Classification
According to the origin of trauma, they are divided into congenital (occurring intrauterine due to fetal pathologies or maternal abdominal trauma) and acquired. The latter can be traumatic or pathological. Pathological ones occur due to changes in the bone tissue structure itself in tumors, osteomyelitis, tuberculosis, echinococcosis, or syphilis. Obstetric traumas, which occur as the fetus passes through the birth canal, are distinguished separately.
In relation to soft tissues, fractures are:
- Open and closed (by the integrity of the skin).
- Complicated and uncomplicated (depending on damage to surrounding organs).
By localization, diaphyseal, epiphyseal, metaphyseal, and apophyseal injuries are distinguished. The fracture line relative to the bone axis can be transverse, oblique, or spiral. The position of the bone fragments is also assessed: they may remain in place or be displaced.
Clinical presentation
Diagnostics begins with a thorough history taking. The mechanism of injury often directly indicates the localization. For example, hitting the head while diving usually leads to cervical spine injury; a direct bumper blow leads to pelvic, femoral, or lower leg injury; falling on buttocks or heels causes vertebral or ischial bone compression, and rolling the foot causes ankle injury.
Symptoms are divided into two large groups:
- Probable (relative) signs:
- Pain: intensifies with movement. Detected by careful palpation with one finger towards the focus or by the axial load method (tapping along the axis of the limb).
- Swelling: edema and hematoma can increase the volume of the limb by one and a half times.
- Deformation: shortening, axis curvature, or rotational displacement when the peripheral end is turned to the side.
- Impairment of function: the patient cannot make active movements due to severe pain syndrome.
- Definitive (absolute) signs:
- Pathological mobility: presence of rocking movements outside a joint.
- Crepitus: characteristic crunch of bone fragments rubbing against each other.
Examination algorithm and displacement diagnostics
Inspection should always be comparative: the injured limb is compared to the healthy one, observing maximum caution. Clinical examination necessarily includes measuring limb length, checking peripheral vessel pulsation, assessing skin sensitivity and active finger movements. This is necessary to exclude vascular and nerve damage.
Displacement can be roughly determined during inspection and palpation:
- Rotational — the distal part is turned, but the length is preserved.
- Axial (angular) — the axis is curved at an angle, the limb is lengthened or shortened.
- Transverse — the volume of the segment increases.
However, accurate determination of the fracture line, integrity of the cortical layer, and the nature of displacement is only possible with X-ray examination. Images are strictly taken in two projections.
Consolidation factors and complications
Bone fusion (consolidation) can slow down under the influence of general and local factors. General factors include old age, chronic debilitating diseases (tuberculosis, amyloidosis), metabolic disorders (diabetes mellitus, obesity), and nutritional deficiencies (protein deficiency,avitaminoses).
Among local factors reducing regeneration:
- Severe soft tissue and periosteal injuries.
- Hemodynamic and innervation disorders in the affected area.
- Intra-articular localization (fragments lack periosteum and are bathed in synovial fluid).
- Interposition of tissues (entrapment of muscles, fascia, or tendons between fragments).
- Treatment errors (incomplete reposition or poor immobilization).
At the pre-hospital stage, due to transport errors, careless repositioning, or improper splinting, secondary displacement often occurs. It threatens skin perforation (transition to an open form), damage to neurovascular bundles, internal organs, or the spinal cord. In open injuries, there is a high risk of infection with subsequent development of soft tissue inflammation and traumatic osteomyelitis.
Briefly: answers to topical questions
What are the definitive (absolute) signs of a fracture?
Definitive (absolute) signs of a fracture include pathological mobility and crepitus of bone fragments.
- Pathological mobility — presence of "rocking" movements in the fracture zone outside a joint. Detected by careful displacement of the peripheral segment of the limb while fixing the proximal one.
- Crepitus of fragments — appearance of a crunch of bone fragments rubbing against each other when the limb is shifted in different directions.
Due to high invasiveness, the detection of these symptoms should be resorted to in exceptional cases.
What types of fractures are distinguished by the direction of the fracture line?
According to the direction of the fracture line, the following types of fractures are distinguished:
- Transverse — a straight fracture line perpendicular to the bone axis.
- Oblique — the line runs at an angle to the bone axis.
- Spiral — the fracture line has a spiral spatial arrangement.
- Comminuted — with different fracture planes, there is an additional fragment — a bone chip.
- Multifragmentary — characterized by the presence of two or more fragments.
- Marginal — damage to the bone edge without disrupting its continuity.
- Avulsion — separation of a bone fragment along with the attaching tendon or ligament as a result of their sharp tension.
- Punched-out — occurs with sharp local impact of significant force.
- Impacted — one bone fragment enters another.
What types of bone fragment displacement are distinguished in traumatology?
In traumatology, several main types of bone fragment displacement are distinguished:
- Lateral displacement (width displacement) (dislocatio ad latus) — fragments are displaced sideways relative to the cross-section of the bone.
- Axial displacement (angular displacement) (dislocatio ad axim / ad angulum) — the bone axis is disrupted, an angle forms between the axes of the fragments.
- Displacement along the length (dislocatio ad longitudinem) — fragments are displaced along the long axis of the bone. It can manifest as shortening with overlapping of fragments (cum contractione), lengthening with separation (per extensionem), or impaction.
- Rotational displacement (peripheral displacement) (dislocatio ad periphericum) — rotation of one of the fragments around its longitudinal axis.
What stages (phases) of callus formation are distinguished during bone regeneration?
During bone regeneration, the following consecutive stages of bone callus formation are distinguished:
- Extravasation of blood, hematoma formation, and aseptic inflammation.
- Formation of mesenchymal tissue — a gelatinous "primary glue" is formed from the hematoma, tissue fluid, and fibrin.
- Osteogenic stage — cell proliferation and differentiation, angiogenesis, formation of fibrous structures and osteoid tissue.
- Formation of soft (primary) callus — formation of granulation and osteoid tissue.
- Formation of secondary callus — osteoid mineralization and calcium deposition.
- Remodeling of the callus and restoration of bone structure — resorption of bone fragments and excess osteoid by osteoclasts, replacement of the callus with trabeculae, and restoration of the medullary cavity.
What types of bone callus are formed during fracture healing?
During fracture healing, the following types of bone callus are formed:
- Periosteal (external) callus — surrounds the opposing bone fragments externally, forms from the periosteum, and performs a fixation function.
- Endosteal (internal) callus — forms inside the medullary cavity.
- Intermediary (intermediate) callus — is located between the fragments, connecting the ends of the cortical plates. It is the most favorable option for healing.
- Paraossal callus — forms in the surrounding soft tissues. This is the most unfavorable variant, which occurs in the absence of conditions for healing and involves all surrounding tissues.
Absolute signs are easy to remember by the acronym PC: Pathological mobility and Crepitation.
Class and exam questions
Why do intra-articular fractures heal worse?
Bone fragments inside a joint lack periosteum. Furthermore, they are constantly bathed in synovial fluid, which severely disrupts normal osteogenesis processes.
Why apply axial loading during examination?
Light tapping along the axis of the limb (e.g., on the heel) provokes localized pain at the site of a hidden lesion. This technique helps diagnose hip or lower leg injuries.
What is the danger of secondary fragment displacement during transportation?
Careless repositioning can cause a closed fracture to become open due to skin perforation by a sharp bone edge. Fragments can also damage major vessels, nerves, the spinal cord, or internal organs.
What else to study on this topic
- Consolidation timelines for various bones of the upper and lower extremities
- Detailed mechanism of development of obstetric and pathological fractures
- Rules and typical errors in applying transportation splints at the prehospital stage
- Traumatic osteomyelitis: pathogenesis and prevention
- Technique for detecting rotational and axial displacement during palpation
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