TRAUMATOLOGY. FRACTURES AND DISLOCATIONS.

1. TRAUMATOLOGY.FRACTURES AND DISLOCATIONS. Trauma is influence on the organism of outward agents (mechanic, thermal, electric, ray, psychical and oth.), which provoked the anatomical and functional breaches in the organs and tissues, which are accompanied by local and general reaction of organism

2. There are distinguished the following types of traumatism: 1. Traumas of unindustrial character: a) transport traumas (railway, car, tram); b) everyday; c) sporting; d) others (traumas, which received as a result of natural catastrophes). 2. Traumas of industrial character (manufactural and agricultural). 3. Intentional traumas (battle traumas, ill-intentioned attacks, attempt of suicide). Traumas are divided on mechanic, chemical, electric, ray, psychical, operational and others by a type provoked the damage agent.

3. The dividing of traumas by character of damage is very important - there are distinguished the open and closed traumas. There is a gaping of skin and mucous membranes wounds by the open damages. The microbes can penetrate through the wound of skin and mucous, that is promote to developmental of early and later complications. There are also distinguished the penetrating damages, in the presence of which the internal organs (of abdomen, of thorax, of skull, of joints) can be affected, and unpenetrating.

4. In the damages of tissue of only of only one type we tell about the simple trauma, if the different tissues are damaged - about the complex trauma, for example, the skin, muscles and bone. Traumas can be direct and undirect (damages developing in the distance from the region of provoking agent influence).

5. Peculiarities of investigations of traumatological patients. At first, the outward look of damaged place not always corresponds to the seriousness of damage. Secondly, not always the trauma, symptoms of which are obvious, is threating for human life, especially hard the diagnostic of plurality traumas of patients, which are unconscious, in a state of serious shock or alcoholic intoxication. Thirdly, the serious general phenomena (shock, acute anemia, traumatic toxicosis) can appearance by traumas. It is necessary to estimate them rightly and render the proper help.

6. It is necessary to elucidate by questioning of victim (or eye-witnesses, if the patient is unconscious) the complaints in present time, what the patient felt at the moment of trauma and then, what help has rendered to it. It is necessary to determine the presenting accompanying diseases.

7. It is necessary to examine the place of damage that is far specification of diagnosis and to represent the preliminary opinion about the methods of treatment and possible complications. For example, the fractures can be accompanied by damage of nerve and great vessels, and the wound of thorax is complicated by hemothorax and heart tamponade. Getting of a soil in the wound can provoke the tetanus later. To check the condition of all systems and organs, estimate the presence of general phenomena and degree of them seriousness. Carry out the laboratory and roentgenological investigations, if they not prevent to rendering of urgent help. It is necessary to take into account the anatomical, comparative and functional shortening of extremity and middle-physiological location of upper and lower extremities.

8. Closed damages in soft tissues. Closed damages of soft tissues are divided on contusions, tensions and ruptures, concussions and squeezes. Closed damages of soft tissues, organs, which localized in cavities are observed.

9. Contusion Contusion - (contusio) - is damage of tissues and organs without the breach of skin integrity as a result of quick and momentary action of traumating factor on the one or another part of a human body. Mechanism of the trauma can be various - fall on something object or blow. Seriousness of damage is determined by two moments: 1. Character of traumating agent, its seriousness, consistence, quickness of action. 2. Type of tissues, on which the trauma act (skin, muscles, fat, bones).

10. Clinical picture - characterized by appearance of pains, swelling, breach of function of contusioned organ or region. It can be observed the exfoliation of skin by the action of great force by (angent, it can develope the shock of paralysis (be contusion of great nerves) of a region, which innervated by contusioned nerve, by contusion of joint breach of its function, by contusion of thorax and lung - cutaneous emphysema. • Treatment. Solution of treatment at first period after contusion is stopping of hemorrhage in tissues, that achieved by quarantee of rest, raised posture, cold, pressing bandage. On 2-3 day when the contusioned vessels thrombosed, the warmth, physiotherapy procedures are applied. In the presence of haematoma sucking off and introduction of antibiotics.

11. Tensions (distorsio) Tensions is damage of soft tissues, which is provoked by the force acting like a tractio n and nor breaching the continuity of tissues. However, if the acting force exceed the resistibility of tissues by such mechanism of trauma, then the rupture of ligaments, fascias, muscles, tendons, nerves etc. Clinically the eupture of ligaments is accompanied by appearance of strong pains, breach of motions, haemorrhages in soft tissues, oedema, swelling of joint. It can be determined the fluctuation by a palpation as a result of haemorrhages. Treatment consists in quarantee of a rest, application of pressing bandage, prolonged immobilization of a joint. After resilution of haemorrhage with third week, they pass to the careful active movements, massage, and medical physical training. The punctions and introduction of antibiotics are by delated resolution.

12. Ruptures Ruptures of fascies are registered rarely and developed from the direct blow in a region of fascia. The crack-like defect of fascia appeared as a result, that is lead to sticking out by the contraction of muscles. Treatment - operative. Ruptures of muscles - complete and uncomplete are registered rarely and happened as a result of strong and quick contraction of them, by rising of heavinesses. The strong pains, haemorrhages, oedema, limits in motion are manifested clinically. Treatment - by uncomplete rupture - immobilization, rest, cold, then the warmth, physioprocedures. By complete rupture - operation with following immobilization on 2-3 weeks. Ruptures of tendons need the operation. Concussions (commotio) - is lead to the significant breaches of function of organs and tissues. Prolonged and strong vibration of upper extremities at first provoked the breach of functions, and then lead to the morphological changes in muscles, nerves, bones, which are expressed in a development of sclerotic processes, pains, limit of capacity for work (vibrational disease).

13. Squeeze Squeeze - is observed by squeeze of lifly important organs (heart, brain, lungs).

14. Fractures of bones and dislocations. Clinic, treatment. Fracture. A fracture is a structural break in the normal continuity of bone. This structural break, and hence fracture, may also occur through cartilage, epiphysis and epiphysal plate (see appendix 14). Dislocation. A dislocation is a total disruption of a joint with partial remaining, but abnormal, contact between the articulating surfaces. Subluxation. A subluxation is a partial disruption of a joint with partial remaining, but abnormal, contact between the articulating surfaces. The treatment of fractures and dislocations requires knowledge of the anatomy, physiology, and biomechanics of the musculoskeletal system. While a fracture represents a disruption in thecontinuity of a bone, it also represents a major soft tissue injury. The fracture surgeon must be aware of the soft tissue structures adjacent to a fracture site and be alert for neurologic and vascular components of the injury. Since many fractures occur in a setting of violent trauma, full evaluation of each patient is necessary, and the surgeon must be prepared to deal with major onjures in other tissue systems.

15. Fracture Fracture - is a partial or total breach of integrity of the bone, which is provoked by quickly - acting force and accompanied damage of soft tissues. The fractures are divides on inborn and acquired depending on the origin. Each of these groups, in one's turn, divided on open and closed, and the acquired fractures are divided on traumatic and pathological. Open fractures are accompanied by damage of integrity of soft tissues and skin integuments. Closed - are the fractures, in the presence of which the skin and mucouse areintact and are the barries for the penetration of infection.

16. 1. By the direct blow - transversal fracture fracture with a dislocation of peripheral osseous piece. Squeze is lead to a compessional fracture for example, body of a vertebra by the strong bending, and by fall. It can be developed the oblique and transversal fracture be bending. The twisting of a bone by fixing one end is lead to the development of helical fracture by spiral. The breaking off fractures is happened by the sharp and strong contraction of muscles. 2. By localization the damages are divided on the epiphysial fractures are unfavourable for the processes of consolidation and quite often accompanied by dislocation of osseous piece of a joint, that is hamper the comparison and fixation of osseous parts.

17. Metaphyseal - are the damages of a spongy part of bone. The important symptoms of a fracture (crepitation, abnormal mobility and others) are absent quite often by such fractures. 3. The fractures are divided on transversal, oblique, longitudinal, spiral, shrapnel. 4. There are total and incomplete fractures. 5. There are simple, complex and combined fractures. 6. Single and plural.

18. Formation of a callus. It can be divided the pathological changes the pathological changes by the fractures and them unions of three periods: a) changes, which connected directly with a trauma and development of aseptic inflammation; b) period of osteogenesis; c) period of reconstruction of a callus.

19. The following development of a callus is happen by two ways: 1) by the way of immediate formation of a callus from osteoid tissue. 2) by the way of preliminary formation of hyaline or fibrous cartilage from the osteoid tissue.

20. Regeneration of the bone depend on: 1. Character and force of traumatic agent serious trauma make (he less favorable conditions for consolidation. 2. Anatomy-physiological states. Different bones had various ability to union. Bones are united quicker of young people. 3. Character of fracture: a) accompanied by large destruction and breach of nourishment of periosteum; b) accompanied by breach of innervation; c) breach of a blood supply; d) fractures in region of bone, which have not the periosteum, for example intraarticulate fractures.

21. Clinic of fractures 1. Pain - is observed at once after the fracture; it abate in a rest and reinforced by any movement of extremity. But the pain doesn't decisive symptom, because it take place by injuries, tensions. 2. The breach function is not always typical symptom of fracture. It is typical, for example, for the fracture of lower extremity that a patient does not stay on the legs after trauma 3. Sometimes the deformation is acutely expressed on the place of fracture, and sometimes expressed little and can be recognized only on R-gramm.

22. There are some types of displacement: a) Displacement under the angle, when the axws of osseous fragments formed the angle of the place of fracture. Angle depend on the direction of the fragments. b) Lateral displacement is observed by the divergence of osseous fragments in a direction of diameter of the bone. c) Displacement by the length, longitudinal displacement - more often type of displacement, when the one fragment slip along another 4. Mobility of osseous fragments along the bone length is very sure sign of the fracture. It can be expressed well by the diaphysial fractures. 5. Crepitating and abnormal mobility of osseous fragments is defined, if the bone fixed by one hand below and by another hand above the place of fracture and does carefully the motion in a opposite side.

23. Modern treatment of fractures direct at restoration of anatomical; structure and physiological structure of a fractural bone. This purpose is attained by successive application of such measures as: 1. setting of osseous fragments - reposition; 2. retention of them in a right posture (ill the union -immobilization; 3. acceleration of the union processes (consolidation) and restoration of function of the damaged organ by the way of; a) functional treatment with the application of a medical physical training; b) improvement of a general state of a patient (nourishment, vitaminization, blood transfusion).

24. Success of the reposition depend on following moments: a) knowledge of the type of fracture and displacement of central and peripheral fragments; b) by well anasthetization - 2% solution of a novocaine in the place of fracture; c) by relaxation of muscles, which fastened to the osseous fragments; d) by right comparison of oseous fragments pehpherial is placed to central; e) use of arm methods for reposition and by reading of different apparatuses (Sokolovsky', cug-apparatus and others)

25. Fixation or immobilization of osseous fragments ill a right posture can be practicable by different methods: a) gypseous bandage; b) drawing out; c) operation. Gypseous bandages: circulary, longetic, longetic-circulary, fenestrated, bridge-like, folding, and gypseous bedstead.

26. Gypseous bandages, which applied on extremity with already developed traumatic oedema, with the hematoma, through 7-14 days in connection with decrease of oedema become free. It is necessary to take off it and apply a new bandage to avoid the secondary displacement. Gypseous bandage immobilize the extremity on date, which is necessary for consolidation.

27. Fig. 1. Sceletal traction in femur (a) and shin (b) fractures

28. Complications of fractures. The early complications of fractures: Local. Sequelae of immediate local complications: skin necrosis and gangrene, Volkmann’s ischaemia, gas gangrene, venous thrombosis, visceral complications, joint infection, bone infection, avascular necrosis, fracture blisters. Remote. Fat embolism, pulmonary embolism, pneumonia, tetanus, delirium tremens. The late complications of fractures: Local. Joint stiffness, secondary osteoarthritis, bone malunion, growth disturbance, chronic infection, difuse osteoporosis, Sudeck’s atrophy, refracture, muscle myositis ossificans, late tendon rupture, tissue atrophy, tendonitis. Remote. Renal calculi, accident neurosis.

29. Dislocation Dislocation is a steady abnormal displacement of articulate surfaces, with respect of one to another. If the articulate surfaces are stop adjoin, the dislocations are named total, by partial contiguity -incomplete or subdislocation. Tell dislocation is usually accompanied by rupture of articulate surface capsule and going out of one articulate surface through this rupture. Depending on the damage of joint we tell about the dislocation of a humeral joint etc. There are distinguished the inborn dislocations, which arise at the time of intrauterine life of a fetus, and acquired, which are developed as a result of trauma or pathological process in a region of a joint.

30. Clinical picture. The questioning of a victim is allowed to elucidate the circumstances of a trauma, mechanism of damage. Pain in a joint and impossibility of movement in it are become stronger by motion. Numbness of extremity is by squeeze of a nerve. Deformation in a joint is present. X-ray photograph is confirming the diagnosis of a dislocation.

31. Treatment Urgent qualified aid. First aid - transport splint or fixing bandage, anodynes. Immediate transportation in a hospitalis needed. Setting is carried out easier and results are better, if it is realized at first hours after trauma. Dislocations of 2-5 days are set difficulty, and 3-4 weeks later are often required the operation. The setting of dislocations must be carried out under the anaesthetization without fail. The complete relaxation of muscles is necessary for quick setting of dislocation that is achieved by total anaesthetization. Use of rough, physical force lead to the complementary damages of capsule of a joint and development of recidivations of dislocation (habitual dislocation), which are more often met in a shoulder and maxillotemporal joint. There are some methods used of setting of a dislocation for the restoration of normal anatomical correlations in a joint, which are based on the relaxation of muscles of articulate region, and setting of dislocated articulate surface. With use of a number of motions, which are typical for every joint. Tills movements in a damaged joint as though repeat the motions in reserve succession, which provoked the dislocation

32. Kocher's method - consist of 4th stages a. crooking in the elbow joint with a putting of shoulder to the trunk. b. Traction downwards and simultaneously rotation of a shoulder. c-d stages - raising of arm upwards and simultaneously rotation of a shoulder with the following throw of hand on the healthy upershoulder. Control X-ray photograph is made at once after setting. Extremity is fixed on 6-10 days in a functionally advantageous posture by bandage or stretching and then the LFC complex is carried out.