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2A NEW APPROACH TO THE TREATMENT OF FRACTURES OF THE
PROXIMAL HUMERUS Davlatov B.N.1, Nuriddinov B.B.2, Botirov N.T.3
1Davlatov Bakhodir Nabiyevich - Doctor of medical sciences, Associate Professor, 2Nuriddinov Bakhodir Bakhtiyorjon ugli - Master, 3Botirov Nozim Turakhonovich - Master, ANDIJAN STATE MEDICAL INSTITUTE ANDIJAN, REPUBLIC OF UZBEKISTAN
Abstract: the tibia is the major weight bearing bone of the leg. It is connected to the less important bone, the fibula, through the proximal and distal tibiofibular joints. Key words: fracture both bones of leg, proximal, direct or indirect injury, open tibial fractures.
Like fractures of forearm bones, these bones frequently fracture together, and are referred to as 'fracture both bones of leg'. The following are some of the characteristics of these bones.
a) A subcutaneous bone: This is responsible for the large number of open tibial fractures; also, often there is loss of bone through the wound.
b) Fractures in this region are often associated with massive loss of skin, necessitating care by plastic surgeons, early in the treatment.
c) Precarious blood supply: The distal-third of tibia is particularly prone to delayed and non-union because of its precarious blood supply. The major source of blood supply to the bone is the medullary vessels. The periosteal blood supply is poor because of few muscular attachments on the distal-third of the bone. The fibula, on the other hand is a bone with many muscular attachments, and thus has a rich blood supply.
d) Hinge joints proximally and distally: Both, the proximal and distal joints (the knee and ankle) are hinge joints. So, even a small degree of rotational malalignment of the leg fracture becomes noticeable.
The tibia and fibula may be fractured by a direct or indirect injury. Direct injury: Road traffic accidents are the commonest cause of these fractures, mostly due to direct violence. The fracture occurs at about the same level in both bones. Frequently the object causing the fracture lacerates the skin over it, resulting in an open fracture.
Indirect injury: A bending or torsional force on the tibia may result in an oblique or spiral fracture respectively. The sharp edge of the fracture fragment may pierce the skin from within, resulting in an open fracture.
Diagnosis:
The diagnosis is usually confirmed by X-ray examination. Evaluation of the anatomical configuration of the fracture on X-ray helps in reduction.
Treatment: For the purpose of treatment, fractures of the tibia and fibula may be divided into two types: closed or open.
Open fractures: The aim in the treatment of open fractures is to convert it into a closed fracture by judicious care of the wound, and maintain the fracture in good alignment. Following methods can be used for treating the fracture, depending upon the grade of open fracture:
• Grade I: Wound dressing through a window in an above-knee plaster cast, and antibiotics.
• Grade II: Wound debridement and primary closure (if less than 6 hours old), and above-knee plaster cast. The wound may need dressings through a window in the plaster cast.
• Grade III: Wound debridement, dressing and external fixator application. The wound is left open.The trend is changing, from primarily conservative treatment to operative treatment, in care of open tibial fractures. More and more open fractures in grade I and II are being fixed internally.In a number of other cases, a delayed operation (ORIF) is done once the wound is taken care of.
Technique of closed reduction: Under anaesthesia, the patient lies supine with his knees flexed over the end of the table. The surgeon is seated on a stool, facing the injured leg. The leg is kept in traction using a halter, made of ordinary bandage, around the ankle (Fig-21.1). The fracture ends are manipulated and good alignment achieved, a below-knee cast is applied over evenly applied cotton padding. Once this part of the plaster sets, the cast is extended to above the knee. Wedging: Sometimes, after a fracture has been reduced and the plaster applied, check X-ray shows a little angulation at the fracture site. Instead of cutting open the plaster and reapplying it, it is better to wedge the plaster as shown in.In this technique, the plaster is cut circumferentially at the level of the fracture, the angulation corrected by forcing open the cut on the concave side of the angulation, and the plaster reinforced with additional plaster bandages.
Currently, the method most surgeons use for treating tibia fractures is intramedullary nailing. During this procedure, a specially designed metal rod is inserted into the canal of the tibia. The rod passes across the fracture to keep it in position. The intramedullary nail is screwed to the bone at both ends.
Intramedullary nails are usually made of titanium. They come in various lengths and diameters to fit most tibia bones.
Intramedullary nailing is not ideal for fractures in children and adolescents because care must be taken to avoid crossing the bone's growth plates.
Plates and screws. During this operation, the bone fragments are first repositioned (reduced) into their normal alignment. They are held together with screws and metal plates attached to the outer surface of the bone.
Plates and screws are often used when intramedullary nailing may not be possible, such as for fractures that extend into either the knee or ankle joints.
External fixation. In this type of operation, metal pins or screws are placed into the bone above and below the fracture site. The pins and screws are attached to a bar outside the skin. This device is a stabilizing frame that holds the bones in the proper position so they can heal.
Open reduction and fixation is necessary when it is not possible to achieve a satisfactory alignment of a fracture by non-operative methods.
The internal fixation device used may be a plate or an intra-medullary nail depending upon the configuration of the fracture. Interlock nailing provides the possibility of internally fixing a wide spectrum of tibial shaft fractures. With the availability of facilities, operative treatment has now become a method of preference. Pain after an injury or surgery is a natural part of the healing process. Your doctor and nurses will work to reduce your pain, which can help you recover faster.
Medications are often prescribed for short-term pain relief after surgery or an injury. Many types of medicines are available to help manage pain. These include acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), gabapentinoids, muscle relaxants, opioids, and topical pain medications. Your doctor may use a combination of these medications to improve pain relief, as well as minimize the need for opioids. Some pain medications may have side effects that can impact your ability to drive and do other activities. Your doctor will talk to you about the side effects of your medications.
Be aware that although opioids help relieve pain after surgery or an injury, they are a narcotic and can be addictive. Opioid dependency and overdose has become a critical public health issue in the U.S. It is important to use opioids only as directed by your doctor. As soon as your pain begins to improve, stop taking opioids. Talk to your doctor if your pain has not begun to improve within a few days of your treatment.
Most tibial shaft fractures take 4 to 6 months to heal completely. Some take even longer, especially if the fracture was open or broken into several pieces or if the patients uses tobacco products.
References
1. B.N. Davlatov, J.J. Tukhtayev, O. Abdukhalilov, Sh. Melikuzizoda. Use of bios in diaphysis fractures of the shin bones. "Экономика и социум" .№12(115) 2023. p. 190-194.
2. B.N. Davlatov, J.J. Tukhtayev, O. Abdukhalilov, Sh. Melikuzizoda. Optimization of the treatment in open fractures of the shin bones. "Экономика и социум" №12(115) 2023. P. 186-190.
3. Beltsios M., Savvidou O., Kovanis J., Alexandropoulos P., Papagelopoulos P. External fixation as a primary and definitive treatment for tibial diaphyseal fractures. Strategies Trauma Limb Reconstr. 2009;4(2):81-87.
