Tibial and fibular diaphysis fractures
Introduction
Introduction to the humeral shaft fracture The humerus is the most frequently fractured part of the long tubular bone, accounting for 13.7% of the total body fracture. Children under 10 years of age are particularly common, with the most fractures of the humerus, the second fracture of the tibia, and the least fracture of the tibia. Due to the relationship between the humerus, there are many opportunities for direct violent blows and rolling. Because the anterior medial aspect of the tibia is close to the skin, open fractures are more common. Serious trauma, large wound area, fracture smashing, serious pollution, tissue damage caused by the symptoms of the disease, the best way to deal with it, has been one of the most controversial issues in fracture treatment. basic knowledge The proportion of illness: 0.91% Susceptible people: children under 10 are especially common Mode of infection: non-infectious Complications: edema, tibia fracture, wear, chronic osteomyelitis
Cause
Causes of humeral shaft fracture
Violence factor (30%):
The fracture of shaft of tibia and fibula is often hit by heavy objects, kicks, impact injuries or wheel rolling injuries. The violence is mostly from the outer anterior side of the calf. The fracture line is mostly transverse or short. Rows, huge violence or traffic accidents are mostly comminuted fractures. The two fracture lines are often in the same plane. For example, transverse fractures may have a triangular fragment of bone on the violent side. After the fracture, the fracture ends are overlapped, angled, and rotated. Displacement, because the front of the humerus is located under the skin, so the fracture end can wear the skin very much, the muscles are more likely to be contused. If the violence is slight, the skin is not worn, such as severe contusion, poor blood supply, skin can also occur. Necrosis, infection of the bones, large violent crushing, squeezing injuries can have large areas of skin exfoliation, muscle tears and exposed ends of the fracture. The fracture site is more common in the lower middle third, due to nutritional vascular injury, soft tissue coverage, poor blood supply, etc., the incidence of delayed healing and non-healing is higher.
In addition, fractures caused by falling from high places, rotating violent sprains or slipping, especially the fracture line are mostly oblique or spiral; the fracture line of the tibia is higher than the fracture line of the tibia, and the soft tissue injury is small, but the fracture is displaced. There are many opportunities to penetrate the skin to form a puncture open injury.
The fracture displacement depends on the size of the external force, the direction, the muscle contraction and the distal weight of the injured limb. The outer side of the calf is more likely to be violent, so the fracture end can be angled inward, and the calf gravity can make the fracture end backward. The side is inclined at an angle, and the weight of the foot can rotate the distal end of the fracture outward, and the muscle contraction can cause the two fracture ends to overlap and shift.
Children with humeral fractures are generally less affected by external forces, and children with greater cortical toughness, mostly green branch fractures.
Prevention
Prevention of humeral shaft fracture
Preventing heavy objects from hitting, kicking, impacting or wheel crushing in life and work is the key to preventing humeral shaft fractures.
Complication
Complications of humeral shaft fracture Complications, edema, tibia fracture, wear, chronic osteomyelitis
Fascial compartment syndrome
Soft tissue injury such as calf fracture or muscle, hematoma, reactive edema, and increased pressure in the fascial space can cause blood circulation disorder and form fascial space syndrome, among which the incidence of anterior tibiofibular syndrome is the highest.
The anterior tibiofibular space is located in the anterior lateral part of the calf, the tibialis anterior muscle, the long extensor muscle, the extensor digitorum longus, the third metatarsal muscle, the common peroneal nerve and the anterior iliac crest. The vein is located in it. Hard, tenderness, passive extension, pain in the flexion of each toe, the pain is related to the degree of compression of the phrenic nerve, early in the first and second metatarsal sensation, followed by long extensor, long toe extensor, The anterior tibialis palsy, because the radial artery has a communication branch and the anterior tibial artery, so the early dorsal artery can be reached.
In addition to the anterior fascial fascia gap, the three syndromes in the posterior iliac crest can also occur in this syndrome. The incidence of posterior tibial deep space syndrome is higher than that of the posterior temporal stenosis and lateral space. The bottom numbness, the flexion of the toe is weakened, the pain is increased when the passive toe is extended, the tension of the medial fascia of the distal leg of the triceps is increased, and the tenderness is obvious. If the symptoms continue to develop, the ischemic contracture of the muscles in the gap may occur. The claw-shaped foot, the posterior incision in the lower leg, from the beginning of the soleus muscle, longitudinally cut the deep fascia, and if necessary, the epicardium is cut at the same time, which can achieve the purpose of decompression.
The anterior tibiofibular syndrome is a continuous increase in intra-gap pressure, vasospasm, increased tissue osmotic pressure, tissue ischemia and hypoxia, especially in cases of closed tibiofibular fractures with obvious contusion in soft tissue. Possibly, fracture reduction should be performed as soon as possible, and 20% mannitol should be instilled intravenously to improve microcirculation and reduce edema, and observe closely.
In addition to the fascial space syndrome, the anterior tibial space near the ankle joint, the tibialis anterior muscle, the long extensor muscle, the long extensor tendon of the toe is close to the tibia, and the fracture is healed. After the formation of the epiphysis, the tendon is worn and caused. Symptoms, if necessary, should also be surgically cut into the fascia for decompression.
2. Infection
The open fracture of the humerus and the internal fixation of the plate after debridement have the highest infection rate. The reason is that the open fracture, the soft tissue has been damaged, and the plate is fixed more than 6 holes. The soft tissue of the periosteum is too much, and the fracture of the fracture is provided. Blood supply, and thus the infection rate is high. In the cases of chronic osteomyelitis after the internal fixation of the fracture treated by the author in recent years, the plate fixation of the open fracture of the tibia is 1/3, and the anterior humerus is the subcutaneous bone. Once infected, The wound is exposed to internal fixation and bone surface, which can be unhealed for 1 year to several years. Therefore, the fracture of the humerus is open, and the I degree can be fixed with intramedullary nail. The second degree is debridement and wound closure, and the wound is healed and then fixed intramedullary nail. The third degree is regarded as the soft tissue repair condition, first fixed with an external fixator, and after the wound is closed, the intramedullary nail is fixed.
3. Delayed healing, non-healing or malunion
There are many reasons for the delayed healing and non-healing of the tibia. It can be roughly divided into two major categories: the fracture itself and the improper treatment. However, for either reason, most of them are not caused by a single factor. There are often several reasons for this. For different reasons, take appropriate measures to achieve the purpose of treatment.
(1) Delayed healing:
This is a common complication of tibiofibular fracture. In general, the adult tibiofibular fracture has not healed for 20 weeks, which is delayed healing. According to different data, it accounts for 1% to 17%. Although most cases continue to fix the fracture, it can heal, but extend the fixed time. It can aggravate muscle atrophy and joint stiffness, increase the degree of disease, and form non-union if improperly treated. Therefore, during the treatment of fracture, regular observation must be made, and the fixed fixation should be done to guide the wounded to perform functional exercise of the affected limb.
The fracture of the tibia is still possible within 20 weeks. It is not necessarily treated by surgery. If there is poor healing after 12 weeks of fracture, the functional exercise of the affected limb should be strengthened in time. Under the plaster fixation, the weight of the affected limb should be walked to promote the bone. Healing, there are also claims, more than 12 weeks of fractures with non-healing tendency, the fracture end of the tibia can be cut off about 2.5cm, in order to increase the longitudinal insertion pressure of the fracture end of the tibia when the weight of the affected limb is increased, to promote the growth of the epiphysis; if the fracture is about 20 weeks If there is still a gap at the end, the non-healing may be extremely great, and the bone cancellous bone should be surgically implanted in time.
In addition, for cases of delayed healing, electrical stimulation therapy, electromagnetic field pulse or direct current, different frequency and waveform of current, change the potential difference of the fracture, can also achieve the purpose of promoting fracture healing.
(2) Non-healing:
The non-union of the humerus fracture showed obvious sclerosis at the fracture end of the X-ray film. Although there were osteophytes at the two fracture ends, there was no bone connection, and the clinical signs had local tenderness, weight-bearing pain or abnormal activity, and many cases did not heal. There are many internal factors, such as excessive crushing of the fracture, severe displacement, open injury or skin defect. Open injury and infection are more important reasons for non-healing. In addition, improper treatment, such as excessive traction, external fixation is not true or internal fixation. Improper application can also cause non-healing.
The boundary between delayed healing and non-healing of the tibia is not very clear. In cases of delayed healing, the weight of the affected limb can promote fracture healing. However, if it has formed non-union, excessive activity can form a pseudo joint at the fracture end, so active surgery should be taken. treatment.
Generally, the humerus does not heal. If the alignment is good, there is fiber connection at the fracture end. As long as the soft tissue with good blood circulation is protected during the operation, the fracture is not widely peeled off, and a sufficient amount of cancellous bone is implanted around the fracture end. Heal.
In the early stage of non-union or delayed healing, Brown, Sorenson et al believe that the iliac bone osteotomy is used to increase the physiological pressure of the fracture of the humerus and promote fracture healing without bone grafting. However, if the fracture end has pseudo-articular formation, the humerus healed. After the posterior tibial fracture end space exists, bone grafting should be performed at the same time as osteotomy. Mullen et al believe that the case of nonunion, simply using compression plate fixation and early limb weight bearing, strengthening functional exercise, bearing limb weight, no need Bone graft can also achieve bone healing, but if the fracture is poorly positioned and the fibrous tissue at the fracture end is poorly healed, it is still necessary to implant the cancellous bone with strong internal fixation. Lottes et al believe that the medullary cavity is enlarged. Internal nail fixation, at the same time, the humerus is cut off, and the weight of the affected limb is not affected at the same time. However, according to a large amount of data, the effect of implanting cancellous bone is better than that of simple internal fixation. .
(3) Malformation healing:
If the humerus fracture is varus, valgus or anterior or posterior angle more than 5° after the reduction, the gypsum should be replaced or the gypsum wedge should be cut open for correction. If bone healing has occurred, the function of the affected limb should be affected. Or whether the appearance of the deformity is obvious to determine whether or not the osteotomy is correct; the X-ray manifestation should not be used as the surgical basis alone. In the rotational deformity, the influence of the internal rotation deformity is large. Generally, the internal rotation is more than 5°, and the gait abnormality may occur. External rotation deformity >20 ° can also have no significant effect.
The deformity of the tibia fracture is easy to find and easy to correct in time, so the incidence is low, but the comminuted fracture, soft tissue defect and severe displacement are prone to malunion, and should be prevented in early treatment.
Symptom
Symptoms of humeral shaft fractures Common symptoms Severe pain sprains Simple fractures Spiral fractures Butterfly fractures
Symptom
Most of the fractures of the tibia are caused by trauma, such as bruises, crushes, sprains or fall injuries in the high places. The pain in the injured limbs is swollen and deformed.
The position of the humerus is superficial and the local symptoms are obvious. While paying attention to the symptoms of the fracture itself, it is also necessary to pay attention to the degree of damage of the soft tissue. The local and systemic complications caused by the fracture of the tibia are more serious, and the consequences are often more serious than the fracture itself. It is necessary to pay attention to the presence or absence of important vascular nerve injury. When the upper end of the humerus is fractured, it is necessary to pay attention to the presence or absence of the anterior iliac artery, the posterior tibial artery and the common peroneal nerve. It is also necessary to pay attention to the degree of swelling of the soft tissue of the calf, and whether there is severe pain. The performance of the calf fascial compartment syndrome.
2. Signs
Should pay attention to observe the shape, length, circumference and the tension of the soft tissue of the entire leg; skin temperature, color of the calf skin; pulsation of the dorsal artery of the foot; activity of the toes, presence or absence of pain, etc. Sagging, etc. Under normal circumstances, the inner edge of the toe, the medial malleolus and the inner edge of the tibia should be on the same line. If the fracture of the ankle is displaced, the normal relationship is lost.
For children with fractures, due to the thick periosteum of the humerus, the fracture can still stand after the fracture. The knee joint can also move in the lying position. The local swelling may not be obvious, that is, the clinical signs are not obvious. If there is obvious tenderness in the calf, the X-ray should be taken. Tablet, be careful not to miss the diagnosis.
Tibial fractures can be divided into three types:
1 simple fractures: including oblique fractures, transverse fractures and spiral fractures;
2 butterfly fracture: the size and shape of the butterfly bone block are different, the butterfly fracture block caused by the torsional stress is longer, and the fracture line can be further formed on the butterfly fracture block directly struck;
3 smash fracture: a fracture rupture, there are multiple fractures.
Examine
Examination of the humeral shaft fracture
For suspected wave and vascular injury, it can be used for lower extremity angiography to confirm the diagnosis. The conditional hospital can perform digtal subtraction angiography (DSA) or ultrasound vascular diagnostic instrument examination. When the calf traumatic blood vessel is broken or embolized, use When the ultrasonic vascular diagnostic apparatus is used for detection, there is no arterial pulsation curve appearing on the oscilloscope, which is in a straight line, and the straight line is also presented on the pen-scanner, and is not visualized in the flow channel type Doppler imaging method. The ultrasonic blood vessel diagnostic apparatus It is a non-invasive examination, and the clinical application is gradually becoming popular.
Imaging examination: At present, the clinical examination of the tibiofibular fracture is still performed by physical examination and ordinary X-ray. If it is found that there is a long oblique or spiral fracture or a significant displacement of the ankle fracture in the lower third of the humerus, it must be Pay attention to the presence or absence of fractures at the upper end of the humerus. For this reason, you must take a full-length X-ray of the humerus, otherwise it is easy to miss the diagnosis.
Diagnosis
Diagnosis and diagnosis of humeral shaft fracture
There is no difficulty in the diagnosis of humeral fractures, but it must be noted that the presence or absence of neurovascular injury, whether it is accompanied by muscle compartment syndrome, as well as the details of the wound and the estimation of the degree of pollution, should be fully considered, and its complications are far Smaller leg fractures are much more severe and the diagnosis is based primarily on:
History of trauma
It should be fully understood to determine whether there is a combined injury, especially early attention should be paid to the presence or absence of a head and chest injury.
2. Clinical manifestations
Mainly based on the patient's systemic and local symptoms, signs and special examinations mentioned above, suspected and common peroneal nerve injury, should be used for EMG examination.
3. Imaging examination
The calf fracture should be routinely performed for the calf and lateral X-ray. If it is found that there is a long oblique or spiral fracture or a humeral fracture in the lower third of the humerus, it is necessary to pay attention to the fracture of the upper end of the humerus. This requires a full-length X-ray film of the humerus, otherwise it is easy to miss the diagnosis, generally do not need CT and MRI, unless suspected of soft tissue injury.
