The closed change – full or partial violation of integrity of a bone without damage of integuments over area of a change. The loading exceeding bone durability is the reason of development. The change can be full or incomplete, traumatic or pathological, without shift or with the shift of otlomk. Weight of a condition of the patient is defined by the number of damages and the size of the broken bones. The main manifestations are pain, hypostasis, bruises, malfunction, pathological mobility, a krepitation and deformation of the damaged segment. Some symptoms can be absent. The diagnosis is exposed on the basis of external signs and data of a X-ray analysis. Sometimes additional researches are required: arthroscopy, KT, MPT etc. Treatment consists in elimination of shift and the subsequent immobilization. Depending on a look and localization of the closed change conservative and operational methods can be applied.
The closed change
The closed change – violation of integrity of a bone without damage of integuments. Is a widespread trauma, at the same time the closed changes meet more often open. Arises owing to usual falling, blow, a criminal incident (fight), falling from height, production or natural disaster, a car accident etc. Pathological changes develop as a result of the minimum influence (for example, a turning in beds). The closed changes can be single or multiple, be combined or not be combined with other injuries: injury of a thorax, ChMT, stupid injury of a stomach and trauma of urinogenital bodies. Traumatologists are engaged in treatment of the closed changes.
There are several classifications of the closed changes.
Taking into account the causes:
- Traumatic – arisen owing to considerable external influence on not changed bone.
- Pathological – arisen owing to the minimum external impact on bones, the struck some pathological process (a tumor of a bone tissue, metastasises of tumors of other genesis, tuberculosis etc.).
Taking into account weight:
- Incomplete: breaks and cracks.
- Full: with shift and without the shift of fragments.
Taking into account character and features of damage:
- Cross – the line of a change is located perpendicular to a bone axis.
- Slanting – the line of a change is located at an angle to a bone axis.
- Longitudinal – the line of a change is located parallel to a bone axis.
- Spiral – the line of a change is located on a spiral, fragments of a bone are developed rather normal arrangement.
- Splintered – the uniform line of a change is absent, there is various quantity of separate otlomk.
- Driven – one bone fragment puts in another (arise at fractures of tubular bones).
- Wedge-shaped – at a vklinivaniye of otlomk wedge-shaped deformation is formed (arise at fractures of vertebras).
- Compression – height of a bone is reduced, there are small bone otlomk, the uniform line of a change is absent.
Taking into account localization (in tubular bones):
- Diafizarnye – is broken integrity of a middle part of a bone.
- Epifizarnye – is broken integrity of the end of a bone.
- Metafizarnye – integrity of a bone is broken in the area between a diaphysis and epifizy.
Taking into account existence or lack of complications:
- Complicated. The complication an internal injury, traumatic shock, bleeding, osteomyelitis, a wound infection, a fatty embolism, sepsis is possible.
Children can also have epifizeoliza – the closed changes in the field of the neogrowing stiff rostkovy zone.
The loading exceeding strength of a bone is the reason of the closed change. Force necessary for developing of a fracture depends on durability of a concrete bone and an axis of influence. The type of a change is defined by a vector of the enclosed loading, for example, at blow parallel to an axis of a bone the splintered or longitudinal closed change can be formed, and at blow perpendicular to a bone axis – a cross change. At the corresponding influence any bone can break in any place, however there are also most widespread changes arising owing to the typical mechanism of damage.
Damage of a beam to the typical place – in most cases arises when falling with the emphasis on a palm, is more often observed at children and elderly people. Fractures of anklebones – are usually formed at a leg podvorachivaniye, at the same time the most widespread is the fracture of an external anklebone, meet two less often - and trekhlodyzhechny changes. Injury of a surgical neck of a shoulder – as a rule, arises when falling on a hand, is more often observed at elderly. The hip neck fracture – is formed when falling, as well as in the previous case, to a thicket elderly suffer. The bumper fracture of a shin (splintered damage of an average third of a bone) – usually arises at blow by a car bumper.
At violation of integrity of a bone there is a number of pathological changes, the most significant of which is shift, pain and bleeding. The mass irritation of pain receptors is the reason of pain. The bleeding reason – violation of integrity of intra bone vessels. Blood loss volume at the closed changes reaches considerable sizes as vessels are rigidly fixed in a bone, are not fallen down, and can be corked with blood clots only.
The most significant blood loss arises at basin changes: at damage of a forward half ring – to 800 ml, at simultaneous damage of a back and forward half ring – 1,5-2 l, at multiple damages – to 3 l. Loss of blood at the closed fracture of a shin fluctuates within 500-700 ml. The expressed pain syndrome in combination with massive blood loss at injuries of large bones can become the reason of development of the traumatic shock posing hazard to life of the patient. Bleeding occurs in surrounding fabrics, the accumulated blood forms a hematoma which in the subsequent gradually resolves.
Character of shift depends on the level of damage and the direction of draft of the muscles which are attached to otlomka below and above the line of a change. The larger and strong muscles "pull" fragments, the it is more difficult to compare them and to hold. In the subsequent on the place of a change the new bone tissue is formed, at the same time the term and probability of an union of a change depends on localization of damage, a type of the closed change, adequacy of comparison of otlomk, age and a condition of an organism of the victim. At children the union comes quicker, at elderly – more slowly. The term of consolidation fluctuates from weeks to one months, on the place of damage the bone callosity is formed.
Allocate absolute and relative symptoms of the closed fracture. Relative allow to suspect this pathology, absolute are its unambiguous confirmation. The pain amplifying at axial loading, the accruing hypostasis, malfunction (mobility restriction, impossibility or, more rare, restriction of loading) and a hematoma in the field of damage is among relative signs. In group of absolute signs refer pathological mobility, deformation of an extremity and a krepitation. One or several absolute signs can be absent, so, at the closed changes without shift there is no deformation, and at compression damages any of the listed symptoms is not observed.
The main tool method of inspection at the closed changes is the X-ray analysis. According to standard rules, the research includes pictures in two projections with "capture" of the damaged segment and two next joints (proximal and disteel). At some damages these rules change. So, at cervical fractures of a shoulder and hip remove the place of a change with one joint, at injuries of bones of a wrist sometimes use additional projections etc.
Among other additional researches – KT, MPT, ultrasonography of a joint and an arthroscopy. Two last techniques are applied at intra articulate damages, KT of a joint allows to study in detail a condition of bone structures, and on MRT bones are well looked through not only bones, but also soft fabrics. At suspicion on secondary injuries of nerves and vessels (a sdavleniye as a result of the shift of otlomk, a gap at contact with a keen edge of a bone fragment) consultations of the vascular surgeon, the neurosurgeon or the neurologist are necessary, at suspicion of an internal injury (for example, at basin changes) – consultations of the urologist or the abdominal surgeon.
The victim is given anesthetic, fix the damaged segment and bring to medical institution. For fixing of the closed change use special tires or any available objects (for example, sticks or plates), when overlaying the tire it is necessary to record not only the place of damage, but also two next joints. At injuries of a backbone of the patient stack on a firm surface. Independent attempts of reposition at any closed changes are inadmissible as such actions can become the reason of shift of otlomk and additional damage of surrounding fabrics.
treatment should be carried out only under the supervision of a doctor. Self-treatment is unacceptable!!!
At the initial stage the doctor estimates the patient's condition, reveals and whenever possible prevents complications (traumatic shock, blood loss), carries out anesthesia, carries out a repozition with the subsequent immobilization. After a repozition it is surely carried out . Treatment of the closed changes can be conservative or quick. At conservative therapy plaster bandages and traction methods (skeletal, leykoplastyrny or glue extension) are used. At injury of nerves and vessels, impossibility to compare or hold otlomk operation is carried out. Depending on features of the closed change chrezkozhny fixing by a spoke, an osteosynthesis a nail, screws, plates or brackets or compression an osteosynthesis with use of devices of external fixing can be carried out.
Now the tendency to increase in number of surgeries at the closed changes is noted. It is caused as the improved operational techniques allowing to provide higher probability of a positive result of treatment and opportunities of early activization of patients. So, skeletal extension at a diafizarny fracture of a shin is imposed for 4 weeks and in the subsequent is replaced with plaster which it is necessary to carry 3-4 months. Use of the device of Ilizarov allows not only to exclude the long stay in lying situation which is hard transferred by the patient, but also to provide preservation of mobility of the next joints (talocrural and knee) during all term of treatment.
At all closed changes auxiliary techniques are applied: LFK, physical therapy and massage. Duration of the rehabilitation period, and also extent of restoration of working capacity depends on a type of a trauma, age and the state of health of the patient. In the absence of an union expeditious treatment in the remote period is necessary.