Upper extremity fracture, forms and treatment

Anatomy of the bones of the upper extremity

The bones of the upper extremity include the scapula, clavicle, humerus, forearm bones (radius and ulna) and hand bones (carpal, metacarpal and phalangeal bones). Fractures occur as a result of mechanical impact and pathological processes (tumors, infections in the bones, such as tuberculosis, etc.), which lead to the violation of the integrity of tubular and flat bones. All human injuries are accompanied by fractures in 6-7% of cases. Fractures are most common (60% of cases) in the hand and foot. Fractures in the forearm and lower leg bones are in the second place in terms of frequency (20% of cases). Percentages of fractures of other bones in human body: ribs and sternum – 6%; femur – 0.9%; vertebrae – 0.5%; scapula – 0.3%.

Signs of fracture

• Pain
• Swelling
• Deformity (curvature)
• Crepitation
• Pathological motion (movements that are not normal)
• Impaired function, etc.

Identification of fractures

Classification of fractures is based on such factors as: period of development; cause of occurrence; skin integrity; qualities, localization and mechanism of fracture occurrence, type, number and combination of injuries; presence of displacement. Depending on the period of development of the human body fractures are divided into two groups: congenital and acquired.

Acquired fractures – depending on their origin they are divided into two groups: traumatic and pathological fractures.

Traumatic fractures are fractures that occur under the influence of mechanical stress on healthy bone tissue.

Pathological fractures are fractures that occur due to primary bone disease, primary or metastatic bone lesions by tumors, tuberculosis, osteomyelitis, syphilis, cysts of echinococcus and other parasites, abscesses and other conditions (Gaucher disease; osteoporosis, which occurs due to parathyroid gland dysfunction; long-term treatment with hormonal drugs). It all results in a disruption of bone density.

X-rays show pathological fractures

Depending on the integrity of the skin and mucous membranes, fractures are divided into two types: open and closed fractures.

Closed fractures are fractures in which the integrity of the skin is not compromised.

Open fractures are fractures in which the integrity of the skin and mucous membranes is broken (fracture of the bones of the jaw). Depending on the cause of the fracture, they are divided into three types: fractures occurring under the impact of cold and firearms (bullets), as well as in a minefield.

The classification also depends on the localization of the fracture in the long tubular bones, so they are subdivided into: epiphysis, metaphysis, diaphysis (upper, middle, lower) and intraarticular fractures.

Classification of fractures according to bone margin juxtaposition

Depending on the qualities of the injury, its structure, and the relationship of the bone margins, fractures are subdivided:

• A complete fracture is a fracture in which the bony edges separate;
• Incomplete fracture is a fracture in which there are fractures under the periosteum;

Twisting the bone around its axis are fractures that occur in a fall from a height when the femur twists around its axis. In this type, the fracture line is spiral.

Fracture classifications based on the direction of the fracture line: transverse, longitudinal, oblique, compression, embedded, spiral, torn, splinter, split, Y and T form fracture.

Classification of fractures according to the number of fractures occurring in the bone tissue: single, double, multiple fractures.

Fractures may be accompanied by disruption of bone tissue integrity, combined damage of adjacent tissues and organs, such as: large-caliber vessels, nerve and joint damage; damage of adjacent soft tissues; fractures that move into body cavities; disruption of hollow organ integrity, etc.

Classification of fractures depending on the displacement of bone fragments: fractures with displacement, fractures without displacement (the distance between the bone edges is not more than two millimeters).

In most cases, the bone margins change their location.

Bone marginal displacement is primary – over time, under the influence of mechanical force, the bone margins change their position; secondary – muscle contraction causes the bone margins to shift in relation to each other. Bone marginal displacement occurs most often when the victim falls from a height, especially when there is a technical error, when the victim is moved, or when the victim is not immobilized.

Bone edges may change their position at an oblique angle, laterally, or along the bone.

Bone ends that shift toward the distal ends of the bone produce the torsion around their axis and result in a rotational fracture.

The displacement of the bone ends results in a limb deformity: transverse displacement increases the fracture area; oblique displacement results in limb curvature; and longitudinal displacement results in limb narrowing.

Depending on the difficulty of movement in the limb, fractures are divided into simple and complex. Simple fractures are fractures that involve the fracture of only one bone. Compound fractures are fractures that occur when two or more bones fracture, and may be accompanied by the end of the bone leaving the joint, tearing ligaments and joint capsule.

So under the influence of injury, fractured bones can cause complications, which divide fractures into complicated and uncomplicated.

Clinical signs of fractures

Clinical signs of fractures are defined by local and general manifestations. In fractures of small bones, local symptoms predominate. Fractures of long tubular bones are accompanied by general signs, such as: bleeding and blood loss; signs of traumatic shock and fat embolism may be observed.

Local signs of fractures are divided into two groups:

1. Precise signs confirming a fracture: bone fragments in the wound, crepitation, pathological mobility in the joint of the limb, and changes in the size of the limb.
2. Other signs: pain, swelling, hamstring hematoma, limitation of range of motion in the limb. These signs contribute to the suspicion of a fracture. Since these signs are also seen with soft tissue injuries of the limb, the diagnosis of a fracture must be confirmed by radiological examinations.

Treatment of fractures

First aid is one of the parts of comprehensive fracture treatment and its delivery at a high (professional) level plays a very important role in the subsequent stages of treatment. The performance of first aid should start with the aim of preventing possible complications.

Respiratory distress – the first thing to do is to prevent the tongue from trapping and to clear the entrance to the larynx of bloody and mucous secretions.

Stop bleeding – under the influence of mechanical impact, bleeding may occur at open fractures of the upper and lower extremities. In this case at the scene the victim should be given an aseptic pressure dressing, but if vessels of large caliber are injured, a tourniquet should be applied to stop the bleeding.

Conducting anti shock measures – in order to prevent an increase in the signs of traumatic shock, at the scene of the victim intravenous or intramuscularly should be given narcotic analgesics (Promedol 2% – 1.0, morphine – 1-2% – 1.0), analgesics (Analgin 50% – 2.0, Tramal – 2.0, Baralgin – 5.0). Continuing intravenous administration of plasma substitutes (polyglukin, reopolyglukin, gelatinol, hemodez), the victim should be transported to centers where they can get specialized care. Also, do not forget about warming the body of the victim in cold weather.

Immobilized transportation – During transportation from the scene to the hospital, the injured person must be immobilized and rest the entire body or a specific part of the body.

Ways of immobilizing the entire body or a limb

Fixation of limbs to the victim’s body – at the scene, if there are no means of fixation at hand, the injured arm of the victim should be strapped to the chest and the lower limb to a healthy leg.

Using improvised means to immobilize the patient – if no medical means for immobilization are available, if possible, you should use objects that are readily available. Thus, a piece of wood, skis, umbrella, rifle, etc. can be used as a means of immobilization by placing them under the limb and securing them with a cloth bandage.

Use of medical means of fixation – medical devices such as: Kramer, Dieterichs, air, plastic, cardboard and vacuum splints are used to transport the patient in a motionless state.

Kramer step splint made of aluminum wire – this splint is used to immobilize the upper and lower extremities. The advantage of this splint is that it can be shaped into any shape and immobilize the limb because aluminum is a malleable (soft) material.

Dieterichs splint – this splint is formed of unfolded plates (outer, inner, lower) and a metal connecting substance. It has not been used as often lately.

Modern air splints are a splint consisting of a double, airtight fabric that forms a sack and is secured with clasps. The bag is placed on the limb, and after the clasps are closed, air is pressed into it and it takes on a rigid shape, thereby securing the limb securely. These splints are used for fractures of the wrist, forearm, elbow, foot, shin, and knee injuries. It lets X-rays through and does not interfere with the examination. Recently, this type of splint has been used more and more frequently.

Treatment methods of fracture

Fractures are treated conservatively and surgically. Both methods of treatment have three basic principles.

• Bringing the edges of the fractured bones into the proper position;
• Appropriate fixation of the ends of the bones in order to prevent their subsequent displacement;
• Acceleration of the formation of the bone callus and the healing of the fractured bone.

Complete reversal of the displacement of the fractured bone margins and bringing the ends of the fractured bone is possible with sufficient anesthesia. This prevents reflex contraction of the muscles and secondary displacement of the bone margins.

Plaster casts are a conservative treatment method that is used for reliable fixation of reduced bone margins and prevention of recurrent bone displacement. The plaster cast is made of bandages covered with plaster powder.

Traction treatment is a method of traction of the edges of fractured bones, they are brought and kept in the same position. There are two types of this method: cutaneous and skeletal traction.

Permanent traction can be performed using cuffs and loops. For example, if there is a fracture of the cervical and upper thoracic vertebrae, traction is performed using a Glisson loop, which is passed through the neck and tied to the head end of the bed. The head end of the bed is raised by 50-60 cm and traction is performed.

Surgical treatment of fractures is the second method of fracture treatment. Surgical treatment of fractures should be performed only if indicated. The indications for surgical treatment are absolute and relative.

Absolute indications for surgical treatment of fractures: open fractures; damage of vital organs (brain and spinal cord; thoracic and abdominal cavity organs; large-caliber vessels; nerves) through the edges of the fractured bone; formation of false joints; occurrence of pyo-inflammatory fracture complications; incorrectly closed fractures that noticeably impair limb function; appearance of muscle, tendon and fascia sections between the fractured bone edges.

Relative indications for surgical treatment: inability to achieve complete reduction of bone margins after repeated attempts; slow course of fracture healing; inability to reduce and hold bone margins in oblique fractures and severe displacements in tubular fractures. Surgical treatment should be performed for an incorrectly fused fracture, even if limb function is slightly impaired.

The figure shows osteosynthesis of fractured head of humerus with metal plate

The figure shows osteosynthesis of fracture of the humerus body with metal plate

The figure shows osteosynthesis of fracture of the ulna (olecranon) with metal plate

The figure shows osteosynthesis of fracture of the ulna body with a metal plate

The figure shows osteosynthesis of fracture of the distal end of the radius with external fixator

The osteosynthesis of fractured bones is performed by different methods, such as osteosynthesis inside the bone marrow canal (intramedullary) and osteosynthesis outside the bone marrow canal (extramedullary), using metal and plastic plates, wires, screws and spiral nails. Compression-distraction treatment is performed by means of apparatuses with a specific structure (Ilizarov, Gudushauri, Volkov), the method of variable connection and separation of the edges of fractured bones.

Complications of fracture treatment

During the first aid and treatment period, complications can arise in patients who have suffered bone injuries and fractures. Incorrect fixation of the body or an injured limb with a splint during first aid, careless movements during patient transportation can lead to complications such as: displacement of bone margins and fragments; damage to blood vessels, nerves, internal organs (brain, lungs, liver); bleeding; paralysis. During treatment, incorrect union of bone ends, incomplete fusion due to secondary displacement, accession of infection, pyo-inflammatory diseases of soft tissues can lead to osteomyelitis; weak and incorrect bone fusion after fracture can lead to false joints.

The healing of fracture

The tissue that forms between and around bone margins is called a callus. A callus consists of four layers: periosteum, bone tissue, Havers’ canals, and the tissue that is inside these canals. The fourth layer is formed by the adjacent soft tissues and is the tissue that surrounds the callus on all sides. The backbone of all of these tissues is the osteoid tissue that forms the callus. The periosteum plays the main role in the fusion of the bone margins.

Subsequent transformations in the bone callus occur within 3-4 months, and in the final stage calcification of the osteoid tissue occurs. At the beginning of this stage vessels regress, edema resolves, blood flow normalizes, and signs of inflammation diminish. Bone development and further fusion of bone margins can follow the path of primary and secondary healing.

When the edges of the fractured bones are fully reduced and sufficiently fixed, the osteoid tissue that forms in the cavity between the edges is immediately calcified because it is very thin. This fusion is more useful and is completed in a short period of time. Bone fusion occurs due to the thin strip that forms between the bone margins and bone layers. This type of fusion is called primary healing.

Other methods of bone fusion are called secondary healing. In this process, hyaline tissue or fibrous cartilage forms from the osteoid tissue and gradually transforms into bone tissue. This is a very long process. This fusion is the method of secondary healing.

In the newly formed bone tissue, in addition to the biological transformations, there is a comprehensive development of the bone, the architectonics of the bone is completely restored. During all these transformations the bone marrow canal and other elements differentiate, which completes bone fusion.