Closed Fracture

These are that i want to review about closed fracture that i got from some sources which is written below.

Introduction

• Fracture, the breaking of a part, especially a bone. A break or rupture in a bone.
• A closed fracture is a fracture that does not produce an open wound in the skin.
• A closed fracture occurs when there is bone breakage but no break in the skin. typically bruising and swelling are present at the fracture site.
• A closed fracture is when the bone breaks but there is no puncture or open wound in the skin.
• Called also simple fracture

 Epidemiology

• Almost all fractures are osteoporotic, in that the risk of fracture increases as bone density decreased.
• Women have a higher risk of fractures than men.
• About 1.5 million osteopororsis-related fractures occur each year. 700,000 vertebral fractures ( U.S)
• In a two-year preiod, 15,293 adults, 7428 males and 7865 females, sustained a fracture.
• Betweem 15-49 years old, males were 2.9 times more likley to sustain a fracture than females (95% CI 2.7 to 3.1)
• Over the age of 60 years, females were 2.3 times more likely to sustain a fracture than males (95% CI 2.1 to 2.4)

Etiology

• A closed fracture is usually caused by an injury to the bone as the result of a fall, accident, or other trauma. Disorders that weaken the bones in the body, such as osteoporosis and cancer, put some people at higher risk for injury.

Mechanisme

• Injury
• Most fractures are caused by sudden and excessive force, which may be direct or indirect.
• With a direct force the bone breaks at the point of impact;  the soft tissues also must be damaged.
• Direct force may be : (1) tapping, which causes a tranverse fracture; or (2) Crushing, which causes a comminuted fracture often with extensive soft-tissue damage.
• With an indirect force the bone breaks at a fistance from where the force is applied;soft tissue damage at the fracture site is not inevitavle.
• An indirect force may be ; (1) Twisting cause a spiral fracture; (2) Compression causes a short oblique fracture; (3) Bending results in fracture with a triangular 'butterfly' fragment; (4) Tension tends to break the bone transverly.

• Fatigue or Stress Fracture
• These fractures occur in normal bone which is subject to repeated heavy loading.
• These high loads create minute deformations that initiate the normal process of remodelling.
• When exposure to stress and deformation is repeated and  prolonged, resorption occurs faster than replacement and leaves the area liable to fracture.
• Stress fractures are increasingly seen in patients with chronic inflammatory disease who are on treatment with streoids or methotrexate.

• Pathological Fractures
• Fractures may occur even with normal stresses if the bone has been weakend by :
• A change in its structure (e.g in osteoporosis, osteogenesis imperfecta or Paget's disease) or
• Through a lytic lesion (e.g A bone cyst or a metastasis)

Classification of Closed Injuries

• Grade 0
• A simple fracture with little or no soft tissue injury
• Grade 1
• A fracture with superficial abrasion or bruising of the skin and subcutaneous tissue
• Grade 2
• A more severe fracture with deep soft tissue contusion and swelling
• Grade 3
• A severe injury with marked soft tissue damage and a threatened compartment syndrome

Clinical Features

• History
• There is usually a history of injury but the fracture is not always at the site of the injury.
• The patient's age and mechanism of injury are important
• Always enquire about symptoms of associated injuries :
• Pain and swelling elsewhere, numbness or loss of movement, skin pallor or cyanosis, blood in the urine, abdominal pain, difficulty with breathing or transient loss of consiciousness.
• It's important, in preparation for anaesthesia or operation.

• General Signs
• Follow the ABCs 
• Look for, and if necessary attend to, Airway obstruction, Breathing problems, Circulatory problems and Cervical spine injury.
• During the secondary survey it will also be necessary to exclude other previously unsuspected injuries and to be alert to any possible predisposing cause

• Local Signs
• Look
• Swelling, bruising and deformity may be obvious, but the skin is not intact.
• Feel
• Gently palpated for localized tenderness.
• The common and characteristic associated injuries should also be felt for, even if the patient doesn't complain of them.
• Vascular and peripheral nerve abnormalitis shoud be tested for both before and after treatment.
• Move
• Crepitus and abnormal movement may be present.

• X-Ray : Rule of Two
• Two views
• A fracture or a dislocation may not be seen on a single X-ray film, at least two views (Anteroposterior & Lateral) must be taken.
• Two joints
• However, is impossible unless the other bone is also broken, or a joint dislocated. The joint above and below the fracture must both the included on the X-ray films.
• Two limbs
• X-ray of the uninjured limb are needed for comparison.
• Two injuries
• Severe force often causes injuries at more than one level.
• Two occasions
• Some fractures are notoriously difficult to detect soon after injury, but another X-ray examination a week or two later may show the lesion.

Treatment

• Consist of manipulation to improve the position of the fragments, followed by splintage to hold them together until they unite; meanwhile joint movement and function must be preserved. Fracture healing is promoted by physiological loading of the bone, so muscle activity and early weighbearing are encouraged.
• These objective are covered by three simple injunction :

A. Reduction

• There are some situations in which reduction is unnecessary : (1) When there is little or no displacement; (2) when displaccement does not matter initially (e.g In fractures of the clavicle) and; (3) when reduction is unlikely to succed (e.g with compression fractures of the vertebrae)
• There are two methods of reduction
• Closed Reduction
• Three-fold manoeuvre : (1) The distal part of the limb is pulled in the line of the bone; (2) As the fragments disengage, they are repositioned (by reversing the original direction of force if this can be deduced) and; (3) Alignment is adjusted in each plane.
• Used for all minimally displaced fractures.
• This avoids direct manipulation of the fracture site by open reduction, which damages the local blood supply and may lead to slower healing times

• Open Reduction
• Indicated : (1) When closed reduction fails, either because of difficulty in controlling the fragments or because of difficulty in controlling the fragments or because soft tissues are interposed between them; (2) When there is a large articular fragment that needs accurate positioning or; (3) For traction (avulsion) fractures in which the fragments are held apart.

B. Hold Reduction

Methods :

• Continuous Traction
• Traction is applied to the distal to the fracture.
• Useful for shaft fractures that are oblique or spiral and easly displaced by msucle contraction.
• Methods

• Traction by gravity
• Skin traction
• Skeletal traction
• Fixed traction
• Balanced traction
• Combined traction

• Cast Splintage

• Plaster is still widely used as a splint, especially for distal limb fractures and for most children's fractures.
• But, joints encased in plaster cannot move and are liable to stiffen.

• Functional Bracing
• Using either plaster or one of the lighter thermoplastic materials, to preventing joint stiffness.
• Applied only over the shafts of the bones, leaving the joints free;the cast segments are connected by metal or plastic hinges that allow movement in one plane.
• Used most widely for fractures of the femur or tibia.
• The fracture can be held reasonably well;the joints can be moved; the fracture joints at normal speed; without keeping the patient in hospital and the method is safe.

• Internal Fixation
• Bone fragments may be fixed with screws, a metal plate held by screws.
• Indication
• Fractures that cannot be reduced except by operation
• Fractures that are inherently unstable and prone to redisplace after reduction
• Fractures that unite poorly and slowly
• Pathological fractures
• Multiple fracture.

• External Fixation
• A fracture may be held by transfixing screws or tensioned wires that pass throug the bone above and below the fractures and are attached to an external frame.
• Indication
• Fractures associated with severe soft-tissue damage.
• The soft tissues are too swollen to allow safe surgery.
• Patients with severe multiple injuries, especially if there are bilateral femoral fractures.
• Ununited fractures,
• Infected fractures.

C. Exercise

• More correctly, restore function -not only to the injured parts but also to the patient as a whole.
• Prevention of oedema.
• Elevation.
• Active exercise.
• Assisted movement
• Functional activity.

References 

• Apley's System of Orthopaedics and Fractures, Ninth Edition.
• Textbook of Disorder and Injuries of The Musculoskeletal System, R.B. Salter.
• Emedicine.medscape
• Nlm.nih.go
• Web.md
• Illustrated Medical Dictionary, Dorland

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