Closed Fracture

What is a closed fracture?

A closed fracture is defined as the interruption in bone continuity, which can be partial or total and is not accompanied by wounds that communicate the focus of the fracture with the outside. In some closed fractures there may be wounds; these are superficial, so there is no serious risk of infection.

In order for a fracture to occur, the bone must receive a trauma with a greater intensity than it is capable of supporting; however, there are other types of fracture that are the exception to this rule. Within this group fall insufficiency fractures, also known as pathological fractures.

Illustration of the differences between an open fracture and a closed fracture

Pathological fractures are those that occur in bone segments altered by general pathologies that affect them – for example: neoplasia, tumors, osteoporosis (the most common cause) – that fracture when receiving a trauma, even if it is of low intensity.

Low intensity trauma fractures caused by stress or fatigue of the bone in the face of reverse cyclical mechanical demands, or repeated microtrauma in the same bone segment are also described.

In the case of the latter, the diagnosis can be complicated, which may lead to the need to perform a bone scan to reveal hyperuptake in the fractured focus.

Diagnosis

X-ray of a closed fracture

Due to the fact that the fractured bone segments are not visible, for the correct diagnosis of a closed fracture the clinic is the initial resource, to derive an X-ray examination and thus confirm the bone interruption.

The symptoms presented in a closed fracture consist of signs of Celsus, such as redness, color, heat, swelling, and loss or decrease of the function of the body segment.

Deformity and functional impotence are the key elements in the initial clinical diagnosis, which would justify the performance of a simple X-ray examination to confirm the clinical suspicion.

However, depending on the site where the fracture occurs, a computerized axial tomography (CT) scan may be necessary, due to the difficulty of its appreciation in a simple X-ray examination; an example is some proximal pelvic or humerus fractures.

The other diagnostic imaging means, such as magnetic resonance imaging (MRI) and bone scan, are often used as a last resort.

First aid

Closed fractures are not in themselves a medical emergency unless the clinic demonstrates vascular injuries; however, the transfer to a specialized center to avoid complications that make the situation a real emergency must be immediate.

Once the emergency service has been contacted, we must begin monitoring vital signs to rule out clinical signs of hypovolemic shock or some other significant trauma.

In the case of a probable closed fracture, the most important recommendation for the first aid worker at the accident site is to avoid mobilization of the limb, both actively and passively.

It is impossible to know with certainty the line of the fracture, and the probability that some bone fragment injures soft tissue or vascular is high. Therefore, fracture reduction maneuvers should not be applied.

To do this, the importance of immobilizing the affected body segment should be explained to the affected person, but body movement in general should also be limited, to avoid displacement of bone fragments.

The body segment must be immobilized in the exact position in which the patient was found, using whatever object is at hand: cardboard, wooden sticks, belts, among others.

Treatment

Like any medical or surgical treatment, the ultimate goal is to achieve maximum functional recovery of the bone segment involved.

For this, knowledge of the consolidation process and all the factors that promote or hinder it are important, as they must be applied or avoided to promote early recovery.

Conservative treatment and orthopedic treatment are the most recommended in closed fractures, except for complications or multiple trauma that require surgical intervention.

Each body segment has its own orthopedic techniques created for the anatomy of each specific bone. In this way, syndactilization, the use of plaster, splints or tractions can be mentioned, which will depend on the type and place of the fracture.

In some very exceptional cases, such as a rib fracture, even therapeutic abstention can be considered as conservative treatment.

However, this results in the suspicion of the patient; therefore, the reason for abstention must be correctly explained.

Surgical treatment

The surgical criteria in closed fractures are due to certain characteristics of the fractures that, if not resolved in the shortest possible time, can bring with them functional limitations later, which in some cases can become permanent.

Some of the characteristics that are considered criteria or indication for surgical treatment are the following:

  • When there is associated vascular injury.
  • In cases of associated compartment syndrome, or if there is a risk of compartment syndrome.
  • If there is multiple trauma with various fracture foci.
  • Interarticular fractures displaced more than 2 mm.
  • Pathological fractures that do not comply with sufficient factors that favor consolidation.
  • Structural fractures that are naturally distracted by adjacent muscles and tendons (eg, patella).
  • Comminuted fractures.
  • Fractures in which conservative treatment does not work.

Difference between closed fracture and open fracture

The characteristic that essentially differentiates a closed fracture from an open fracture is that in the closed fracture there is no break in continuity in the surrounding skin or soft tissues communicating outside with the fracture site.

On the contrary, in the open fracture there is a visible wound that, although it does not have to be right at the level of the bone lesion, it is in the same body segment, becoming an area of ​​high risk of contamination.

Another characteristic that differentiates them in some cases is that the open fracture is almost always evident, although not in 100% of the cases; fractured fragments may peek through or show through the wound. If not, the segment deformity may be more clearly noted.

In the case of closed fractures, the deformity is not always evident and imaging studies are required for diagnosis.

References

  1. Burgo Flores. Fractures Orthopedic Surgery and Traumatology. Editorial Médica Panamericana. 1999. Pages 3-27.
  2. Ronald Mcrae. Max Esser. Practical treatment of fractures. 5th Edition. Editorial Elsevier. 2009. pp. 4-5, 25-30
  3. CTO Manual. Medicine and Surgery. Traumatology and orthopedics. 8th Edition. Spain. 2014. pp. 1-9.
  4. Christian Nordqvist. What is a fracture? Medical News Today. December 2017. Recovered from: medicalnewstoday.com
  5. Richard Bucley MD. General Principles of Fractures Care Tratment & Management. Medscape. 2018. Recovered from: emedicine.medscape.com

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