Fracture isPhalangeStructuralContinuityComplete or partial fracture.This disease is mostly seen in children and the elderly, and also in young and middle-aged people.Patients often suffer from fracture of one part, and a few of them suffer from fracture of one partMultiple fractures。After timely and appropriate treatment, most patients can recover their original functions, and a few patients can leave somesequela。
TCM disease name
fracture
Foreign name
fracture[2]
Visiting department
Trauma orthopaedics, pediatric orthopaedics
Multiple population
Children, elderly
Common causes
Direct and indirect violence, cumulative strain
common symptom
Abnormality, abnormal activity, bone fricative or bone rubbing sensation
violenceDirect actionFracture occurs at a certain part of the bone, resulting in fracture of the injured part, often accompanied by soft tissue injury of varying degrees.If the wheel impacts the calf, it will occur at the impact placeFracture of tibia and fibula shaft。
Indirect violence acts through vertical conductionLeverageOr the torsion may cause fracture at a distance. For example, when the foot lands from a high place, the trunk will buckle forward sharply due to gravity, and the vertebral body at the junction of the thoracolumbar spine will occurCompressibilityorBurst fracture。
Long term, repeated and slight direct or indirect injuries can lead to fracture of a specific part of the limbs, also known asFatigue fracture, such as long-distance walking, it is easy to lead to the second and third placemetatarsal boneandthe fibulaLower 1/3 shaft fracture.
classification
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In order to clarify the nature, diagnosis and treatment principles of fractures, fractures can be classified as follows:
1. According toWhether the fracture is connected to the outside worldAnd divide
（1）Closed fracture: The skin or mucosa at the fracture site is intact and not connected with the outside world.
Schematic diagram of open fracture[2]
（2）Open fracture: The skin or mucosa near the fracture is broken, and the fracture is connected with the outside world. Bacteria can enter from the wound, which is easy to cause infection.Open fractureWoundIt can be formed from outside to inside, such asFirearm woundFracture;It can also be punctured from the inside out by the sharp fracture endsoft tissueTo form, such asPubic boneAndIschial branchAt the same time, it is easy to cause fracturePosterior urethraandBladder injury, sacrumCaudate fractureIt may puncture the rectum.[1]
2. According toCondition of fracture lineAnd points.
4. According toAnatomical location of fracture on boneDivided into
（1）Diaphyseal fracture: Finger lengthTubular boneThe fracture of the shaft can be divided into upper 1/3, middle 1/3 and lower 1/3 fractures;It can also extend to upper, middle and lower 1/3 fractures.
（3）MetaphysisFracture: fingerlong boneFracture of the metaphysis at both ends, when the fracture line affectsArticular surfaceIt is intra-articular fracture.
（5）Injury of epiphysis: Refers to childrenepiphysisThe department is involved, which can be subdivided intoEpiphyseal separation(Type I injury), epiphyseal separation with metaphyseal fracture (Type II injury)Epiphyseal fracture(Type III injury), fracture of epiphysis and metaphysis (Type IV injury), compression injury of epiphysis (Type V injury).Epiphyseal separation with metaphyseal fracture is common.
(6) Cartilage fracture: it is a special type of intra-articular fracture, which needs the help ofarthroscopeorMRIThe diagnosis can only be confirmed after examination.[1]
5. According toNameFracture of
Some fractures are named according to the name of the scholar who first described them. Commonly used fractures are:
（2）Smith fracture(Smith fracture): The fracture line is also within 2.5cm of the lower end of the radius, but the distal end of the fracture moves to the ulnar and volar sides (the distal end of Colley fracture moves in the opposite direction).
（3）Barton fracture(Barton fracture): refers to the back of the distal radiusLateral marginOr volar margin fracture (the latter is also called anti Barton fracture) with wristSubluxation of jointThe.
The AO alphanumeric classification published by M ü ller et al. is the result of an international cooperation and the most commonly used standardized fracture at presentclassification method 。This system is not only used to record all fractures, but also to helpbiomechanicsAnd biology to understand these fractures.Letters used by the systemNumeric symbolExpressionIt is convenient for doctors to evaluate, record and store clinical findings of fractures as needed.In this system, any fracture can be identified by answering relevant questions: which bone?Which segment of bone?Which type of fracture?Which group do you belong to?To whichSubgroup？
along withImagingDevelopment of inspection means, such asMagnetic resonance imagingIt can be found in some epiphysesBone injuryOnlyTrabeculaInjury and edema, andBone cortexAnd bonesOverall structureKeep intact. It used to call this kind of damage“Bone contusion”Its classification is still inconclusive.In recent years, with the agingOsteoporosisPatient 2PhosphonateWith the popularization of its use, the so-called "atypical fractures" related to it are often seen in clinical practice, especially the atypical fractures of the proximal femur. The classification, treatment and healing process of such fractures need further research.[1]
clinical manifestation
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1. General performance
（1）Shock is associated with multiple fracturesPelvic fracture、Femoral fracture、Spinal fractureAnd severe open fracture, patients often suffer from extensive soft tissue injury, massive bleeding, severe pain or complicationsVisceral injuryShock.
(2) FeverThere is a lot of internal bleeding at the fracture,hematomaThe body temperature rises slightly during absorption, but generally does not exceed 38 ℃. The possibility of infection should be considered when the body temperature of open fractures rises.
2. Local manifestations
The local manifestations of fracture include the specific signs and other manifestations of fracture.
3. Special signs of fracture
(1) MalformationThe displacement of the fracture end can change the shape of the affected limb, which is mainly manifested as shortening, angulation and lengthening.
(2) Abnormal activityUnder normal circumstances, abnormal movement occurs in the part where the limb cannot move, after fracture.
(3) Bone fricative or bone rubbing sensationAfter fracture, the two fracture ends rub and collide with each other, which can produce bone fricative sound or bone rubbing feeling.
The diagnosis can be made as long as one of the above three signs is found, but the possibility of fracture cannot be ruled out in those without these three signs, such asEmbedded fractureFracture.Generally, the above physical signs should not be checked for diagnosis, because it will aggravate the injury.
Those suspected of fracture should undergo routine X-ray examination, which can show clinically difficult to findIncomplete fracture, deep fracture, intra-articular fracture and smallAvulsion fractureThe X-ray examination is also necessary even for those who have clinically manifested obvious fractures. It can understand the type and specific conditions of fractures and has guiding significance for treatment.
X-ray photographyIt should include both anteroposterior and lateral radiographs, and must include adjacent joints, sometimes additional photography is requiredOblique position、Tangent bitOr the corresponding part on the contralateral sideX-ray film。
For those whose fracture is not clear but cannot be excludedSpinal fractureIt is feasible for those who may compress the spinal cord nerve root and those who have complex fracturesCTCheck.3D CT reconstruction can be more intuitive and convenient for fracture classification and treatmentScheme selectionIt is very helpful and commonly used in clinical practice.
3. MRI examination
Although the fracture line is not as good as that of CT, the spinal nerve root andsoft tissue injury The display of has unique advantages and has been widely usedSpinal fractureInspection of.
diagnosis
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According to clinical manifestations andImagingThe diagnosis can be confirmed or eliminated by inspection.
The diagnosis of general fractures is not difficult, especially the length of limbsTubular boneDiaphyseal fracture, easy to diagnose, even the patient himself can judge.For intra-articular fractures, or patients in comaDenervationIt is easy to miss or misdiagnose the fracture of children's epiphysis before it is closed.[1]
(1) Trauma history: in addition to detailed inquiry about the time and direction of violence and the posture of the patient's body or limb, we should also understandWounding substanceType, injury site andExternal force actionForm, etc., which are crucial to the judgment, diagnosis and treatment of injuries, especially the diagnosis and treatment of spinal injuries.[1]
(2) First aid and out of hospital treatment history: on site and fromOn site transferFirst aid before arriving at the hospital and its treatment process, especially the sensory and motor changes of the injured limb,tourniquetUsage of,Spinal fractureThe patient's posture when moving, blood loss and fluid replacement on the way, and what kind of drugs he has used.[1]
（3）Past history: Mainly understand the medical history related to fracture, including whether there isjointDisease, with or withoutosteoporosisorEndocrine disorder, as well as heart, lung, liverrenal functionIt is not only closely related to the determination of some fractures, but also often affects the selection of treatment methods andprognosis。[1]
2. Symptoms of fracture
(1) Pain: severe pain occurs in the fracture area, especially in the affected limb during exercise, with obvious tenderness. In addition, local swelling and pain can make the affected limbRestricted activity。
(2) Shock: the patient suffered from massive bleeding (the amount of bleeding can reach more than 2000ml), severe pain or complicationsVisceral injuryCauses shock.
(3) Elevated body temperature: generally, the body temperature is normal after fracture. When there is a fracture sitehematomaDuring absorption, the body temperature can rise slightly, usually not more than 38 ℃.Open fractureThe main cause of the patient's temperature rise is infection.
(4) Accompanying injury: those with complicated injury mechanism or multiple injuries in the whole body are prone to injury in other parts.Other tissues can also be injured from the fracture end, and corresponding symptoms appear. The examination should be comprehensive to prevent missed diagnosis.
(1) Deformities: due to external forcetendonThe effects of traction and limb gravity can cause various deformities at the fracture endDegree of damageIt is also closely related to the gravity of the fracture end and the direction of contraction of nearby muscles.
（2）Bone fricativeorBone rubbing sensation: When two fracture segments rub against each other, bone fricative sounds or bone fricative feelings may occur.This sign should not be checked actively to avoid increasing pain andtissue damage 。
(3) Abnormal activity: it can occur in the parts of the limbs without jointsPseudarthrosis activity。[1]
If one of the above three signs is found, the diagnosis can be made.But when these three signs are not seen, there may also be fractures, such as impactionFissure fractureEtc.Attention should be paid to the patient during the initial examination, and repeated examinations should not be carried out on purpose to avoid aggravating the damage of surrounding tissues, especially important blood vesselsNerve injury。[1]
4. Other manifestations of fracture
(1) Localtenderness: Local tenderness can be found at the fracture, squeezing from a distance to the fracture, and indirect tenderness can also be found at the fracture, which can be used to diagnose deep fracture and its location.for examplePelvic fractureWhen pressing the two iliac bone wings gently with both hands, it can cause pain at the fracture.
(2) Local swelling andecchymosis: When the fracture occurs, the blood vessel at the injured part ruptures and bleeds,soft tissueEdema occurs due to injury, and the affected limb is significantly swollen.The skin may brighten and produce tension blisters.Can be obstructed in serious casesVenous reflux, increase the pressure in the bone fascia chamber, and even block the arteriesblood circulation, occursIschemic contracture。The fracture at the superficial part, due to the superficial hematoma,hemoglobinAfter decomposition, it can become purple, cyan or yellow subcutaneous ecchymosis.
（3）dysfunction: Fracture causes fracture and pain of the internal support of the limb, which causes the limb to lose part or all of its movement function.
(4) Percussion pain: For deep fractures, it is difficult to check tenderness. Percussion pain can be used as a substituteFemoral neckThe discovery of intra-articular fractures such as intercalated fractures and scaphoid fractures is of great value.[1]
5. Neurological and vascular examination
(1) Nerve injury: no matter the spine or limb fracture, the movement andSensory functionCheck to determine whether there is nerve damage and the extent and scope of damage.ClinicallyFracture of humeral shaftafterRadial nerveAttention should be paid to the more opportunities involved.[1]
Generally, there is no special change, but after 24 hours, it may occur depending on the degree of fractureWhite blood cell countIncrease or slightly increase;Blood cell sedimentation rateIt can also be slightly raised.[1]
7. Imaging examination
(1) NormalX-ray filmCheck:X-ray photographyThe examination can show the problems that are difficult to find in clinical examination, such as incomplete fracture, deep fracture, small pieceAvulsion fractureOr oblique fracture fracture dislocation, etc.Even those who have clinically manifested obvious fractures, X-ray examination is also necessary, which can help understand the type of fractures and the displacement of fracture segments, and has important guiding significance for the treatment of fractures.The majority of fractures can be diagnosed by X-ray photography, and it is the main basis for classification and selection of treatment methods.However, attention shall be paid to:
1) Projection position: at least including the positive position (front and rear position) andLateral positionTwo directions, left and right still need to be photographed for individual casesOblique positionorTangent bit。
2) Radiography scope: the projection scope of long bone injury of limbs shall at least include one adjacent joint;For pelvic injuries, large negative films shall be used to show the whole pelvis and both sides at the same timeSacroiliac joint、hip jointAnd take oblique films of bilateral sacroiliac joints as appropriate;For spinal injury, tenderness and percussion pain should be taken as the center, with 4~6 vertebral segments in the upper and lower parts respectively. At the same time, attention should be paid to multiple segmental injuries far away.
3) Photographydefinition: The boundary between muscle and bone tissue can be distinguished, and joints can be displayed as far as possibleCyst wallShadows are used to judge or infer intra-articular fractures.
4) Contrast photography: when it is difficult to determine the injury or the child's joint injury (such asepiphysisX ray films of the corresponding parts of the opposite limb shall be taken for comparison in order to facilitate the determination.
5) Photography skills: special photography is available for special parts, such as the opening position of the odontoid process and the lateral position of the lower cervical spinetechnical requirementPay attention to careful operation.
6) Follow up photography: For fractures that are difficult to show the fracture line in the initial photography, in addition to changing the angle of repeated photography, it can also be photographed again in a short time.At this time, the bone at the edge of the fracture end is absorbed and the fracture line is easily displayed.
7) X-ray fluoroscopy: at present, it is only used for reduction and fixation during operation, and protection work should be done well.[1]
(2) Fault photography:CT technologyAfter popularization, it has been used less.[1]
（3）CT examination: For intra-articular fractures, complex fractures (such as pelvisAcetabular fracture）And so on.CT or CT reconstruction can accurately determine the size and number of fracture blocks, and the degree of injury and collapse of the joint surface, which is the basis for preoperative planningOperative approachFor reference.At present, routine CT examination and three-dimensional reconstruction before joint fracture surgery have been widely considered as the standard process.Generally, CT examination should includeAxial positionPlain scan, at least including coronal andsagittal The reconstruction of multi-layered reconstruction and three-dimensional reconstruction.[1]
(5) Angiography: such asMyelography, intra-articular angiography and angiography are seldom used at present.[1]
first aid
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Fractures are usually seriousMultiple injuriesPart of.Therefore, on-site first aid should not only pay attention to the treatment of fractures, but also to the treatment of the whole body. Its purpose is to save lives, protect the affected limbs and transport them quickly in the simplest and most effective way so that they can be properly treated as soon as possible.[1]
1. Rescue shock
First, check the patient's general condition. If the patient is in shock, pay attention to heat preservation and minimize moving. If possible, transfusion and blood transfusion should be carried out immediately.mergecraniocerebral injury People in coma should pay attention to keepingrespiratory tractunobstructed.[1]
2. bandage the wound
For open fracture and wound bleeding, most of them can be stopped by pressure bandage.Large blood vesselWhen bleeding and pressure bandage cannot stop bleeding, it can be usedtourniquetStop bleeding.Best useInflatable tourniquetAnd the pressure and time used shall be recorded.Wound usesterileDressing or cleaning cloth shall be bound to reduce re pollution.If the fracture end has poked out the wound and has been contaminated, and it also compresses important blood vessels and nerves, it should not be reset to avoid bringing the dirt to the depth of the wound.They should be sent to the hospital for debridement and then reset.If the fracture end slides into the wound by itself during dressing, a record should be made for further treatment during debridement.[1]
3. Properly fixed
Fixed YesFirst aid for fractureImportant measures.Any suspected fracture shall be treated as fracture.In case of closed fracture, it is not necessary to take off the clothes, pants, shoes and socks of the affected limb during emergency treatment to avoid excessive moving of the affected limb and increasing pain.If the affected limb is severely swollen, use scissors to cut the affected limbSleevesandbottom of a trouser legCut it to reduce pressure.When the fracture has obvious deformity, and there is a risk of penetrating soft tissue or damaging important blood vessels and nerves nearby, the affected limb can be properly pulled to straighten it before fixation.[1]
The purpose of fracture emergency fixation: ① to avoid damage to important surrounding tissues, such as blood vessels, nerves and viscera during the handling of the fracture end; ②Reduce the movement of the fracture end and relieve the pain of the patient; ③Easy to transport.Special plywood or wood, sticks and branches can be used for fixing.If there is no available material,Fracture of upper limbThe affected limb can be fixed on the chest, and the lower limb fracture can be bound and fixed with the opposite healthy limb.[1]
4. Rapid transfer
After initial treatment and proper fixation, patients should be transferred to the nearest hospital for treatment as soon as possible.[1]
treatment
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The typical manifestation of fracture patients is local deformation after injury, abnormal movement of limbs, etc., which can be heard when moving limbsBone fricative。In addition, the wound is extremely painful, local swellingCongestion, appears after injuryDyskinesia。
The ultimate goal of fracture treatment is to maximize the recovery of injured limbs.Therefore, in the treatment of fracture, its reduction, fixationFunctional exerciseThese threebasic principleVery important.
1. Reset
It is to restore the displaced fracture end to normal or close to the original anatomical relationship to restore the boneSupport function。The methods of reduction include closed reduction and surgical reduction.
2. Fixing
After fracture reduction, due to instability, it is easy to move again. Therefore, different methods should be used to fix the fracture in a satisfactory position to gradually heal it.frequently-usedFixing methodyes:Small splint、Plaster bandage、External fixationSupport, traction braking fixation, etc. These fixation methods are called external fixation.If the plate, steel needle, intramedullary needleScrewFixation by nailsInternal fixation。
3. Functional exercise
Through injured limbsMuscle contraction, increase theblood circulation, promoteFracture healing, preventMuscular atrophy, prevent joint adhesion, joint capsule contracture, etc. by actively or passively moving the unfixed joint, so as to restore the function of the injured limb to that before the fracture as soon as possibleNormal state。
