the ankle joint). Such fixation allows immobilization with a shortened plaster cast, which in turn prevents vein thrombosis, embolism, muscle atrophy and contractures in the joints.

Treatment of fractures by focal osteosynthesis. Focal osteosynthesis can be performed with external structures (osseous osteosynthesis) and structures inserted into the bone canal of fragments (intramedullary osteosynthesis).

Bone osteosynthesis can be performed with short constructions (short plates, cerclages, bolts, screws) and constructions from long plates attached to fragments a large number(8-12) screws. Providing a complete comparison of the ends of fragments, osteosynthesis with short constructions does not provide rigid fixation of the fracture. Moreover, under the action of large lever loads on the bone around short structures, bone tissue resorption occurs and osteosynthesis becomes unstable after 2-3 weeks. Therefore, after osteosynthesis with short constructions, it is necessary to perform additional external immobilization of the limb with a plaster cast, as if there was no osteosynthesis at all. Immobilization should continue until complete union of the fracture. After removing the plaster cast, it takes a long time to restore the function of the immobilized limb. If we take into account the possibility of such severe complications of open focal osteosynthesis as wound suppuration, osteomyelitis, nonunion and false joint, then its positive aspects: the possibility of a complete comparison of fragments, the preservation of intraosseous circulation, lose their significance.

Bone osteosynthesis with long plates provides rigid fixation of fragments and their complete comparison. Therefore, after the operation, there is no need for external immobilization of the injured limb, and its function is restored in parallel with the healing of the fracture or even earlier. This is the advantage of plate osteosynthesis with long plates. Significant disadvantages of the method are the invasiveness of the operation, damage to the muscles and periosteum over a large extent of fragments, the possibility of suppuration of the wound and postoperative osteomyelitis, the invasiveness of removing the plates. In our country, the experience of using long bone structures that provide rigid fixation of the fracture is only being accumulated in large trauma clinics. Its widespread introduction in the country's traumatology departments will make it possible to give a real assessment and draw the necessary conclusions about the advisability of its use in the treatment of fractures.

Intramedullary osteosynthesis is carried out with rods. Osteosynthesis with rods is the generally accepted and most widely used method of joining fragments.

Rod osteosynthesis is based on the following principles.

First principle- jamming of a low-elastic massive rod, which, if possible, fills the entire medullary canal of the connected bone fragments (osteosynthesis with rods of Dubrov, Krupko, CITO, Berkutov, etc.). To enhance jamming, some rods have a helical surface (Krupko rod screw, Sivash rod screw, Petrov twisted rod).

In order to achieve wedging, two long rods are inserted into the medullary canal or the medullary canal is reamed, fitting it under the rod.

Rods with special jamming devices are also used - retractable parts.

Second principle- fixation of bone fragments with non-massive elastic rods [rods Rush, Hackethal, Bogdanov, Korkhov, flat titanium rods, Ender rods].

Third principle- connection of fragments with short and thin rods ("reponding rods", as defined by A.N. Berkutov, 1958): Friedland fixators, short rods according to Berkutov, thin rods for open fractures according to Bbhler (1943). Osteosynthesis with repositioning rods has not received wide distribution.

Positive aspects of osteosynthesis with rods:

• rods are the most commonly used and most versatile of all retainers. Through the rods, osteosynthesis of all diaphyseal fractures is possible, and with some methods of introducing rods, osteosynthesis of metaphyseal and periarticular fractures;
• the production of most rods is not difficult;
• the technique of osteosynthesis with rods is simple and does not require many special devices and tools (with the open method of osteosynthesis);
• the rods, passing for a long time in the bone fragments, have many fixation points, which reduces the mechanical load on the bone tissue, increases the strength of the connection of the fragments. Such large area no other structure has a support;
• in osteosynthesis with rods, there are more favorable ratios of forming levers than in synthesis with short structures;
• intramedullary fixation with rods is accompanied by less than with extraosseous osteosynthesis, damage to the tissues surrounding the bone and, therefore, less disorder of the extraosseous blood supply to the bone;
• rods, especially massive ones, being in the place of passage of the anatomical axis of the bone, serve as a prosthesis that perceives the load until the bone is fused;
• the rods serve as an axis to which many fragments and several fragments are fixed in case of multi-fragmented and multi-fragmented bone fractures;
• osteosynthesis with rods can be combined with the use of other structures, thus creating a good and stable connection of fragments and fragments ("combined osteosynthesis"), - osteosynthesis with rods and circular sutures;
• the use of rods makes it possible to perform osteosynthesis in case of a bone tissue defect that occurs after the removal of many small free fragments;
• through osteosynthesis, it is possible to achieve a stable connection of bone fragments and thereby create favorable conditions for surgical interventions on vessels, nerves and tendons, for skin plasty;
• after osteosynthesis with rods more often than after osteosynthesis with other structures, it is possible further treatment without a plaster cast or bulky plaster casts (this is especially important for the elderly). It has significant advantage in the treatment of multiple fractures of the extremities and associated injuries;
• by means of some methods of introducing the rod into the bone, it is possible to change its direction - "to direct the rod" ("to control the rod");
• usually, with rare exceptions, the operation of removing the rod after the union of the fracture is simple and less traumatic than the removal of beams, plates.

Negative aspects of osteosynthesis with rods:

• the manufacture and polishing of composite rods of complex cross-sectional shape, especially tubular ones, is difficult, so the rods may not be of sufficient quality;
• corrosion of even monolithic rods made of high-quality steel grades is possible;
• possible deformation and fracture of the rods due to insufficient strength of the metal;
• possible curvature of the rod, resulting in deformation of the operated segment of the limb.

Round rods, as well as tubular, square, cruciform rods have the same bending resistance in all planes. Slotted tubular, grooved, angle-shaped rods easily acquire helical curvature when bent in one plane and flatten when bent in another plane.

Flat and oval rods are most elastic when bent in a certain plane, but are not prone to spiral bends;

• intramedullary osteosynthesis with rods leads to the destruction of the bone marrow and causes circulatory disorders. Based on this, Bohler recommended that osteosynthesis be performed not with massive, but with thin rods;
• during osteosynthesis with rods, additional fractures of the ends of fragments and even longitudinal splitting of bone fragments are possible. This can happen when choosing a too massive rod, inconsistency of the straight rod with the natural curvature of the bone;
• massive rods acting. piston-like, when introduced into the medullary canal, they cause an increase in pressure in it and can cause fat embolism;
• straight rods do not provide the necessary fixation for periarticular fractures;
• straight rods can cause straightening of the physiological curvature during osteosynthesis of the femur and tibia, radius and ulna;
• rod migration is possible;
• rotation of fragments on the rod is possible;
• in some cases, when removing the rod after the union of fractures, significant difficulties are possible. The operation of removing the rod becomes very traumatic;
• osteosynthesis with rods is dangerous for suppuration of the wound and osteomyelitis. Osteomyelitis extends in these cases to the entire length of fragments.

Currently, titanium and stainless steel are the main materials for the manufacture of bone fixators, although the latter, due to its susceptibility to corrosion and incomplete indifference to tissues, is not considered an ideal material.

Titanium and its alloys are stronger than stainless steel. At the same time, it is a very ductile material compared to stainless steel, tantalum and cobalt alloys. This is important for fixation of bone fractures, allowing the surgeon to model structures in accordance with the task of osteosynthesis and the physiological curvature of the bones.

Antegrade intraosseous osteosynthesis with rods after closed reposition has significant advantages over other methods of osteosynthesis. During the operation on the orthopedic table, special devices are used to reposition the diaphyseal fracture, antegradely introduce a conductor guide, through which the bone marrow canal of fragments is drilled and a rod corresponding to the diameter of the drill is inserted. This type of osteosynthesis does not require external immobilization and allows you to immediately start restoring the function of the damaged limb. The possibility of infection of the fracture zone, traumatization of the periosteum and muscles are sharply reduced. Therefore, the union of fractures occurs faster.

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Fractures are a pathological condition in which there is a deformation of the bones under the influence of a damaging factor that exceeds the strength of the bone tissue in strength. Injuries are more common in childhood and old age, which is associated with the anatomical and physiological characteristics of the body.

In a child, the bones are more elastic and less durable than in adults. This causes the vulnerability of the skeleton to the action of traumatic factors. The high risk of fractures in children is associated with the mobility of the child and poor development of self-preservation skills. In older people, due to age-related changes, calcium salts are washed out of the bones, which leads to the phenomenon of osteoporosis and a decrease in skeletal strength. Impairment of cerebral circulation, leading to poor balance and dizziness, causes unsteady gait and frequent falls.

In young people, the risk of bone deformity is associated with seasonality (ice), professional activity (intense physical exercise), sports (professional athletes). In the modern international classification of diseases (abbreviated as ICD 10), fractures are assigned class 19 - injuries, poisoning and other consequences when exposed to external factors.

Classification

The classification of fractures was created to simplify the diagnosis, determine the tactics of treatment and the prognosis of the disease. Injuries are distinguished by etiology (cause of origin), form of bone defect, displacement of bone fragments, formation of bone fragments and other factors. What are the fractures, we will consider below and present different classifications of skeletal injuries.

From left to right, a fracture inside the joint, open and closed injury is shown.

Fractures are classified according to the cause of their occurrence:

• traumatic - occur when exposed to an intense traumatic factor on healthy bones with a sufficient degree of strength;
• pathological - occur when a traumatic factor of an insignificant damaging force acts on pathologically altered bones with a low strength potential.

Traumatic bone defects appear with a direct blow, falling from a height, violent actions, awkward movements, gunshot wounds. Such fractures are called straight. Sometimes the place of application of force and the area of ​​injury formation can be at some distance. These are indirect fractures. Pathological bone defects occur against the background of diseases that lead to weakening of bone tissue and reduce its strength. A high risk of skeletal injuries is caused by bone cysts, tumors or metastases, osteomyelitis, osteoporosis, impaired osteogenesis during embryonic development, and chronic debilitating diseases.

According to the report of bone fragments from environment distinguish fractures:

• open - accompanied by damage to the external integument;
• closed - occur without the formation of a wound.

Open bone defects can be primary or secondary. Primary are characterized by the formation of a wound when exposed to a traumatic factor. Secondary ones appear after the moment of injury as a result of eruption of the skin by sharp edges of the bones during improper transportation of the patient to the emergency room or unsuccessful reduction of the bone during treatment.

Bone fractures differ in the direction of the line of the bone defect

Closed fractures are:

• incomplete - are formed according to the type of crack without displacement of bone fragments;
• complete - characterized by complete separation of the ends of the bone and displacement in different sides;
• single - injury to one bone;
• multiple - trauma to several bones;
• combined - the occurrence of a bone defect as a result of the influence of various negative factors (mechanical, radiation, chemical);
• combined - skeletal injuries are combined with damage to visceral organs.

Incomplete fractures occur due to the impact of a minor traumatic force. More often such defects occur in children whose bones are covered with a thick and elastic periosteum. The child is characterized by injuries of the "green branch" type - bone fractures without displacement of fragments. Incomplete defects include marginal and perforated fractures, fractures and cracks. Complete separation of bone fragments develops when exposed to a significant impact force or the formation of a defect in areas of bones with well-developed muscle muscles. Muscle contraction leads to displacement of bone fragments in different directions along the trajectory of muscle fiber traction.

A displaced fracture is considered a serious injury that requires long-term treatment and recovery period. Open injuries are also included in this group. In addition, they are accompanied primary infection wounds, which can lead to osteomyelitis and sepsis. The displacement of fragments of damaged bones causes the development of complications associated with damage to muscle tissue, nerves and blood vessels.

Fracture inside the joint

As a result, there are open and closed bleeding, impaired innervation of the limbs, paralysis and decreased sensitivity. Damage to soft tissues and large blood vessels leads to pain and hemorrhagic shock, which complicates the treatment of injury and can be fatal. A fracture without displacement usually does not lead to undesirable consequences and in most cases has a favorable outcome.

According to the localization of the bone defect, the following types of fractures are distinguished:

• formation in the lower, middle or upper third of the bone (with injuries of tubular bones);
• impacted or impression (in case of injuries spongy bones, for example, vertebrae);
• diaphyseal (located between the ends of tubular bones);
• metaphyseal (located near the joints);
• epiphyseal (located in the joint cavity);
• epiphysiolysis (in the zone of bone growth in childhood).

Epiphary injuries can occur as a fracture-dislocation, which complicates the treatment of the disease and lengthens the rehabilitation period. Epiphysiolysis with inadequate therapy contributes to the premature closure of skeletal growth zones and causes shortening of the damaged limb.

Depending on the shape of the bone defect line, the following types of fractures are distinguished:

• oblique,
• transverse,
• longitudinal,
• screw,
• splintered.

A comminuted fracture is accompanied by the formation of one or more bone fragments, which are completely separated from the bone and are located in the soft tissues. Such injuries require surgical treatment and a long recovery period. A comminuted fracture with the formation of multiple fragments is commonly called a comminuted fracture. It causes a significant defect in the damaged bone. Comminuted fractures can be small- and large-comminuted.

Defects with a transverse fracture line are classified as stable injuries with a rare displacement of bone fragments. Other types of fractures lead to displacement of fragments due to muscle traction after injury and are included in the group of unstable fractures. Proper transportation of the patient to the emergency room and adequate methods of treatment prevent the development of complications due to displacement of bone fragments.

Classification of bone fractures helps to choose the right treatment tactics, prevent the development undesirable consequences, to predict the duration of therapy and rehabilitation period. Making an accurate diagnosis, according to modern classification, improves the prognosis of injury and reduces the risk of severe complications.

Effects

After a fracture occurs, urgent medical attention should be sought. In severe injuries that are accompanied by the formation of a wound or displacement of damaged bones, bleeding, multiple bone lesions, deterioration general condition victim due to hemorrhagic and painful shock, an ambulance should be called. If it is impossible to call the doctors, the patient is independently transported to the trauma department after providing first aid and applying transport tires.

With the technique of using immobilization splints, the rules for providing first aid and methods of treating fractures.

Internal blood loss leads to hematoma formation

Undesirable consequences of a fracture occur when the victim is not properly transported to the hospital, late seeking medical help, inadequate choice of therapy and violation of the treatment regimen. If an injury is suspected, it is necessary to consult a doctor, undergo X-ray diagnostics and start treatment in a timely manner if a bone defect is confirmed.

Fracture healing outcomes:

• full restoration of the anatomical structure and function of the injured leg or body part;
• full restoration of the anatomical structure with limited functionality;
• improper fusion of bones with impaired function of a limb or part of the body (deformity, shortening of a limb);
• non-union of bone fragments with the formation.

Complications that arise after injury healing depend on the correct reposition (comparison) of fragments and sufficient fixation of the bone, concomitant soft tissue injuries, rehabilitation measures, and the duration of the period of limitation of motor activity. Types of bone fractures affect the healing time of the injury. Longer therapeutic immobilization is needed for open injuries, closed damage with displacement of bones and the formation of bone fragments, as well as in the case of intra-articular disorders and the formation of fractures and dislocations.

Useful information on how to recognize fracture formation, clinical signs of injury and diagnosis of the disease.

Complications of fractures can be divided into 3 main groups:

1. Static disorders of the bone tissue (absence or improper healing, deformity or shortening of the leg, the formation of a false joint).
2. Soft tissue disorders (deterioration of blood flow and innervation, muscle atrophy, bleeding).
3. Local infection at the site of injury (wound, bones) or spread of infection throughout the body (sepsis).

Limb deformity due to malunion of the bone

Unclosed bone fractures are formed when the fragments are incorrectly compared, as a result of which the formation of callus is disrupted. When soft tissues get between the ends of the damaged bone, a false joint can occur, which leads to pathological mobility in the area of ​​injury and disruption of the normal function of the limb. Due to the pathology of bone consolidation, shortening or deformity of the limbs develops, which leads to disability.

Bleeding from large vessels in violation of their integrity by the sharp edges of the bones causes the development of bleeding. At closed injury hip blood loss is 1-2 l, leg bones - 600-800 ml, shoulder bones - 300-500 ml and forearm - 100-250 ml. With open injuries in the area of ​​large blood vessels (carotid, inguinal, femoral arteries and aorta), bleeding can cause significant blood loss (more than 2 liters) and lead to death.

Fracture of bones with damage to the nerve trunks causes a violation of the motor function and the sensitive sphere. After the union of the defect, a large bone callus may form, which compresses the blood vessels and nerves. As a result, paralysis and paresis develop, congestion in tissues leading to disability.

Prolonged immobilization of the limb contributes to muscle atrophy and the formation of immobility of the joints (ankylosis). After removing the plaster, traction or external fixation apparatus, a violation of the outflow of blood and lymph from the damaged area of ​​​​the limb is observed, which causes swelling, blueness of the skin and stiffness of the joints. To prevent the formation of undesirable consequences of a fracture of the limbs, adequate therapy and apply rehabilitation measures at different stages of injury healing.

Formation of a false joint

Infectious complications are typical for open bone injuries. As a result of injury, pathogens enter the wound, which cause suppuration of soft tissues, bones (osteomyelitis) or generalization of infection (sepsis). Rarely, abscesses form in the area of ​​internal or external osteosynthesis (comparison of bones with the help of pins, plates, screws). To prevent infection, aseptic treatment of the wound is carried out, suturing of the defect of the skin, and a course of antibiotics is prescribed.

Improper or prolonged healing of fractures causes scarring that puts pressure on blood vessels and nerves. This leads to chronic pain syndrome after the consolidation of bone fragments and return to normal. physical activity. Pain intensify after a long walk, carrying heavy loads, changing weather conditions, can cause insomnia and mental exhaustion of the body. Significant reduction in work capacity due to constant pain leads to disability.

Fractures of bones differ in various parameters. To make an accurate diagnosis and choose the right treatment method, a classification was created that reflects the specific features of a particular injury. The consequences of fractures depend on the severity of the injury, the timely provision of first aid, and the right tactics of treatment and rehabilitation. If the doctor's recommendations are followed, in most clinical cases it is possible to completely restore the anatomical integrity of the damaged bone and functional activity limbs or body parts.