Change – the full or partial violation of integrity of a bone which resulted from the influence exceeding strength characteristics of a bone tissue. The blow, falling, industrial or natural disaster, a car accident etc. can become the reason of development. Symptoms of a fracture are pathological mobility, a krepitation (a bone crunch), external deformation, hypostasis, restriction of function and sharp morbidity, at the same time one or several symptoms can be absent. The diagnosis is exposed on the basis of the anamnesises, complaints yielded survey and results of a X-ray analysis. Treatment can be conservative or quick.
Change – violation of integrity of a bone as a result of the injuring influence. Is widespread damage. Throughout life most of people should have one or several fractures. About 80% of total number of damages make fractures of tubular bones. Along with a bone during a trauma also surrounding fabrics suffer. Violation of integrity of nearby muscles is more often observed, there is a sdavleniye or a rupture of nerves and vessels less often.
Changes can be single or multiple, become complicated or not be complicated by damage of various anatomical structures and internals. There are certain combinations of injuries which are often found in traumatology. So, at fractures of edges injury of a pleura and lungs with development of a gemotoraks or pheumothorax is quite often observed, at violation of integrity of bones of a skull formation of an intracerebral hematoma, damage of brain covers and substance of a brain etc. is possible. Treatment of changes is performed by traumatologists.
Depending on initial structure of a bone all changes divide into two big groups: traumatic and pathological. Traumatic changes arise on the healthy not changed bone, pathological – on the bone affected with some pathological process and thereof partially lost the durability. Formation of a traumatic change requires considerable influence: strong blow, falling from rather big height etc. Pathological changes develop at insignificant influences: small blow, falling from height of own growth, tension of muscles or even a revolution in a bed.
Taking into account existence or lack of the message between the field of damage and the external environment all changes are subdivided on closed (without damage of integuments and mucous membranes) and opened (with violation of integrity of skin or mucous). In other words, at open changes on skin or a mucous membrane there is a wound, and at closed the wound is absent. Open changes, in turn, divide on initially open at which the wound arises at the time of traumatic influence and again open at which the wound is formed after a trauma as a result of the secondary shift and injury of skin by one of otlomk after a while.
Depending on the level of damage allocate the following changes:
- Epifizarny (intra articulate) – are followed by damage of articulate surfaces, a rupture of the capsule and ligaments of a joint. Are sometimes combined with dislocation or an incomplete dislocation – in this case speak about a perelomovyvikha.
- Metafizarny (circumarticular) – arise in a zone between epifizy and a diaphysis. Often happen driven (distalny takes root into proximal). Shift of fragments, as a rule, is absent.
- – are formed by Diafizarnye in a middle part of a bone. The most widespread. Differ in the greatest variety – from rather simple before heavy multisplintered damages. Usually are followed by the shift of otlomk. The direction and degree of shift are defined by a vector of the injuring influence, draft of the muscles attached to otlomka, weight of a peripheral part of an extremity and some other factors.
Taking into account character of a break distinguish the cross, slanting, longitudinal, spiral, splintered, polyfocal, shattered, compression, driven and detachable changes. In a metafizarny and epifizarny zone there are V-and T-shaped damages more often. At violation of integrity of a spongy bone introduction of one fragment in another and a compression of a bone tissue at which substance of a bone collapses and rumpled is usually observed. At simple changes the bone is divided into two fragments: distalny (peripheral) and proximal (central). At polyfocal (double, threefold etc.) damages throughout a bone two or larger otlomk are formed.
Formation of several otlomk is also characteristic of splintered changes, but located "it is closer", in one zone of a bone (distinction between polyfocal and splintered damages is rather conditional therefore in clinical practice for their designation changes usually use the general term "splintered"). In case the bone collapses and turns into the mass of otlomk on a considerable extent, changes call shattered.
Taking into account the mechanism of a trauma allocate changes from compression or a sdavleniye, twisting and bending, damage to result of shift and detachable changes. Damages from compression or a sdavleniye are formed in the field of metafiz of tubular bones and bodies of vertebras. Changes from bending can arise under the influence of indirect or direct forces; formation of a cross rupture of a bone on the one hand and a triangular fragment with another is characteristic of such damages.
Damages from twisting are formed in attempt of the forced turn of a bone around its longitudinal axis (a characteristic example – "a police fracture" of shoulder when twisting a hand); the line of a break passes spiralno or spirally. The strong muscular tension owing to which comes off a bone small in the field of an attachment of muscles is the reason of detachable changes; such injuries can arise in anklebones, a patella and nadmyshchelok of a shoulder. Damages from shift are observed at influence of direct force; the cross plane of a break is characteristic of them.
Depending on a damage rate of a bone allocate complete and incomplete fractures. Refer violations of integrity of a bone as a break (the break extends less than to a half of diameter of a bone) to incomplete, cracks (the break occupies more than a half of diameter), cracking or a vdavleniye. At incomplete injuries of a bone of shift of otlomk it is not observed. At complete fractures shift (a change with shift) on length, at an angle, on the periphery, on width and on an axis is possible (rotational).
Distinguish also multiple and isolated changes. At isolated violation of integrity of one anatomo-functional education (a hip diaphysis change, a fracture of anklebones) is observed, at multiple – injury of several bones or one bone in several places (a simultaneous change of a diaphysis and a neck of a hip; fracture of both shins; fracture of a shoulder and forearm). If bones are put by damage to internals, speak about the complicated change (for example, spinal fracture with injury of a spinal cord).
All changes are followed by more or less expressed destruction of soft fabrics that is caused as directly injuring influence, and the shift of bone fragments. Usually in a zone of a trauma there are hemorrhages, a bruise of soft fabrics, local ruptures of muscles and ruptures of small vessels. All listed in combination with bleeding from otlomk of a bone becomes the reason of formation of a hematoma. In some cases the displaced bone fragments injure nerves and the main vessels. Perhaps also sdavleny nerves, vessels and muscles between otlomka.
Allocate absolute and relative symptoms of a fracture. Absolute signs are deformation of an extremity, a krepitation (a bone crunch which can differ with an ear or be defined under fingers of the doctor at a palpation), pathological mobility, and at open damages – the bone otlomk seen in a wound. Pain, hypostasis, a hematoma, malfunction and (is among relative signs only at intra articulate changes). Pain amplifies in attempt of movements and axial loading. Hypostasis and a hematoma usually arise after a trauma after a while and gradually accrue. Malfunction is expressed in restriction of mobility, impossibility or difficulty of a support. Depending on localization and a type of damage some of absolute or relative signs can be absent.
Along with local symptoms, for large and multiple fractures, the general manifestations caused by traumatic shock and blood loss owing to bleeding from otlomk of a bone and the damaged nearby vessels are characteristic. At the initial stage excitement, underestimation of weight of own state, tachycardia, , pallor, cold sticky sweat is observed. Depending on prevalence of these or those factors HELL can be lowered, is more rare – is slightly raised. In the subsequent the patient becomes sluggish, slowed down, HELL decreases, the amount of the emitted urine decreases, observed thirst and dryness in a mouth, in hard cases loss of consciousness and respiratory violations is possible.
Carry a skin necrosis because of direct damage or pressure of bone fragments to early complications from within. At a blood congestion in subfastsialny space there is a subfastsialny gipertenzionny syndrome caused by a sdavleniye of a neurovascular bunch and which is followed by violation of blood supply and an innervation of peripheral departments of an extremity. In some cases thereof syndrome or the accompanying injury of the main artery insufficiency of blood supply of an extremity, extremity gangrene, thrombosis of arteries and veins can develop. Damage or a sdavleniye of a nerve is fraught with development of paresis or paralysis. Very seldom closed injuries of bones are complicated by hematoma suppuration. The most widespread early complications of open changes is suppuration of a wound and osteomyelitis. At the multiple and combined injuries the fatty embolism is possible.
Late complications of changes are the wrong and slowed-down union of otlomk, lack of an union and false joints. At intra articulate and circumarticular damages geterotopichesky paraarticulary ossifikata are often formed, post-traumatic arthrosis develops. Post-traumatic contractures can be formed at all types of changes as inside - and extra articulate. The long immobilization of an extremity or incongruence of articulate surfaces owing to the wrong union of otlomk is their reason.
As the clinic at such injuries is very various, and some signs in some cases are absent, at diagnosis much attention is paid not only to a clinical picture, but also clarification of circumstances of the injuring influence. The typical mechanism is characteristic of the majority of changes, so, when falling with the emphasis on a palm often there is a beam change in the typical place, at a leg podvorachivaniye – a fracture of anklebones, when falling on legs or buttocks from height – a compression fracture of vertebras.
Inspection of the patient includes careful survey regarding possible complications. At injury of bones of extremities surely check pulse and sensitivity in disteel departments, at spinal fractures and skulls estimate reflexes and skin sensitivity, at injury of edges carry out an auskultation of lungs etc. Special attention is paid to the patients who are in unconsciousness or in a condition of the expressed alcoholic intoxication. At suspicion of the complicated fracture appoint consultations of the corresponding experts (the neurosurgeon, the vascular surgeon) and additional researches (for example, an angiography or EhoEG).
The final diagnosis is established on the basis of a X-ray analysis. Carry the line of an enlightenment in the field of damage to number of radiological symptoms of a fracture, the shift of otlomk, a break of a cortical layer, deformation of a bone and change of bone structure (an enlightenment at the shift of fragments of flat bones, consolidation at the compression and driven changes). At children, except the listed radiological symptoms, at epifizeoliza deformation of a cartilaginous plate of a rostkovy zone can be observed, and at changes as a green branch – a limited vystoyaniye of a cortical layer.
treatment should be carried out only under the supervision of a doctor. Self-treatment is unacceptable!!!
Treatment can be performed in emergency station or in the conditions of traumatologic office, to be conservative or quick. The purpose of treatment is the most exact comparison of otlomk for the subsequent adequate union and restoration of function of the damaged segment. Along with it, at shock events for normalization of activity of all bodies and systems are held, at internal injuries or important anatomic educations – operations or manipulations on restoration of their integrity and normal function.
At a stage of first aid perform anesthesia and a temporary immobilization with use of special tires or improvised objects (for example, boards). At open changes whenever possible delete pollution around a wound, close a wound a sterile bandage. At intensive bleeding impose a plait. Hold events for fight against shock and blood loss. At receipt in a hospital carry out blockade of the place of damage, carry out a repozition under local anesthesia or the general anesthesia. Repozition can be closed or opened, that is, through an operational section. Then otlomk fix, using plaster bandages, skeletal extension, and also an external or internal metalwork: plates, pins, screws, spokes, brackets and compression devices.
Conservative methods of treatment are subdivided on immobilized, functional and traction. Immobilized techniques (plaster bandages) usually apply at changes without shift or with small shift. In some cases plaster is also used at difficult damages at the final stage, after removal of skeletal extension or expeditious treatment. Functional techniques are shown, generally at compression fractures of vertebras. Skeletal extension is usually used at treatment of unstable changes: splintered, spiral, slanting etc.
Along with conservative techniques, there is a huge number of surgical methods of treatment of changes. Absolute indications to operation are the considerable divergence between otlomka excluding a possibility of an union (for example, a fracture of a patella or an elbow shoot); injury of nerves and main vessels; interposition of an otlomk in a joint cavity at intra articulate changes; threat of developing of a secondary open fracture at the closed damages. Interposition of soft fabrics, secondary shift of fragments of a bone, a possibility of early activization of the patient, reduction of terms of treatment and simplification of care of the patient is among relative indications.
As additional methods of treatment widely use LFK and physical therapy. At the initial stage for fight against pain, improvements of blood circulation and reduction of hypostasis appoint UVCh, an induktotermiya and ultrasound. Further apply electrostimulation of muscles, UF-radiation, an electrophoresis or . For stimulation of an union use laser therapy, remote and application magnetotherapy, alternating and direct currents.
The physiotherapy exercises are one of the most important components of treatment and rehabilitation at changes. At the initial stage use exercises for the prevention of hypostatic complications, in the subsequent stimulation of reparative exchange processes, and also prevention of contractures becomes the main objective of LFK. Doctors of LFK or rehabilitology make the program of exercises individually, taking into account character and the period of a trauma, age and the general condition of the patient. At early stages apply breathing exercises, exercises on the isometric tension of muscles and the active movements in healthy segments of an extremity. Then the patient is trained to go on crutches (without loading or with load of the injured extremity), in the subsequent loading is gradually increased. After removal of a plaster bandage hold events for restoration of slozhnokoordinirovanny movements, forces of muscles and mobility of joints.
When using functional methods (for example, at compression spinal fractures) LFK is the leading medical technique. The patient is trained in the special exercises directed to strengthening of a muscular corset, a decompression of a backbone and development of the motive stereotypes excluding aggravation of a trauma. In the beginning exercises carry out lying, then – being kneeling, and then – and in a standing position.
Besides, at all types of changes apply the massage allowing to improve blood circulation and to intensify exchange processes in the field of damage. At the final stage of patients direct to sanatorium treatment, appoint iodine-bromine, radonic, hloridno-sodium, coniferous and salt and coniferous medical bathtubs, and also carry out recovery actions in the conditions of the specialized rehabilitation centers.