Runny nose

Types and consequences of bone fractures. Bone fractures

Etiology

The immediate causes of fractures are various mechanical injuries. These are all kinds of blows, falls, collisions with vehicles, gunshot wounds, forcible removal of a stuck limb, sudden muscle contractions, for example, due to electrical injuries, and others.

Contributing factors are: mineral and vitamin deficiency, bone diseases, as well as some physiological conditions such as pregnancy and old age.

Classification of fractures

1. According to the time of occurrence, fractures are divided into congenital and acquired.

Congenital ones occur during the uterine period as a result of injuries to the mother or as a result of strong contractions of the uterus. Intrauterine pathological changes in the skeletal system - rickets, fetal developmental anomalies, maternal osteomalacia - predispose to such fractures.

Acquired fractures occur either at the time of birth, for example, during obstetrics, or, most often, after birth throughout life. They are divided into: traumatic and pathological (or spontaneous), because they usually occur without visible mechanical forces.

2. According to the nature of the damage, fractures are divided into open and closed.

In open fractures, the sharp ends of the bones damage soft tissues and the skin or mucous membrane, resulting in direct or indirect communication between the bones and the external environment.

At closed In fractures, soft tissue is also often damaged, but the integrity of the skin is preserved.

Open fractures pose the greatest danger, since they are easily infected by pathogenic microflora and are often complicated by phlegmon, osteomyelitis and even gangrene. Closed fractures are almost always aseptic.

3. Based on their anatomical nature, fractures are divided into diaphyseal, epiphyseal or intra-articular and metaphyseal. In the course of the disease, the most unfavorable are epiphyseal fractures, as they can lead to dysfunction of the joint.
4. Depending on the nature of the damage, fractures can be incomplete or complete.

Incomplete fractures are characterized by partial disruption of the integrity of the bone. These include:

Cracks (Fissurae), in which the main substance of the bone is split, and the periosteum retains its integrity. Cracks can be through - through the entire thickness of the bone and superficial (determined by X-ray).

Fractures (Infactiones) - represent a violation of the integrity of the cortical layer and periosteum up to half the diameter of the bone. They occur when the bones are strongly bent (on the convex side of the ribs).

Fractures are marginal defects of bones; most often occur on flat bones (fractures of the scapula, tubercles of the pelvic bones, spinous or transverse costal processes of the vertebrae).

Subperiosteal fractures are a violation of the integrity of the bone without compromising the integrity of the periosteum.

Perforated fractures or holes - occur mainly as a result of gunshot or puncture wounds.

Complete fractures are characterized by complete separation of the bone along its entire length or width.

5. If a violation of the integrity of the bone occurs in one place, then such a fracture is called a single fracture, in two places it is called a double fracture. There may also be multiple fractures.
6. Depending on the position of the fracture line to the longitudinal axis of the bone, the following types of fractures are distinguished:

transverse - the fracture line runs across the bone;

oblique - the fracture line runs at an angle; the surfaces of bone fragments are often sharp; by shifting and injuring tissue, they can cause an open fracture;

longitudinal - the fracture line runs along the long axis; such fractures are rare;

spiral - the fracture line is a spiral; it is the result of twisting of the bone;

jagged - fragments have irregularly pointed, jagged edges;

impacted - observed due to compression of the bone in the longitudinal direction; most often such fractures are epi- or metaphyseal, when the diaphysis of the bone is pressed into the epiphysis;

comminuted fracture - characterized by the formation of one to three fragments;

comminuted fracture - characterized by the formation of a large number of fragments; occur with severe injuries or gunshot wounds of long tubular bones;

a crush fracture is, in fact, a combination of a crush fracture with crushing of soft tissues, when bone fragments are mixed with soft tissues; this type of fracture is the most unfavorable, since it is almost impossible to restore the anatomical integrity of the bone;

avulsion - a fracture characterized by the separation of the end or tubercle of a bone as a result of strong muscle contractions; Most often, avulsions of the calcaneal and ulnar tuberosities and the coronoid process of the hoof bone are observed.

When fractures occur, the ends of the bone may move relative to each other. This occurs under the influence of a traumatic factor, as well as muscle contraction. The ends of bone fragments can shift at an angle, to the side, as well as with shortening or divergence in length.

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The Universal Classification of Fractures (UCF) was developed by a group of authors led by Maurice Muller. The principle of the UKP is to determine the type, group and subgroup of fracture of each bone segment with details of the damage.

In Fig. Figure 1 shows a hierarchical division of fractures characteristic of any distal segment of a long bone into three type and 27 subgroups

Rice. 1.

The three types of fractures of any bone segment are designated by the capital letters A, B, and C.

Each type is divided into three groups, designated by letters with Arabic numerals (A1, A2, A3, B1, B2, B3, C1, C2, C3). Group A1 injuries are the simplest with the best prognosis, and C3 are the most severe fractures with a poor prognosis.

After accurately determining the type and group of fracture, it is necessary to begin determining the subgroup and detailing.

Anatomical location

Anatomical localization is indicated by two numbers (the first is for the bone, the second is for its segment).

Each bone or group of bones is designated by a number from 1 to 8 (Fig. 2): 1 - humerus; 2 - radius and ulna; 3 - femur; 4 - tibia and fibula; 5 - spinal column; 6 - pelvic bones; 7 - hand bones; 8 - bones of the foot.

Rice. 2.

All other bones are classified under the number 9: 91.1 - patella; 91.2 - collarbone; 91.3 - shoulder blade; 92 - lower jaw; 93 - bones of the face and skull.

(Fig. 3). Each long bone has three segments: proximal, diaphyseal and distal. The ankles are an exception and are classified as the 4th segment of the tibia or fibula (44).

Rice. 3.

Rule of "squares". The proximal and distal segments of the long bone are limited by a square, the side of which is equal to the diameter of the widest part of its epiphysis.

Exceptions: 31 - proximal segment of the femur, limited by a line running transversely along the lower edge of the lesser trochanter; 44 - ankle fractures are not included in segment 43-, they are separated into a separate segment.

Distribution of fractures by segment. Before assigning a fracture to a particular segment, it is necessary to determine it center. Determining the center of a simple fracture is not difficult. The center of the wedge-shaped fracture is located at the level of the wide edge of the wedge-shaped fragment. The center of a complex fracture can only be determined after reduction.

Any fracture in which there is displacement of a fragment of the articular surface is intra-articular. If a non-displaced fracture is represented by a crack reaching the articular surface, then it is classified as metaphyseal or diaphyseal, depending on the location of the center.

Three types of long bone fractures. The types of fractures of the diaphyseal segments of long bones are identical. These are either simple fractures (type A), or splintered. Comminuted fractures can be either wedge-shaped (type B), or complex (type C), depending on the contact between the fragments after reposition (Fig. 4).

Rice. 4.

Three types of fractures of the distal segments (13-, 23-, 33-, 43-) and two of the four proximal segments (21-, 41-) are identical. These are either periarticular fractures (type A), or intra-articular fractures, which may be either incomplete (type B), or complete (type C).

The three exceptions are the proximal shoulder, proximal hip and ankle: 11 - proximal shoulder: type A- periarticular unifocal fracture; type B - periarticular bifocal fracture; type C- intra-articular fracture. 31 - proximal segment of the femur: type A - trochanteric zone fracture; type B - neck fracture; type C - head fracture. 44 - ankles: type A - damage to the subsyndesmotic zone; type B - transsyndesmotic fracture of the fibula; type C - damage to the suprasyndesmotic zone.

Diagnosis coding

An alphanumeric coding system was chosen to designate the diagnosis, ensure it was entered into the computer, and received back. Two numbers are used to indicate the location of fractures of the long bones and pelvis. They are followed by a letter and two more numbers to express the morphological characteristics of the fracture.

Alphanumeric coding for the diagnosis of long bone fractures is presented in Fig. 5.

Rice. 5.

An example of coding a distal segment fracture (Fig. 6):

2 - radius and ulna;

3 - distal segment;

C - complete intra-articular fracture;

3 - articular comminuted fracture;

2 - metaphyseal comminuted fracture.

Rice. 6.

The diagnosis can be supplemented by detailing, selected from the following options:

1) dislocation in the radioulnar joint (fracture of the styloid process);

2) simple fracture of the neck of the ulna;

3) comminuted fracture of the neck of the ulna;

4) fracture of the head of the ulna;

5) fracture of the head and neck of the ulna;

6) fracture of the ulna proximal to the neck.

Let's assume we have chosen a detail - a dislocation in the radioulnar joint, a fracture of the styloid process. Then the full diagnosis code is 23—C3.2(1)— radial and ulnar bones, distal segment, complete intra-articular fracture, articular comminuted, metaphyseal comminuted, dislocation of the radioulnar joint, fracture of the styloid process.

Sometimes an extremely high level of precision is required to identify a subgroup. Under the new system, the surgeon simply finds the appropriate detail numbered from 1 to 9 and places it in parentheses immediately after the number indicating the subgroup.

Detail numbers 1 to 6 provide additional information about the location and extent of the fracture, while the second numbers (7-9) add descriptive information. These three common additional parts are:

7 - bone defect;

8 - incomplete separation;

9 - complete separation.

Detailing is more often used when describing subgroups in order to make the diagnosis more detailed. However, it can be used for groups and even types of fractures. When granularity is used to describe groups of fractures, it classifies all subgroups within that group.

Detailing is used similarly to describe types of fractures: it classifies all groups and subgroups of a given type. For example, for fractures of the distal segment of the radius/ulna to indicate all incomplete intra-articular (type B) and complete intra-articular (type C) fractures, it is important to indicate whether there is a concomitant injury to the radioulnar joint (see above).

In types B and C vertebral fractures (5-), it is necessary to determine the combination of anterior and posterior injuries. Thus, anterior injuries to the vertebral bodies and discs are indicated by a lowercase letter a(a1, a2, etc.), and all posterior injuries of the intervertebral ligaments of the spinous processes and apophyses of the joints - lowercase b(b1, b2, etc.).

For pelvic fractures (61-) letter A details the main damage to the rear half-ring, while the letter b defines the concomitant contralateral injury, and the letter With- associated damage to the anterior semi-ring.

Acetabular fractures are a more complex problem, therefore, instead of two or three additional data in an already known subgroup, we have seven definition options:

a - indicates the main damage;

b - provides additional detail of the main damage.

To describe in detail the associated joint damage found during surgery:

c — determines damage to articular cartilage;

d - determines the number of fragments of the articular surface, including the walls;

e — determines the displacement of fragments of the acetabulum;

f—determines a fracture of the femoral head;

g - describes intra-articular fragments that require surgical removal.

Methodology for using classification

To determine the location of a fracture, you first need to identify a bone or group of bones, and then a segment of the bone. In our example, segment 23—radius and ulna bones, distal segment.

After determining the segment, you can begin to determine the type and group of fracture by answering 2-4 questions.

Question 1a for segment 23-: “Is the fracture periarticular or intraarticular?” If the fracture is periarticular, then you can immediately proceed directly to determining its group. If the fracture is intra-articular, as in our case, then it is necessary to answer question 1b: “Is the fracture incomplete intra-articular?” (type B) or complete intra-articular (type C)?

The type C fracture group is determined almost similarly.

The second question: “Is the fracture simple or comminuted intra-articular?” The fracture shown in Fig. 6 and chosen as an example, is a complete intra-articular comminuted (CI). This is the most severe type C fracture.

When defining a subgroup, a choice must be made from three options. According to the rule of squares, which locates the fracture in the distal segment of the radius or ulna, the correct answer is “comminuted metaphyseal fracture.”

To indicate concomitant damage to the distal radioulnar joint, we must refer to detailing. The radiograph shows a rupture of the radioulnar syndesmosis and a fracture of the styloid process of the ulna.

Full diagnosis code 23—C3.2(1).

23 - radius and ulna, distal segment;

C3 - complete intra-articular fracture of the radius, articular comminuted;

2 - metaphyseal comminuted fracture;

(1) - rupture of the radioulnar syndesmosis with a fracture of the styloid process.

Traumatology and orthopedics. N.V. Kornilov

I.By origin: a) congenital (intrauterine); b) acquired (traumatic and pathological).

II. Depending on damage of certain organs or tissues (complicated, uncomplicated) or skin (open, closed).

III.By localization: a) diaphyseal; b) epiphyseal; c) metaphyseal.

IV.In relation to the fracture line to the longitudinal axis of the bone: a) transverse; b) oblique; c) helical (spiral).

V.According to the position of bone fragments relative to each other: a) with an offset; b) without displacement.

Reason congenital fractures are changes in the bones of the fetus or abdominal trauma during pregnancy. Such fractures are often multiple. Pathological fractures are caused by changes in the bone under the influence of a tumor, osteomyelitis, tuberculosis, echinococcosis, bone syphilis. There are obstetric fractures that occur during the passage of the fetus through the birth canal.

Complicated include open fractures with damage to the skin or mucous membrane (which creates conditions for a microbe to penetrate through the wound and develop inflammation in the area of the bone fracture), as well as fractures accompanied by damage to large vessels, nerve trunks, internal organs (lungs, pelvic organs, brain or spinal cord, joints - intra-articular fractures). At closed fractures no damage to the skin occurs.

Incomplete fractures.fissura - incomplete front, in which the connection between parts of the bone is partially broken. Fractures are also identified subperiosteal, in which fragments are held by the surviving periosteum and do not move, are observed in childhood.

Action of a traumatic agent on the bone can be different, its nature is determined by the type of bone fracture. Mechanical impact, depending on the point of application and direction of the acting force, can lead to fractures from direct impact, bending, compression, twisting, tearing, and crushing (Fig. 68). Direct hit hits a fixed bone with an object moving at high speed; when the body falls, a sharp load on the bone fixed at its ends leads to its bending; compression bones are observed during a sharp load along the length of the bone, for example, a fall on an outstretched arm or compression of the vertebrae during a sudden strong load along the length of the spine in the event of a fall from a height onto the buttocks; twisting bones occur when the body rotates when the limb is fixed (for example, when a skater moves on a turn, when the skate gets into a crack).

The fracture line may be straight (transverse fracture) - with a direct blow, oblique - when bending, spiral (helical) - when twisting a bone, hammered - when the bone is compressed, when one bone fragment enters another. At tear-off In a fracture, a severed bone fragment moves away from the main bone; such fractures occur with a sudden, sharp, strong contraction of the muscles, which create a sharp pull on the tendons attached to the bone, when the ligaments are strained due to a sharp hyperextension of the joints. When a bone is fractured, several bone fragments (splinters) can form - splintered fractures.

Rice. 68. Types of bone fractures depending on the mechanism of injury: a - from bending; b - from a direct blow; c - from twisting; g - from fragmentation; d - from compression along the length. The arrow indicates the direction of action of the traumatic agent.

Open bone fractures that occur under different conditions have their own characteristics: those working in industrial enterprises are more likely to experience open fractures of the bones of the forearm, hand and fingers, which occur when their hands get caught in rapidly rotating mechanisms; such fractures are accompanied by extensive lacerations, bone fragmentation, crushing of soft tissues, damage to blood vessels and nerves, tendons, extensive skin detachment and defects.

Open fractures of both upper and lower extremities are observed in those employed in agriculture. The wound is deep, large, and contaminated with soil or manure.

Open fractures sustained in a train accident, transport accident, or building collapses are characterized by crushed fractures of the limbs with extensive crushing of the skin and muscles, and contamination of the wound; the tissues are imbibed with blood, dirt, and earth.

The more extensive, deeper and more severe the damage to the skin and underlying tissues during open bone fractures, the greater the risk of infection. With agricultural and road injuries, there is a high risk of developing aerobic and anaerobic infections (tetanus, gas gangrene). The severity of open bone fractures largely depends on the location of the fracture. The risk of developing infection in open fractures of the lower extremities is greater than that of the upper extremities, since the lower extremity has a larger array of muscles, the skin is more contaminated, and there is a higher possibility of infection and soil contamination of the wound. Open fractures with crushing of bones and crushing of soft tissues over a large area, with damage to large main vessels and nerves, are especially dangerous.

Displacement of fragments(dislocatio). When bones are fractured, the fragments rarely remain in their usual place (as happens with a subperiosteal fracture - a fracture without displacement of the fragments). More often they change their position - a fracture with displacement of fragments. Displacement of fragments can be primary (under the influence of the mechanical force that caused the fracture - impact, flexion) and secondary - under the influence of muscle contraction, which leads to movement of the bone fragment.

Rice. 69. Types of displacement of bone fragments during fractures: a - lateral displacement (width); b - displacement along the axis (at an angle); c - displacement along the length with elongation; d - displacement along the length with shortening; d - rotational displacement.

Displacement of fragments is possible both from a fall during an injury, and from improper transfer and transportation of the victim.

The following types of displacement of fragments are distinguished: along the axis, or at an angle (dislocatio ad аn), when the axis of the bone is disrupted and the fragments are located at an angle to each other; lateral offset, or in width (dislocatio ad latum), in which the fragments diverge to the sides; bias along the length (dislocatio ad longitudinem), when fragments are displaced along the long axis of the bone; bias along the periphery (dislocatio ad periferium), when the peripheral fragment is rotated around the axis of the bone, there is a rotational displacement (Fig. 69).

Displacement of bone fragments leads to deformation of the limb, which has a certain appearance with one displacement or another: thickening, increase in circumference - with transverse displacement, disruption of the axis (curvature) - with axial displacement, shortening or lengthening - with displacement along the length. When examining a patient, a comparative examination of both limbs should be performed. All techniques must be gentle.

There are probable and reliable (unconditional) clinical signs of fractures. Probable signs include pain and tenderness, swelling, deformation, dysfunction, and reliable signs include pathological mobility of the limb in an unusual place (outside the joint) and crepitus of fragments.

Pain- a constant subjective sign that usually occurs at the site of the fracture and intensifies when attempting to move. To identify pain, begin careful palpation with one finger, carefully, at a distance from the intended fracture site. Localized pain in one place is an important sign. It can be determined by lightly tapping the axis of the limb; for example, with a light blow to the heel, the patient feels pain in the area of the hip or tibia fracture.

Swelling may be caused by hemorrhage, hematoma, impaired blood and lymph circulation, and tissue edema. The circumference of the limb increases compared to a healthy one, sometimes by 1.5 times.

Upon examination it is determined limb deformity, depending on the displacement of fragments at an angle. There may be curvature of the limb or its shortening. The peripheral end of the limb can be rotated in one direction or another (rotational displacement).

Examination of the limb, measurement and palpation make it possible to roughly determine the position (displacement) of the fragments. Thus, rotation of the distal part of the limb without changing its length indicates a rotational displacement of fragments, lengthening or shortening of the limb - a displacement in length, a change in the axis of the limb, i.e. curvature at the fracture site at an angle indicates an axial (angular) displacement, an increase in the volume of the limb indicates a transverse displacement. The nature of the fracture and the position of the fragments are accurately determined by radiography. Pictures are taken in two projections.

ABOUT dysfunction judged by maintaining active movements. As a rule, immediately after an injury, the patient cannot move a limb or part of it due to severe pain. The lying patient is asked to move the foot, hand, or bend the limb at the joint (elbow, knee, shoulder). Sometimes even an attempt to move causes severe pain.

Pathological mobility- a reliable sign of a fracture. It must be identified carefully so as not to damage the tissue surrounding the fracture. Very carefully displace the peripheral portion of the limb and observe mobility in the fracture zone. Rocking movements in the hip, shoulder, lower leg, and forearm indicate the presence of a fracture

Crepitation of fragments determined by hand. The limb is fixed above and below the fracture site and shifted to one side or the other. The appearance of crunching sounds between fragments rubbing against each other is an absolute sign of a fracture. Due to tissue trauma, identification of the last two symptoms should be resorted to in exceptional cases.

At clinical examination In a patient with a fracture, the length of the limb is measured, the pulsation of peripheral vessels, skin sensitivity, and active movements of the fingers or toes are determined to determine possible damage to the vessels and nerves of the limb.

X-ray studies to determine bone integrity play an important role in diagnosis. This method allows you to determine the presence of bone damage, the fracture line and the type of displacement of the fragments. X-rays are performed not only if a fracture is suspected, but also with a clinically clear diagnosis. During treatment, repeated X-ray examination allows us to evaluate the process of callus formation and fracture consolidation.

ABSTRACT

Diaphyseal fractures of long tubular bones.

Completed:
resident Uvaidillaev Z.Z.

Curator of the abstract topic:

Anikin K.A

Clinical Residency Supervisor:

Doctor of Medical Sciences V.V.Roerich

Novosibirsk 2016

1. Introductions……………………………………………………………...………….…………………..3

2. Classification of fractures according to AO……………..………….…………………...5

2.1 Classification of diaphyseal fractures of long tubular bones according to (AO/ASIF)……………………………………………………………..9

3. Fracture of the femoral diaphysis……………………………………………………13

3.1 Subtrochanteric fracture of the femur …………………………14

3.2 Causes and classification…………..…………………………………17

3.3 Clinical picture and diagnosis……………………………..18

3.4 First aid……………………………………………………………..19

3.5 Skeletal traction for a hip fracture……………………20

3.6 Surgical treatment……………………………………………………………...…21

4. Diaphyseal fractures of the leg bones…………………………………22

4.1 Reasons………………………………………………………………………………….………23

4.2 Clinical picture and diagnosis…………………….………23

4.3 Treatments……………………………………………………………….……….24

5. Conclusion………………………………………………………...………………….26

6. Literature………………………………………………..…………………………….27

Introduction

Fractures are a violation of the anatomical integrity of the bone caused by mechanical stress, with damage to surrounding tissues and disruption of the function of the damaged segment of the body. Fractures that are a consequence of a pathological process in the bones (tumors, osteomyelitis, tuberculosis) are called pathological.

If the bone is damaged with the formation of fragments, then comminuted fractures occur. When a large number of small fragments are formed, the fracture is called comminuted. Under the influence of external force and subsequent muscle traction, most fractures are accompanied by displacement of fragments. They can shift in width, length, at an angle, along the periphery. With insignificant force of traumatic agents, fragments can be held by the periosteum and not displace - subperiosteal fractures. In bones with a spongy structure (spine, calcaneus, epiphyses of long tubular bones), when injured, broken trabeculae interpenetrate and a compression fracture occurs.

In case of mechanical injuries, depending on their volume, isolated (fracture of one bone), multiple (several bones), combined fractures (fracture and damage to another organ) are distinguished. If an injury occurs as a result of the action of two or more types of damaging agents, then it is called combined. An example of a combined injury could be a fracture of a bone and frostbite of the foot, i.e. the action of mechanical and thermal factors.

The diagnosis of a fracture is made on the basis of relative (pain, swelling, deformation, dysfunction) and absolute (pathological mobility, crepitus) signs. A conclusion about the presence and nature of a fracture is obtained from an x-ray. Treatment of fractures consists of restoring the anatomical integrity of the broken bone and the function of the damaged segment.

The solution to these problems is achieved:

1) early and accurate comparison of fragments;

2) strong fixation of the reduced fragments until they heal completely;

3) creating a good blood supply to the fracture area;

4) modern functional treatment of the victim. There are two main methods for treating diseases and injuries of the musculoskeletal system: conservative and surgical. Despite the development of surgical methods of treatment and traumatology, conservative methods have been the main ones until recently. With the conservative method of treatment, there are two main points: fixation and traction. Fixation means can be plaster casts, various splints, devices, etc. A correctly applied plaster cast holds the associated fragments well and provides immobilization of the injured limb. To achieve immobility and rest of the injured limb, a plaster cast fixes two or three nearby joints. The whole variety of plaster casts is divided into plaster splints and circular casts. Circular dressings can be fenestrated or bridge-like.

Long tubular bones.

When exposed to blunt hard objects in the transverse direction, these bones are destroyed with the formation of fragments, but non-fragmented fractures can also occur (Fig.).

The resistance of long tubular bones to external influences is not the same and depends on many factors (type of bone, direction of impact, gender, age, etc.). So, for example, for the diaphysis of the femur, the destructive energy during impact is 140-170 J, during torsion - 150-180 J, and the destructive load during bending - 3000-4000 N.
Bone is stronger in compression than in tension, so when it bends, the bone will fracture at the point of greatest tension, that is, on the convex side. The resulting crack propagates towards the concave side, which in most cases is the site of external influence. Thus, a fracture forms and propagates in the direction opposite to the direction of external influence. In the zone of bone compression, the crack often bifurcates, forming a kind of triangular (in profile) fragment. In the initial part, the fracture line in relation to the diaphysis is located in the transverse direction. On the sides lateral to the impact site, cortical cracks extend from the edge of the fracture. In the compression zone of the bone, the fracture surface is always coarsely toothed, while in the tension zone it is fine-grained.
Fractures that are similar in appearance but different in location occur with different mechanisms of injury (For example, flexion of the diaphysis of a long tubular bone under transverse pressure, flexion with one pinched end, flexion with longitudinal impact). In this case, different external forces are required (the least when bending a bone with a pinched epiphysis, the greatest when longitudinal impact). A fairly common type of fracture of long tubular bones is their deformation due to rotation of the body around a fixed limb or a limb relative to a fixed body. When torsion occurs, helical fractures are formed.
If you (mentally) restore the perpendicular to the helical segment of the fracture line, you can determine in which direction the rotation occurred. Conditions for the occurrence of diaphyseal fractures of long tubular bones. a - transverse bending (impact with a blunt object in the transverse direction); b - bending due to longitudinal impact; c - blow at an acute angle; d - bending with one fixed epiphysis; d - rotation.

Fractures of long tubular bones in the same place can form under different conditions of external influence (for example, fractures in the area of the surgical neck of the humerus). Analysis of the features of the fracture surface helps to correctly navigate the mechanisms of injury (Table).

Table. Morphological signs of diaphyseal fractures of long tubular bones during bending deformation
Sign	Characteristics of the trait
on the compression side	on the stretch side	on the side
Fracture edge outline	In the form of a sharply broken line, oriented obliquely transversely to the longitudinal axis of the bone	In the form of a finely toothed or smooth line located transversely to the longitudinal axis of the bone	In the form of a broken line, obliquely located to the longitudinal axis of the bone. Bifurcates in cases of comminuted fractures
Cracks	Rarely longitudinal cortical	None	They extend in an arcuate manner from the edge of the fracture. May develop into longitudinal fissures of the cortical layer
Shards	Most often diamond-shaped (triangular in profile)	None	Sometimes small, crescent-shaped
Fracture surface	Coarse-toothed	Fine grain	Serrated
Fracture plane	Oblique to the surface of the bone		Perpendicular to the bone surface
Degree of comparison of fragments	The comparison is incomplete. Fracture edge defect (from spalling to splinter formation)	The comparison is complete, without a defect in bone mass	The comparison is complete. Possible chipping in the form of small triangular or semi-lunar defects

Exposure to significant force along a bone can cause impaction fractures (for example, from a fall from a height onto your feet). With great elasticity of the bones (in children), under these conditions, cortical roller-like swellings of the bone substance occur in the metaepiphyseal regions without compromising the integrity of the bone.

2. Classification of fractures according to AO.

Classification of long bone fractures (AO/ASIF).

There are classifications of fractures, such as the Kaplan classification (1968), the C.S. classification. Neer (1970).

Currently, many countries around the world have adopted the classification proposed by M. Muller (AO/ASIF 1993), since it divides fractures depending on the morphological characteristics of each segment into types, groups and subgroups, and this classification is also universal (since it is used by traumatologists in all over the world, both for diagnosis and for printed works in various international publications), it directly shows the type of fracture and the tactics of further treatment (Müller M.E.M. Algover, R. Schneider, H. Willinger).

The fundamental principle of the universal classification of fractures AO/ASIF is the division of fractures of all bone segments into three types and their further division into three groups and their subgroups, as well as their distribution along an increasing line of severity in accordance with the morphology of the fracture, the complexity of treatment and prognosis. What type?.. Which group?... Which subgroup?.. These three questions and three possible answers to each question are the key to classification. These three types are called: A, B, C. Each type is divided into three groups: A1, A2, A3; B1, B2, VZ; C1, C2, NW. Thus there are 9 groups. Because each group is then divided into 3 subgroups, indicated by numbers. 1, .2, .3, there are 27 subgroups for each segment. These subgroups represent the three characteristic types of fracture for each group. The colors green, orange, and red, as well as the darker color of the arrows, indicate increasing severity: A1 represents the simplest fracture with the best prognosis, and S3 represents the most complex fracture with a poor prognosis.

Anatomical localization. It is identified by two numbers, one for the bone and one for its segment. The long bones, the ulna and radius, as well as the tibia and fibula, are taken as one bone. Therefore we have 4 long bones:

1 = shoulder

3 = femoral

4 == tibial/peroneal.

Bone segments.

Each long bone is divided into three segments: proximal, diaphyseal and distal segment. The ankle segment is an exception and is classified as the fourth segment of the tibia/fibula. The segments are designated by numbers: 1 = proximal, 2 = central, 3 = distal segment. The size of the proximal and distal segments of long bones is determined by a square, each side of which corresponds to the wide part of the epiphysis of the bone. Before a fracture can be assigned to a particular segment, its center must first be determined. In the case of a simple fracture, the localization of its center is obvious. In a wedge-shaped fracture, its center is located at the level of the widest part of the wedge. For a complex fracture

its center can be determined only after reposition. Any fracture accompanied by displacement of a portion of the articular surface is classified as an intra-articular fracture. If a non-displaced fracture is represented by a gap that reaches the articular surface, it is classified as metaphyseal or diaphyseal, depending on the location of its center.

According to the AO/ASIF classification, all diaphyseal fractures are divided into

into 3 types based on the presence of contact between two fragments

after reposition:

A (simple fracture) - contact > 90%, B (wedge fracture) - there is some contact, C (complex fracture - no contact. Simple fracture (type A) - a single circular line of fracture of the diaphysis with small cortical fragments comprising less than 10% bone circumference, which can be neglected, since they do not affect treatment and prognosis. A1 - spiral fracture, A2 - oblique fracture, A3 - transverse fracture (type B) - comminuted fracture of the diaphysis with one or more intermediate fragments. in which after reposition there is some contact between the fragments, B1 - wedge-shaped spiral fracture, B2 - wedge-shaped flexion fracture, VZ - wedge-shaped fragmented fracture. Compound fracture (type C) - comminuted fracture of the diaphysis with one or more intermediate fragments, in which there is no contact after reposition. between the proximal and distal fragments, C1 - complex spiral fracture, C2 - complex segmental fracture, S3 - complex irregular fracture. Type A fractures are the simplest injuries with the best prognosis for full functional restoration of the limb. Type C fractures are the most complex injuries with a poor prognosis. These fractures give rise to the greatest number of nonunions, false joints and persistent post-traumatic contractures of large joints. Proximal and distal segments. Fractures of the proximal and distal segments are either “extra-articular” (type A) or “intra-articular”. Intra-articular fractures are either “incomplete articular” (type B) or “complete articular” (type C). Given the many different options that must be considered when creating a classification of open or closed fractures, we have combined the widely accepted AO classification for long bones (Maurice E. Miiller et al. 1987) with the classification of soft tissue injuries: I = INTEGUMENT = skin, Closed Integument = closed skin, Open Integument = open skin; MT=Muscles, Tendon=damage to underlying muscles and tendons.

classification of diaphyseal fractures according to AO

32 – Femur – diaphysis

A= Simple fracture

1. subtrochanteric zone

2. middle zone

3. distal zone

A2 Simple fracture, oblique (>, = 30o)

1. subtrochanteric zone

2. middle zone

3. distal zone –

A3 Simple fracture, transverse(< 30о)

1. subtrochanteric zone

2. middle zone

3. distal zone

B = Wedge-shaped fracture

B1 Wedge-shaped fracture, spiral wedge

1. subtrochanteric zone

2. middle zone

3. distal zone

B2 Wedge-shaped fracture, flexion wedge

1. subtrochanteric zone

2. middle zone

3. distal zone

B3 Wedge-shaped fracture, fragmented wedge

1. subtrochanteric zone

2. middle zone

3. distal zone

C=Compound fracture

C1 Complex fracture, spiral

1. two intermediate fragments

2. three intermediate fragments

3. more than three intermediate fragments

C2 Complex fracture, segmental fragment

1. one intermediate segmental fragment

2. one intermediate segmental fragment and additional wedge-shaped fragment(s)

3. two intermediate segmental fragments

C3 Complex fracture, comminuted

1. two or three intermediate fragments

2. limited fragmentation (< 5см)

3. intensive crushing (>, = 5cm)

42 – Tibia/fibula – diaphysis

A=Simple fracture

A1 Simple fracture, spiral

1. fibula intact

A2 Simple fracture, oblique (>, = 30o)

1. fibula intact

2. fibula is broken at a different level