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1INJURIES TO THE LOWER EXTREMITIES IN POLYTRAUMA: TIBIAL BONES FRACTURE AND TREATMENT Davlatov B.N.1, Mirzayuldashev N.Yu.2, Abdukhalimov O.O.3
1Davlatov Bakhodir Nabiyevich - Doctor of medical sciences, Associate Professor, 2Mirzayuldashev Numon Yuldashevich - Associate Professor, 3Abdukhalimov Obidjon Odiljon ugli - Master, ANDIJAN STATE MEDICAL INSTITUTE ANDIJAN, REPUBLIC OF UZBEKISTAN
Abstract: 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.
Keywords: injuries, treatment, polytrauma, tibial bone fracture, plastic surgeons, fracture lacerates, skin.
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. 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 o f 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.
d) Hinge joints proximally and distally: Both, the proximal and distal joints (the knee and ankle) are hinge joints. Mechanism. 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. The fracture may be closed or open, and may have various patterns. It may occur at different levels (upper, middle or lower-third). Occasionally, it may be a single bone fracture i.e., only the tibia or fibula is fractured. Displacements may be sideways, angulatory or rotational. Occasionally, the fracture may remain undisplaced.
Treatment. For the purpose of treatment, fractures of the tibia and fibula may be divided into two types: closed or open.
Closed fractures: Treatment of closed fractures, both in children and in adults, is by closed reduction under anaesthesia followed by an above-knee plaster cast. In
children, it is possible to achieve good alignment in most cases, and the fracture unites in about 6 weeks. In adults, the fracture unites in 16-20 weeks. Sometimes, reduction is not achieved, or the fracture displaces in the plaster. In both these cases open reduction and internal fixation is required. The trend is changing with the availability of minimally invasive techniques such as of closed nailing. More and more unstable tibial fractures are being treated with closed interlock nailing.
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. The fracture ends are manipulated and good alignment achieved. Initially, 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. Once the fracture becomes 'sticky' (in about 6 weeks), above-knee plaster is removed and below-knee PTB (patellar tendon bearing) cast is put. Use of modern, synthetic casting tapes (made of plastic polymer) has made 'plaster' treatment more convenient. Once the fracture has partly united, the cast can be replaced by removable plastic supports (braces), and the joints mobilised.
Role of operative treatment: Open reduction and internal fixation is necessary when it is not possible to achieve a satisfactory alignment of a fracture by nonoperative methods. The internal fixation device used may be a plate or an intramedullary 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. The bones forming the ankle joint are a frequent site of injury. A large variety of bending and twisting forces result in a number of fractures and fracture-dislocation at this joint. All these injuries are sometimes grouped under a general title 'Pott's fracture'.
It is based on the mechanism of injury. It is believed that a specific pattern of bending and twisting forces results in specific fracture pattern. Different types of ankle injuries have been classified on the basis of five basic mechanisms. These are as follows:
a) Adduction injuries.
b) Abduction injuries.
c) Pronation-external rotation injuries.
d) Supination-external rotation injuries.
e) Vertical compression injuries
Operative methods: More and more surgeons are now resorting to internal fixation for all displaced fractures of ankle without attempting closed reduction. This is done because by operative reduction, it is possible to achieve perfect alignment as well as stable fixation of fragments. This allows early motion of the ankle joint, thereby improving overall results.
This approach is justified in hospitals where trained staff and all equipment necessary for such work is available.
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. Giannoudis P.V., Papakostidis C., Roberts C. A review of the management of open fractures of the tibia and femur. 2006;88(3):281-289.
