Bone fracture

A broken bone or a fracture (Latin frangere: "break" ) is an interruption in the continuity of a bone to form two or more fragments (fragments ) with or without displacement ( dislocation ).

• 4.1 Transverse fracture
• 4.2 oblique fracture
• 4.3 bending fracture
• 4.4 spiral or Torsionsfraktur
• 4.5 Burst fracture
• 4.6 compression fracture
• 4.7 avulsion fracture
• 4.8 Abscherfraktur
• 4.9 greenstick fracture
• 4:10 fatigue fracture

• 7.1 Measures
• 7.2 Other supply

Causes

Bone fractures are usually a result of direct or indirect force action in the course of the accident, a fall, blow or shock. A bone may break even by acutely acting repeated overloading partially or completely. One such stress fracture is eg a march fracture of a metatarsal bone, also called a stress fracture.

Fracture occurs even though the applied force is not sufficient to break a healthy bone, there is a pathological fracture, also known as spontaneous fracture. Then underlies another disease, such as a generalized or local osteoporosis, a bone metastasis or a benign or malignant bone tumor, which reduce the resistance of the bone.

Often a fracture is connected to the other injury. On the one hand through the broken bone itself adjacent vessels and nerves are injured or a bone fracture that extends into a joint may be associated with a joint dislocation. Because of the accident but also multiple injuries with injuries of internal organs, a brain injury or major wounds can be triggered. In particularly severe multiple injuries a trauma is present.

One of delayed complication especially in lower leg fractures is a compartment syndrome; in open fractures, there is a significant risk of bacterial infection that can lead to sepsis or osteomyelitis.

Diagnostics

On clinical examination, safe and unsafe signs of fracture can be distinguished, where the lack of safe fracture character is not a reliable indication of the non- existence of a fracture. Is not visible fracture in the X-ray image, it is called an occult fracture.

The safe signs of fracture should be without manipulation revealed a specific test should avoid in terms of pain reduction and providing other associated injuries can be avoided. However, in apparent misalignment of an immediate reduction should be done under train in the natural position, also to prevent further injury. Secure signs of fracture are:

• Dislocation as Malalignment (eg foot pointing in the wrong direction)
• Protruding from the wound fragments
• Step formation in the bone contour
• Bone gaps ( diastase )

A fracture on the radiograph is seen systematically actually no safe signs of fracture, since it is not clear from the clinical examination, but from further imaging.

All clinical signs that may occur without fracture, ie they are not conclusive and are considered unsafe signs of fracture. These are in particular the five signs of inflammation:

• Pain ( dolor )
• Swelling ( tumor)
• Redness ( rubor )
• Heat ( calor )
• Restricted mobility ( functio laesa )

Another uncertain signs of fracture is the bruise ( hematoma).

Very important in the study is the exclusion of peripheral nerve and vascular injuries, which distal to the fracture and the keys of the peripheral pulses is done by testing the sensitivity and muscle strength. Since violations of vessels and nerves can still occur until the stable supply and a compartment syndrome occurs only after a delay, these tests need to be repeated regularly.

Classification of Fractures

A distinction fractures according to several criteria:

• Number of fragments
• Localization
• Completeness (complete / incomplete)
• AO classification
• Open and closed fractures

According to the number of fragments

• Einfragmentfrakturen (only one fracture )
• Piece fractures ( up to three additional fragments)
• Comminuted fractures (more than three additional fragments )

After the localization

• Shaft fractures ( diaphyseal fractures)
• Close joint fractures ( metaphyseal fractures)
• Articular fractures ( fractures involving the articular surface and fracture-dislocations )

AO classification

A systematic classification of fractures of long bones was developed in 1958 by the Association for the Study of Internal Fixation (AO). This AO classification is now generally used as a basis of the description of fractures both in clinical practice and in scientific publications.

The AO classification is primarily composed of four letters or numbers to describe a bone fracture. More codes describe the skin, soft tissue and vaskulärnervösen damage associated. The first digit describes the affected body region (eg 2 = forearm, ie spoke or Elle ). The next digit describes the precise localization and different proximal / proximal fractures ( 1), shaft fractures (2, diaphyseal ) and distal / distal fractures ( 3). It is followed by a letter AC, indicating the complexity of the fracture, and differs in the description, according to whether the fracture is located in the shaft or hinge region. The following figure further subdivided into simple, multiple and complex fractions.

Examples are:

• 22A1 - a simple fracture in the center of the forearm, medical words, a Ulnaschaftfraktur
• 23C3 - a severe fracture of the distal forearm with joint involvement, with both ulna and radius are fragmented several times ( comminuted fracture of the wrist )
• 32A3 - a fracture in the middle of the femur with additional angular deformity

Open or closed fracture

Furthermore, a distinction is made between open fractures and closed fractures. Open fractures are usually more complicated than closed; by the injury to the skin infection is also given. The severity of soft tissue injury is documented according to Tscherne and esters in both cases as follows:

Closed fractures

• Grade 0: No or minor soft tissue injury, indirect trauma, simple fracture shape
• Grade I: Superficial abrasion or bruise ( contusion ) by fragment pressure from the inside, easy to moderate fracture shape
• Grade II: depth, contaminated abrasion, contusion by direct trauma, threatening compartment syndrome, moderate to severe fracture type
• Grade III: Extensive skin contusion or destruction of muscle, subcutaneous décollement, manifest compartment syndrome injury to a major vessel

Open fractures

• Grade I: Durchspießung of the skin, minor contamination ( contamination), simple fracture shape.
• Grade II: cutting through the skin, circumscribed skin and Weichteilkontusion, moderate contamination, all types of fractures
• Grade III: Extensive soft tissue destruction, often vascular and nerve injury, severe wound contamination, extensive bone destruction
• Grade IV: " subtotal " (i.e. incomplete ) Amputation, wherein less than 1/4 of the soft shell is intact and be extended injury to nerves and blood vessels.

In the Anglo - American world, the classification according to Gustilo and Anderson is used for open fractures usually that the above classification is very similar, but instead of grade IV indicate the degree III divided in degrees IIIA -C.

Overview of the types of fractures

Transverse fracture

Simple transverse fracture. Often caused by direct force to the fixed extremity, eg by a fantastic effort at soccer.

Oblique fracture

As transverse fracture, but inclined at different angles fracture line. The accident also similar, with only obliquely acting force.

Bending fracture

Caused by bending of the limb at an edge or direct impact. There may be a transverse fracture, oblique fracture or a piece of broken ( oblique fracture with bending wedge). One example is the so-called Parierfraktur, which is due to direct trauma to an isolated fracture of the ulna ( ulna ) comes in the shaft area.

Spiral or Torsionsfraktur

On a longer or shorter distance spiraling fracture line. Is caused by indirect trauma (twisting of the fixed limb). Frequently during alpine skiing.

Burst fracture

Come before the bony skull. Fracture by the action of blunt violence. Star-shaped fracture lines, often with depression of fragments.

Compression fracture

Fracture by trauma to the longitudinal axis of a bone. Accident happened often fall from a great height.

Examples:

• Calcaneus fracture ( fracture Roofers )
• Radial head fracture
• Tibial plateau fracture
• Vertebral fracture

Avulsion fracture

The avulsion fracture is also called " bony avulsion ". The mechanism is based on a sudden increase in voltage of a tendon or ligament at the bony insertion. Because of - especially with younger people - higher tensile strength of tendons and ligaments compared with the bone a Kortikalisschale or even a whole bone fragment is pulled down.

Examples:

• Lateral malleolus fracture ( Weber -A)
• Demolition of the base of the fifth metatarsal bone ( by the tendon of the peroneus brevis )
• Demolition of the medial epicondyle at the Ellbogenluxation

A special form represents the child of the demolition of the tibial tuberosity by the patellar tendon, because the cartilaginous investment represents a continuation of the tibial epiphysis, thus it can come to the involvement of the articular surface.

According to Ogden a division is made in

• I: demolition of the distal portion of the tibial
• II: Summary of the tuberosity and / or parts of the epiphysis
• III: extent of injury through the epiphysis into the joint space ..

Abscherfraktur

Also called chisel fracture: When compression of a joint part of the bone is as sheared with a chisel blow. Occurs on the spoke head and the head of the tibia.

Greenstick fracture

The green stick fracture is a fracture shape in children, in which the bone skin ( periosteum ) does not tear. This leads to a buckling like a fresh green branch.

Fatigue fracture

( Synonyms: fatigue fracture, stress fracture) fracture by continuous cyclic loading of a bone; the metatarsals also called " march fracture ".

The diagnosis is difficult because such a fracture is visible on the X-ray absorption after a periosteal reaction after a few weeks. For the diagnosis and differentiation of other diseases, a suitable magnetic resonance imaging.

Pathological fractures are fractures without " adequate trauma " ie without major force in metastasis by tumor ( metastasis ) or tumor-like changes (eg, aneurysmal bone cysts ..) pathologically weakened bone. Frequently in the bone metastatic tumors include breast cancer ( breast cancer) and prostate cancer. The pathological fracture is distinguished from stress fractures and insufficiency fractures.

In insufficiency fractures of the bone breaks due to structural weakness even under normal or slightly increased load. In general, there is a reduced calcium salt content of the bone [( osteoporosis) ]. Examples are compression or Sinterungsfrakturen of the vertebral bodies with loss of height and deformity of the spine up to the so-called " dowager's hump " or spontaneous fractures of the sacrum.

In contrast, stress fractures fractures in normally stable bone occur by repetitive, chronic congestion eg in the context of excessive exercise.

Complications

Examples:

• Injuries of nerves, blood vessels, joints and other adjacent structures
• Compartment syndrome
• Volume deficiency shock due to external or internal bleeding
• Infection ( post-traumatic osteomyelitis)
• Pseudoarthrosis ( formation of a false joint by not Done coalescence of the bone ends )
• Reflex sympathetic dystrophy ( complex regional pain syndrome)
• Fat embolism
• Synostosis
• Ischemic contracture

Fracture healing and treatment

In essence, the decision must be made whether a conservative fracture treatment eg can be performed by a cast immobilization, or whether surgical treatment must be done. To conservative treatment, the closed reduction of a deformity counts under anesthesia followed by plaster. When surgical treatment is usually done, open reduction of the fracture parts and their subsequent fixation by osteosynthesis ( " ORIF " - open reduction and internal fixation ). In general, surgical correction is recommended in several fragments, not closed reponierbaren fractures, persistent instability in fractures that extend into the joint. An absolute indication for surgery exists in the presence of an arterial occlusion, nerve injury or compartment syndrome. Even in open fractures usually occurs an operation to perform a debridement can and because through a secure stabilization of the risk of subsequent infection is reduced. For large defects often more repeat interventions to restore and debridement must be performed.

Essentially, the procedure but also depends only on the type of fracture also after which bone is affected, according to comorbidities and concomitant injury to the patient, according to the available resources.

First aid

Measures

The fracture is not set right yet addressed by the first responders, there are no unnecessary pain is caused. The victim is to move as little as possible or to transport. It supports the Bruchextremität peacefully and notes if necessary the fracture of the adjacent joints also with an aluminum cushion rail or suitable soft cushioning material (eg, rolled blankets, neckerchiefs from the first aid kit, clothing, pillows etc.). Quiet: The broken body part is carefully upholstered with the material and otherwise left in the found location. Further manipulation of the fracture should be left to the emergency services. This should be alarmed by the first aid measures.

In the first-aid measures should be taken to the current position of the injured consideration. He will assume a protective posture by itself, in this case it is important to support the patient and relieve it. Storage should be secure and adequately protected against hypothermia or overheating. Since the fracture of large bone or several bones, as well as any soft tissue damage or internal injuries, there is a risk of shock, the injured person should not be left alone. When storing, make sure that in the event of a shock is enough space for action.

In closed fractures often result in swelling. To prevent such, the area of ​​bone fracture with cold compresses or similar should. be carefully cooled. This can reduce hemorrhaging into the tissue and the pain of the person concerned - both also risk factors for life-threatening shock - be alleviated.

Through open fractures caused bleeding wounds, like other bleeding also supplied - sterile wound dressing but no pressure bandage! Protruding bone parts are, where appropriate, be treated as a foreign body that is gentle and drape.

Other supply

After quiet storage is continued with the other measures for the supply of the patient, important is

• Monitoring for shock
• Checking of vital signs (breathing, pulse) at regular intervals
• Supply of bleeding wounds
• Conservation of body heat (see hypothermia ), for example with the help of a rescue blanket or clothing
• DMS control ( blood flow, motor skills, sensory )
• Where appropriate, stabilize the body and vital functions ( intensive care, resuscitation )

Frequency (examples)

Hip fractures are according to new study data apparently more common than previously thought: an estimated 141 per 100,000 people suffer a hip fracture every year in Germany. In order for these fractures can be described as common event. Icks et al. had nationwide analyzed on the basis of hospital diagnosis statistics all cases of dismissal with a diagnosis of hip fracture in 2004. From 116 281 patients were calculated with at least one hospitalization per year due to hip fracture. This corresponds to an incidence of 141 per 100,000 population. So far, the incidence was due to data from a large nationwide health insurance estimated at 122 per 100,000 population. Hip fractures are a particularly feared complication in patients with osteoporosis except vertebral fractures. Because an estimated 30 percent of patients die within a year. And one out of three with hip fracture is permanently disabled.