External pathology of fracture on the brachial convex

2021-01-30 12:00 AM

Fracture on a bridge is the tenth most common fracture in children in general, often the complication rate higher than other fractures, often have scoliosis sequelae.

Outline

Bone fracture on Bay Bridge c light hand is a very common type of fracture in children aged 5-12 (especially in children 8 years of age). This is a type of osteoarthritis, in the parietal region of the head below the brachial bone and the fracture line located on the protrusion and pulley, across the elbow.

Fractures on the brachial bridge account for about 10% of the lower brachial fractures, which are divided into two types:

Stretch fracture

The lower head is moved behind the arm bone.

Broken urgently

The lower head has deviated from the front of the arm bone.

The more common type of stretch fracture, this type of fracture is not related to the joint and is common in children: 60% of the stretch fractures are found in children under 15 years old, of which the majority are in boys, aged 5-8 years.

Fracture on the tenth ranking of the fracture in children in general, often has a higher complication rate than other fractures, often with inward or outward scoliosis, if treatment is not good. .

The rate of manipulation failure, related nerve damage and surgical intervention is also higher than that of other fractures. Open fracture accounts for 1%, nerve damage accounts for 7.7%. Commonly, internal rotational nerve damage in stretch fracture and cylindrical nerve damage in folding fracture. In both children and adults, the incidence of fracture on a folding stereotype is usually rare (2%), vascular damage requiring surgical intervention is found in 0.5% of cases, combined fractures on the same limbs account for 1-13%, including rotational body fracture, arm stem fracture, muzzle fracture and elbow dislocation.

Cause - Mechanism

In children, often due to an indirect cause, falls on the ground against the ground in a stretched position (stretching fracture), while in adults, in the fracture it is usually caused by direct trauma to the back of the elbow in a folded position. cause the lower head to move forward (folded).

Stretch fracture: The victim falls with his hand on a hard floor in the elbow position, the body weight transmitted from top to bottom through the arm bone meets the force transmitted from the bottom up through the forearm bones, causing a weak area at the lower end of the arm bone arms, and at the same time the head on the bone rotates to push the lower fracture backwards.

Quick fracture: Victim falls on the elbow in a folded elbow position, the elbow pushes the lower fractured head forward.

Pathology

Broken line

The fracture line is about 3-4cm above the elbow, going across the elbow hole on the back or the parrot hole in the front.

Stretch fracture

The fracture line is usually diagonal from top to bottom.

Broken urgently

On inclined film, the diagonal fracture is seen from front top to back bottom.

Deviation

Stretch fracture

The lower head was displaced backwards, meeting 97.7% in children; of these, in 75% of cases the lower end moved backwards, inward and rotated inward, the pointed tip of the upper segment moved forward; otherwise, the lower end moves backwards, outward and outwards, and the tip of the upper segment moves forward.

Broken urgently

The lower head is displaced to the front and folded at the elbow. This fracture is rare, approximately 2-4% of the fractures on the convex, the plane passing through the three markers at the elbow moves to the front of the arm bone.

Classify

Garland’s scale, in the type of stretch fracture, is divided into three degrees as follows.

Grade I: G was not displaced.

Grade II: G ay displaced but the cortical bone was sticking behind each other, not to leave.

Grade III: Fracture completely deviated, the two ends of the bone are not interlocking, the lower head moves backwards inwards or backwards and out.

In the folding fracture, it is divided into three degrees as follows:

The degree I: Fracture does not move or deviate very little, the angle between the body of the arm bone and protrusion is not more than 10-15 degrees.

Degree II: Fracture displaced but the front bone is still sticking together.

Grade III: Fracture completely deviated.

Marion and Lagrange's scale

Grade I: G ay previous shell wing bone tayDo II: humerus fracture completely but not displaced

Grade III: Complete fracture, displacement but two fracture areas are still in contact.

Grade IV: Completely fractured, two fractured ends displaced from each other and no longer contact.

Symptoms and diagnosis

Symptom

clinical

After the accident, the patient has a lot of pain in the elbow, loss of muscle function, swelling, often confused with a posterior elbow dislocation, often bruising the front of the elbow due to the sharp end of the upper fracture piercing the forearm muscle Early stages may have streaks at the back of the elbow. When there is a sign of sunken anterior skin (due to the pointy tip of the fracture on the skin), it is a prognostic sign of difficulty in manipulation. In contrast, in the case of fracture with little displacement, often only palpable signs of elbow joint effusion, local pain on the protrusion. Touching three anatomical landmarks: the elbow, the apex on the inner convex and the outer apex in the normal position, the passive movement of the normal elbow. Examination of accompanying blood vessel and nerve damage is very important. Both sensory and motor neuron signs must be examined. No vascular damage needs to be identified by signs of anaemia in the forearm, e.g., rotational versus the opposite, pain when passively stretching the fingers. Combined fractures of the collarbone to the wrist joint should also be detected if present.

X-ray

Film the elbow in a straight and lateral position, showing the type of fracture and fracture. Only the horizontal fracture line can be seen on straight film, it is easy to confuse in low-displacement fractures, the lateral film must be coordinated to record the angular deviations of the lower end, as well as to recognize defects in the backside. the front of both ends of the bone fracture, and at the same time see the direction of displacement to the back or front of the lower fracture head.

Diagnose

Based on clinical pain, loss of muscle function, swelling and deformity of the elbow, X-rays can help diagnose the degree and fracture.

Differential diagnosis

Dislocated elbows

There is a treadmill movement, three anatomical landmarks in the elbow change: the tip of the elbow moves up.

Spherical convex, inter-convex fractures

The three anatomical landmarks change their respective positions. In particular, it should be differentiated from fractures in the elbows, such as fractures on the convex of the inner convex, fractures of the neck bones ...

Symptoms

Early complications

Nerve damage

The rate of 3% -22% is common with spins, medial nerve, the anterior synovial nerve in stretch fracture and medial nerve in folding fracture. Paralysis completely recovers after a few months, if after 6-8 weeks without recovery, nerve release surgery should be done to avoid the nerve sticking to the bone mass.

Infection

In patients with manipulation, piercing surgery or combined bone surgery.

Arm artery damage

A pinched arm artery caused by a displacement of the fractured bone or a hematoma, or a fractured bone leading to a complete or incomplete rupture of the artery, or a collision causing the endothelium to fall, leading to an embolism. An angiogram or Doppler ultrasound should be performed when artery injury is suspected for appropriate management.

Open fracture

Less common.

Compression of the cavity in the forearm

Usually, the result of a compression of the arm artery. Attention should be exercised when the patient develops paraesthesia, increased pain, loss of limb muscle, weak or lost spinal pulse, measurement of cavity pressure to conduct an open incision as needed to prevent limb necrosis or complications from Volkmann later on.

Late complications

The elbows inward

Losing gill angle, a complication that occurs in 9-58% of fractures on a protrusion. The advantageous factor is that the lower end is still rotated and displaced inward, causing the lower head to tilt, pressing against the upper mass of the inner spheroid and opening the fracture angle outside. Internal crooked distortion increases outward rotation but is compensated for by shoulder amplitude. Often there is a lump anterior outward due to the protrusion of the outer end of the upper fracture. This bulge is enlarged when the forearms are fully extended, this is also a factor affecting aesthetics.

Outward crooked elbows

Conversely, this complication is rarer, only about 2%. This complication is related to displacement of the lower head to back out in the protruding fractures. The scoliosis of the elbows restricts stretching as well as causes incomplete paralysis of the late cylindrical nerve.

Osteoarthritis

Meet less than 2% of cases.

Musculoskeletal inflammation

Usually rare, involves manipulation, repeated attempts to suppress, and excessive exercise during rehab.

Volkmann syndrome

The consequences of anaemia nourishing the forearm, especially the folding muscles and the medial nerve and the pillar, are caused by compression, poor flexion or excessive elbow deformation, which specifically causes hand deformity: wrist fold over-stretching the knuckles and folding the knuckles. Because the folded muscles are fibrous and contractile, in order to stretch the fingers must contract the wrist. Conversely, when you stretch your wrists, your fingers will be contracted. This is a serious complication affecting the function of the hand, so it is necessary to be cautious by shaping it well, the cast has a vertical incision, avoiding the cast too tight, avoiding too folded the elbow. Be alert when detecting: purple hands, increased forearm pain, needle-like paraesthesia, and loss of finger movement.

The principles of treatment

The emergency doctor needs to intervene in the following two situations:

When signs of circulatory decline are detected

Temporary stretching is required to maintain vasculature under appropriate pain relief, at least by regional anaesthesia. The stretching technique includes axial pulling of the arm with elbow posture, then to squeeze the lower fracture forward or backwards, keeping the fracture ends in position with the elbow folds to 5-100; forearms are tipped to correct inward or backward displacement in case of outward movement.

Closed fracture cases do not have associated nerve vascular damage

According to the terms of Marion and Lagrange:

Grade I and II: Conservative treatment.

Grade III: Pinch and motionless. If it fails, it is indicated that surgery is needed.

Grade IV: There are indications of immediate manipulation to avoid soft tissue damage caused by manipulation.

Fracture does not move or deviate slightly (angle between the shaft and convex not more than 200), soft swelling only. These cases do not require any stretching. Just immobilize with the forearm brace, 900 folding elbows, follow up for 1-2 days is necessary, these cases correspond to fracture degree I, immobilization with the cast back brace like so 3 weeks. For immobile grade, II fracture with forearm powder with a vertical incision. Complications of these cases are Volkmann anaemia syndrome and angled in or out.

For fractures of grade III and IV in children and fractures of relative or large displacement in adults, it is necessary to seal or open and cast, must be treated by an orthopaedic trauma specialist.

The nail-piercing technique for fixation is essential, but the minimum conditions require a brightening screen (C-Arm- Image Intensifier). Surgery is indicated in the case of an open fracture or a closed fracture that the manipulation is not successful (as in the case of the lower end of the upper segment stuck into the muscle), or fracture accompanied by severe damage to blood vessels (especially in the case of trying to manipulate many times without success). If the conditions are not available, the Kirschner nail can be opened through the fracture. In adults, you can install foam screws or Y or T braces.

The treatment failure rate in children is 4-6%, which are cases of large displacement, incomplete manipulation, cases of large soft tissue injuries, or cases with previous elbow joint damage.  A range of about 50 is acceptable. In the cases of the lower head lateral displacement in or posterior out, usually with the corresponding rotational and medial nerve damage. Medial nerve damage is often accompanied by vascular damage, often with damage to the anterior intercostal branch of the median nerve, manifested by the limited motor of the thumb, elongated tendon of the thumb and index finger. Surgical intervention is indicated when there is evidence of vascular damage, since the median nerve and blood vessels may become trapped between broken fragments. Damage to blood vessels accounts for about 0.5% of cases, commonly seen in cases of lower head displaced back out.

Preventive

Propaganda and education in the community about traffic and labour laws.

It is necessary to educate students in elementary schools about the causes of fractures in order to limit accidents occurring in daily life and in schools.

It is necessary to educate the community of good local first aid in fracture cases to limit complications in fractures.