The comminuted fracture or crushed fracture occurs when the bone surface is interrupted in its continuity in more than one line, consequently forming more than two bone fragments. Fractures usually occur as a consequence of trauma of an intensity greater than the bone can withstand.
The comminuted fracture is classified according to its pattern of bone disruption as a complete fracture, and according to its production mechanism it can belong to both the group of direct and indirect production mechanisms (flexion). It can be classified as a comminuted fracture with butterfly fragments and a segmental fracture.
The butterfly fragment fracture is characterized by the wedge-shaped pieces. On the other hand, the segmental comminuted fracture is characterized in that two lines of the fracture isolate a bone segment from the rest of the surface.
In the Gustilo classification, the comminuted fracture is generally located at a grade IIIA; however, in some cases of moderate comminution it could be classified as grade II.
A typical complication of these fractures is the interruption of the vascularization of a bone fragment and, consequently, its necrosis. The consolidation of these fractures is slower, sometimes requiring the resection of the small fragments to avoid complications and favor the osteosynthesis between healthy fragments and their correct consolidation.
Signs and symptoms
In general, the symptomatology of comminuted fractures does not differ from the symptoms of the rest of the fractures.
Pain in comminuted fractures is usually more severe than pain in simple fractures; This is because the periosteal involvement occurs in more than one site, and this periosteum contains a high number of painful nociceptors.
However, pain is such a subjective symptom that it is difficult to establish whether it is a simple fracture or a comminuted fracture from the pain history alone.
In addition to pain, the rest of the signs of Celsus are also present in this type of fracture: increase in size and edema due to the rupture of microvessels, erythema, heat and decrease or loss of function.
The obvious deformity, as well as the crepitus of the segment upon mobilization, will be what incline the clinical diagnosis and will require the performance of complementary studies to establish the imaging diagnosis.
Diagnosis
The diagnosis of comminuted fractures can only be made through imaging studies where the number of bone traces and segments resulting from the trauma can be evidenced.
A simple X-ray analysis, in one or more projections of the segment, according to the site of the injury, is enough to demonstrate the comminution of the fracture.
In some less frequent cases, a computerized tomography is required to be able to observe the bone fragments, especially if they occur intra-articularly.
Causes
The causes of comminuted fracture do not differ broadly from those of simple fractures; However, some conditions predispose the occurrence of this type of fracture, especially those that refer to the site of the injury.
The most common cause of comminuted fracture includes those conditions or pathologies that weaken the bone structure.
In imperfect osteogenic conditions, osteomalacia, osteopenia, osteosporosis, cancer and tumors - regardless of the age of the patient - the bone structure will be compromised to such an extent that a trauma that lacks intensity can "explode" the bone.
The elderly are the age group with the greatest predisposition to comminuted fracture due to the structural changes produced by the aging of bone cells, which weaken the integrity of the bone.
Comminuted fractures are characteristic of direct projectile trauma fractures, as well as from motor vehicle accidents or falls from great heights.
This type of violent direct trauma fractures can produce what is known as secondary projectiles, which refer to bone or projectile fragments that dislodge at the moment of impact and can cause damage to adjacent tissues.
Treatment
Treatment is the most difficult aspect of comminuted fractures. In the past, these types of fractures were treated with conservative orthopedic methods, such as tractions and immobilizations.
However, due to the complications derived from prolonged immobilization or incorrect consolidation, the search for other methods of resolution became imperative.
Currently, comminuted fractures require surgical treatment, in addition to the use of osteosynthesis material to be able to fix the bone fragments with each other. The technique to be used will depend on the place of the fracture and the amount of fragments derived from it.
Ilizarov Surgery
The use of external fixation of the Ilizarov type is ideal for fractures in which the loss of bone substance is significant; however, the risk of infection through the fixator is quite high.
Ilizarov surgery is a method of bone elongation that is used in cases in which bone tissue has been lost, as well as in congenital bone malformations.
This Ilizarov surgery consists of two stainless steel rings attached to the healthy bone ends by means of screws that go through the skin, the muscles and the bone tissue. These are fixed once the non-vascularized bone fragments have been removed.
A minimum space is created between both ends of healthy bone tissue, and the space is expanded by 1 mm daily, so that new bone tissue is formed between both ends.
This technique is extremely painful and with a high risk of soft tissue infections if it is not performed in a suitable environment and with strict care. However, it is one of the most used techniques in the orthopedic and trauma services of South America.
In some comminuted fractures of the humerus in elderly patients with little functional demand on the bone structure, some practitioners consciously choose to bypass the fracture (a technique called skillful neglect) and focus solely on the mobility of the underlying joint.
References
- Martinez RA. Damage control in orthopedics and traumatology. Rev Col Or Tra. 2006; 20 (3): 55-64
- Francesco Mario de Pasquale. The employment of the tutor Ilizarov in traumatology. Rev. Asoc. Arg. Ortop. and Traumatolo. Vol 59, N ° 2, Pages 205-214 Recovered from: aaot.org.ar
- CTO Group. CTO Manual of Medicine and Surgery. 8th Edition. Traumatology. Editorial CTO. Pages 1-20.
- Act for Libraries. Comminuted Fractue - Definition, causes, symptoms, treatment and recovery. Recovered from: actforlibraries.org
- Corinne grace. How to handel a comminuted fracture. April 4, 2014. Edmonton First Aid. Recovered from: firstaidcpredmonton.ca