Fracture

Diagnosis

The first elements being able to make think of a fracture are:

the mechanism : shock, falls;
the Pain , abruptly appeared and located;
the functional impotence : it is painful or impossible to carry out certain movements;
the deformation : formation of a edema (swelling), angulation of the member (fracture with displacement), depression.

But these signs are not specific and can also indicate an articular problem (distorsion, Luxation). Contrary, certain fractures present Symptôme S attenuated, such as for example the fracture of the child called in “green heart”, or a crack.

The only examination which can indicate without ambiguity if there is fracture or not is the Radiographie.

Types of fractures

closed fracture: the osseous fragments do not bore the skin.

open fracture: the osseous fragments bore the skin.

comminutive fracture: Fracture which includes/understands several intermediate fragments escaping description.

green heart fracture (only in the children): a face of the bone is presented in broken plate and the other face of the bone is curved.

the Fracture of tiredness: by repeated microtraumatism (described at the young recruits of the quota at the beginning of the XX° century, can see itself also in certain sportsmen in particular in the basketball players and the runners has feet, and in all the situations of mechanical stress without sufficient preliminary drive).

pathological fracture: had with the embrittlement of the bone caused by cancer (Néoplasie), Osteoporosis, Osteomalacia.

Mechanism

direct Shock : the part of the body receives a shock and breaks;
indirect Shock : part of the body receives a shock, the shock wave is propagated in the bones and another distant part, but more fragile rompt.
For example, a person falls and is received on the hand, but breaks the elbow;
Inflection : the bone is requested in inflection;
Torsion : the bone is requested in torsion;
Small repeated traumatisms : fracture known as “of tiredness”;
Disease : certain diseases will facilitate the fracture, this one will occur for nontraumatic situations at the healthy people: Cancer of the bones, Demineralization (Osteoporosis, Osteomalacia), Ostéogénose imperfect (Disease of the bones of glass)

Consequences

Except near a vital body or in the event of opened fracture, the rupture of a Os is often not always in itself dangerous;
Le danger comes:

of functional impotence, in particular related to the Pain (state of shock, fainding.) who can prevent from fleeing a Danger, to nourish itself (nobody isolated and without means of preventing the helps);
of possible damage caused by the displacement of the fractured bones or of esquille osseous (Neurological S, vascular S, cutaneous S (open fracture)).
and in certain cases of a “induced lead poisoning” or “secondary” . Indeed, any fracture involves in physiological answer a release (fast, normal and important) of calcium in blood. This calcium is taken in the bones. However it is in these same bones as 80% to approximately 95% of the lead absorptive by the patient (human), or the neat animal was stored in the previous years and decades (the cycle of lead or average time of stay of lead in the bone is estimated to be 20 years at the man). This explains, why at an individual not presenting abnormal plombemy before the fracture or at the time of the fracture, but having stored lead in the bones before, a Saturnisme can be induced by the release of a significant quantity of lead “osseous” in blood. This type of lead poisoning has very little chance to be detected if the doctor were not alerted on this risk by the patient (who often of it is not conscious). The symptoms are put on the account of the state of shock or of the Traumatisme related to the accident.
Si the patient is an expectant mother or nursing, this lead can poison the fetus respectively or the embryo and the baby allaité.
Si it or the patient are a person preparing to have children, he is possible that this lead can cause provisional infertility (lead is indeed known as being Reprotoxique at the man, at least as a factor of délétion of the Spermatogenèse, and its effects on the female fertility seem not to be very studied).

These 3 factors can be sources of after-effects in the medium and long term. Progress of the emergency Medicine, the Radiology and the treatment - possibly surgical - invoices, just as those of functional rehabilitation (Kinesitherapy), makes that the after-effects are increasingly rare.

Particular cases

Cranial traumatism

In the case of a cranial Traumatism, the rupture of the bone is not in oneself problematic, it is the neurological attack which it is necessary to fear.

Indeed, the shock with the head can cause a violent inflection of the neck and thus a traumatism of the cervical ones. In addition, it can occur an attack of the Cerveau even in the absence of fracture. It is in particular necessary to fear the formation of a Hématome which can compress part of the brain.

That can be revealed by the neurological examination:

turbid of the conscience, the behavior;
turbid of the mobility or the motricity of the ends, fingers and toes: feeling of swarmings, insensitivity, impossibility of moving;
anomaly of the pupillary reflexes, and in particular dissymmetry of the pupils (, the other is dilated contracted).

Thoracic traumatism

The fracture of one or more coasts makes breathing painful, difficult. It can involve an attack of the Poumon S, and in particular a Hémothorax (the lung fills of blood) or a Pneumothorax (the lung has a “escape of air” and cannot play any more its part), which can bring into play the vital prognosis.

In addition to the pain and the breathing difficulty, one can have:

of spittles of Blood, with a quite red blood and containing bubbles;
a “costal shutter”: part of the chest moves with misconception of breathing: it drops to the inspiration and rises with the expiry.

Fracture clavicle

Traumatism of the basin

One of the risks of the fracture of the basin is the section of the Urètre. Among the characteristic signs, one can avoir :

a loss of urine (wet clothing), but which can also be due to the Stress or has a loss of conscience ;
a pain when one exerts a careful pressure on the iliaques wings (sides of the basin).

However, the principal risk is hemorrhagic, the basin being a spongy bone good vascularized and surrounded by soft fabrics which do not oppose practically any resistance to the formation of a hématome. The heavy bleeding can reach 2 liters, which can cause serious complications (shock hypovolemic).

Traumatism of the spinal column

The Spinal column is the place where forwards the Spinal-cord, which are part of the central Nervous system, and the roots nervous, which belong to the peripheral Nervous system. A traumatism of the Spinal column can endanger these structures and thus cause a deterioration of the sensitivity (fourmillements : Paraesthesia S, absence of sensation : Anesthesia, reduction in feeling: hypoesthesy) or of the motricity (Paralysie), which can be irreversible. In the actual position of medical knowledge, one cannot repair the neurological lesions on this level.

In certain cases, the traumatism did not cause a lesion of the spinal-cord, but it returns the spinal column instable : in the event of movement, there can be creation of a neurological lesion and thus of disorders of motricity or sensitivity.

Lower extremity

Fracture of the collar of the femur
Fracture of the tibia
Fracture doubles

In the child

The fractures in the child are characterized by the existence from the Cartilage from growth and by the Périoste which is a very resistant structure. The traumatisms interesting the cartilage of growth are called: separation épiphysaire, classified in 5 types according to the classification of SALTER-HARRIS:

Standard I: pure separation
Standard II: separation associated with a Standard fracture métaphysaire
III: separation associated with a Standard fracture épiphysaire
IV: separation associated with a fracture épiphyso-métaphysaire
Standard V: compressing of the marital plate

OGDEN added other types to the classification of SALTER-HARRIS

Type VI: fracture peripheral compared to the ring périchondrale (conjunctive sheath which

surround the cartilage of growth)

Type VII: who carries a fragment épiphysaire

Types V-VI-VII are very frequent in the sportsmen

Care

The fracture is a traumatism having to be dealt with by doctor.

Before the arrival of the helps

The principal risk is to move the victime : that is likely to make move the fracture, and thus to cause or worsen an internal wound. The victim thus should be left on the spot (except need for a emergency Dégagement), to recommend to him not to move and to prohibit another person making it from move.

If the person complains about pains to the back or the neck,
or if it presents a wound or a depression on the head, or that it adopts an incoherent attitude (changing mood, difficulty of locating themselves, of speaking, loss of memory, somnolence),
or if it presents a bleeding of the nose or ears,
or if it made a fall great height or that it was reversed by a vehicle,

one will always suspect an attack of the cervical vertebrae (cou). It is necessary then, while waiting for the helps, to carry out a Maintien of head : one places oneself at knees in the axis of the body, on the side of the head and while looking towards the feet, one poses his front armlevers on his knees and one maintains the head of the victim in the position where it was found, by paying attention not to stop the ears.

If the victim falls unconscious (does not speak, does not react) but breathes (see assessment), it should be turned on the side, in side Position of safety (PLS), in spite of the traumatisms supposés ; one will turn on the side which is wounded. The purpose of this is to avoid with the victim blocking the respiratory tracts in the event of vomiting, which take place in 90% of the cases at the time of kind of traumatism. If the person does not manage to move her fingers or her toes, there is a risk of section of the spinal-cord. One should not mobilize the victim but remain close to it and await the helps.

Prompt helps

After being itself occupied vital functions, the team of first-aid worker must immobilize the seat of the fracture in order to avoid an aggravation of the traumatism at the time of the movements related to the evacuation (Relevage, Brancardage, possibly put in PLS if the victim falls unconscious).

It is necessary to be able to directly observe the wounded part, and in particular the aspect of the skin, and to detect a possible wound. It is thus necessary to withdraw clothing of the part in question. If that cannot be done without mobilizing the victim, the vêtements should be cut out; ; possibly, in absence of urgency and if the victim protests and does not let itself convince, one will be able to try to demolish the seams.

The immobilization is done in general by an installation of Attelle. In the case of a member, it may be that the installation of splint requires a realignment of the fracture (reduction) or a mobilization of the articulation ; that will be done in this case under the control of a medical team (or ancillary medical) and under sedation.

Types of immobilization:

for the cervical rachis: pose of a cervical Collier; that requires an alignment of the head with the chest, gesture made by the first-aid worker with the assistance of the person if it is conscious, usually without medical control except in the event of pain;
for the wrist and the front armlever: pose of a splint of arm, supported by a scarf;
for the arm: pose of a right scarf and a against-scarf;
for the shoulder: pose of a diagonal scarf;
for the foot, the leg and the knee: pose of a splint of leg;
for the thigh (femur), the basin and the back: require a medical assumption of responsibility normally (Smur), with sedation and poses of a splint of traction for the femur;
the immobilization is made either by a girthing on a hard Plan, or with a Matelas immobilisator with depression;
for the head: immobilization of the neck with a cervical collar by precaution (the cranial traumatism is frequently associated with a cervical traumatism).

For a traumatism with a member, one will try to remove all the objects (rings, bracelet, shoe) before the member gonfle ; the ends will be supervised: coloring, heat, distant pulse (radial or pedal).

Medical care

Reduction.
Immobilization of long life by a plaster or resin (Gypsothérapie), a corset, metal plates, pins.
Prevention of the Escarre S.
Rehabilitation (Kinesitherapy).

External bonds

skeletal fabrics, CHU Pity-Salpétrière (Paris)
Fracture of the hand, the General practitioner , n°2137, September 18th 2001
Treatment of the fractures of the lower end of the radius in winter sports resort, an article of the Urgency-practical site

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