Closed fracture is a complete or partial violation of the integrity of the bone without damaging the skin over the fracture area. The severity of the patient’s condition is determined by the size of the broken bones, the presence of displacement and damage to surrounding structures. The main manifestations are pain, swelling, bruising, dysfunction, pathological mobility, crepitation and deformation of the damaged segment. Some symptoms may be absent. The diagnosis is made on the basis of external signs and radiography data. Sometimes additional studies are required: arthroscopy, CT, MRI. Treatment consists in the closed or open elimination of displacement and subsequent immobilization.
ICD 10
S42 S52 S72 S82
Meaning
A closed fracture is a violation of the integrity of the bone without damaging the skin. It is a widespread injury, while closed fractures are more common than open ones. Occurs as a result of an ordinary fall, impact, criminal incident (fight), falling from a height, industrial or natural disaster, car accident, etc. Pathological fractures develop as a result of minimal exposure (for example, turning over in bed). Closed fractures can be single or multiple, combined or not combined with other injuries: chest injury, TBI, blunt abdominal trauma and trauma to the genitourinary organs. Orthopedic traumatologists are engaged in the treatment of closed fractures.
Causes
The cause of a closed fracture is a load exceeding the bone strength limit. The force required for a fracture to occur depends on the strength of the specific bone and the axis of impact. The type of fracture is determined by the vector of the applied load, for example, when struck parallel to the axis of the bone, a comminuted or longitudinal closed fracture may form, and when struck perpendicular to the axis of the bone, a transverse fracture. With appropriate exposure, any bone can break anywhere, but there are also the most common fractures that occur due to the typical mechanism of damage.
Damage to the beam in a typical place – in most cases occurs when falling with an emphasis on the palm, more often observed in children and the elderly. Ankle fractures are usually formed when the leg is turned up, while the most common is a fracture of the outer ankle, two- and three-ankle fractures are less common. Damage to the surgical neck of the shoulder – as a rule, occurs when falling on the arm, is more often observed in the elderly. Fracture of the femoral neck – formed when falling, as in the previous case, the elderly suffer more often. Bumper fracture of the lower leg (comminuted damage to the middle third of the bone) – usually occurs when a car bumper hits.
Pathogenesis
When the integrity of the bone is violated, a number of pathological changes occur, the most significant of which are displacement, pain and bleeding. The cause of pain is massive irritation of pain receptors. The cause of bleeding is a violation of the integrity of the intraosseous vessels. The volume of blood loss in closed fractures reaches significant values, since the vessels are rigidly fixed in the bone, do not fall off, but can only become clogged with blood clots.
The most significant blood loss occurs with pelvic fractures: with damage to the anterior semicircle – up to 800 ml, with simultaneous damage to the posterior and anterior semicircle – 1.5-2 liters, with multiple injuries – up to 3 liters. Blood loss with a closed fracture of the lower leg ranges from 500-700 ml. Severe pain syndrome in combination with massive blood loss in case of damage to large bones can cause the development of traumatic shock, which poses a danger to the patient’s life. Bleeding occurs in the surrounding tissues, accumulated blood forms a hematoma, which subsequently gradually resolves.
The nature of the displacement depends on the level of damage and the direction of traction of the muscles attached to the fragments below and above the fracture line. The larger and stronger the muscles “pull” the fragments, the more difficult it is to match and hold them. Subsequently, new bone tissue is formed at the site of the fracture, while the duration and probability of fracture fusion depends on the localization of the damage, the type of closed fracture, the adequacy of the comparison of fragments, the age and condition of the victim’s body. In children, fusion occurs faster, in the elderly – slower. The period of consolidation varies from weeks to months, a bone callus forms at the site of damage.
Classification
In traumatology and orthopedics, there are several classifications of closed fractures.
Taking into account the causes of occurrence:
- Traumatic – caused by a significant external impact on the unchanged bone.
- Pathological – caused by minimal external impact on the bones affected by some pathological process (bone tumor, metastases of tumors of other genesis, tuberculosis, etc.).
Taking into account the severity:
- Incomplete: fractures and cracks.
- Complete: with and without offset fragments.
Taking into account the nature and features of the damage:
- Transverse – the fracture line is perpendicular to the axis of the bone.
- Oblique – the fracture line is located at an angle to the axis of the bone.
- Longitudinal – the fracture line is located parallel to the axis of the bone.
- Helical – the fracture line is located in a spiral, bone fragments unfold relative to the normal location.
- Comminuted – there is no single fracture line, there is a different number of individual fragments.
- Embedded – one bone fragment is wedged into another (occur with fractures of tubular bones).
- Wedge – shaped – when the fragments are wedged, a wedge-shaped deformation is formed (they occur with fractures of the vertebrae).
- Compression – the height of the bone is reduced, there are small bone fragments, there is no single fracture line.
Taking into account localization (in the area of tubular bones):
- Diaphyseal – the integrity of the middle part of the bone is violated.
- Epiphyseal – the integrity of the end of the bone is violated.
- Metaphysical – the integrity of the bone is violated in the area between the diaphysis and the epiphysis.
Taking into account the presence or absence of complications:
- Uncomplicated.
- Complicated. It may be complicated by damage to internal organs, traumatic shock, bleeding, osteomyelitis, wound infection, fat embolism, sepsis.
Children may also experience epiphyseolysis – closed fractures in the area of the non-ossified growth zone.
Closed fracture symptoms
There are absolute and relative signs of bone damage. Relative ones allow us to suspect this pathology, absolute ones are its unambiguous confirmation. Relative signs include pain that increases with axial load, increasing swelling, impaired function (limitation of mobility, inability or, less often, limitation of load) and hematoma in the area of injury. The group of absolute signs includes pathological mobility, limb deformity and crepitation. One or more absolute signs may be absent, so, with closed fractures without displacement, there is no deformation, and with compression injuries, none of these symptoms are observed.
Diagnostics
The main instrumental method of examination for closed fractures is radiography. According to standard rules, the study includes images in two projections with the “capture” of the damaged segment and two adjacent joints (proximal and distal). With some damages, these rules change. So, with cervical fractures of the shoulder and hip, the fracture site with one joint is removed, with damage to the wrist bones, additional projections are sometimes used, etc.
Other additional studies include CT, MRI, ultrasound of the joint and arthroscopy. The last two techniques are used for intra-articular injuries, CT of the joint allows you to study the condition of bone structures in detail, and on MRI of the bone, not only bones, but also soft tissues are clearly visible. If secondary damage to nerves and blood vessels is suspected (compression as a result of displacement of fragments, rupture in contact with the sharp edge of a bone fragment), consultations of a vascular surgeon, neurosurgeon or neurologist are necessary, if damage to internal organs is suspected (for example, pelvic fractures) – consultations of a urologist or abdominal surgeon.
Xlosed fracture treatment
At the first aid stage, the victim is given an anesthetic, the damaged segment is fixed and delivered to the med. institution. To fix a closed fracture, special splints or any available objects (for example, sticks or planks) are used, when applying a splint, it is necessary to fix not only the injury site itself, but also two adjacent joints. In case of spinal injuries, the patient is placed on a hard surface. Independent attempts to correct any closed fractures are unacceptable, since such actions can cause displacement of fragments and additional damage to surrounding tissues.
In the emergency room or emergency room, the doctor assesses the patient’s condition, identifies and, if possible, prevents complications (traumatic shock, blood loss), performs anesthesia, performs reposition with subsequent immobilization. After the reposition, X-ray monitoring is mandatory. Treatment of closed fractures can be conservative or operative. In conservative therapy, plaster bandages and traction methods (skeletal, adhesive or adhesive stretching) are used.
If nerves and blood vessels are damaged, it is impossible to match or hold the fragments, an operation is performed. Depending on the features of a closed fracture, percutaneous fixation with a spoke, osteosynthesis with a nail, screws, plates or staples, or compression-distraction osteosynthesis using external fixation devices can be performed.
Currently, there is a tendency to increase the number of surgical interventions for closed fractures. This is due to both improving surgical techniques that allow for a higher probability of a positive outcome of treatment, and the possibilities of early activation of patients.
Thus, skeletal traction with a diaphyseal fracture of the lower leg is applied for 4 weeks and subsequently replaced with plaster, which must be worn for 3-4 months. The use of the Ilizarov apparatus makes it possible not only to exclude a long stay in a supine position that is difficult for the patient, but also to ensure the preservation of mobility of adjacent joints (ankle and knee) during the entire period of treatment. For all closed fractures, auxiliary techniques are used: physical therapy, physiotherapy and massage.
Prognosis and prevention
The duration of the rehabilitation period, as well as the degree of recovery depends on the type of injury, age and health status of the patient. In the absence of fusion, surgical treatment is necessary in the long term. Prevention consists in the development and implementation of measures to reduce the level of injuries.
