Traumatology - Fractures and Dislocations

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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
generalreaction of organism (B.I. Dmitriev).
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 (manufacturaland 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 of
provoked the damage agent.
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 promoted to developmental of early and later complications. There are
also distinguished the penetrating damages, in the presence of which the interna: organs (of abdomen, of thorax, of
skull, of joints) can be affected,and unpenetrating.
In case of damages of tissue 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.
Trauma is homogenous in those cases, if it provoked by only one factor. If the trauma is sipulated by several
factors, for example, mechanic trauma with a burn, it named the combined trauma. While the single-moment lesion of
various systems (for example,the contussion of the brain and fracture of skin bones) the conjuncted trauma are named.
Traumas can be direct and undirect (damages developing in the distance from the region of provoking agent
influence).
The single and also plurality traumas (polytraumas) are possible. Usually the traumas are acute, however,it can
tell about chronicaltraumas,which are provoked in some i cases by professional harmfulnesses.
Peculiarities of investigations of traumatological patients
Symptomatics of patient with serious traumas is developed very quickly, state often serious,often it is
necessary forsurgeon to orientate quickly,be able to specify the diagnosis and render first help. Some circumstances
require the especialattention in the gathering of anamnesis and objective investigation of traumatological patient in
contrast of surgical patient.
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,the diagnostic of
plurality traumas is especially hard in patients, which are unconscious, in a state of serious shock or alcoholic
intoxication.
Thirdly, the serious general phenomena (shock,acute anemia, traumatic toxicosis) can to conceal traumas. It is
necessary to estimate them rightly and render the proper help.
In the cases of serious traumas, when the life of patient is under the threat,at first it is necessary to render the
urgent help and then to proceed, gathering of anamnesis and carrying out of more total investigation of patient.
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.
It is necessary to examine the place of damage that is far specification of diagnosis and to represent the

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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.
Closed damages of 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.
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 ofa 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 acts (skin, muscles, fat,and bones).
Clinical picture - characterized by appearance of pains, swelling, and 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 (contusion of great nerves) ofa region, which innervated by contusioned nerve, by contusion of joint
breach of its function, by contusion of thorax and lung - subcutaneous emphysema.
Treatment.The main task of treatmentat first period aftercontusion is stopping of hemorrhage in tissues,which
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 - it sucking off and
antibiotics is introduction in the plevral cavity.
Tensions (distorsio) and ruptures (ruptura)
Tensions is damage of soft tissues, which is provoked by the force acting like a traction and nor breaching the
continuity of tissues. However, if the acting force exceed the resist-ibility of tissues by such mechanism of trauma,then the
rupture of ligaments,fascias,muscles,tendons, nerves etc. Clinically the rupture of ligaments isaccompanied by appearance
of strong pain, breach of motions, haemorrhages in soft tissues, oedema and 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 and prolonged immobilization of a
joint. After resolution of haemorrhage with third week, it is passed to the careful active movements, massage, and
medical physical training. The punctions and introduction of antibiotics make by delated resolution.
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 is 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 pain, haemorrhages, oedema, limits in motion are
manifested clinically.
Treatment. In case of uncomplete rupture are immobilization, rest, cold, then the warmth, physioprocedures.
In case of complete rupture is 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 leads to the morphological
changes in muscles, nerves,bones, which are expressed in a development of sclerotic processes, pain, limit of capacity
for work (vibrational disease).
Squeeze - is observed by squeeze of lifry important organs (heart, brain, lungs).

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Traumatic toxicosis (crush syndrome) It is especial type of damages representing the distinctive syndrome,
which is observed by prolonged squeeze, pressure of wide parts of soft tissues, more often of extremities, with the
following general and local phenomena. It is happened by the landslides, earthquakes, bombardments, railway
catastrophes; syndrome is appeared after the removal of the squeezing heavinesses. Detailed description of this
syndrome is made by A. J. Pytel(1841), N. N. Elanin (1950).
Extremity, which liberated from squeeze,is pale,with a cyanosed spots.Pulse on it is not felt, sensitivity loosed,
the movements is impossible. The clinical picture of serious shock with a breach of functions - agitation, fear, anxiety,
and then, apathy, and sleepiness - is developed through the 3-5 hours. Disorder of hemodynamics, plasmorhea and
toxical damage of the liver and kidneys are present. Degenerative changes in kidneys and liver are developed in the
serious cases - oliguria, hematuria, albumen, and cylinders in a urine, anuria, and uremia. Oedema of the brain, lungs
are present. Extremity is sharply swollen on 3-5 day, become compact,and paralyses are developed. There are serious
degenerative changes in kidneys and liver, oedema of the brain, lungs and others are observed after death by the
post-mortem examination.
Fractures ofbones 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 representsa disruption in the continuity of a bone,it also represents a major
soft tissue injury. Incase of fracture the surgeon must be aware of the soft tissue structuresadjacent 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 injures in other tissue
systems.
Classification of fractures
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 (see appendix 14).
Intrauterine fracturesare registered rarely: there are developed in connection with inferiority,fragility of bones
of a fetus.
Acquired are the fractures, which provoked by outwards violence, contraction of muscles or in connection
with pathological process in the osseous tissue.
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 are intact. Clased fracture is the barrier for the penetration of
infection. 1. Traumatic fractures are happen asa result of influence of mechanic force. They divide by a mechanism of
force action on the fractures as a result of direct blow, squeeze,bending, twisting and tearing off of a bone.
By the direct blow - is transversalfracture,fracture with a dislocation of peripheralosseous 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 by 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:
• epiphysial fractures are unfavourable for the processes of consolidation and quite often accompanied by
dislocation of osseous piece of a joint, which is hamper the comparison and fixation of osseous parts.

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• 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.
• diaphyseal - the important symptoms of a fracture (crepitation, abnormal mobility and others) are present
quite often.
3. The fractures are divided on transversal, oblique, longitudinal, spiral, splintered.
4. There are total and incomplete fractures.
5. There are simple, complex and combined fractures.
6. There are single and plural fractures.
Morphological changes in various dates after the fracture
Formation ofa 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 inflam-
mation;
b) period of osteogenesis;
c) period of reconstruction of a callus.
A callus is formed by the way of reproduction of the periostealcells, cells of bone marrow,Haversions canals,
and connective tissue. Each of these sources of osteogenesis is lead to development of special layer of a callus.
Callus consists of some layers: periosteal, outwards callus is developed from the cells of periosteum
enveloping the ends of bones from the outside as a muff.
The proliferation of cells is started from the side ofa cambial layer of periosteum on the place of fracture from
the 2nd day, large quantity of embryonal cells. Young forming again vessels and osteoblasts are to the 3-4 day. These
osteoblasts are main cells, which formed the new osseous tissue.
Osteogenesis can go on two ways: by the way of immediate development of a callus from osteoid tissue or by
the way of preliminary formation of cartilage. The more perfectreposition of osseous fragmentsand immobilization of
damaged extremity the more facts for the development of a callus without formation of cartilage.
Endostal or internal layer of a callus is developed from the cells of endosteum, bone marrow of peripheraland
central osseous fragments. Young cells, which fell the defect between osseous fragments, are merget in a united
endostal layer of a callus.
Intermediary or interventing layer of a callus is developed from the cellular elements of Haversian canals of
osseous fragments and occupy, the interval between periostal and endostal layers. The better reposition, i. e. the more
compactly osseous fragments adjoin one to another (B.I.Dmitriev).
Periostallayer of a callus is developed from the tissues,which surrounded the place of fracture.
As result, 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.
The dates of a union (consolidation) are different by the fractures.
Formation of a primary callus, i. e. the cohesionness of osseous fragments by osteoid tissue, is happening during
4-5 weeks. Then the sediment ofa lime is take place, i.e. (the process of ossification,formation ofsecondarycallus,which is
continued during 5-6 weeks.
The process of architectural reconstruction of a callus is started simultaneously with osteogenesis and
sediment of calcium salts in the osteoid tissue. Osteoclasts are resolved the ends of osseous fragments, splinters,
abundance of a callus.
Architectonical reconstruction is very prolonged process, which can continued some years.
Regeneration of the bone depends on:
1. Character and force of traumatic agent, serious trauma makes the less favourable conditions for
consolidation.

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2. Anatomy-physiological state. Different bones have various abilities to union. Bones
are united quicker in 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.
Clinic of fractures
It is very various by the fractures and not always expressed well. Basic symptoms of fracture are:
1. Pain - is observed at once after the fracture; it abates 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 alwaystypicalsymptom offracture.It is typical,for example,
for the fracture oflower extremity when a patient does notstay on the legsaftertrauma.
3. Sometimes the deformation is acutely expressed on the place of fracture, and sometimes expressed
little and can be recognized only on R-gramm.
There are some types of displacement:
a) Displacement under the angle, when the axis of osseous fragments formed the angle of the place of
fracture. Angle depends 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. Crepitation 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 moved in a opposite
side.
Principles of treatment, reposition and immobilization (see appendix 15)
The basic problem of treatment of fractures is a restoration of anatomical integrity of a damaged extremity and
physiological function of the damaged organ.
As far back as 2000 yearsago Hippocrates' used the reposition and immovable splint bandages. The main aim
was the anatomical restoration of integrity of the bone by the treatment of fractures. N. I. Pirogov widely used the
gypsous bandages for the treatment of fractures in 50th
years of last century. However the study of results of gypseous
bandages use shown, that prolonged preting of the bones, not always lead to the restoration of function of suffered
extremity: atrophy of muscles, hard -mobility, immobility of joints are remained.
Berdengeer proposed the treatment of fractures by drawing out in 1880.
Russian scientist K. F. Vegner elaborated the original method of treatment by drawing out with the help of
adhesive plaster.
Modern treatment of fractures directat restoration ofanatomicalstructure and physiologicalstructure ofa 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 till 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 generalstate of a patient (nourishment, vitaminization, blood transfusion).
Reposition. Setting of osseous fragments must be made at once after the fracture till the development of a

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traumatic oedema and reflectory contracture of vuscles. Osseous fragments must be compared exactly.
Success of the reposition depends 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 osseous fragments - the peripherial fragment is placed to the central;
e)use of arm methods for reposition and different apparatuses (Sokolovsky',cug-apparatus and others)
Fixation or immobilization of osseous fragments in a right posture can be practicable by different methods:
a) plaster bandage;
b) drawing out;
c) operation.
Plaster bandages: circulary, longetic, longetic-circulary, fenestrated, bridge-like, folding, and gypseous
bedstead.
Plaster is a calcium sulphate like a small powder. It is able to harden, when connecting with water. Became
damp gypsym loss this ability, so it is necessary to keep the dry powder of gypsum in a dry place after the tempering to
120-130°.
The splint-plaster bandage is for setting of bone fragments,wooden or wire splints into a plaster bandage. Plaster
bandages are applied in a physiologically advantageous posture, that is important in a case of development of ankylosis or
hard - mobility of joints. The modelling is made by contours of extremity by palm stroking by the application of plaster
bandages. The edges are cliped carefully after application of bandage that they should not provoke the pressure. The
bandage, which made from well plaster, is dry out during the 10-15 minutes. Patient is needed in observation after
application of plaster bandage: the pressure can lead to the breach of blood circulation along all extremity, breach or
nourishment, necrosis.It is necessary to remember:to cut the bandage if the squeeze is observed.
Plaster of Paris bandages, which are 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 toavoid the secondary displacement. Gypseous bandage immobilize the extremity on date,which is
necessary for consolidation.
Method of drawing out - widely used for treatment of fractures, because it allows keeping the relative
immobility of joints and function of muscles by the securing of immobility of osseous fragments. The extremity doesn't
squeezed by bandage and blood circulation doesn't breached, that is hasten the formation of a callus, prevent the
atrophies, bedsores etc. All extremity is accessile examination and observation to the doctor in charge of the case, and
movement is started from the lust days of treatment.
Inconveniences of the method: it demands the maintenance patient on the bed, hamper the roentgenological
control.
Method is realized by application of adhesive plaster or skeletal drawing out.
Technique of the adhesive plaster drawing out When wiping dry the skin of damaged extremity by the spirit, the
lateral surfaces are smeared by a cleol and the sticking plaster or pieces of a flannel 6-8 cm wide are glued to them, then
they are threw over the joint like a loop and glued to the outwardsurface,change the dressing on is after that. The suffered
extremity is packing up on the splint (Beler's etc.). The cord,which is threw over the blocks of splint and the necessive
weight is suspensed to it, is fastened to the loop of adhesive plaster in a plywood distance piece. Splint is setted in such
posture that peripherialosseous fragment should localized by the direction of axis of centralfragment.
It is necessary to take into account the following peculiarities by the application of a sticking plaster drawing
out:
a) it must be used at the first hours after the fracture till the appearance of muscular retraction and traumatic
oedema;
b) stripes of adhesive plaster are fastened to all segment of extremity independently of level of fracture, that is
secure the even relaxation of muscles;

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c) the joints are remained mobile, that is make possible the early movement, beginning from 2-3 day. Skeletal
drawing out (fig. 1) is realized from the bone by the way of puting of metallic spoke through it or retention of the bone
by crampon. This method allows applying the significant weights (till 16 kg) for the stretching of muscles and
comparison of fragments, taking the spokes through the condyles or tuberosity of a shinbone.
Fig. 1. Sceletal traction in femur (a) and shin (b) fractures.
Operative method is allowed to realize the reposition and fixation of osseous fragments. The assistant stretches
the peripherial part of extremity for reposition and simultaneously the surgeon carry out the comparison of osseous
fragments.
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 Are fat embolism,pulmonary embolism, pneumonia, tetanus and 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 Are renalcalculi, accident neurosis.
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 partialcontiguity -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.
Pathological picture - the rupture of articulate capsule,rupture of a ligamentalapparatus,tendons, nerves and
large vessels is observed.
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 become stronger by movement. Numbness of extremity
is by squeeze of a nerve. Deformation in a joint is present.
X-ray film is confirming the diagnosis of a dislocation.
Treatment: urgent qualified aid. First aid are - transport splint or fixing bandage and analgetics. Immediate
transportation in a hospital is needed. Setting is carried out easierand results are better,if it is realized at first hours after

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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 totalanaesthetization. Use of rough, physical
force is result in the complementary damages of capsule of a joint and development of recidivations of dislocation
(habitualdislocation), which are more often metin a shoulder and maxillotemporaljoint.
There are some methods used ofsetting 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 (B.I.Dmitriev).
Kocher's method - consist of 4th stages (fig. 2):
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.
Pathological dislocations are result of destructive pathological processes, which lead to the destruction of
capsule and ligaments (tumour etc.)
Fig. 2. Reducing humeral dislocation by Kocher's method:
a) crooking in the elbow joint with a putting of shoulder to the trunk;
b) Traction downward 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 supershoulder.