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GENERAL PRINCIPLES OF FRACTURE
The word „ORTHOPEDIAE” is Greac origin (ortos=upright; paideia=child). Nicolas
Andry uses for first time this term and in 1741 he published the treatise „ORTHOPEDIAE,
OR ART TO PREVENT AND TO CORRECT A BODY DEFORMATION OF CHILDREN”
.Orthopediae and traumatology is the science which studies and treats congenital and gain
disease of musculoskeletal system.
Bone, a calcified connective tissue, forms most of the adult skeleton, which consist of
approximately 206 bones. The axial skeleton consists of the bone of the head, the bone of the
vertebral column, the ribs, and the sternum. The apendicular skeleton consists of the bones of
the extremities.
Basic function of the skeleton:
1. bone suports and protects certain internal organs
2. bones act as biomechanical levers on which muscles act to produce motion
3. as a tisue, bone is in dynamic equilibrium with its bathing medium and serves as
a reservoir of ions ( Ca++, PO-4, and CO--3 ) in mineral homeostasis
4. the bone marrow in the adult is the source of red blood cells, granular white
blood cells, and platelets.
Composition of bone. Bone is composed of living cells and an organic intercellular
matrix an inorganic component.
a. Connective tissue cells become osteocytes as the collagen meshwork that they
secrete undergoes calcification and ossification.
b. The collagenous matrix provides tensile strength. If the mineral content of bone is
removed by acid, the remaining collagenous meshwork is flexibile but not
particularly extensile.
c. The mineral content, a crystalline hydroxiapatite complex of calcium, provides
shear strenght and compressive srength. If the collagenous matrix is removed by
incineration, the remaining inorganic matrix is very brittle.
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SKELETAL ORGANIZATION-206 BONES
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LONG BONE STRUCTURE
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BIOLOGY OF FRACTURE HEALING (BONE REGENERATION)
Ever since Hunter demonstrated that the bone is a dynamic tissue involved in the
equilibrium of bone deposition and resorption, the mechanisms of bone repair have been
studied. Hunter described the classic stages of natural bone repair: (1) inflamation, (2) soft
callus, (3) hard callus, and (4) remodeling. Brighton added stages of impact and
induction.
The impact stage includes the interval from the first application of force to the bone
until the energy of the force is completely dissipated, resulting in energy absorption by the
bone until fracture occurs.
The inflamation stage follows, usually lasts 1 to 3 days clinically, bleeding and
fracture hematoma forms, and is evidenced by pain, swelling, and heat. Inflammatory cells
arrive at the injuried site accompanied by vascular ingrowth and cellular proliferation.
Osteogenic cells invade tissue and lay down osteoid. This stage persists until the
cartilaginous elements appear.
Brighton’s induction stage begins during the impact and inflammatory stage and is
believed to involve the formation of inducers and humoral factors that direct the regeneration
of bone.
The soft callus stage. At 3 weeks a soft callus forms consisting of osteoid and
cartilage, corresponds clinically to the time when clinical union occurs by fibrous or
cartilaginous tissue. Histologically it is characterized by vascular ingrowth of capillaries into
the fracture callus and the appearance of chondroblasts.
In the hard callus stage the fibrocartilaginous union is replaced by fibro-osseous
union. Clinically this usually occurs at 3 to 4 months.
The final stage of remodeling of united fracture begins with clinical and
roentgenographic union and persists until the bone is returned to normal, including
restoration of the medullary canal. Histologically the fibrous bone is replaced with lamellar
bone, which may take months to years.
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FRACTURE REPAIR PROCESS
A classic study by White et al. (1977, Journal of Bone and Joint Surgery, "The four
biomechanical stages of fracture repair", 59A:188-192), characterized the mechanical
properties of healing fracture tissue into four stages. These four stages are as follows:
Stage 1: Bone fails through original fracture site; has low stiffness similar to soft tissue
stiffness. Fracture site has low stiffness and low strength.
Stage 2: Bone fails through original fracture site, but stiffness is more similar to mineralized
tissue. Fracture site has normal bone stiffness but low strength.
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Stage 3: Bone fails partially through original site and partially through surrounding bone.
Fracture site has normal bone stiffness and medium strength.
Stage 4: Site of failure is not related to original fracture. Fracture site has normal bone
stiffness and normal bone strength.
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PRINCIPLES OF SURGICAL TREATMENT
Rather than a listing of absolute indication for surgical reduction and stabilization,
those situation are described in which the probability is high that surgical treatment will be
required to obtain an optimal result:
1. Displaced intraarticular fractures suitable for surgical reduction and stabilization.
2. Unstable fractures in which an appropiate trial of nonoperative management has
failed.
3. Major avulsion fractures associated with disrubtion of important musculotendinous
units or ligamentous groups that have been shown to have a poor result with
nonoperative treatment.
4. Displaced pathologic fractures in patiens not imminently terminal.
5. Fractures for which nonoperative treatment is known to yield poor functional results,
such as femural neck fractures, Galeazzi fracture-dislocations, and Monteggia
fracture-dislocations.
6. Displaced epiphyseal injuries that have a propensity for growth arrest (Salter-Harris
types III-IV).
7. Fractures with compartment syndromes that require fasciotomies.
8. Nonunions, especially malreduced ones, in which previous nonoperative or surgical
treatments have failed.
The Salter-Harris Classification System Since the 1960's, the Salter-Harris
classification, which divides most growth plate fractures into five categories based on the
type of damage, has been the standard. The categories are as follows
Type I. The epiphysis is completely separated from the end of the bone, or the metaphysis.
The vital portions of the growth plate remain attached to the epiphysis. Only rarely will the
doctor have to put the fracture back into place, but all type I injuries generally require a cast
to keep the fracture in place as it heals. Unless there is damage to the blood supply, the
likelihood that the bone will grow normally is excellent.
Type II. This is the most common type of growth plate fracture. The epiphysis, together
with the growth plate, is partially separated from the metaphysis, which is cracked. Unlike
type I fractures, type II fractures typically have to be put back into place and immobilized for
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normal growth to continue. Because these fractures usually return to their normal shape
during growth, sometimes the doctor does not have to manipulate this fracture back into
position.
Type III. This fracture occurs only rarely, usually at the lower end of the tibia, one of the
long bones of the lower leg. It happens when a fracture runs completely through the
epiphysis and separates part of the epiphysis and growth plate from the metaphysis. Surgery
is sometimes necessary to restore the joint surface to normal. The outlook or prognosis for
growth is good if the blood supply to the separated portion of the epiphysis is still intact, if
the fracture is not displaced, and if a bridge of new bone has not formed at the site of the
fracture.
Type IV. This fracture runs through the epiphysis, across the growth plate, and into the
metaphysis. Surgery is needed to restore the joint surface to normal and to perfectly align the
growth plate. Unless perfect alignment is achieved and maintained during healing, prognosis
for growth is poor. This injury occurs most commonly at the end of the humerus (the upper
arm bone) near the elbow.
Type V. This uncommon injury occurs when the end of the bone is crushed and the growth
plate is compressed. It is most likely to occur at the knee or ankle. Prognosis is poor, since
premature stunting of growth is almost inevitable.
A newer classification, called the Peterson classification, adds a type VI fracture, in
which a portion of the epiphysis, growth plate, and metaphysis is missing. This usually
occurs with an open wound or compound fracture, often involving lawnmowers, farm
machinery, snowmobiles, or gunshot wounds. All type VI fractures require surgery, and
most will require later reconstructive or corrective surgery. Bone growth is almost always
stunted.
Fractures in which surgical reduction and stabilization have a moderate probability of
resulting in improved function include:
1.
Unstable spinal injuries, long bone fractures, and unstable pelvic fractures,
especially in polytrauma patients.
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2.
Delayed unions after an appropiate trial of nonoperative management.
3.
Impeding pathologic fractures.
4.
Unstable open fractures.
5.
Fractures associated with complex soft tissue lesions (Gustilo type 3B open
fractures, burns over fractured areas, or preexisting dermatitis).
6.
Fractures in patients in whom prolonged immobilization will lead to increased
systemic complication (such as hip and femoral fractures in elderly patiens and
multiple fractures in patiens with injury severity scores of less than 18. Unstable
infected fractures or unstable septic nonunions.
7.
Fractures associated with vascular or neurologic deficits that require surgical
repair, including long bone fractures in patiens with spinal cord, conus, or proximal
nerve root lesion.
Situation with a low probability for improvement of functional outcome after surgery
include:
1. Cosmetic improvement of fractures deformities that do not impair function.
2. Stabilization for economic considerations to allow more rapid discharge from an
acute care facility without a significant functional improvement over nonoperative
modalities.
INJURIES OF THE SHOULDER GIRDLE
The shoulder joint consists of 2 bones, the Scapula and the Humerus. The scapula has
several parts. The blade of the scapula is what can be felt as the shoulder blade. This
provides a surface for the attachment of many muscles. The acromion is a continuation of a
thickening of the blade called the spine of the scapula. The acromion lies over the top of the
shoulder joint, covering the rotator cuff muscles. Part of the deltoid muscle takes its origin
from this bone. The acromion forms a joint with the clavicle (collar bone) at the front of the
shoulder (the acromio-clavicular joint). A small protrusion of the scapula forwards is the
coracoid and this has the origin of part of the biceps muscle. The final part of the scapula id
the glenoid. This is a flattened area in facing outwards and serves as the articulating or joint
surface with the humerus. The humerus has the long shaft of the upper arm and ends with the
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humeral head, which articulates with the glenoid. There is a groove for the long head of the
biceps muscle and tuberosities (bumps) for the attachment of the rotator cuff muscles.
The humeral head articulates with the glenoid. Both are covered with articular
cartilage that allows low friction movement. One side (the humerus) is convex and the other
(the glenoid) is flat. As this is an inherently unstable arrangement a rim of tissue, the labrum,
deepens the glenoid. If this rim becomes damaged or detached the shoulder joint can become
unstable or dislocate. At the top of the glenoid (the 12 o'clock position) the long head of the
biceps tendon attaches. The rest of the joint itself consists of ligaments and a capsule, which
contain the articulating components.
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1. FRACTURE OF THE CLAVICLE
The clavicle forms the anterior portion of the shoulder girdle. It is a long bone, curved
somewhat like the italic letter f, and placed nearly horizontally at the upper and anterior part
of the thorax, immediately above the first rib. It articulates medially with the manubrium
sterni, and laterally with the acromion of the scapula. It presents a double curvature, the
convexity being directed forward at the sternal end, and the concavity at the scapular end. Its
lateral third is flattened from above downward, while its medial two-thirds is of a rounded or
prismatic form
Etiology: work injuries, sport injuries, road injuries.
Fractures of the clavicle may occur as a result of a direct trauma or indirect force
transmitted through the shoulder. Fracture of the clavicle is most commonly due to a violent
upwards and backwards force as might be sustained by landing on the outstretched hand after
being thrown from a horse or over the handlebars of a bicycle. Less commonly the clavicle
may be fractured by blows or falls on the point of the shoulder or by direct violence.
Sites:

most commonly, the clavicle fractures somewhere along the middle one-third,
frequently, at the middle one-third / outer one-third junction

less commonly, a fracture occurs within the outer one-third; these may be severely
displaced if associated with a coracoclavicular tear
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Most fractures of the clavicle occur in the middle third. Because of the relative
fixation of the medial fragment and the weight of the arm, the distal fragment is displaced
downward and toward the midline.
Simptomatology:
-pain, deformity
-swelling
-bone friction (abrasion or rubbed)
-discontinuous bone
-abnormal mobility
-„piano key’s” symptom
A person with a fractured clavicle usually shows definite symptoms. When the victim
stands, the injured shoulder is lower than the uninjured one. The victim is usually unable to
raise the arm above the level of the shoulder and may attempt to support the injured shoulder
by holding the elbow of that side in the other hand; this is the characteristic position of a
person with a broken clavicle. Since the clavicle lies immediately under the skin, you may be
able to detect the point of fracture by the deformity and localized pain and tenderness.
Diagnosis:
The fracture can be seen on anteroposterior X-rays, and occasionally an oblique
cephalad projection will give additional information.
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Complications:
-the open fracture
-hemo - pneumothorax
-vicious consolidation
-pseudartrosy (non-union)
-injury to the brachial plexus or subclavian vessels is not common but should be
sought on physical examination.
Clasification:
Clavicle fractures are basically divided into three types based upon location. A.
Fractures near the sternum are the least common (less than five percent of all clavicle
fractures). B. The most common fractures of the clavicle are in the middle of the shaft of the
bone, approximately halfway between the sternum and the AC joint. C. Fractures near the
AC joint are the second most common and can come in many different patterns.
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Treatment:
If the fracture is open, stop the flow of blood and treat the wound before attempting to
treat the fracture. Then apply a sling and swathe splint as described below: Bend the victim’s
arm on the injured side, and place the forearm across the chest. The palm of the hand should
be turned in, with the thumb pointed up. The hand should be raised about 4 weeks.!!!!!!!
The most common way to treat the fractures in the middle is with immobilization with
either a sling or a special bandage called a "figure-of-8 splint." Studies have shown that these
fractures heal just as quickly and as well with a sling as with the figure-of-8 splint, so we
recommend a sling in a majority of cases. The figure-of-8 splint generally is uncomfortable,
difficult to wear non-stop for six or eight weeks, can result in skin problems and a smelly
patient because it should not be removed to wash the armpit. Figure-of-8 splints are not
indicated or useful in fractures of the clavicle near the AC joint. However, some orthopaedic
doctors have strong opinions about the use of this figure-of-8 device, and it can produce an
acceptable result.
A. Fracture without displacementtreatment is by immobilization in a sling or figureof-eight dressing for 4-6 weeks.
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B. Fracture with displacment or comminution.
1. Closed reduction. Reduction need not be exact, because excessive callus formation will be
partially or completely obliterated in the late stages of the natural healing process. Reduction
of fragments may be performed easily, but maintenance of reduction is more difficult.
Immobilization must be maintained for 6-8 weeks. The incidence of non-union is less than
1% after closed treatment.
2. Open reduction. Open reduction and internal fixation may be justifable where there is
interposition of soft tissue or when the fractures is not reductible and is causing damage to
the overlying skin. Fixation may be achieved by used of a metal plate and screws or pin
drilled retrograde through the lateral fragment. The fractures is then reduced, and the pin is
driven across the fractures site.
Complication of open reduction include infection, migration or breakage of the
fixation device, and an increased incidence of nonunion.
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2. FRACTURE OF THE SCAPULA
There is very rare and the fracture of neck, acromion, spine, coracoid process, or body
of the scapula is most often caused by a blow on the shoulder or by a fall on the outstretched
arm or may result from violent muscular contraction.
Simptomatology:
-pain
-limitation of shoulder joint motion
-deformity
The treatment: of impacted or undisplaced fractures in patiens 40 years of age or older
should be directed toward the preservation of shoulder joint function, since stiffnes may cause
prolonged disability. In young unstable fractures require arm traction with the arm at right
angles to the trunk for about 4 weeks and protection in a Dessault sling and swathe for an
additional 2-4 weeks. Open reduction is rarely required even for major displaced fragments,
except for those involving the articular surface. These fractures are likely to involve only a
segment of the articular surface and may be impacted. When major displacement of an
articular fragment is present, accurate repositioning and internal fixation are desirable
because of the likelihood of secondary glenohumeral osteoarthritis.
Eighty-five percent of patiens with fracture of the scapula have associated bone and
soft tissue injuries, most commonly in the thoracic area.
3. ACROMIOCLAVICULAR DISLOCATION
Dislocation of the acromioclavicular joint may be incomplete or complete. Injuries to
the acromioclavicular joint can be classified according to the severity of damage done by the
force of injury:
Rockwood described six types of injuries to the acromioclavicular joint (Figure 2).1,2
This classification has proven useful in terms of prognosis and treatment.
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Type I injuries involve acromioclavicular ligament sprain; the joint itself is not
disrupted. In type II injuries, the acromioclavicular ligaments are completely torn and the
coracoclavicular ligaments are sprained; this results in slight vertical subluxation of the
clavicle. Type I and II injuries are incomplete in that the acromioclavicular joint is not
dislocated.
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Type III injuries are complete and involve disruption of the acromio- and
coracoclavicular ligaments, resulting in an acromioclavicular joint dislocation. The clavicle
is displaced superiorly by 25%-100%. Type IV injuries also are complete; however, in these
cases, the clavicle is displaced posteriorly into or through the trapezius muscle.
Type V injuries are severe type III injuries, in which detachment of the deltoid and
trapezius from the distal clavicle is extensive, resulting in extreme superior displacement of
the clavicle by. 100%-300%.
Type VI injuries, which are extremely rare, involve inferior dislocations of the
acromioclavicular joint in which the clavicle is displaced into a subacromial or subcoracoid
position.
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Diagnosis: Anteroposterior X-rays should be taken of both shoulders with the patient
erect. Displacement is more likely to be demonstrate when the patient holds a 6-8 kg weight
in each hand.
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Treatment:
Acute AC Joint Dislocations
Type I and II:

Sling and early motion based on symptoms
Closed treatment methods are almost universally recommended for type I, II and III
injuries; may be treated by a sling until acute pain from movement and the weight of the
upper extremity has been relieved. Is necessary external immobilization in a Dessault sling
for 10 days.
Type III:

Any discussion of the management of acute injuries to the AC joint must confront not
only the question of which of the more than 30 methods of surgical treatment
described is best, but whether surgery should be considered at all for injury type III

Is contra-indicated in athletes participating in contact sports as they will simply reinjure the shoulder in the future

When read closely, most studies have the same results, regardless of the authors'
conclusions - longer recovery times and high local complication rates for surgically
treated patients without any improvement in long-term function yet most authors
hedged their conclusions, suggesting surgical treatment for patients whose work
required frequent abduction to 90 degrees with forward flexion.
Type IV-VI

Account for less than 10% to 15% of the total number of AC dislocations and should
be managed surgically.
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Of the few statistically valid, prospective series comparing closed with surgical
treatment of acromioclavicular dislocations, none show superior results after surgical
management
Surgical Techniques
Of the many types of surgical treatment described, there are basically two general
approaches:
1. Fixation of the AC joint directly by K-wires ± tension band
2. Indirect purchase on the AC joint with coracoclavicular fixation such as screw, wire
loop, woven Dacron loop, other ligament substitutes or hook plates
3. Plication of the torn deltotrapezius at the distal clavicle is an important part of the
repair
These procedures may be combined with debridement of the AC joint and repair of the
coracoclavicular ligaments, and ligament transfer
Treatment of Non-acute Injuries

For the patient with a chronic AC joint dislocation or subluxation that remains painful
after 3 to 6 months of closed treatment and rehabilitation, surgery is indicated to
improve function and comfort.

Only a minority of patients with untreated AC joint injuries will actually choose to
have surgical treatment.

For sequel of untreated type IV-VI, or painful type
Type III injury is indicated to be surgical realignment and fixation within 2 weeks
after complete dislocation offers the best hope of restoring anatomic alignement. Fixation is
obtained by Kirschner wires or a Steinmann pin driven across the acromioclavicular joint or
by fixation of the clavicle to the coracoid process by means of a screw or wire.
Old and unreduced dislocation with secondary osteoarthritis can be treated by
resection of the distal 1-1,5 cm of the lateral clavicle.
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Complications of the surgical treatment include infection, redislocation after hardware
removal, and migration of hardware.
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4. STERNOCCLAVICULAR DISLOCATION
Displacement of the sternal end of the clavicle may occur superiorly, anteriorly,
orinferiorly. Retrosternal displacement is less common.
Symptoms include:
Pain when you push in at the point where your collar bone meets your breast bone.
Pain radiating into the shoulder.
Diagnosis: can be diagnosed by physical examination suplemented by anteroposterior
and oblique X-rays. Sometimes, examination by CT scan may be necessary to confirm the
diagnosis.
Complications. Occlusion of the subclavian artery. Pneumothorax. Rupture of the
esophagus. Unreduced anterior subluxation is asymptomatic except for a bump that may be
cosmetically objectionable.
Treatment. The dislocation are generally not difficult to reduce. If a retrosternal
dislocation does not reduce with lateral traction applied to the abducted arm, the skin can be
sterilized and a sterile towel clip used to grasp the medial clavicle and reduced it. Open
reduction with repair of torn sternoclavicular and costoclavicular ligaments with or without
internal fixation may be required to maintain adequate reduction. Extraperiosteal resection of
the medial portion of the clavicle may be necessary for relief of pain. However it is reported
that few Surgeons will attempt it and it is only 50% successful The external immobilization
may be maked!!! by a sling.
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5. DISLOCATION OF THE SHOULDER JOINT
Shoulder dislocation is documented in Egyptian tomb murals as early as 3000 BC,
with depiction of a manipulation for glenohumeral dislocation resembling the Kocher
technique. Hippocrates detailed the oldest known reduction method still in use today.
The shoulder dislocates more than any other joint. It moves almost without restriction,
but pays the price of vulnerability. The shoulder's integrity is maintained by the
glenohumeral joint capsule, the cartilaginous glenoid labrum (which extends the shallow
glenoid fossa), and muscles of the rotator cuff.
Anterior dislocations account for over 95% of dislocations, with posterior dislocations
making up 4% and inferior dislocations about 0.5%. Superior and intrathoracic dislocations
are extremely rare.
Frequency: A Dutch study estimated the incidence of shoulder dislocation at 17 per
100,000.
Sex: Distribution is bimodal, with peak incidence in men aged 20-30 years and women aged
61-80 years.
Age: Shoulder dislocation occurs more frequently in adolescents than children, because the
weaker epiphyseal growth plates in children tend to fracture before dislocation occurs. In
older adults, collagen fibers have fewer cross-links, making the joint capsule and supporting
tendons and ligaments weaker and dislocation more likely. Older adults also fall more
frequently.
History: Patients generally complain of severe shoulder pain and decreased range of motion
with a history of trauma.
Anterior dislocations of the shoulder joint
Anterior shoulder dislocations usually result from abduction, extension, and external
rotation, such as when preparing for a volleyball spike. Falls on an outstretched hand are a
common cause in older adults. The humeral head is forced out of the glenohumeral joint,
rupturing or detaching the anterior capsule from its attachment to the head of the humerus or
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from its insertion to the edge of the glenoid fossa. This occurs with or without lateral
detachment.
Simptomatology:
-flattening of the deltoid region - epaulette’s symptom. Shoulder is "squared off" (ie,
boxlike) with loss of deltoid contour compared to contralateral side
-anterior fullness, arm is held in slight abduction and external rotation
-restriction of motion due to pain
-humeral head is palpable anteriorly (in the subcoracoid region, beneath the clavicle).
-Berger’s symptom - elastic abduction of arm. Patient resists abduction and internal rotation
and is unable to touch the opposite shoulder
Diagnosis: is clinical and X-rays. Both anteroposterior and axillary are necessary to
determine the site of the head and the presence or absence of complicating fracture, which
may involve either the head of the humerus or the glenoid.
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Complications:
-injury to major nerves arising from the brachial plexus, most commonly the axillary nerve;
in all cases, evaluate the axillary nerve before and after reduction by testing both pinprick
sensation in the "regimental badge" area of the deltoid and palpable contraction of the deltoid
during attempted abduction. Evaluate sensory and motor function of the musculocutaneous
and radial nerves.
-vascular injury; compare bilateral radial pulses to help rule out vascular injury.
-fracture of the humeral head or neck or greater tuberosity
-compresion or avulsion of the anterior glenoid
-tears of the capsulotendinous rotator cuff
Treatment. With analgesia, reduction can usually be accomplished by simple traction on the
arm for a few minutes or until the head has been disengaged from under the coracoid.
If reduction cannot be achieved in this way, the surgeon should apply lateral traction
manually to the upper arm, close to the axila, while an assistant continues to exert axial
traction on the extremity.
Hippocrate's manipulation, in which the surgeon exerts traction on the patient’s arm
while placing an unshod heel in the axila to provide countertraction and simultaneously force
the head of the humerus laterally from beneath the glenoid.
Kocher’s method, in which general anesthesia with complete relaxation is usually
successful. The elbow is flexed to a right angle, and the surgeon applies traction and gentle
external rotation to the forearm in the axis of the humerus. The surgeon continues traction to
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the arm while the gentle external rotation about the longitudinal axis of the humerus is
applied, using the patient’s forearm flexed to a right angle at the elbow as a lever.
After closed reduction of an initial dislocation, the extremity is placed in a shoulder
immobilizer or Dessault sling for 1-3 weeks before active motion is begun.
Posterior dislocations of the shoulder joint occurs either from direct or indirecct force
to the anterior shoulder, so that the humeral head is pushed out posteriorly. Posterior
dislocations are caused by severe internal rotation and adduction. This usually occurs during
a seizure, a fall on an outstretched arm, or electrocution. Occasionally, a severe direct blow
may cause a posterior dislocation. Bilateral posterior dislocation is rare and almost always
results from seizure activity.
Simptomatology:
-arm is held in adduction and internal rotation
-anterior shoulder is "squared off" and flat with prominent coracoid process; shoulders may
look identical in bilateral dislocation, making it a commonly missed injury.
-posterior shoulder is full with humeral head palpable beneath the acromion process
-fullness beneath the spine of the scapula
-flattening of the anterior shoulder
-pain
-restriction of motion in external rotation and abduction
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Diagnosis: is clinical and X-rays. Anteroposterior X-rays of the shoulder may look
deceptively normal with posterior dislocation, but an axillary view will show the true
position of the head in relation to the glenoid.
Treatment. This dislocation may be reduced by the combination of coaxial and transverse
traction. If the reduction is stable, immobilization in a shoulder immobilizer is sufficient. If
the reduction is not stable, immobilization following an initial episode should be
accomplished by a plaster, with the arm in 30 degrees of external rotation and the elbow
flexed to a right angle for 3-6 weeks before active motion is permitted.
Inferior shoulder dislocation (luxatio erecta)
Arm is fully abducted with elbow commonly flexed on or behind head Humeral head
may be palpable on the lateral chest wall.
Rare, but serious, inferior dislocations (luxatio erecta) may be due to axial force
applied to an arm raised overhead, such as when a motorcycle collision victim tumbles to the
ground. More commonly, the shoulder is dislocated inferiorly by indirect forces
hyperabducting the arm. The neck of the humerus is levered against the acromion and the
inferior capsule tears as the humeral head is forced out inferiorly. This injury always is
accompanied by fracture and/or serious soft-tissue injury.
Treatment:
Maintain gentle axial traction on the humerus while gentle abduction is applied. Apply
countertraction across the ipsilateral shoulder.
Following reduction, slowly adduct the arm.
Buttonholing of the humeral head through the capsule usually requires open reduction.
6. RECURRENT & CHRONIC DISLOCATIONS OF THE SHOULDER JOINT
Recurrent dislocation of the shoulder is almost always anterior. Various factors can
influence recurrent dislocation:
-severity of the original trauma
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-immobilization weeks after initial dislocation followed an rehabilitation program
-avulsion of the anterior and inferior glenoid labrum or tears in the anterior capsule remove
the natural buttress that gives stability to the arm with abduction and external rotation
-other lesion that impair the stability of the shoulder joint are fractures of the posterior and
superior surface of the head of the humerus and longitudinal tears of the rotator cuff between
the supraspinatus and subscapularis muscles
-wedge-shaped defect or groove in the posterolateral aspect of the humeral head, can be
demonstrated by X-rays.
Adequate treatment of recurrent dislocation of the shoulder is only surgical repair.
Most of the procedures are direccted toward repair of the anterior capsular mechanism,
subscapularis muscle shortening, or subscapular transfer. If the humeral head is severely
damaged, replacement with Neer prothesis may be preferable. After operative repair, the
shoulder is usually immobilized in a shoulder immobilizer for 3-6 weeks before active
motion is begun.
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FRACTURE OF THE PROXIMAL HUMERUS
Humerus fractures, particularly fractures of the proximal humerus, are encountered
commonly in the ED, occurs most frequentely during the sixth decade (patiens with
osteoporosis). Rarely do these injuries represent surgical emergencies; however, the
emergency physician must recognize which fractures require urgent, versus emergent,
orthopedic referral.
Pathophysiology: Humerus fractures typically are caused by direct trauma to the arm or
shoulder or axial loading transmitted through the elbow. Attachments from pectoralis major,
deltoid, and rotator cuff muscles influence the degree of displacement of proximal humerus
fractures.
Frequency: Humerus fractures represent 4-5% of all fractures.
Age: Fracture patterns are similar across all ages, though older persons are more prone
to fracture because of osteoporosis.
History:

Most patients convey blunt trauma to the arm or shoulder or axial loading through the
elbow. Typical history involves a fall on an outstretched, abducted arm.

Pathologic fractures of the humerus may occur with minimal trauma. Fractures that
occur spontaneously, without apparent injury, suggest pathologic fracture. Suspect
these in patients with the following history:
o
Cancer metastatic to bone
o
Paget disease
o
Bone cyst
o
Pain
o
Edema
o
Decreased range of motion (ROM)
Simptomatology:
-pain occurs with palpation or movement of shoulder or elbow
-swelling of the shoulder region, ecchymosis and edema usually are present
30
-visible or palpable deformity
-restriction of motion due to pain
Diagnosis: is clinical and roengenografic.!!!!!!!!!The precise diagnosis is established
by X-rays taken perpendicular to the plane of the scapula and by a lateral view made at a
right angle to the former, tangential to the body of the scapula. Axillary and transthoracic Xrays are helpful to demonstrate the direction of any displacement of the head of the humerus
from the glenoid or infractions involving the articular surfaces of the shoulder joint.
Classification of proximal humeral fractures proposed by Neer is based on the
presence or absence of displacement of the articular surface of the humeral head, greater
tuberosity, lesser tuberosity, and shaft. Proximal humerus has 4 parts: articulating surface,
greater tuberosity, lesser tuberosity, and humeral shaft.
Neer classification system describes how many of these parts are fractured, displaced,
and/or angulated (not just fractured).
31
Undisplaced fractures of the proximal humerus
Fracures without displacement, regardless of the number of fractures lines or the
anatomic structures involved, are essentially one-part fractures and can be treated with sling
support and gradual judicious exercises. Restoration of firm bone continuity occurs in about
8-12 weeks.
Operative treatment decisions are based primarily on the number of segments involved
and degree of displacement. Most fractures are displaced minimally and treated
conservatively. Three- and 4-part fractures often need operative repair.
The subgroups represent a variation within the group and the one illustrated is
indicated with red in the text.
32
A1 Extra-articular unifocal fracture, tuberosity
.1 greater tuberosity, not displaced
.2 greater tuberosity, displaced
.3 with a glenohumeral dislocation
A2 Extra-articular unifocal fracture, impacted metaphyseal
.1 without frontal malalignment
.2 with varus malalignment
.3 with valgus malalignment
A3 Extra-articular unifocal fracture, non-impacted metaphyseal
.1 simple, with angulation
.2 simple, with translation
.3 multifragmentary
B1 BA extra-articular bifocal fracture, with metaphyseal impaction
.1 lateral + greater tuberosity
.2 medial + lesser tuberosity
.3 posterior + greater tuberosity
B2 Extra-articular bifocal fracture, without metaphyseal impaction
.1 without rotatory displacement of the epiphyseal fragment
.2 with rotatory displacement of the epiphyseal fragment
.3 multifragmentary metaphyseal + one of the tuberosities
B3 Extra-articular bifocal fracture, with glenohumeral dislocation
.1 "vertical" cervical line + greater tuberosity intact + anterior and medical dislocation
.2 "vertical" cervical line + greater tuberosity fractured + anterior and medial dislocation
.3 lesser tuberosity fractured + posterior dislocation
C1 Articular fracture, with slight displacement
.1 cephalotubercular, with valgus malalignment
.2 cephalotubercular, with varus malalignment
.3 anatomical neck
C2 Articular fracture, impacted with marked displacement
.1 cephalotubercular, with valgus malalignment
33
.2 cephalotubercular, with varus malalignment
.3 transcephalic and tubercular, with varus malalignment
C3 Articular fracture, dislocated
.1 anatomical neck
.2 anatomical neck and tuberosities
.3 cephaltubercular fragmentation
Fractures of the anatomic neck
It is uncommon and may be followed by avascular necrosis even in the absence of
displacement. It is requires prosthetic replacement.
Fractures of the surgical neck
Fracture through the metaphysis proximal to the insertion of the pectoralis major is
classified as fracture of the surgical neck of the humerus. The main fracture claft is distal to
the tuberosity.
Impacted and minimally angulated fractures can be treated by means of a shoulder
immobilizer.
When displacement of the fractures site is complete, closed manipulation is justifiable,
but because persistent instability is a frequent complication, impaction or looking of the
fragments is desirable if it can be done. If reduction is stable a Velpeau dressing provides
reliable immobilization after correction of anterior angulation. Continuous traction by a
34
Kirschner wire thorugh the proximal ulna with the arm at right angle elevation is advisable,
when the fracture cannot be maintained in reduction by a Velpeau or other dressing.
This closed method of traction treatment is commonly required also for comminuted
fractures of the surgical neck.
Open reduction and internal fixation of uncomplicated fractures of the surgical neck
are sometimes required to ensure an adequate functional rezult.
Fracture of the surgical neck and both tuberosities
Separation of the tuberosities and displacement of the shaft provide a mechanism for
subluxation or dislocation of the main articular fragment that may occur anteriorly,
posteriorly, laterally, or inferiorly. Extensive laceration of the rotator cuff is a part of the
injury.
Hemiarthroplasty is the best method for preserving some function with minimal
discomfort. The proethesis replaces the articular portion of the proximal humerus and allows
the tuberosities to be reattached. The rotator cuff tear should be repaired also. Passive rangeof-motion exercises are started on the fourth of fifth day. For a satisfactory outcome, the
patient must take part in a rehabilitation program for many months.
35
Fractures of the shaft of the humerus
Most fractures of the shaft of the humerus result from direct violence, although spiral
fracture of the middle third of the shaft occasionally result from violent muscular activity
such as throwing of a ball. Humerus shaft fracture may be transverse, oblique, or spiral
Simphtomatology:
– swelling of the arm region
– visible or palpable deformity
– restriction of motion due to pain
– abnormal motion and bone friction in arm region.
Diagnosis: is clinical and roentgenographic.
X-rays in two planes are necessary to determine the configuration of the fracture and
the direction of displacement of the fragments.
36
Clasification:
The subgroups represent a variation within the group and the one illustrated is indicated
with red in the text.
A1 Simple fracture, spiral
.1 proximal zone
.2 middle zone
.3 distal zone
A2 Simple fracture, oblique(> or = 30°)
.1 proximal zone
.2 middle zone
.3 distal zone
A3 Simple fracture, transverse (< 30°:)
.1 proximal zone
.2 middle zone
.3 distal zone
B1 Wedge fracture, spiral wedge
.1 proximal zone
37
.2 middle zone
.3 distal zone
B2 Wedge fracture, bending wedge
.1 proximal zone
.2 middle zone
.3 distal zone
B3 Wedge fracture, fragmented wedge
.1 proximal zone
.2 middle zone
.3 distal zone
C1 Complex fracture, spiral
.1 with two intermediate fragments
.2 with three intermediate fragments
.3 with more than three intermediate fragments
C2 Complex fracture, segmental
.1 with one intermediate segmental fragment
.2 with one intermediate segmental and additional wedge fragment(s)
.3 with two intermediate segmental fragments
C3 Complex fracture, irregular
.1 with two or three intermediate fragments
.2 with limited shattering (< 4 cm)
.3 with extensive shattering (> or = 4 cm)
Complication:
– injury to the radial nerve
– injury to the brachial vessels
– the open fracture
38
Fig. 4 relationship of radial nerve to fractures in the spiral groove
Treatment:
Humeral shaft fractures generally are treated non-operatively. Because of the
shoulder's ability to compensate, 30-40° of angulation is acceptable.
Fracture through the metaphysis proximal to the insertion of the pectoralis major is
classified as fracture of the surgical neck of the humerus.
Fractures of the upper third of the shaft
Fractures between the insertion of the pectoralis major and the deltoid commonly
demonstrate adduction of the distal end of the proximal fragment . If the fracture occurs
distal to the insertion of the deltoid in the middle third of the shaft, medical displacement of
the occurs.
Treatment depends upon the presence or absence of complicating neurovascular
injury, the site and configuration of the fracture, and the magnitude of displacement. An
effort should be made to reduce completely displaced transverse or slightly oblique fractures
by manipulation. To prevent recurrence of medial convex angulation and maintain proper
alignment, it may be necessry to bring the distal fragment into alignment with the proximal
one by bringing the arm across the chest and immobilizing it with a plaster Velpeau dressing.
39
If the ands of the fragments cannot be approximated by manipulation, skeletal traction
with a wire throug the olecranon may be indicated. Traction should be continued for 3-4
weeks until stabilization occurs, after which time the patient can be ambulatory with an
external immobilization device. If adequate approximation and alignment of the fragments
canot be obtained by manipulation or traction, internal fixation may be necessary.
Fractures of the mild and lower thirds of the shaft.
Spiral, oblique, and comminuted fractures of the humeral shaft below the insertion of
the pectoralis major may be trated by application of a U-shaped coaptation plaster splint with
a shoulder immobilizer (Figure 43-20).
These fractures may also be treated by Caldwell’s hanging cast which consists of a
plaster dressing from the axilla to the wrist with the elbow in 90 degrees of flexion and the
forearm in midposition.
40
Significant success in the treatment of these fractures has been reported with the use of a
prefabricated polypropylene sleeve applied soon after pain and welling subside.
Fractures of the shaft of the humerus – especially transverse fractures – may heal
slowly. If stabilization has not taken place after 6-8 weeks, consideration of internal fixation
and bone grafting is justified.
About 5-10% of humeral fractures demonstrate radial nerve involvement.
Most radial nerve injuries are result of stretching or contusion, and function will return
in days or months.
If the radial nerve lesion is complete, results may be as good with delayed repair as
with primary repair.
INJURIES OF THE ELBOW REGION
Anatomy of the Elbow
There are 3 bones which allow the elbow to bend to the mouth, straighten and allow the hand
and wrist to turn up (to carry a plate) or tun down (to use a keyboard). These are the humerus,
the radius and the ulna. (Fig 1 & 2.)
The humerus runs from the shoulder and froms the upper bone of the elbow joint. The lateral epicondyle provides
attachment for the wrist extensor muscles (which bend the wrist and fingers back). The medial epicondyle provides
attachment for the wrist flexor muscles which bend the wrist down. (Figs 3,4 & 5.)
The humerus ends in a rounded capitellum which articulates with the head of the radius and
grooved region, the trochlea, which articulates with the ulna.
41
The radius and ulna run from the elbow to the wrist. The two are joined together throughout
their length by a strong interosseous ligament and have a small joint between them at each
end.
The radius has a small button shaped head at the elbow which articulates with the capitellum of
the humerus. This allows the radius (and hencs the whole of the forearm) to rotate. The other
end is broader and ends under the thumb, giving 3/4 of the width of the wrist.
The ulna has a saddle shaped end, the olecranon, which articulates with the trochlea of the
humerus. This allows the ulna to glide round the end of the humerus and enables the elbow to
flex and extend. The distal (wrist) end of the ulna is similar to the head of the radius and
enables wrist rotation.
The elbow joint coordinates movements of the upper extremity, facilitating execution
of activities of daily living in areas such as hygiene, dressing, and cooking. When the distal
humerus is injured, elbow joint function can be impaired. The goal of open reduction and
internal fixation is restoration of normal anatomy. Distal humerus fractures continue to
provide challenging reconstructive problems for the orthopedic surgeon.
The difficulty in treating complex distal humerus fractures lies in the unique and
specific anatomy of the distal humerus that allows it to articulate freely with the radius and
ulna. The elbow is a trochoginglymoid joint; it has the capacity to flex and extend within the
sagittal plane and also to rotate around a single axis. In fact, the elbow joint consists of 3
different articulations: the radiocapitellar, the trochlear-olecranon, and the proximal
radioulnar joints. Motion within the sagittal plane occurs at the ulnohumeral articulation
within the semilunar notch.
FRACTURE OF THE DISTAL HUMERUS
Fracture of the distal humerus is most after caused by indirect violence. The
configuration of the fracture cleft and the direction of displacement of the fragments are
likely to be typical.
Frequency: The incidence of fractures of the elbow joint is small compared to that of
fractures of other bones. Elbow joint fractures have been estimated to comprise 4,3% of all
fractures. Typically occurring following high-energy injury, these fractures can lead to
significant functional impairment. Distal humerus fractures most commonly involve both the
medial and lateral columns. Single condylar fractures comprise approximately 5% of distal
42
humerus fractures. Epicondylar and coronal shear fractures of the articular surface are less
commonly observed. In the pediatric population, 80% of all elbow fractures occur in the
supracondylar region. The injury typically occurs in young boys aged 5-10 years.
Simptomathology:
– pain
– swelling and minor deformity
– restriction of motion
Diagnosis:
Is clinical and roentgenographic. The type of fracture is determined by X-Ray
examination.
The fracture personality, including the bone quality, fracture pattern, level of
comminution, articular involvement, displacement, and associated injuries, must be
understood completely before treatment is attempted. Multiplane radiographs, including
anteroposterior (AP) and lateral views, are appropriate
Complications:
-injuries of major vessels and nerves. The brachial artery and median nerve lie anterior
to the elbow joint and are at risk for disruption. Palpate distal pulses, assess capillary refill,
and compare to the contralateral upper extremity
-elbow joint dislocation.
-bruising, ecchymosis, and lacerations may represent significant ligamentous damage
and resultant instability
-compartment syndrome of the forearm or upper arm
Classification: no perfect classification system has been developed for distal humerus
fractures that allows accurate direction for treatment considerations and prognostic outcome.
Many classifications have been proposed, and they often overlap
The AO-ASIF classification is the most commonly used system for clinical research
and treatment. The Orthopaedic Trauma Association and the International Society for
Fracture Repair expanded the AO-ASIF classification to provide a more detailed system for
reproducibility. It contains 38 different fractures of the distal humerus. It separates the
patterns into groups and subgroups based on the specific fracture propagation and
involvement. Subgroups are based on the fracture comminution and orientation. For
43
example, a unicondylar fracture or tangential fracture of a single condyle would be a group B
fracture, while a bicondylar fracture with extensive comminution of the condyles and
columns would be a group C3 fracture.
The subgroups represent a variation within the group and the one illustrated is
indicated with red in the text.
A1 Extra-articular fracture, apophyseal avulsion
.1 lateral epicondyle
.2 medial epicondyle, non incarcerated
.3 medial epicondyle, incarcerated
A2 Extra-articular fracture, metaphyseal simple
.1 oblique downwards and inwards
.2 oblique downwards and outwards
.3 transverse
A3 Extra-articular fracture, metaphyseal multifragmentary
.1 with an intact wedge
.2 with a fragmented wedge
.3 complex
B1 Partial articular fracture, lateral sagittal
.1 capitellum
.2 transtrochlear simple
.3 transtrochlear multifragmentary
B2 Partial articular fracture, medial sagittal
.1 transtrochlear simple, through the medial side (Milch I)
.2 transtrochlear simple, through the groove
.3 transtrochlear multifragmentary
B3 Partial articular fracture, frontal
.1 capitellum
.2 trochlea
.3 capitellum and trochlea
44
C1 Complete articular fracture, articular simple, metaphyseal simple
.1 with slight displacement
.2 with marked displacement
.3 T-shaped epiphyseal
C2 Complete articular fracture, articular simple, metaphyseal multifragmentary
.1 with an intact wedge
.2 with a fragmented wedge
.3 complex
C3 Complete articular fracture, multifragmentary
.1 metaphyseal simple
.2 metaphyseal wedge
.3 metaphyseal complex
Supracondylar fracture of the humerus occurs proximal to the olecranon fossa,
transcondylar fracture occurs more distally and extends into the olecranon fossa. Neither
fracture extends to the articular surface of the humerus.
The direction of displacement of the distal fragment from the midcoronal plane of the
arm serves to differentiate the “extension” from the less common “flexion” type. This
differentiation has important implication for treatment. The usual direction of displacement
of the main distal fragment is posterior and proximal.
Displaced supracondylar fractures are emergencies. Immediate treatment is required to
avoid occlusion of the brachial artery and to prevent or avoid further peripheral nerve injury.
45
Intercondylar fracture of the humerus is classically described as being of the T or
Y (or both), according to the configuration of the fracture cleft observed on an
anteroposterior x-ray. This fracture is commonly the result of a blow to the posterior aspect
of the flexed elbow. Open fracture and other injuries to the soft tissues are frequently
present. The fracture often extends into the trochlear surface of the elbow joint, and unless
the articular surfaces of the distal humerus can be accurately repositioned, restriction of joint
motion, pain, insatability, and deformity can be expected.
A. Closed reduction:
Signigicant displacement requires overhead skeletal traction by means of a Kirschner
wire inserted thourgh the proximal ulna. Complete bone healing usually occurs within 12
weeks.
B. Open Reduction:
A requirement for acceptable results of open reduction and internal fixation is that the
fragments be sufficiently large so that they can be fixed to one another.
Posttraumatic arthritis and restriction of joint motion can occur even if the articular
surface is restored anatomically.
Neurovascular injury is quite common in distal humeral fractures, and infection may
occur following open reduction. Late complications of injury include limitation of motion,
deformity, and pain.
46
Fractures of the lateral condyle of the humerus are of two types. One type involves
articular and non articular components of the condyle and must be differentiated from the
second type-fractures of the capitellum.
Undisplaced or minimally displaced fractures of the lateral condyle may be treated with
immobilization in a long-arm plaster cast for 6-8 weeks until stable.
Fracture of the capitellum is characterized by proximal displacement of the anterior
detached fragment and probably occurs as one component of a spontaneously reduced
dincomplete dislocation of the elbow joint. Closed reduction should be attempted by placing
the elbow in acute flexion. After reduction, the extremity is immobilized in a posterior
plasted splint with the elbow in full flexion to prevent displacement of the small distal
fragment.
Fracture of the trochlea of the humerus. Insolated fractures of the trochlea are very
unusual. Signs of intra-articular injury, including pain, effusion, restriction of motion and
crepitus, are usually present. The diagnosis is confirmed by x-ray showing a fragment lying
an the medial side of the joint. Large fragments may be replaced; smaller are better excised.
47
FRACTURE OF THE PROXIMAL ULNA
(Olecranon Fractures)
The olecranon is the proximal bony projection of the ulna at the elbow. Olecranon
fractures are a diverse group of injuries, ranging from simple nondisplaced fractures to
complex fracture dislocations of the elbow joint.
Fracture of the olecranon that occurs as a result of indirect violence (eg, forced flexion
of the forearm against the actively contracted triceps muscle) is typically transverse or
slightly oblique. The next most frequent cause of this injury is direct trauma, as in falls on, or
blows to, the point of the elbow. Fracture due to direct violence is usually comminuted and
associated with other fracture or anterior dislocation of the joint. Occasionally, the olecranon
may be fractured by hyperextension injuries, such as those resulting in elbow dislocation in
adults or supracondylar fractures in children. Very rarely is the olecranon broken by
muscular violence, as in throwing
Simptomathology:
-swelling of the elbow or in the area immediately above or below the elbow
-deformity of the elbow, or the areas near the elbow
-discoloration, such as bruising or redness of the elbow
-difficulty moving the elbow through its complete range of motion
-numbness, decreased sensation, or a cool sensation of your forearm, hand, or fingers
-severe pain after an elbow injury
-a "tight sensation" in the area of the elbow or forearm
Diagnosis, is clinical and radiological????/

Standard anteroposterior and lateral radiographs of the elbow are sufficient for
evaluation of isolated olecranon fractures.
48
-direct supervision of the x-ray process may be necessary to ensure that true anteroposterior
and lateral radiographs are obtained.
-the radiocapitellar view may be helpful for delineation of the radial head and capitellar
fractures
Classification: A.O.
The subgroups represent a variation within the group and the one illustrated is
indicated with red in the text.
A1 Extra-articular fracture, radius intact
.1 avulsion of the triceps insertion from the olecranon
.2 metaphyseal simple
.3 with a glenohumeral dislocation
A2 Extra-articular fracture, of the radius, ulna intact
.1 avulsion of the bicipital tuberosity of the radius
.2 neck simple
.3 neck multifragmentary
49
A3 Extra-articular fracture of both bones
.1 simple of both bones
.2 multifragmentary of one bone and simple of the other
.3 multifragmentary of both bones
B1 Articular fracture, of the ulna, radius intact
.1 unifocal
.2 bifocal simple
.3 bifocal multifragmentary
B2 Articular fracture, of the radius, ulna intact
.1 simple
.2 multifragmentary without depression
.3 multifragmentary with depression
B3 Articular fracture, of the one bone, with extra-articular fracture of the other
.1 ulna, articular simple
.2 radius, articular simple
.3 lesser tuberosity fractured + posterior dislocation
C1 Articular fracture, of both bones, simple
.1 olecranon and head of radius
.2 coronoid process and head of radius
C2 Articular fracture, of both bones, the one simple and the other multifragmentary
.1 olecranon multifragmentary, radial head simple
.2 olecranon simple, radial head multifragmentary
.3 coronoid process simple, radial head multifragmentary
C3 Articular fracture, of both bones, multifragmentary
.1 three fragments of each bone
.2 ulna, more than three fragments
.3 radius, more than three fragments
Complications:
-open fractures occur in 2-31% of cases.
-neurologic injuries to median, radial, or ulnar nerves occasionally may occur, ulnar
neurapraxia has been reported in 2-5% of cases.
-blood vessels may become injured or compressed when trauma or swelling occurs.
50
Treatment:
Since the major fracture cleft extends into the elbow joint, treatment should be
directed toward restoration of anatomic position to afford maximal recovery of range of
motion and functional competency of the triceps.
Treatment depends upon the degree of displacement and the extend of comminution.
Fractures with significant displacement (>2 mm) or comminution may require surgical
intervention
A. Closed Reduction: Minimal displacement (1-2mm) can be treated by closed
manipulation with the elbow in full extension and immobilization in a plaster cast that
extends from the anterior axillary fold to the wrist. X-rays should be taken weekly for 2
weeks after reduction to determine wether reduction has been maintained. Immobilization
must be continued for at least 6 weeks before active flexion exercices are begun. Position of
the arm in full extension for this length of time keeps the hand far away from the body and
makes the extremity quite useless during the time of immobilization. This treatment
generally has poor patient acceptance.
B. Open reduction and Internal Fixation:
Open reduction and internal fixation are indicated (1) if closed methods are not successful in
approximating displaced fragments and restoring congruity to articular surfaces, or (2) if
early motion is desired even in a minimally displaced farcture. A number of different
methods of fixation are available (eg, screws, plates figure-of-eight wires) foe the purpose of
compression of the fracture fragments and restoration of the articular surface. If stable
fixation is obtained, active range of motion can be started at 5-7 days. The internalfixation
device must often be removed after healing, because its location subcutaneously on the ulna
produces discomfort.
51
C. Excension of ProximalFragments: As much as 80% of the olecranon can be removed
without produncing instability of the elbow joint, as long as the coronoid process and the
distal surface of the semilunar notch of the ulna are intact and the triceps is adequately
repaired.This procedure is a effective as open reduction and internal fixation and does not
require subsequent operation ford hardware removal.
3 FRACTURE OF THE PROXIMAL RADIUS
Fracture of the head and neck of the radius may occur as an isolated injury
uncomplicated by dislocation of the elbow or the proximal rodioulnar joint. This fracture is
usually caused by indirect force, such as a fall on the outstretched hand, when the radial head
is driven against the capitellum.
Discussion:
-upto 10 % of comminuted frx of radial head occurr in association with elbow dislocation;
-there is usually significant soft tissue injury of both joint capsule and brachialis;
-result is often joint stiffness, degenerative changes, and myositis ossificans;
Care must be taken to obtain true anteroposterior ans lateral X-rays of the proximal
radius as well as of the elbow joint, since minor lesions may be obscured by a change in
position from midposition to full supination during exposure of the films.
52
Treatment :
Conservative Treatment: Radial head fractures ranging from no displacement to
involvement of two-thirds of the head and 2-3 mm of depresion can be treated
symptomatically, with evacuation of the tense hermathrosis by aspiration to minimize pain.
The extremity may be supported by a sling or immobilized in a posterior plaster splint with
the elbow in 90 degrees of flexion. Active exercises of the elbow are to be encouraged within
a few days to a week. Recovery of function can take up to 6 weeks. Slight restriction of
motion (expecially extension) may persist but usually is not functionally significant.
Surgical Treatment: When severe comminution involves the entire articular surface
or there is a loose fragment in the joint, surgical treatments is indicated. Excesion of either
loose fragment or the entire comminuted radial head allows return to satisfactory elbow
fuction. After excision of the head, the radius may migrate proximally, but migration is
usually less than 2 mm and rarely major symptoms other than a moderate decrease in
forearm strength.
If radial excision is indicated, it is best one early unlees this will contribute to serious
instability of the elbow joint. A silicone radial head replacement arthroplasty may be done
primarily to improve stability in an unstable joint or to minimize proximal migration of the
radius.
53
SUBLUXATION & DISLOCATION OF THE ELBOW JOINT
Dislocation of the head of the Radius
Insolated dislocation of the radius at the elbow is a rare lesion that implies dislocation
of the proximal radio-ulnar and radio-humeral joints without fracture. It occurs in children
over age 5 years or occasionally in adults and must be differentiated from subluxation of the
head of the radius. To cause dislocation, injury must be severe enough to disrupt the
capsulotendinous support-especially the annular ligament of the proximal radius. The
direction of displacement of the radial head is usually anterior or lateral, but it may be
posterior.
Reduction can usually be accomplished by forced supination of the forearm under
local or general anesthesia. The extremity should be immobilized for 3-4 weeks with elbow
in flexion and the forearm in supination.
Dislocation of the Elbow Joint without Fracture
Elbow dislocation is the second most common major joint dislocation; ?????to that of
dislocations of the shoulder incidence of elbow dislocations is 6-8 cases per 100,000
population; these dislocations represent 11-28% of all injuries to the elbow.
Etiology:
The cause of most elbow dislocations is usually occurs from a fall on the outstretched
hand. However, any traumatic injury (such as a car crash) can result in an elbow dislocation.
54
Complete backward dislocation of the ulna and radius implies extensive tearing of the
capsulo-ligamentous structures and in jury to the region of insertion of the brachialis muscle.
Clinical:
-severe pain in the elbow, swelling, and inability to bend the arm are all signs of an
elbow dislocation.
-obvious elbow deformity. Elbow flexed to 90 degrees. Abnormal alignment of
olecranon and both epicondyles.
-in some cases, may lose feeling in hand or no longer have a pulse.
Classification :
Elbow dislocations are classified as either simple or complex. Simple dislocations are
classified by the direction of radial and/or ulnar displacement in relation to the distal part of
the humerus. Complex elbow dislocations involve related fractures and/or neurovascular
injuries
Dislocations are classified according to direction of dislocation, namely: posterior,
posterolateral, posteromedial, lateral, medial, divergent. Dislocation is usually closed and
posterior.
Complications:
-vascular injury:
 closed dislocations are rarely associated with vascular injury, whereas open and, or
anterior dislocations are commonly associated with such injury;
 in open dislocations, brachial artery is disrupted by forcible hyperextension (median
nerve injury is commonly associated with such injuries);
-neuro injury:
 neuropraxia is occurs in 20%, usually involving ulnar or median n (AIN branch);
 ulnar nerve palsy may occur up to 14% of adult elbow dislocations, and the occurance
of ulnar nerve palsy is much higher in pediatric dislocations with an associated medial
epicondyle fracture;
Most neurologic deficits are transient, but entrapment of median nerve with elbow
joint after manipulation is more common in pediatric dislocations;
Diagnosis : is clinical and radiological????/
55
Biplane x-rays of the highest quality are necessary to determine that no fracture is
associated.
Simpson classification
Simpson classification of elbow dislocation
Lateral
Posterior
Medial
Medial
Both Radius and Ulna
Lateral
Anteroposterior
Divergent
Mediolateral
Anterior
Ulna alone
Posterior
Anterior
Radius
Posterior
Lateral
56
Treatment:
Peripheral nerve function must be carefully assessed before definitive treatment is
instituted.
Complete muscle relaxation is necessary to achieve atraumatic reduction. This can be
accomplished by sedation, regional block, or general anesthesia and is the choice of the
surgeon. Closed reduction can be achieved by axial traction on the forearm with elbow in the
position of deformity. Hyperextension is not necessary. Lateral or medial dislocation can be
corrected during traction. As soon displacement is corrected, the elbow should be fully
flexed and extended to make certain reduction has actually occurred. The medial and lateral
ligaments should also be tested, as major instability in either plane may require surgical
repair. The elbow should then be immobilized in at least 90 degrees of flexion by applying a
posterior plaster splint that reaches from the posterior axillary fold to the wrist. The duration
immobilization depends mainly on the stability of the elbow after reduction. The elbow must
be x-rayed at 3, 7, and 10 days post-reduction in the cast to make certain that is maintained.
As swelling decrease, the elbow may redislocate in the cast with minimal pain experienced
by the patient. In uncomplicated stable dislocation with intact and stable collateral ligaments
and an intact coronoid process, the splint may be removed after 3-4 days and active motion
started. There is no place for passive motion or any form of manipulation in the rehabilitation
process, as forceful treatment may lead to severe loss of motion and joint stiffness.
57
Closed reduction should be attempted even if unreduced dislocation has persisted for
2-3 weeks following injury. Open reduction of the persistent dislocation may be successful
for up to 2 months after injury.
Complications, after treatment, of elbow dislocations include the following:
posttraumatic periarticular calcification, which occurs in 3-5% of elbow injuries; myositis
ossificans or calcific tendinitis of the brachialis muscle (Resnick, 1992); neurovascular
injuries (in 8-21% of cases), in which ulnar nerve injuries are most common, followed by
brachial artery injuries (5-13%); osteochondral defects, intra-articular loose bodies, and
avascular necrosis of the capitellum; and instability.
Dislocation of the Elbow Joint With Fracture
Dislocation of the elbow is frequently associated with fracture. Some fractures are
insignificant and require no specific treatment; others specialized care.
Fracture of the coronoid “Process of the Ulna”
Fracture of the coronoid process of the ulna is the most frequent complication of
posterior dislocation of the elbow joint. Treatment requires at least 3-4 weeks of
immobilization to obtain stability.
Fracture of the Head of the Radius With Posterior Dislocation of the elbow Joint
58
This injury is treated as two separate lesions. The severity of comminution and the
magnitude of displacement of the radial head fragment are first determined by x-ray. If
comminution has occurred or the fragments are widely displaced, the dislocation is reduced
by closed manipulation; the head of he radius is then excised.
If fracture of the head of the radius is not comminuted and the fragments are not
widely displaced, treatment is as for uncomplicated posterior dislocation of the elbow joint.
Posterior dislocation of the elbow with associated fractures of the radial head and
the coronoid process
Background: Posterior dislocation of the elbow with associated fractures of the radial
head and the coronoid process of the ulna has been referred to as the "terrible triad of the
elbow" because of the difficulties encountered in its management. However, there are few
published reports on this injury.
With operative treatment, the surgeon should attempt to restore stability by providing
radiocapitellar contact (preserving the radial head when possible and replacing it with a
59
prosthesis otherwise), repairing the lateral collateral ligament, and perhaps performing
internal fixation of the coronoid fracture.
radial head excision and coronoid screw fixation
Fracture of the Olecranon With Anterior Dislocation of the Elbow Joint
This very unstable injury usually occurs from a blow to the flexed elbow that drives
the olecranon forward. Fracture through the olecranon permits the distal fragment of the ulna
and the proximal radius to be displaced anterior to the humerus and may cause extensive
tearing of the capsulo-ligamentous structures around the elbow joint. The dislocation can be
reduced by bringing the elbow into full extension, but anatomic reduction of the olecranon
fracture by closed manipulation is not likely to be successful, and immediate open reduction
is usually indicated. Recovery of function is apt to be delayed and incomplete.
1.FRACTURES OF THE SHAFTS OF THE RADIUS & ULNA
General Consideration
A.
Causative Injury: Spiral and oblique fractures are apt to be caused by indirect injury.
Greestick, transverse, and comminuted, fractures are commonly the result of direct injury.
B.
Radiography: In addition to antero-posterior and lateral films of the entire forearm,
including the elbow and wrist joints, oblique views are often desirable.
60
Torsional displacement by muscle activity has important implications for manipulative
treatment of certain fractures of the radial shaft. The direction of displacement of the distal
fragment following fracture of the shaft is influenced by the location of the lesion in
reference to muscle insertion. If the fracture is in the upper third, the proximal fragment will
be drawn into relative supination by the biceps and supinator and the distal fragment into
pronation by the pronator teres and pronator quadratus.
In fractures below the middle of the radius (below the insertion of the pronator teres),
the proximal fragment characteristically remains in mid-position and the distal fragment is
pronated; this is due to the antagonistic action of the pronator teres on the biceps and
supinator.
D. Closed Reduction and Splinting:
Reduction of uncomplicated fractures of the radius and ulna should be attempted. The
type of manipulative maneuver depends upon the configuration and location of the fracture
and the age of the patient. The position of immobilization of the elbow, forearm, and wrist
depends upon the location of the fracture and its inherent stability.
Fracture of the Shaft of the Ulna
Insolated fracture of the shaft of the proximal third of the ulna with displacement is
often associated with dislocation of the head of the radius.
Nightstick fracture of the ulna is the second most common single bone forearm
fracture, generally resulting from blunt forearm trauma. The junction of the middle
and distal thirds of the ulna is mechanically the most susceptible to fracture because
of its cross sectional geometry at that point (Hsu). Because this is usually a low
61
energy injury, it may be treated in a cast with close observation, reserving plate or
intramedullary fixation for displaced fractures or those failing closed treatment
Fracture of the distal shaft of the ulna is apt to be complicated by angulation. The
proximal end of the distal fragment is displaced toward the radius by the pronator quadratus
muscle.
Stabilization by bone healing may require longer than 3-4 months of immobilization.
An oblique fracture cleft creates an unstable mechanism with a tendency toward
displacement, and immobilization in a tubular plaster cast is not reliable. Open reduction and
rigid internal fixation with bone plates or an intramedullary rod are indicated.
62
Fracture of the Shaft of the Radius
Insolated closed fracture of the shaft of the radius can be caused by direct violence;
open fracture usually results from penetrating injury. Closed fracture with displacement is
usually associated with other injury
If the fracture is proximal to the insertion of the pronator teres, closed reduction is indicated.
The extremity should then be immobilized in a tubular plaster cast that extends from the
axilla to the metacarpophalangeal joints, with the elbow at a right angle and the forearm in
full supination.
If the fracture is distal to the insertion of the pronator teres, manipulation and
immobilization are as described above except that the forearm should be in midrotation
rather than full supination. Since injury to the distal radio-ulnar joint is apt to be associated
with fracture of the radial shaft below the insertion of the pronator teres, weekly anteroposterior and lateral x-ray projections should be taken during the first month to determine the
exact status of reduction. If stability cannot be achieved, open reduction and internal fixation
with metal plate and screws are recommended.
Fracture of the Shafts of Both Bones
The management of fractures of the shafts of both bones of the forearm is essentially a
combination of those techniques that have been described for the individual bones. If both
bones are fractured at the same time, dislocation of either radio-ulnar joint is not likely to
occur. If the configuration of the fracture cleft is approximately transverse, stability may be
attained by closed methods provided reduction is anatomic or nearly so. Oblique or
comminuted fractures are unstable.
Treatment depends in part upon the degree of displacement, the severity of
comminution, and the age of the patient.
63
A. Without Displacement: In adults, fracture of the shaft of the radius and ulna without
displacement can be treated by immobilization in a tubular plaster cast extending from the
axilla to the metacarpophalangeal joints with the elbow at a right angle and the forearm in
supination (fractures of the mid and lower thirds). Immobilization for 16-20 weeks is
generally sufficient for restoration of bone continuity. To avoid late angulation or refracture,
the elbow should be included in the plaster until the callus is well mineralized.
B. With Displacement: Although it is not always possible to correct displaced fractures of
both bones of the forearm by closed methods, an attempt can be made to do so if x-ray
studies show a configuration whereby stabilization can be accomplished without operation.
Most commonly, accurate apposition and stability of fragments cannot be achieved in
fractures of both bones. Therefore, open reduction and internal fixation (with bone plate and
screws or intramedullary rods) are recommended provided experienced personnel and
adequate equipment are available. Persistent displacement of the fragment of one or both
bones may be associated with delay of healing, restriction of forearm movements,
derangement of the radio-ulnar joints, and deformity. In fractures in which open reduction is
justifiable in the adult, rigid internal fixation is indicated; a technical; pitfall to be avoided is
the use of a single wire loop or trans-fixation screw, a short bone plate attached with
unicortical screws, or small intramedullary wires. If excellent stability is achieved at
64
operation with bone plates, motion of the extremity may be started as soon as the surgical
wound is healed.
FRACTURE & DISLOCATION OF THE RADIUS & ULNA
angulated fracture at the junction of the proximal and middle third of ulna accompained by
ANTERIOR dislocation of the radial head
etiology:

transmission of force thorugh the hand and forearm with the elbow partially flexed

interosseous ligament "drags" the radius with the distal two-thirds of the ulna
Fracture of the Ulna With Dislocation or the Radial Head
(Monteggia’s Fracture).
65
Fracture of the ulna, especially when it occurs near the junction of the middle and upper
thirds of the shaft, may be complicated by dislocation of the radial head. This unstable
fracture-dislocation, the so-called Monteggia’s fracture, is categorized commonly under
three types. The most common type is anterior dislocation of the radial head with fracture of
the ulnar diaphysis with anterior angulation (type I). In type II, posterior dislocation of the
radial head is accompanied by posterior convex angulation at the fracture of the ulna in its
proximal third, distal to the coronoid process-is rare.
In all types, there is marked pain and tenderness in the forearm and around the elbow,
and the patient resists any motion of the elbow joint. Complete neurological examination of
the extremity is indicated, since paralysis of the deep branch of the radial nerve is the most
common associated neurological lesion. Spontaneous recovery is usual, and exploration of
the nerve is rarely indicated.
These injuries are usually caused by direct violence to the forearm. The annular
ligament may be torn, or the head may be displaced distally from beneath the annular
ligament without causing a significant tear. The injured ligament may be interposed between
66
the articular surface of the head of the radius and the capitellum of the humerus or the
adjacent ulna.
X-rays of the elbow and forearm in the antero-posterior and lateral planes confirm the
diagnosis. Fracture of the ulna is obvious, but dislocation of the radial head is frequently
missed. Proper positioning of the x-ray tube in relation to the elbow and the film will
improve identification of the radial head dislocation, as will familiarity of the physician, with
the lesion.
Good results are most readily obtained by rigid internal fixation of the fractured ulna with
plate and screws and complete reduction of the dislocated radial head. The radial head can
usually be adequately reduced by closed manipulation. Open reduction of the radial head is
indicated only when a portion of the annular ligament may be obstructing closed reduction.
The extremity should be immobilized in 110degrees of flexion for 6 weeks to maintain
reduction of the radial head. X-rays should be taken 1,2, and6 weeks postoperatively to
ensure maintenance of reduction.
Fracture of the Shaft of the Radius With Dislocation of the Ulnar head.
In fracture of the shaft of the radius near the junction of the middle and lower thirds with
dislocation of the head of the ulna distally (Galeazzi's fracture), the apex of major angulation
is usually directed anteriorly while the ulnar head lies volar to the distal end of the radius.
67
The results of closed treatment are poor, since anatomic alignment is difficult to maintain in
plaster. Good results can be obtained by accurate reduction and internal fixation of the
fractured radius with plate and screws and immobilization in a long as the forearm is
immobilized in supination to allow for reduction. Complications of fracture–dislocations of
the radius and ulna are similar to those of forearm fractures in general: infection, malunion,
and nonunion.
INJURIES OF THE WRIST REGION
1. SPRAINS OF THE WRIST
Insolated severe sprain of the ligaments of the wrist joint is
Not common, and the diagnosis of wrist sprain should not be made until other lesions
(e.g., carpel fractures and dislocations) have been ruled out. If symptoms for more than 2
weeks, and especially if pain swelling are present, x-ray examination should be repeated.
Treatment may be by immobilization with a volar splint extending from the palmary
flexion crease to the elbow. The splint should be attached with elastic bandages so that it can
be removed at least three times daily for gentle active exercise and warm soaks.
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2. COLLE’S FRACTURE
Abraham Colles described this fracture as an impacted fracture of the radius 2-3 cm
proximal to the wrist joint. Modern usage has extended the term Colles’ fracture to include a
variety of complete fractures of the distal radius characterized by varying degrees of dorsal
displacement of the distal fragment.
The fracture is commonly caused by a fall with the hand outstretched, the wrist in
dorsiflexion, and the forearm in pronation, so that the force is applied to the palmary surface
of the hand. Colles’ fracture is most common in middle life and old age. Avulsion of the
ulnar styloid may accompany the distal radius fracture. If the ulnar styloid process is not
fractured, the collateral ulnar ligament may be torn. The head of the ulna may lie anterior to,
the distal fragment of the radius.
Radiological features
Anterposterior and lateral radiographs are taken. In the lateral view, the fracture line
runs upward and backwards from the anterior surface about an inch above the articular end.
The lower fragment is displaced and tilted dorsally and laterally with some impaction. The
articular surface of the surface of the radius, faces dorsally according to the degree of the
dorsal tilt. Normally, it faces about 15 degrees palmarwards.
The lower fragment is sometimes comminuted and the fracture line run into the
articular surface.
69
Clinical Findings
Clinical findings vary according to the magnitude of injury, the degree of
displacement of fragments, and the interval since injury. If the fragments are not displaced,
examination soon after injury will demonstrate only slight tenderness and insignificant
swelling. Marked displacement produces the classic “silver fork,” or “bayonet”, deformity,
in which a dorsal prominence caused by displacement of the distal fragment replaces the
normal convex curve of the lower radius and the ulnar head is prominent on the anteromedial aspect of the wrist. Later, swelling may extend from the fingertips to the elbow.
Complications
Derangement of the distal radio-ulnar joint is the most common complicating injury.
Direct injury to the median nerve by bone spicules is not common.
Compression of the nerve by hemorrhage and edema or by displaced bone fragments
can occur and may cause all gradation of sensory and motor paralysis. Initial treatment of the
fracture by immobilization of the wrist in acute flexion can be a significant factor in
aggravation of compression. Persistent compression of the nerve creates classic symptoms of
the carpal tunnel syndrome, which may require operative division of the volar carpal
ligament for relief.
Treatment
Complete recovery of function and a pleasing cosmetic result are goals of treatment
that cannot always be achieved. The patient’s age, sex, and occupation, the presence of
complicating injury or disease, the severity of comminution, and the configuration of the
fracture cleft govern the selection of treatment.
Open reduction of recent closed Colle’s fracture is rarely the treatment of choice.
Many techniques of closed reduction and external immobilization have been advocated; the
experience and preference of the surgeon determine the selection.
A. Minor Displacement: Colle’s fracture with minimal displacement is characterized
by absence of comminution and slight dorsal impaction. Deformity is rarely perceptible or
may not be visible even to a trained observer. In the elderly patient, treatment is directed
70
toward early recovery of function. In young patients, prevention of further displacement is
the first consideration.
Reduction is not necessary. In an elderly patient, the wrist immobilized for 3-4 weeks
in a short-arm cast or volar splint for comfort: then motion is begun.
B. Marked Displacement: Early reduction and immobilization are indicated.
Muscular relaxation of the extremity can usually be attained by systemic and local
anesthesia. Regional block or general anesthesia will give more complete pain relief.
Reduction by manipulation is accomplished by applying traction through the grasped injured
hand with counter traction to the forearm or humerus. After disimpaction of the fragments,
the fracture is reduced by palmary displacement of the distal fragment and ulnar deviation.
The wrist is immobilized in this position. Some authors advocate immobilization of the wrist
in pronation and some in supination. The latter position is felt to decrease the tension of the
brachioradialis and its tendency to redisplace the fracture.
A lightly padded tubular cast or a “sugar tong” splint is preferred. The plaster should
extend distally only to the flexion crease on the palmary side (to allow full flexion of
metacarpophalangeal joints) and out to the web space of the fingers dorsally (to decrease
swelling over the dorsum of the hand) The cast or sugar splint may be extended above the
elbow, particularly in obese patients, to allow more complete immobilization. After the
plaster has been applied, x-ray is taken while anesthesia is continued. If x-ray show that
reduction is not adequate, remanipulation is carried out immediately.
Immobilization is maintained for 6 weeks, during which the patients is strongly
encouraged to exercise and use the fingers, elbow, and shoulder of the affected extremity. Xray examination is repeated on the third day and thereafter at weekly intervals during the first
2-3 weeks.
C. Unstable Fractures: If x-rays show extensive comminution with intra-articular
extension and involvement of the volar cortex, the fracture is likely to be unstable, and
skeletal distraction is probably indicated. This can be accomplished by use of an external
fixation device or with skeletal traction pins incorporated in plaster. In either case, pins are
drilled into or through the bone above and below the fracture to allow for distraction and
71
manipulation of the fragments to obtain adequate alignment and length. The pins are left in
place 6-8 weeks. Initial reduction may be improved by the use of Chinese finger traps or
weight placed on the traction pins to allow distraction of the fracture fragments.
72
Post-reduction Treatment
Frequent observation and careful management can prevent or minimize some of the
disabling sequela of Colles’ fracture. The patient’s full cooperation in the exercise program
is essential. If comminution is marked, if swelling is severe, or if there is evidence of median
nerve deficit, the patient should remain under close observation (preferably in a hospital) for
at least 72 hours. The extremity should be elevated to minimize swelling, and the adequacy
of circulation should be determined at frequent intervals. Active exercise of the fingers and
shoulder is encouraged. In order that extremity be used as much as possible, the plaster
should be trimmed in the palm to permit full finger flexion.
Increased use of the hand and shoulder will be encouraged if the patient is not allowed to use
a sling.
As soon as the plaster is removed, the patient is advised to use the extremity for
routine daily activities.
Sequela
Joint stiffness is the most disabling sequela of Colles' fracture. Derangement of the
distal radio-ulnar joint may be caused by the original injury and perpetuated by incomplete
reduction; it is characterized by restriction of forearm movements and pain. Late rupture of
the extensor pollicis longus tendon is relatively uncommon. Symptoms of median nerve
injury due to compression caused by acute swelling alone usually do not persist more then 6
months. Prolonged symptoms can cause carpal tunnel syndrome. Failure to perform shoulder
joint exercises several times daily can result in disabling stiffness.
73
Shoulder-hand syndrome (reflex sympathetic dystrophy) is an infrequent but
severely disabling complication of Colle’s fracture. It is characterized by marked pain,
tenderness, swelling, and induration of the hand associated with severe stiffness of the
fingers and shoulder, which may lead to atrophy and residual contractures. Prompt
recognition will allow for affective treatment. Gentle, progressive exercises of the shoulder
and hand have been most helpful for relief of pain and stiffness. More controversial methods
of treatment include intramuscularly injections of lidocaine or corticosteroids, sympathetic
nerve blocks, and oral corticosteroids.
3.SMITH’S FRACTURE
(Reverse Colles’ Fracture)
Although Smith did not observe an anatomic preparation of this lesion, his description
in 1847 placed the fracture of the radius 2-2,5 cm proximal to the wrist joint. The distal
fragment is displaced volarly. The ulnar head is prominent dorsally, and there may be
derangement of the distal radio-ulnar joint. This lesion should be differentiated from
Barton’s fracture dislocation (see below).
The fracture can be reduced by closed manipulation and immobilized with the wrist in
dorsiflexion. Unstable fractures may require skeletal distraction (see above foe unstable
Colles’ fracture). Fractures that cannot be reduced adequately by closed methods may
require open reduction and bone plating.
74
3. FRACTURE OF THE RADIAL STYLOID
Forced radial deviation of the hand at the wrist joint can fracture the radial styloid process. A
large fragment of the process is usually displaced by impingement against the scaphoid bone.
If the fragment is large, it can be displaced farther by the brachioradialis muscle, which
inserts into it.
Because the fracture is intra-articular, reduction of large fragments should be
anatomic. If the styloid fragment is not displaced, immobilization in a plaster gauntlet for 3
weeks is sufficient. If the fragment is displaced, manipulative reduction should be tried. If
the distal, smaller fragment tends to displace but can be apposed by digital pressure,
percutaneous fixation can be achieved by a medium Kirschner wire inserted through the
proximal anatomic snuffbox so as to transfix fragments. The wrist is then immobilized in a
snugly molded plaster gauntlet foe 6 weeks. X-ray examination is repeated every week for 23 weeks.
If closed methods fail, open reduction is indicated since persistent displacement is
likely to cause posttraumatic degenerative arthritis relatively early.
4.
FRACTURE&DISLOCATION OF THE RADIOCARPAL JOINT
Dislocation of the radio carpal joint without injury to one of the carpal bones is usually
associated with fracture of the anterior surface of the radius or ulna. Comminuted fracture of
the distal radius may involve either the anterior or posterior cortex and may extend into the
75
wrist joint. Subluxation of the carpus may occur at the same time. The most common
fracture-dislocation of the wrist joins involves the posterior or anterior margin of the
articular surface of the radius.
Anterior Fracture-Dislocation of the Radio carpal Joint
Anterior fracture-dislocation of the wrist joint is characterized by intra-articular
fracture of the volar margin of the carpal surface of the radius. The fracture cleft extends
proximally in the coronal plane in an oblique direction, so that the free fragment has a
wedge-shaped configuration. The carpus is displaced volarly and proximally with the
articular fragment. This uncommon injury should be differentiated from Smith’s fracture by
x-ray examination.
These fractures tend to be very unstable and frequently require percutaneous fixation
with pins or open reduction and internal fixation with a volar bone plate and screws.
Immobilization in a short-arm plaster cast or splint is continued for 5-6 weeks. Long arm
support may be necessary.
Posterior Fracture-Dislocation of the Radio carpal Joint
(Barton’s Fractures)
Posterior fracture-dislocation of the wrist joint (dorsal rim fracture) should be
differentiated by x-ray from Colle’s fracture. In most cases, the marginal fragment is smaller
than in anterior injury and often involves the medial aspect where the extensor pollicis
76
longus crosses the distal radius. If reduction is not anatomic, fraying of the tendon at this
level may lead to late rupture.
Treatment is by manipulative reduction as for Colles’ fracture and immobilization for
6 weeks in a short-arm plaster cast with the wrist in neutral position. A tendency to
redisplacement requires percutaneous fixation with pins or open reduction and fixation with
a bone plate and screws. Prognosis and complications are similar to those described in the
section on Colles’ Fractures.
5.
DISLOCATIONS OF THE DISTAL RADIOULNAR JOINT
The articular disk is the most important structure in preventing dislocations of the
distal radioulnar joint. The accessory ligaments and the pronator quadratus muscle play a
secondary role. Complete anterior or posterior dislocation implies a tear of the articular disk
and disruption of accessory joint ligaments. Tearing of the articular disk in the absence of
major injury to the supporting capsular ligaments causes subluxation or abnormal laxity of
the joint. Since the ulnar attachment of the articular disk is at the base of the styloid process,
x-ray may demonstrate an associated fracture. Widening of the cleft in comparison with the
apposite radioulnar joint suggests dislocation even if frank anterior or posterior displacement
is not present.
Dorsal dislocation or subluxation is treated by reducing the ulnar head by full
supination of the forearm. The arm placed in an above-the-elbow cast with the elbow in 90
degrees of flexion and the forearm in supination.
Volar dislocation is rare and usually stable after reduction.
77
7. FRACTURES&DISLOCATIONS OF THE CARPUS
Injury to the carpal bones occurs predominantly in men during the most active period
of life. Because it is difficult to differentiate these injuries by clinical examination, it is
imperative to obtain x-ray films of the best possible quality. The oblique film should be
taken in midpronation, the anteroposterior film with the wrist in maximal ulnar deviation.
Special views, such as midsupination to demonstrate the pisiform, and carpal tunnel views
for the hamate, may be necessary.
Fracture of the Carpal Scaphoid
The most common injury to the carpus is fracture of the scaphoid bone. This fracture
should be suspected in any injury to the wrist in men unless a specific diagnosis of another
type of injury is obvious. Since 2-5% of these fractures are not visible on the first
radiograph, if tenderness on the radial aspect of the wrist is present and fracture cannot be
demonstrated, initial treatment should be the same as if fracture were present (see below) and
78
should be continued foe at least 2 weeks. X-rays taken immediately after the injury may
not show a fracture. Still, most surgeons will put a cast on the wrist and get another
X-ray in ten days. This gives the edges of the fractured bone time to heal, and may
prevent non-union. By waiting ten days, the fracture is easier to see on an X-ray
Further x-ray examination after 2 weeks may demonstrate an occult fracture.
Three types of carpal scaffold fracture are distinguished.
(1)
Fracture of the tubercle: This fracture usually is not widely displaced, and healing is
generally prompt if immobilization in a plaster gauntlet is maintained for 3-4 weeks.
Fracture through the waist: Fracture through the narrowest portion of the bone is the
most common type. The supply to the proximal fragment is usually not disturbed, and
healing will take place if reduction is adequate and treatment is instituted early. If the
nutrient artery to the proximal third is injured, avascular necrosis of that portion of the bone
may occur. X-ray examination in multiple projections may be necessary to determine
displacement of the proximal fragment. If the proximal fragment is displaced, it may be
reduced under local anesthesia by radial deviation of the wrist. Immobilization in a plaster
79
gauntlet with the wrist in neutral is necessary. The plaster should extend distally to the
palmar flexion crease in the hand and to the base of the thumbnail. If reduction has been
anatomic and the blood supply to the proximal fragment has not been jeopardized, adequate
bone healing can be expected within 10-12 weeks. However, such healing must be
demonstrated by the disappearance of the fracture cleft and restoration of the trabecular
pattern between the two main fragments. X-ray examination to verify healing should be
repeated 3 weeks after removal of the cast.
Waist factures may be difficult to see
Examine the film magnified
(3) Fracture through the proximal third: Fracture through the proximal third of the
scaffold bone is apt to be associated with injury to the arterial supply of the minor fragment.
This can be manifested by avascular necrosis of that fragment. If the lesion is observed soon
after injury, reduction and immobilization in a plaster gauntlet will promote healing. The
plaster gauntlet should be applied snugly and must be changed if it becomes loose. X-ray
should be taken every 4-6 weeks to determine the progress of bone healing; it may be
necessary to prolong immobilization for 4-6 months. The same criteria of radiographic
examination as are used for healing of fractures through the waist are used in fractures of the
proximal third. It is advisable to make an additional x-ray examination 3-4 weeks after
removal of the cast.
80
About 95% of carpal scaffold fractures unite following treatment by standard
techniques. If evidence of healing is not apparent after immobilization for 6 months or more,
further immobilization will probably not be active. Poor prognostic factors for healing are
displacement during treatment, increasing visibility of the fracture line, and presence of early
cystic changes. If the interval between the time of injury and the establishment of a diagnosis
is 3 months or more, a trial of immobilization for 2-3 months may be elected. If obliteration
of the fracture cleft and evidence of restoration of bone continuity are not visible in x-rays
taken after this trial period, some of operative treatment will be necessary to initiate bone
healing. Bone grafting is most successful. Prolonged immobilization in a plaster gauntlet
after bone grafting is necessary before bony continuity is restored.
If avascular necrosis has occurred in the proximal fragment (exhibited by increased
radiodensity of the fragment), bone grafting is less likely to be successful. Although excision
of the avascular fragment may relieve painful symptoms for a time, the patient usually notes
weakness of grasp and discomfort after prolonged use. Posttraumatic arthritis is apt to
develop late.
Prolonged failure of bone healing predisposes to posttraumatic arthritis. Bone grafting
operations or other procedures directed toward restoration of bone continuity may be
successful can cause continued disability. Arthrodesis of the wrist gives the best assurance of
relief of pain and functionally competent extremity in these cases.
Fractures of the Lunate
81
Fracture of the lunate bone may be manifested by minor avulsion fractures of the
posterior or anterior horn. Careful multiplane x-ray examination is necessary to establish the
diagnosis. Either of these lesions may be treated by the use of a volar splint for 3 weeks.
Fracture of the body may be manifested by a crack, by comminution, or by impaction.
A fissure fracture can be treated immobilization in plaster for 3 weeks.
One complication of this fracture is persistent pain in the wrist, slight restriction of motion,
and tenderness over the lunate bone. X-ray examination can demonstrate areas of sclerosis
and rarefaction. Impaction or collapse can be accompanied by arthritic changes surrounding
the lunate bone. This x-ray appearance is referred to as Kienbock’s disease, osteochondrosis
of the lunate bone, or avascular necrosis.
Fracture of the Hamate
Fracture of the hamate bone may occur through the body and is shown on x-ray as a
fissure or compression. Fracture of the base of the hamulus is less common and more
difficult to diagnose; special projections are necessary to demonstrate the cleft. If the
hamulus is displaced, closed manipulation will not be affective. Prolonged pain or evidence
of irritation of the ulnar nerve may require excision of the loose fragment.
Lateral radiograph of the wrist This
shows
a bony fragments
at the carpometacarpal region
Fracture of the Triquetrum
Oblique radiograph of the wrist This
shows a fracture of the body of the
hamate.
82
Fracture of the triquetrum bone is caused commonly by direct violence and
is often associated with fracture of other carpal bones. Treatment is by
immobilization in a plaster gauntlet for 4 weeks.
Lateral radiograph of the hand. shows a small bone
fragment located dorsally. This a fractured triquetrum.
Traumatic Carpal Instability
Carpal
dislocations,
fracture-dislocations,
and
collapse
deformities
secondary to ligamentous injuries occur by similar mechanism and have similar
tendencies to deform. Dislocation is caused by forced dorsiflexion of the wrist. Xrays of excellent technical quality taken in the anteroposterior and the true lateral
projections are necessary. Even with the highest-quality films, the diagnosis may
be missed by experienced physicians.
The carpal injury is focused around the lunate and proximal scaffold, leading
to perilunate or transscaphoid perilunate fracture-dislocation. Dislocation may be
manifested by dorsal displacement of the capitate bone though the lunate retains
contact with the radius. A further degree of injury is manifested by complete
displacement of the lunate bone from the radius, so that it comes to lie anterior to
83
the capitale bone and loses its relationship to the articular surface of the radius.
Most surgeons agree that perilunate and lunate dislocations are two stages of the
same injury. If the lunate is subluxated and the scaffold is not fractured, a
triangular gap between the scaffold and lunate can often be demonstrated on the
anteroposterior X-ray. If the schaphoid is fractured, no gap will be present, as the
lunate bone and the proximal fragment of the scaffold retain their relantionship. On
the lateral x-ray, the scaffold normally lies at an angle of 45-50 degrees to the
longitudinal axis of the radius. With carpal instability, the scaffold lies in a vertical
position.
In carpal dislocations without fracture, reduction may be achieved by closed
manipulation with a strong longitudinal distraction force assisted by dorsally
directed pressure on the palmar dislocated lunate. Follow-up x-ray are then taken.
If reduction is adequate, the extremity is immobilized in neutral position for 6
weeks in a plaster cast extending from the elbow to the palmar flexion crease and
to the base of the thumb. Repeat x-rays at 1and 2 weeks postreduction to ensure
that reduction has been maintained.
If manipulative reduction is unsuccessful or lost, or if there is fracture of the
scaffold, open reduction and internal fixarion with Kirschner wires are indicated.
Adequate reduction is confirmed by x-rays showing absence of the triangular gap
between the scaffold and lunate on an anteroposterior film plus proper relationship
of the carpal bones of lateral x-ray. In unstable carpal dislocations without fracture,
the Kirshner wires are left in place and the wrist is immobilized in a short-arm
plaster cast for a minimum of 6 weeks. If scaphoid fracture complicates the
dislocation. The wrist is immobilized until the fracture heals.
Failure to recognize and treat this serious injury leads to significant
disability from a painful, weak “collapsing wrist”.
84
INJURIES OF THE HIP REGION
1. FRACTURE OF THE FEMOREL NECK
Fracture of the femoral neck occurs most commonly patients over 50. If
displacement has occurred, the extremity is externally rotated and shortened.
Motion of the hip joint causes pain. If the fragments are not displaced and the
fracture is stable, pain at the extremes of passive hip motion may be the only
significant finding. The fact that the patient can actively move the extremity often
interferes with prompt diagnosis.
Before treatment is instituted, anteroposterior and lateral films of excellent
quality must be obtained.
Gentle traction and internal rotation of the extremity while the
anteroposterior films is exposed may provide a more favorable relation of
fragments to demonstrate the fracture cleft.
Fractures may be classified as stable or unstable. Stable fractures include
stress fractures and impacted fractures. The unstable category includes displaced
and comminuted fractures. The unstable category includes displaced and
comminuted fractures.
Stable Fractures of the femoral Neck
Patients with stress fractures or impacted fractures may have minimal groin
pain and be able to walk with some pain and a limp. No obvious deformity or
shortening is apparent on physical examination. A high index of suspicion must be
maintained in these patients, as the diagnosis may be difficult to make. If initial xrays do not reveal the stress fracture, a repeat x-ray made 10-14 days after the
injury will show the radiolucent line. An impacted fracture is usually in valgus
position. Impaction must be seen on both anteroposterior and lateral films for
diagnosis.
85
Stress fractures can be treated by crutch ambulation to minimize weightbearing stress. The patient should be instructed not to place the leg in stressful
positions or use it for leverage. If the fracture appears to be healing, partial weight
bearing may be started at 6 weeks after injury, with progression to full weight
bearing when the fracture is healed. Healing usually takes place in 3-6 months.
Impacted fractures may also be treated nonoperatively, but tendency for
displacement is much greater than in stress fractures. Most surgeons prefer to use
internal fixation for impacted fractures to allow maintenance of reduction, earlier
crutch ambulation, and earlier weight bearing. Multiple screw or pin fixation is
frequently the method of choice and should be secure enough to allow weight
bearing immediately. Truly impacted fractures treated with internal fixation
without disruption of the fracture have healing rates approaching 100%.
Unstable Fractures of the Femoral Neck
Displaced and comminuted femoral neck fractures can be a life-endangering
injury, especially in elderly persons. Treatment is directed toward preservation of
life and restoration of function to the hip joint. In most case, reduction and internal
fixation are the treatment of choice. Immobilization of this fracture by means of a
plaster spica is unreliable. Definitive treatment by skeletal traction requires
prolonged recumbency with constant nursing care and is associated with more
numerous complications than early mobilization. Operative treatment usually
consists of internal fixation or primary arthroplasty and should be done as soon as
the patient is medically prepared for surgery.
(1) Internal fixation: The goal of internal fixation is to preserve the femoral
head fragment by providing a setting for bony healing of the fracture. The
objective is to allow the patient as much general physical activity during healing as
is compatible with the mechanics of fixation. To permit necessary preoperative
evaluation of the patient when internal fixation is elected, initial treatment may be
by balanced suspensions, skeletal traction, and prompt closed reduction of the
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fracture. Persistent displacement may cause further compromise of the retinacular
blood supply to the articular fragment.
Anatomic or near-anatomic reduction and firm fixation are desirable to
provide optimal conditions for bone healing. Comminution at the fracture site,
injury to the retinacular blood supply of the capital fragment, excessive stressing of
the fracture site, and insecure fixation are some of the factors that lead to failure.
When the fragments are undisplaced or minimally displaced, manipulation is
unnecessary. Displacement may be corrected by closed reduction preliminary to
fixation or by surgical exposure of the fracture site. Adequate closed reduction is
usually obtained by traction and marked internal rotation of the extremityfrequently to 90 degrees. The fixation apparatus may consist of multiple pins
applied percutaneously or more elaborate implants that require open operation, the
patient does not require traction and may be mobilized at an early date. If operative
fixation is precarious, traction in balanced suspension or immobilization in a
plaster spica for 1-4 months may be necessary until preliminary healing gives
additional stability.
Depending upon the relative security of fixation, the extent of early weight
bearing must be regulated until bone continuity is restored to the point where
displacement of fragments is unlikely. Patients may be ambulatory on crutches or
with a walker within a few days after operative treatment.
(2) Primary arthroplasty: In selecting primary arthroplasty, the surgeon
realizes that the main proximal fragment must be sacrificed because of injury to the
blood supply, preexisting disease, or inability to obtain satisfactory reduction of
the fracture for internal fixation.
When the acetabulum is undamaged or is not the site of preexisting disease,
the commonly accepted technique is hemiarthroplasty using a femoral component
(generally of the intramedullary type) that may or may not be stabilized by a
grouting substance such as methylmethacrylate. In the rare circumstance when
there is concomitant involvement of the acetabulum, total joint replacement may
87
be justified. Primary head and neck resection may be indicated when there is
preexisting infection or local tumor.
The most common sequelae of fracture of the femoral neck are displacement
after reduction and internal fixation, failure of bone healing, and vascular necrosis
of the head fragment. Vascular necrosis and associated collapse occur in 15-35 of
these patients from interruption of the blood supply to the femoral neck at the time
of injury. It is most likely to appear during the 2 years after fracture. Secondary
osteoarthritis (posttraumatic arthritis) appears somewhat later and may be
complicated by any of the common sequelae mentioned above. The most serious
complication of any open operative treatment is infection.
2. TROCHANTERIC FRACTURES
Fracture of the Lesser Trochanter
Isolated fracture of the lesser trochanter is quite rare but may develop as a
result of the avulsion force of the iliopsoas muscle. It occurs commonly as a
component of intertrochanteric fracture.
Fracture of the Greater Trochanter.
Isolated fracture of the greater trochanter may be caused by direct injury or
may occur indirectly as a result of the activity of the gluteus medius and gluteus
minimus muscles. It occurs most commonly as a component of intertrochanteric
fracture.
If displacement is less than 1cm and there is no tendency to further
displacement (determined by repeated x-ray examination), treatment may be by
bed rest with the affected extremity in balanced suspension until acute pain
subsides. As rapidly as symptoms permit, activity can increase gradually to
protected weight bearing with crutches. Full weight bearing is permitted as soon as
healing is apparent, usually in 6-8 weeks. If displacement is greater than 1cm and
increases on adduction of the thigh, extensive tearing of surrounding soft tissues
may be assumed, and open reduction and internal fixation are indicated.
88
Intertrochanteric (Including peritrochanteric) Fractures.
These fractures occur most commonly among elderly persons, usually after a
fall. The cleft of an intertrochanteric fracture extends upward and outward from the
medial region of the junction of the neck and lesser trochanter toward the summit
of the greater trochanter. Peritrochanteric fracture includes both throchanter and is
likely to be comminuted.
It is important to determine whether comminution has occurred and the
magnitude of displacement. These fractures may vary from fissure fracture without
significant separation to severe comminution into four major fragments: headneck, greater throchanter, lesser trochanter, and shaft. Displacement may be
marked, with obvious extreme rotation and shortening of the extremity more
severe than with femoral neck fractures.
These fractures are extracapsular and occur through cancellous bone, which
has a good blood supply. Healing occurs in 3-4 months, and lack of healing is
uncommon.
Initial treatment of the fracture in the hospital can be by balanced suspension
and, when indicated, by the addition of traction. The selection of definitive
treatment-closed or operative techniques-depends in part upon the general
condition of the patient and the type of fracture. Rates of illness and death are
lower when the fracture is internally fixed, allowing for early mobilization.
Operative treatment is indicated as soon as the patient is medically able to tolerate
surgery.
If the patient is unable to tolerate anesthesia or if the fracture is too severely
comminuted to permit internal with good stability, the fracture may be treated by
skeletal traction with a Kirschner wire through the proximal tibia. Within 3-4
months, healing is usually sufficient to allow the patient to be out of bed. Longterm traction is associated with many complications, including bedsores,
pulmonary complications, deterioration of mental status, and varus position of the
fracture.
89
Open reduction may be done electively or may be mandatory for optimal
treatment. Reduction of the fracture can be accomplished by closed techniques, or
it can be an integral part of the open operation. Some surgeons do not prefer to
anatomically reduce unstable fractures caused by comminution of the medial
femoral cortex. It is maintained by some authors that medial displacement of the
upper end of the main distal fragment enhances mechanical stability (although it
may cause concomitant varus deformity), and this advantageously permits earlier
weight bearing and earlier healing. The chief objective of open operation is to
provide sufficient fixation of the fragments by a metallic surgical implant so that
the patient need not be confined to bed during the healing process.
The fixation most widely used is a sliding screw with a side plate. The screw
can slide in the barrel of the side plate, allowing the fracture to impact. A fixed nail
and side plate may cause the fracture to be “nailed apart” and contribute to lack of
healing. As the fracture impacts, the nail cannot slide and may instead cut through
the head of the femur.
3. SUBTROCHANTERIC FRACTURE
Subtrochanteric fracture due to severe trauma occurs below the level of the
lesser trochanter at the junction of cancellous and cortical bone. It is most common
in men during the active years of life. Soft tissue damage is extensive. The
direction of the fracture cleft may be transverse or oblique. Comminution occurs,
and the fracture may extend proximally into the intertrochanteric or distally into
the shaft.
Closed reduction should be attempted by continuous traction to bring the
distal fragment into alignment with the proximal fragment. If comminution is not
extensive and lesser trochanter is not detached, the proximal fragment is often
drawn into relative flexion, external rotation, and abduction by the predominant
activity of the iliopsoas, gluteus medius and gluteus minimus muscles.
90
Prolonged skeletal traction by means of a Kirschner wire inserted through
the supracondylar region of the femur (with the hip and Knee flexed to a right
angle) is necessary if traction treatment is chosen. Thereafter, the extremity is left
in this position with an appropriate amount of traction until stabilization occurs,
usually in 8-12 weeks. The angle of flexion is then reduced by gradually bringing
the hip and knee into extension. After 2-3 months of continuous traction, the
extremity can be immobilized in a plaster spica provided stabilization of the
fracture has occurred. Weight bearing must not be resumed for 4-6 months or oven
longer, until bone healing obliterates the fracture cleft.
Interposition of soft tissue between the major fragments may prevent closed
reduction. If open reduction of this fracture is anticipated, it should be undertaken
early: if treatment is delayed until the third week following injury, the fracture
fragments are more difficult to align and extensive bleeding at the fracture site is
likely to be encountered.
After open reduction has been performed, internal fixation is required to
prevent redisplacement. A variety of devices are available (eg, interlocking nail,
Zickel nail, condylocephalic devices, nail with long side plate) that give varying
degrees of rotational control, longitudinal alignment, and stability.
The activity status after operation depends upon the adequacy of internal
fixation. If fixation is precarious, additional protection with a spica cast or skeletal
traction may be necessary until healing is well underway. If fixation is secure and
the patient is agile and cooperative, ambulation on crutches (non-weight-bearing or
partial weight bearing) on the affected side may be allowed a few days after the
operation.
4 TRAUMATIC DISLOCATION OF THE HIP JOINT
Traumatic dislocation of the hip joint may occur with or without fracture of
the acetabulum or the proximal end of the femur. It is most common during the
active years of life and is usually the result of severe trauma unless there is
preexisting disease of the femoral head, acetabulum, or neuromuscular system. The
91
head of the femur cannot be completely displaced from the normal acetabulum
unless the ligamentum teres is ruptured or deficient because of some unrelated
cause. Traumatic dislocations can be classified according to the direction of
displacement of the femoral head from the acetabulum.
Posterior Hip Dislocation
The head of the femur usually dislocated posterior to the acetabulum while
the is flexed, eg, as may occur in a head-on automobile collision when the driver’s
or passenger’s knee is driven violently against the dashboard.
The significant clinical findings are shortening, adduction, and internal
rotation of the extremity. Anteroposterior, transpelvic, and, if fracture of the
acetabulum is demonstrated, oblique x-ray projections are required. Common
complications are fracture of the acetabulum, injury to the sciatic nerve, and
fracture of the head or shaft of the femur. The head of the femur may be displaced
through a rent in the posterior hip joint capsule, or the glenoid lip may be avulsed
from the acetabulum. The short external rotator muscles of the femur are
commonly lacerated. Fracture of the posterior margin of the acetabulum can create
instability.
If the acetabulum is not fractured or if the fragment is small, reduction by
closed manipulation is indicated. General anesthesia provides maximum muscle
relaxation and allows gentle reduction. Reduction should be achieved as soon as
possible, preferably within the first few hours after injury as soon as the patient’s
general injury status has been adequately assessed. The main feature of reduction is
traction in the line of deformity, followed by gentle flexion of the hip to 90 degrees
with stabilization of the pelvis by an assistant. While manual traction is continued,
the hip is gently rotated into internal and then external rotation to obtain reduction.
The success of reduction is determined immediately by anteroposterior and lateral
x-rays. Interposition substance or bone fragments will be manifest by widening of
the joint cleft. If x-rays are difficult to interpret, CT scan can be helpful in
assessing concentricity of reduction. If reduction is adequate, the hip will usually
be stable with the extremity in extension and slight external rotation.
92
Stability of the hip should be tested immediately after reduction by motion of
the hip in flexion and adduction to assess the maximum limits of stability. A very
easy manipulative reduction (eg, the hip “slides in” with very little effort) may
suggest major instability and potential for redislocation even though the hip is
maintained in traction.
Postreduction treatment may be immobilization in traction or balanced
suspension or in a plaster spica cast. Since this is primarily a soft tissue injury,
sound healing should occur in 4 weeks. Opinion differs on when unsupported
weight should be resumed. Some authors believe that disability caused by ischemic
osteonecrosis of the femoral head is less likely when complete weight bearing for 6
months after injury: others believe that early loading is not harmful.
If the posterior or superior acetabulum is fractured, dislocation of the hip
must be assumed to have occurred even though displacement is not present at the
time of examination. Undisplaced fissure fractures may be treated initially by bed
rest and avoidance of full weight bearing for 2 months. Frequent examination is
necessary to make certain than head of the femur has not become displaced from
the acetabulum.
Minor fragments of the posterior margin of the acetabulum may be
disregarded unless they are in the hip joint cavity. Larger displaced fragments often
cannot be reduced adequately by closed methods. If the fragment is large and the
hip is unstable following closed manipulation, open operation is indicated. The
fragment is then placed in anatomic position and fixed with bone screws or a bone
plate and screws.
After the operation, if fixation is tenuous because of severe comminution of the
fracture, the patient is placed in bed with the extremity in balanced suspension with
5-8 kg of skeletal traction on the tibial tubercle for about 4-6 weeks or until healing
of the acetabular fracture is sound. If fixation is stable, the patient may be allowed
out of bed in a few days with progression to ambulation on crutches that is
nonweight bearing on the injured side. Full weight bearing is not permitted until
healing is complete- a process that takes about 3-6 months.
93
Anterior Hip Dislocation
In anterior hip dislocations, the head of the femur may lie medially on the
obturator membrane, beneath the obturator externus muscle (obturator dislocation),
or in a somewhat more superior position, beneath the iliopsoas muscle and in
contact with the superior ramus of the pubis (pubic dislocations). The thigh is
classically in flexion, abduction, and external rotation, and the head of the femur is
palpable anteriorly and distal to the inguinal flexion crease. Anteroposterior and
lateral films are required; films prepared by transpelvic projection may be helpful.
Closed manipulation with general anesthesia is usually adequate. Postreduction
treatment may be by balanced suspension or by immobilization in a plaster spica
with the hip in extension and the extremity in neutral rotation. Active hip motion is
permitted after 3 weeks
Central Dislocation of the Hip With Fracture of the Pelvis
Central dislocations of the head of the femur with fracture of the acetabulum
may be caused by crushing injury or by axial force transmitted through the
abducted extremity to the acetabulum. Comminution is commonly present. There
are usually two main fragments: superiorly, the ilium with the roof of the
acetabulum; inferiorly and medially, the remainder of the acetabulum and the
obturator ring. Fracture occurs near the roof of the acetabulum, and the
components of the obturator ring are displaced inward with the head of the femur.
Extensive soft tissue injury and massive bleeding into the soft tissues are likely to
be
present.
Intra-abdominal
injury
must
not
be
overlooked.
Initially,
anteroposterior and oblique x-rays are required.
In the absence of complicating injury or immediately after such an injury has
received priority attention, closed treatment of the fracture-dislocation by skeletal
traction should be tried. For the average adult, approximately 10 kg of force is
applied axially to the shaft of the femur, in neither abduction nor adduction,
through a Kirschner wire placed in the distal femur or proximal tibia. A
trochanteric screw or Kirschner wire and bow may be inserted in the greater
94
trochanter to apply force at a right angle to the direction of axial traction. The
extremity is placed in balanced suspension. Progress of reduction is observed by
serial portable x-rays until adequate positioning is manifested by relocation of the
head of the femur beneath the roof of the acetabulum. Bi-directional traction is
maintained for 4-6 weeks. Daily inspection of the trochanteric traction apparatus is
necessary to rule out localized infection, because motion of skin and fat around the
device predisposes to sepsis. The transverse traction component is gradually
diminished under appropriate x-ray control until it can be discontinued. Axial
traction is maintained until stabilization of the fracture fragments by early bone
healing has occurred, usually 8 weeks after injury. During the next 4-6 weeks,
While balanced suspension is continued, gentle active exercises of the knee and hip
are encouraged. After discontinuation of balanced suspension, more elaborate
exercises designed to aid recovery of maximal hip function are performed
frequently during the day. Full and unprotected weight bearing should not be
advised until healing is complete, usually in 4 months.
Sequelae are common, and the patient should be warned of their probable
occurrence. Anatomic reduction is an unattainable goal in most severely
comminuted and widely displaced fractures of this type. Scarring within and
around the hip joint, with or without ectopic bone and exuberant callus formation,
is incidental to the healing process and can be a significant factor in restriction of
motion in varying degrees. Osteonecrosis of the femoral head and secondary
osteoarthritis are common sequelae that appear somewhat later.
Indications for open reduction and internal fixation include the presence for free
osteochondral fragments in the joint, associated femoral head fracture, instability
severe enough to allow chronic dislocation of the femoral head, and incongruity of
weight-bearing surfaces. Some authors feel that all displaced acetabular fractures
should undergo open reduction and internal fixation, as there is a correlation of
anatomic position with prognosis.
Letournel has classified acetabular fractures according to which column of the
pelvis is involved. The anterior column comprises the anterior iliac crest, the
95
anterior acetabulum, and the pubic symphysis. The posterior column contains the
posterior portion of the acetabulum, the ischial tuberosity, and the great sciatic
notch. Fractures may involve one or both columns.
Four radiographic views are necessary to delineate the extent of the fracture: a
standard anteroposterior view of the pelvis, and anteroposterior view of the
affected hip, and two oblique taken with the patient rolled 45 degrees toward and
away from (respectively) the affected side. Accurate assessment of the fracture
fragments allows the surgeon to choose the most appropriate surgical approach. CT
scan may give additional information. These complex acetabular fractures are
difficult to manage surgically, and the procedure should be performed only by an
expert in the technique.
5. TREATMENT OF SEQUELAE OF FRACTURES&DISLOCATIONS OF
THE HIP REGION.
Sequelae of fractures, dislocations, and fracture-dislocations of the hip region
may be due to or modified by the nature of the initial lesion, preexisting local or
systemic disease, or the type of treatment that has been given. Some sequelae are
unique to one injury, while others are common to the three major categories.
Femoral Neck fractures
Comminution can make precise reduction difficult or impossible by either open or
closed techniques. When comminution is so severe that intimate approximation of
major fragments is impossible, fibrous healing or pseudarthrosis is probable.
Further complications result from injury to the retinacular blood supply of the
proximal articular fragment of the femur, which enhances the likelihood of
ischemic necrosis. Preexisting osteopenia due to osteoporosis or other causes is
characterized by a reduced volume of cancellous bone at the fracture site available
for endosteal healing. Lack of bone substance offers insecure support to an internal
fixation apparatus. Infection after the primary surgical procedure may limit or
determine the selection of types of reconstructive operations. Excessive physical
activity such as unsupported weight bearing prior to bone healing may cause
96
loosening at the surgical implant and bone or may cause fatique breakage of the
fixation apparatus.
This fracture occurs most commonly in elderly persons but can occur with
major trauma in younger people. The incidence of complications (ie, nonunion and
vascular necrosis) is as high in the young as in the elderly.
Operations designed to enhance bone healing may be done primarily as
prophylaxis or secondarily as corrective procedures. These operations include
cancellous or cortical bone grafting; muscle pedicle flap transfers to the fracture
site with or without attached bone; supportive or displacement osteotomies with or
without internal fixation apparatus; and refixation.
As time passes, either partial or complete ischemic osteonecrosis of the
femoral head is likely to complicate or be associated with secondary osteoarthritis.
Before infraction or collapse of the superior sector of the head occurs, operations
designed to enhance blood supply, such as bone grafting or muscle pedicle flap
transfers, have been performed with varying success. The rationale of osteotomy in
the trochanteric region for the treatment of osteonecrosis is to place an uninvolved
area of the femoral head in contact with the major weight-bearing surface of the
acetabulum. Arthrodesis for this condition was used more frequently in the past.
Arthroplasty (replacement of the femoral head and acetabulum) provides both
mobility and stability. It is currently more popular than head and neck resection,
which provides only mobility, or arthrodesis, which provides only stability.
If active infection has been of short duration and apparently has been
suppressed, any of the operations mentioned above may be justified if there is
reasonable assurance that reactivation of infection can be controlled. Otherwise,
head and neck resection or perhaps arthrodesis combined with removal of implants
and aggressive adjunctive antimicrobial drug therapy is a more realistic alternative.
A tertiary reconstructive procedure such as total hip joint replacement may be
feasible at some later date.
Trochanteric Fractures
97
Undisplaced or anatomically reduced fractures of the trochanteric region that
have been firmly fixed and have not been loaded excessively during the phase of
restoration of bone continuity are unlikely to exhibit prolonged delay of healing.
Comminution and incomplete reduction are factors that to delay healing.
Occasionally, especially in younger persons, extensive comminution and marked
displacement may be complicated by ischemic necrosis of the femoral head and
secondary osteoarthritis.
If the fracture has no intracapsular extension and infection is limited to the
fracture site, treatment is as for chronic osteomyelitis. If the internal fixation
apparatus is firmly attached and adequately stabilizes an incompletely healed
fracture, removal of the implant may be deferred until sound bone healing occurs.
The treatment of complicating intra-articular infection is similar to that for femoral
neck fractures with pyogenic arthritis.
Traumatic Dislocation of the Hip Joint
Recurrent posttraumatic dislocation of the hip joint uncomplicated by
acetabular fracture, fracture of the femoral head, or a neurologic lesion is
uncommon and may be anterior or posterior; it is likely to be due to extensive soft
tissue dehiscence. Treatment is by repair of the soft tissues. Recurrent or persistent
subluxation or dislocation is more commonly due to fracture-dislocation. The
precise cause must be determined by physical and x-ray examination. If significant
secondary osteoarthritis is not a complication, operative replacement and fixation
of displaced acetabular fragments or removal of a minor but offending fragment of
the femoral head can correct articular instability. If it is a complication,
arthroplasty or arthrodesis will probably give a more favorable long-term result
than repair of the fracture followed by tertiary osteotomy (see below).
Persistent infection of the joint after operation for fracture-dislocation
requires treatment similar to that for infection complicating neck or trochanteric
fractures.
98
FRACTURE OF THE SHAFT OF THE FEMUR
Fracture of the shaft of the femur usually occurs as a result of severe trauma.
Indirect violence, especially torsional stress, is likely to cause spiral fractures that
extend proximally or, more commonly, distally into the metaphyseal regions. Most
are closed fractures; open fractures is often the result of compounding from within.
Extensive soft tissue injury, bleeding, and shock are commonly present.
The most significant features are severe pain in the thigh and deformity of
the lower extremity. Surgical shock is likely to be present, as several units of blood
may be lost into the thigh with only moderate swelling becoming apparent. Careful
x-ray examination in at least two planes is necessary to determine the exact site
and configuration of the fracture cleft. The hip and knee should be examined and
x-rays obtained to look for associated injury.
Injuries to the sciatic nerve and to the superficial femoral artery and vein are
not common bust must be recognized promptly. Surgical shock and secondary
anemia are the most important early complication. Later complications are
essentially those of prolonged recumbency, eg, the formation of renal calculi.
Treatment
Closed treatment: Treatment depends upon the age and medical status of the
patient as well as the site and configuration of the fracture. Skeletal traction is
generally the most effective form of closed treatment. However, 2-3 months of
traction are often required, followed by external plaster or brace support. Fractures
of the distal femoral shaft are more amenable to cast-brace treatment. After about 6
weeks in traction, the patient may be placed in a cast brace (long-leg cast with a
hinged knee) to allow early knee motion and progressive weight bearing.
Operative treatment: Most fractures in the middle third of the femur can be
internally fixed by an intramedullary rod. Intramedullary fixation of femoral shaft
fractures allows early mobilization of the patient (within 2-3 days if the fracture
fixation is stable), more anatomic alignment, improved knee function by
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decreasing the time spent in traction, and a marked decrease in the cost of
hospitalization.
The procedure may be performed open or “blind”. In open nailing, the
fracture site is opened and the nail is driven retrograde from the fracture site into
the proximal fragment. The fracture is then reduced and the nail driven across the
fracture into the distal fragment. This requires a large incision and major
manipulation of the fracture fragments, with significant blood loss.
In “blind” nailing, the fracture is reduced by closed manipulation on the
fracture table under fluoroscopic control. An 8=to 10-cm incision is made proximal
to the greater trochanter, and the nail is inserted through the trochanteric notch
down into the intramedullary canal. The fracture site is not opened. :”Blind”
nailing decreases the chance of infection by decreasing the amount of soft tissue
dissection necessary and by leaving the fracture site closed.
If the fracture is comminuted, interlocking nails can be used to maintain
length by increased fixation proximally and distally. These may allow patients
early mobilization even with comminuted femoral shaft fractures. If there is
extensive soft tissue loss surrounding the fracture, stability of the fracture, stability
of the bone fragments may be achieved with an external fixation device.
Complications of this procedure usually involve technical problems at the time of
surgery resulting in malalignment or shortening from choosing a rod that is too
short or too narrow. Infection can occur after any open procedure but is very
uncommon in “blind nailing”. Occasionally, a painful bursa may develop over the
proximal end of the nail that causes discomfort when the patient sits or walks. The
rod may be removed after healing is complete-usually after 1-1,5 years. The
healing rate of femoral shaft fractures is general is very high and approaches 100%
after “blind” nailing.
1.INJURIES OF THE KNEE REGION
Supracondylar Fracture of the Femur.
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This comparatively uncommon fracture (at the junction of cortical and
cancellous bone) may be transverse, oblique, or comminuted. The distal end of the
proximal fragments is apt to perforate the overlying vastus intermedius, vastus
medialis, or rectus femoris muscles and may penetrate the suprapatellar pouch of
the knee joint to cause hemarthrosis. The proximal end of the distal fragment is
usually displaced posteriorly and slightly laterally.
Since the distal fragment may impinge upon the popliteal vessels,
circulatory adequacy distal to the fracture site should be verified as soon as
possible. Absence or marked diminution of pedal pulsations is an indication for
immediate reduction. If pulsation does not return promptly after reduction, an
immediate arteriogram or exploration (or both) with appropriate treatment of the
vascular lesion is indicated.
A less frequent complication is injury to the peroneal or tibial nerve.
If the fracture is transverse or nearly so, closed manipulation under general
anesthesia will occasionally be successful. Stable fractures with minimal
displacement can be immobilized in a single plaster hip spica with the hip and knee
in about 30 degrees of flexion. Frequent x-ray examination is necessary to make
certain that redisplacement has not occurred.
Stable or unstable uncomplicated supracondylar fracture can be treated with
skeletal traction if soft tissue interposition does not interfere with reduction. Two
traction pins may be necessary-one in the distal femur foe vertical traction and one
in the proximal tibia for longitudinal traction-in order to maintain alignment. If
adequate reduction cannot be obtained, it may be necessary to manipulate the
fragments under general anesthesia, using skeletal traction to control the distal
fragment.
Traction must be continued for about 6 weeks or until stabilization occurs.
The extremity can then be immobilized in a cast-brace for another 2-3 months until
complete healing occurs. This combines support with early motion of the knee to
decrease restriction due to scarring and adhesion formation in adjacent soft tissues.
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If reduction is inadequate by closed technique or if early motion of the
patient and the joint is desired, internal fixation with a condylar nail or screw and
side plate or with a supracondylar intramedullary device may be performed.
Intercondylar Fracture of the femur
This comminuted fracture is classically described as a T or Y fracture according to
x-ray configuration of the fragments. Closed reduction is difficult when the
proximal shaft fragment is interposed between the two main distal fragments.
Maximal recovery of function of the knee joint requires anatomic reduction of the
articular components if possible. If alignment is satisfactory and displacement
minimal, skeletal traction for 6-10 weeks followed by a cast-brace will be
sufficient. If displacement is marked, open reduction and internal fixation of the
fragments are indicated to restore articular congruity. A condylar screw and site
plate are used to maintain alignment of the articular fragments to each other and to
the femoral shaft. Even if the articular fragments are restored to their anatomic
positions, posttraumatic arthritis with joint stiffness and pain is common.
Condylar Fracture of the Femur
Isolated fracture of the lateral or medial condyle of the femur is rare.
Occasionally, only the posterior portion of the condyle is separated. Injury to the
cruciate ligaments or the collateral ligaments of the opposite side of the knee often
occurs.
The objective of treatment is restoration of anatomic intra-articular
relationships. If displacement is minimal, closed reduction can be attempted by
manipulation, with a bending stress used in the direction opposite to the apex of
angular deformity. If anatomic reduction cannot be obtained by closed
manipulation, with a bending stress used in the direction opposite to the apex of
angular deformity. If anatomic reduction cannot be obtained by closed
manipulation, open reduction and fixation of the minor fragment with two or the
bone screws are recommended. The ligaments must be explored and repaired if
they are found to be injured.
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4. FRACTURE OF THE PATELLA
Transverse Fractures of the Patella
Transverse fracture of the patella is the result of indirect violence, usually with the
knee in semiflexion. Fracture may be due to sudden voluntary contraction of the
quadriceps muscles or sudden forced flexion of the leg when these muscles are
contracted. The level of fracture is most often in the middle. The extent of tearing
of the patellar retinacula depends upon the degree of force of the initiating injury.
The activity of the quadriceps muscles causes displacement of the proximal
fragment; the magnitude of displacement is dependent upon the extent of the tear
of the quadriceps expansion.
Swelling of the anterior knee region is caused by hemarthrosis and
hemorrhage into the soft tissues overlying the joint. If displacement is present, the
defect in the patella can be palpated, and active extension of the knee is lost.
Open reduction is indicated if the fragments are offset or separated more
than 2-3 mm. The fragments must be accurately
repositioned to prevent early posttraumatic arthritis of the patellofemoral joint. If
the minor fragment is small (no more than 1cm in length) or severely comminuted,
it may be excised and the rectus or patellar tendon (depending upon which pole of
the patella is involved) sutured directly to the major fragment. If the fragments. If
the fragments are approximately the same size, repair by wire cerclage or figureof-eight wire is preferred.
Accurate reduction of the articular surface must be confirmed by lateral xrays taken itraoperatively.
Comminuted Fracture of the Patella
Comminuted fracture of the patella is caused only by direct violence. Little
or no separation of the fragments occurs, because the quadriceps expansion is not
extensively torn. Severe injury may cause extensive comminution of the articular
cartilages of both the patella and the opposing femur. If comminution is not severe
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and displacement is insignificant, immobilization for 8 weeks in a plaster cylinder
extending from the groin to the supramalleolar region is sufficient.
Severe comminution requires excision of the patella and repair of the defect
by imbrication of the quadriceps expansion. Excision of the patella can result in
decreased strength, pain in the knee, and general restriction of activity.
3.TEAR OF THE QUADRICEPS TENDON
Tear of the quadriceps tendon occurs most often in patients over age 40.
Preexisting attritional disease of the tendon is apt to be present, and causative
injury may be minor. The tear commonly results from sudden deceleration, such as
stumbling, or slipping on a wet surface. A small flake of bone may be avulsed
from the superior pole of the patella, or the tear may occur entirely through
tendinous and muscle tissue.
Pain may be noted in the anterior knee region. Swelling is due to
hemathrosis and extravasation of blood into the soft tissues. The patient is unable
to extend the knee completely. X-rays may show avulsion of a bit of bone from the
superior patella.
Operative repair is recommended for complete tear. If treatment is delayed
until partial healing has occurred, the suture line can be reinforced by
transplantation of the iliotibial band from the upper area of the tibia.
5. TEAR OF THE PATELLAR LIGAMENT
The same mechanism that causes tears of the quadriceps tendon, transverse
fracture of the patella, or avulsion of the tibial tuberosity may also cause tear of the
patellar ligament. The characteristic finding is proximal displacement of the
patella. A bit of bone may be avulsed from the lower pole of the patella if the tear
takes place in the proximal patellar tendon.
Operative treatment is necessary for complete tear. The ligament is resutured
to the patella, and any tear in the quadriceps expansion is repaired. The extremity
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should be immobilized for 8weeks in a tubular plaster cast extending from the
groin to the supramalleolar region. Guarded exercises may then be started.
DISLOCATION OF THE PATELLA
Acute traumatic dislocation of the patella should be differentiated from
episodic recurrent dislocation, since the latter condition is likely to be associated
with occult organic lesion. When this injury occurs alone, it may be due to direct
violence or muscle activity of the quadriceps, and the direction of dislocation of
the patella lateral. Spontaneous reduction is apt to occur if the knee joint is
extended; if so, the clinical findings may consist merely of hemarthrosis and
localized tenderness over the medial patellar retinaculum. Gross instability of the
patella, which can be demonstrated by physical examination, indicates that injury
to the soft tissues of the medial aspect of the knee has been extensive. Recurrent
episodes require operative for effective treatment.
6.DISLOCATIONS OF THE KNEE JOINT
Traumatic dislocation of the knee joint is uncommon. It is caused by severe
trauma. Displacement may be transverse or torsional. Complete dislocation can
occur only after extensive tearing of the supporting ligaments and is apt to cause
injury to the popliteal vessels or the tibial and peroneal nerves.
Signs of neurovascular injury below the site of dislocation are an absolute
indication for prompt reduction, preferably under general anesthesia, since failure
of circulation will undoubtedly result in gangrene of the leg and foot. Axial
traction is applied to the leg to obtain reduction. If pedal pulses do not return
promptly, patency of the popliteal vessels should be investigated immediately by
angiography. Even if pulses do return, angiography is usually indicated to rule out
an intimal tear of the vessel. Inadequate assessment and treatment of the vascular
injuries can lead to an amputation rate of 50%. If a vascular injury is confirmed,
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repair should be started as soon as the patient’s general status allows. Ischemia of
more than 4 hours implies a poor prognosis for limb salvage. Prophylactic
fasciotomy of the leg compartments should be performed at the time of vascular
repair to eliminate the compartment syndrome caused by postischemic edema.
Anatomic reduction of uncomplicated dislocation should be attempted. If
impinging soft tissues cannot be removed by closed manipulation, arthrotomy is
indicated. After reduction, repair of the major ligamentous injuries may be
performed, but this should not be done if the time and dissection necessary will
further jeopardize survival of the limb. The extremity should be immobilized in a
plaster cast extending from the inguinal region to the toes, with the knee in slight
flexion. A window should be cut in the plaster over the dorsum of the foot to allow
for frequent determination of dorsalis pedis artery pulsation. In anteroposterior
dislocations, adequacy of reduction should be assessed at frequent intervals during
the first 3-4 weeks to rule out posterior subluxation. If subluxation occurs, the knee
joint must be reduced and placed in an external fixation device. After 8 weeks of
immobilization, the knee can be protected by a long-leg brace. Intensive
quadriceps exercises are necessary to minimize functional loss.
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7. INTERNAL DERANGEMENTS OF THE KNEE JOINT
Internal derangements of the knee joint mechanism may be caused by trauma or
attritional disease. Although ligamentous and cartilaginous injuries are discussed
separately, they commonly occur as combined lesions.
Arthroscopy and newer techniques of arthrography using single or double
contrast media can be valuable adjuncts in establishing a precise diagnosis when
the usual diagnostic methods are inconclusive.
Injury to the Menisci
Injury to the medial meniscus is the most frequent internal derangement of the
knee joint. The significant clinical findings after acute injury are swelling (due to
hemarthrosis) and varying degrees of restriction of flexion or extension. True
locking (inability to fully extend the knee) is highly suggestive of meniscal tear. A
marginal tear permits displacement of the medial fragment into the intercondylar
region (bucket-handle tear) and prevents either complete extension or complete
flexion. Motion may cause pain over the anteromedial or posteromedial joint line.
Tenderness can often be elicited at the point of pain. Forcible rotation of the foot
with the knee flexed to a right angle may cause pain over the medial joint line. If
symptoms have persisted for 2-3weeks, weakness and atrophy of the quadriceps
femoris may be present.
Injury to the lateral meniscus less often causes mechanical blockage of joint
motion. Pain and tenderness may be present over the lateral joint line. Pain can be
elicited by forcible rotation of the leg with the knee flexed to a right angle.
Arthrography is less accurate for diagnosing tears of the lateral meniscus, because
of interference by the presence of the popliteus tendon.
Initial treatment may be conservative. Swelling and pain caused by tense
hemarthrosis can be relieved by aspiration. The knee may be placed in a removable
knee immobilizer for comfort. Younger patients usually prefer to be ambulatory on
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crutches. As long as acute symptoms persist, isometric quadriceps exercises should
be performed frequently throughout the day with the knee in maximum extension
(as a “straight leg lift”). Unrestricted activity must not be resumed until complete
motion is recovered.
Arthroscopy or exploratory arthrotomy is advisable for recurrent or
persistent “locking”, recurrent effusion, or disabling pain. Isometric quadriceps
exercisesare instituted after meniscectomy and gradually increased in frequency.
As soon as the patients is able to perform these exercises comfortably, graded
resistance maneuvers should be started. Exercises must be continued until all
motion has been recovered and the volume and competency of the quadriceps are
equal to those of the uninjured side.
8. FRACTURES OF THE PROXIMAL TIBIA
Fracture of the Lateral Tibial condyle
Fracture of the lateral condyle, or plateau, of the tibia is commonly caused by a
blow on the lateral aspect of the knee with the foot in fixed position, producing an
abduction strain. The lateral femoral condyle is driven down into the tibial
condyle, causing fracture. Hemarthrosis is always present, as the fracture cleft
involves the knee joint. Soft tissue injuries are apt to be present also. The tibial
collateral and anterior cruciate ligaments may be torn. A displaced free fragment
may tear the overlying lateral meniscus. If displacement is marked, fracture of the
proximal fibula may be present also.
The objective of treatment is to restore the articular surface and normal
anatomic relationships, so that torn ligaments can heal without elongation. In cases
of minimal displacement where ligaments have not been extensively damaged,
treatment be by immobilization for 6-12 weeks in a tubular plaster cast extending
from the toes in the inguinal region.
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Many fractures of the lateral condyle of the tibia, especially comminuted
fractures, cannot be reduced adequately by closed methods. If depression of the
articular surface exceeds 7-8 mm in younger patients, open reduction is usually
indicated.
After elevation of the articular surface, insertion of bone graft may be
necessary to maintain alignment. Stabilization with a bolt or multiple bone screws
is usually necessary. Weight bearing is resumed after 3 months.
Fracture of the Medial Tibial Condyle
Fracture of the medial condyle of the tibia is caused by the adduction strain
produced by a blow against the medial aspect of the knee with the foot in fixed
position. The medial meniscus and the fibular collateral ligament may be torn.
Severe comminution is not usually present, and there is only one major free
fragment.
Treatments is by closed reduction to restore the articular surface of the tibia
so that ligamentous healing can occur without elongation. If closed reduction is
unsuccessful, open reduction and stabilization with multiple screws may be
necessary. After reduction, the extremity is immobilized for10-12 weeks in a
tubular cast extending from the inguinal region to the toes with the knee in full
extension. If internal fixation has provided stability, early motion may be started,
although weight hearing is not permitted for at least 3 months.
Fracture of Both Tibial Condyles
Axial force, such as may result from falling on the foot or sudden
deceleration with the knee in full extension (as during an automobile accident), can
cause simultaneous fracture of both condyles of the tibia. Comminution is apt to be
severe. Swelling of the knee due to hemarthrosis is marked. Deformity is either
genu varum or genu valgum. X-ray examination should include oblique
projections.
Severe comminution makes anatomic reduction difficult to achieve by any
means and difficult to maintain following closed manipulation alone. Sustained
skeletal traction is usually necessary. When stability has been achieved, the
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extremity can be immobilized for another 4-6 weeks in a tubular plaster cast
extending from the toes to the inguinal region with the knee in full extension.
Unassisted weight bearing is not permitted for 3-4 moths.
Is closed methods are not effective, open reduction must be attempted.
Instability and restriction of motion of the knee are common sequelae of this
type of fracture. If reduction is not adequate, posttraumatic arthritis will appear
early.
Fracture of the Tibial Tuberosity
Violent contraction of the quadriceps muscle may cause avulsion of the
tibial tuberosity. When avulsion of the tuberosity is complete, active extension of
the knee is not possible.
If displacement is minimal, treatment is by immobilization in a tubular
plaster cast extending from the inguinal to the supramalleolar region with the knee
in full extension. Immobilization is maintained for 8 weeks or until stabilization
occurs.
A loose fragment that has been displaced more than 0,5 cm can be treated either by
closed reduction and percutaneous fixation, with plaster immobilization, or by
open reduction.
Fracture of the Tibial Eminence
This injury usually occurs in associated with comminuted fracture of the
condyles. The medial intercondylar tubercle may be avulsed with adjacent bone
attached to the anterior cruciate ligament, and injury to that structure is of greater
importance. In addition to avulsion of the anterior cruciate ligament, there may
also be injury to the tibial collateral ligament and the medial knee joint capsule.
Hemarthrosis is always present.
Isolated and undisplaced fracture may be treated by immobilization of the
extremity for 6 weeks in a tubular plaster cast extending from the inguinal region
to the toes with knee in slight flexion. The treatment of displaced fracture is the
same as that of rupture of the anterior cruciate ligament (see above).
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FRACTURE OF THE SHAFTS OF THE TIBIA& FIBULA
Fracture of the shaft of the tibia or fibula occurs at any age but is most
common during adolescence and active adulthood. Is general, open, transverse,
comminuted, and segmental fractures are caused by indirect violence. Fracture of
the middle third of the shaft (especially if comminuted) is apt to be complicated by
delay of bone healing.
If fracture is complete and displacement is present, clinical diagnosis is not
difficult. However, critical local examination is of utmost importance in planing
treatment. The nature of the skin wounds that may communicate with the fracture
site often suggests the mechanism of compounding, whether it has occurred from
within or from without. A small laceration without contused edges suggests that
the point of a bone fragment has caused compounding from within. A large wound
with contused edges, especially over the subcutaneous surface of the tibia, suggests
compounding from without. The presence of abrasions more than 6 hours old,
pyoderma, and preexisting ulcers precludes immediate open treatment of closed
fracture. Extensive swelling due to hemorrhagic exudate in closed fascial
compartments
may
prevent
complete
reduction
immediately.
Extensive
hemorrhagic and edematous infiltration can make difficult satisfactory closure of
the subcutaneous tissue and skin incidental to elective open reduction.
Neurovascular integrity below the level of the fracture must be verified before
definitive treatment is instituted.
X-rays in the anteroposterior and lateral projection of the entire leg,
including both the knee and ankle joints, are always necessary, and oblique
projections are often desirable. The surgeon must know the exact site and
configuration, and the direction of displacement of fragments. Inadequate x-ray
examination can lead to an incomplete diagnosis.
1. FRACTURE OF THE SHAFT OF THE FIBULA
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Isolated fracture of the shaft of the fibula is uncommon and is usually
associated with other injury of the leg, such as fracture of the tibia or fracturedislocation of the ankle joint. If no other lesion is present, immobilization is for
comfort only. This requires 3-4 weeks in a plaster boot (equipped with a walking
surface) extending from the knee to the toes or in a removable knee immobilizer.
Complete healing of uncomplicated fracture can be expected.
2. FRACTURE OF THE SHAFT OF THE TIBIA
Isolated fracture of the shaft of the tibia is apt to be caused by indirect injury,
such as torsional stress. Because of mechanical stability provided by the intact
fibula, marked displacement is not apt to occur. Marked overriding suggests a
lesion of either tibiofibular joint.
If the fragments are not displaced, reliable treatment may be given be
immobilization in a tubular plaster cast extending from the inguinal region to the
toes with the foot in neutral position. The plaster should be changed at appropriate
intervals to correct the loosening that will occur as a result of absorption of
hemorrhagic exudate and atrophy of the thigh and calf muscles. Immobilization
should be continued for at least 16-20 weeks or until healing is demonstrated by xray.
If the fragments are displaced, manipulation under anesthesia may be
necessary a long-leg plaster cast is applied as for undisplaced fracture. Alignment
should be checked by x-ray frequently during the first 6-8 weeks of treatment,
because varus angulation can be a significant problem with isolated tibial shaft
fractures. If x-rays do not show satisfactory apposition of fragments, alternative
methods of treatment should be used (se below).
3. FARCTURE OF THE SHAFTS OF BOTH BONES IN ADULTS
Simultaneous fractures of the shafts of the tibia and fibula are unstable and
tend to become displaced following reduction. Treatment is directed toward
reduction and stabilization of the tibial fracture until healing takes place. For
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adequate reduction, the fragments must be in contact, and angulation and torsional
displacement of the tibial fracture must be corrected.
If reduction by closed manipulation is anatomic, transverse fractures tend to
be stable. X-rays must be repeated weekly for the first 4 weeks and then at
decreasing intervals to determine whether displacement has recurred. Recurrent
angular displacement can be corrected by “cast wedging”. This involves dividing
the plaster circumferentially and inserting wedges in the appropriate direction.
After satisfactory reduction has been obtained and early healing has begun, the
long-leg cast may be replaced by a prefabricated functional brace to allow motion
of the knee and ankle.
If oblique and spiral fractures are unstable following manipulation and
immobilization, internal fixation, percutaneous fixation, or skeletal traction may be
required. Percutaneous fixation can be accomplished either by incorporation into
the cast of pins or wires that transfix the major bone fragments or by use of an
extraskeletal apparatus called an external fixator. Comminuted fractures with large
overlying wounds or major soft tissue loss are frequently best treated by use of an
external fixator. This provides fairly rigid fixation of the fracture fragments yet
allows for accessibility for wound treatment.
If adequate apposition and correction of the deformity cannot be achieved by
closed methods, open reduction and internal fixation are required. Intramedullary
rods give excellent fixation in middle-third shaft fractures and can be introduced
through the area of the tibial tubercle, proximal to the fracture site, thus allowing
the closed fracture to remain “closed”. The fracture is reduced and the nail inserted
under fluoroscopic control. Segmental fractures can be treated very satisfactorily
with interlocking nails that maintain length and proper rotational control resulting
in significantly improved alignment and healing rates superior to those achieved
with plaster cast treatment.
Metal plates and screws provide more rigid fixation than intramedullary rods
but require more soft tissue dissection, thus increasing the risk of infection and
delayed union
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INJURIES OF THE ANKLE REGION
1.ANKLE SPRAIN
Ankle sprain is most often caused by forced inversion of the foot, as may
occur in stumbling on uneven ground. Pain is usually maximal over the
anterolateral aspect of the joint; greater tenderness is apt to be found in the region
of the anterior talofibular and talocalcaneal ligaments. Eversion sprain is less
common; maximal tenderness and swelling are usually found over the deltoid
ligament.
Sprain is differentiated from major partial or complete ligamentous tears by
anteroposterior, lateral, and 30-degree internal oblique (mortise view) x-ray
projections; if the joint cleft between either malleolus and the talus is greater than
4mm, major ligamentous tear is probable. Occult lesions can be demonstrated by
x-ray examination under inversion stress after infiltration of the area of maximal
swelling and tenderness with 5mL of 1% lidocaine.
If swelling is marked, elevation of the extremity and avoidance of weight
bearing for a few days are advisable. The ankle can be supported with Gibney
strapping or a cast for 2-3 weeks to relieve pain and swelling. Further treatment
may be by warm foot baths and elastic bandages continue treatment until muscle
strength and full joint motion are recovered. Tears of major ligaments of the ankle
joint are discussed below.
2.FRACTURES& DISLOCATIONS OF THE ANKLE JOINT
Fractures and dislocations of the ankle joint may be caused by direct force,
in which case they are apt to be open: or by indirect force, which often causes
typical lesions (see below).
Pain swelling are the prominent findings. Deformity may or may not be
present. X-rays of excellent technical quality must be prepared in a sufficient
variety of projections to demonstrate the extent and configuration of all major
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fragments. A special oblique (mortise) view is required. This is taken with the foot
in 20-30 degrees of internal rotation in order to demonstrate widening of the
medial clear space between the talus and the medial malleolus.
This confirms lateral shift of the talus, usually caused by rupture of the deltoid
ligaments or fracture of the medial malleolus.
Fracture of the Medial Malleolus
Fracture of the medial malleolus may occur as an isolated lesion of any part
of the malleolus (including the tip) or may be associated with (1) fracture of the
talus and (2) dislocation of the inferior tibiofibular joint with or without fracture of
the fibula. Isolated fracture does not usually cause instability of the ankle joint.
Undisplaced isolated fracture of the medial malleolus should be treated by
immobilization in a plaster boot extending from the knee to the toes with the ankle
flexed to a right angle and the foot slightly inverted to relax the tension on the
deltoid ligament. Immobilization must be continued for 6-8 weeks or until bone
healing is sound.
Displaced isolated fracture of the medial malleolus can be treated by closed
manipulation under general or local anesthesia. The essential maneuver consists of
anatomic realignment by digital pressure over the distal fragment, followed by
immobilization in a plaster boot (as for undisplaced fracture) until bone healing is
sound. If anatomic reduction cannot be achieved by closed methods, open
reduction and internal fixation with one or two bone screws are required.
Fracture of the Lateral Malleolus
Fracture of the lateral malleolus may occur as an isolated lesion or may be
associated with fracture of the medial malleolus, tear of the deltoid or posterior
lateral malleolar ligament, or avulsion of the posterior tibial tubercle. If the medial
aspect of the ankle is injured, lateral subluxation of the ankle is injured, lateral
subluxation of the talus is apt to be present. The tip of the lateral malleolus may be
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avulsed by the calcaneofibular and anterior talofibular ligaments. Transverse or
oblique fracture may occur.
Oblique fractures commonly extend downward and anteriorly from the posterior
and superior aspects.
Isolated undisplaced fracture of the lateral malleolus may be treated by a
plaster walking boot for 6 weeks. An elastic bandage is worn thereafter until full
joint motion is recovered and the calf muscles are functioning normally. If
anatomic reduction cannot be achieved by closed methods, additional injury to the
medial side of the joint should be suspected and open reduction is required.
Combined Fracture of the Medial &Lateral Malleoli
The combination of external rotation and abduction is the most common
mechanism producing ankle fracture. Bimalleolar fractures are often accompanied
by displacement of the talus, usually in a medial or lateral direction. In conjunction
with dislocation in the coronal plane, concurrent may take place in the sagittal
plane, either anteriorly or posteriorly, or in torsion about the longitudinal axis of
the tibia.
Bimalleolar fracture may be treated by closed manipulation. Knowledge of
the mechanism of injury is necessary to carry out manipulative reduction. The
fracture is reduced by placing the ankle in the position reverse to that of the
injuring forces - eg, an injury caused by external rotation and abduction should be
reduced by internal rotation and abduction. Immobilization in a long-leg cast for 6
weeks and then a short-leg walking cast for 2-4 weeks allows complete healing in
most cases.
Radiologic examination may give valuable information regarding the
mechanism of injury. If the medial malleolus is fractured in the horizontal plane,
the injury was caused by an avulsion mechanism with the talus being displaced
laterally. If the fracture of the medial malleolus is vertical, the injury was most
probably caused by the talus being driven medially.
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Open reduction and internal fixation are indicated if x-rays show that perfect
anatomic reduction has not been achieved by closed manipulation or if early joint
motion is desired. The talus must be positioned anatomically under the tibial
plafond, since even slight shift may cause degenerative changes from joint
incongruity. The medial malleolus is fixed with a bone screw or Kirschner wires.
The lateral malleolus may be fixed with a single screw across the fracture site or
with a plate and multiple screws.
Damage to the syndesmotic ligaments between the distal tibia and fibula is
demonstrated by distal tibiofibular diastasic. Anatomic reduction must be
maintained by a transverse acrew placed from screw placed from the distal fibula
into the tibia. It is generally suggested that rigid tibiofibular fixation be removed
before unprocteted weight bearing is permitted. If the screw is removed before 3
months after injury, tibiofibular diastasis may occasionally recur.
Fracture of the Distal Tibia
Fracture of the distal tibia is usually associated with other lesions.
A. Fracture of the Posterior Margin: fracture of the posterior margin involve
part or all of the entire posterior half and is apt to be accompanied by fracture of
either malleolus and posterior dislocation of the talus. It must be differentiated
from fracture of the posterior tibial tubercle, which is usually caused by avulsion
with the attached posterior lateral maleolar ligament.
Anatomic reduction by closed manipulation or open reduction is required if
the fracture involves more than 25% of the articular surface. The extremity is
immobilized in a plaster cast extending from the inguinal region to the toe.
Frequent x-ray examination is necessary to make certain that redisplacement
does not occur. The plaster should be changed as soon as loosening becomes
apparent. Immobilization must be maintained for 8-12 weeks. Weight bearing must
not be resumed until bone healing is sound, usually in about 12 weeks.
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B. Fracture of the Anterior Margin: Fracture of the anterior articular margin of
the tibia (rare) is likely to be caused by forced dorsiflexion of the foot. If
displacement is marked and the talus is dislocated, tears of the collateral ligaments
or fractures of the malleoli are likely to be present.
If closed reduction is unsuccessful, open reduction and internal fixation with bone
screws or a plate and screws should be done. If comminution is present, the
extremity should be immobilized for 12 weeks. Weight bearing should not be
permitted until bone healing is sound.
Comminuted Fractures: Extensive comminution of the distal tibia (“compression
type” fracture presents a difficult problem of management. The congruity of
articular surfaces cannot be restored by closed manipulation, and satisfactory
anatomic restoration may be difficult and sometimes impossible even by open
reduction. If the fractures is amenable to internal fixation, an attempt should be
made to restore the congruity of the articular surface. Extensively comminuted and
widely displaced fractures may be best treated by closed manipulation and skeletal
traction. After traction has been applied and impaction of fragments has been
disrupted, displacement in the transverse plane is corrected by manual molding
with compression. A tubular plaster cast is applied from the inguinal region to the
toes with the knee in 10-15 degrees of flexion and the foot in neutral position. With
the extremity immobilized in plaster, continuous skeletal traction can be
maintained for 8-12 weeks or until stabilization by early bone healing occurs. An
alternative is distraction with pins in the calcaneus and shaft of the tibia .The pins
are attached to an external fixator or incorporated in plaster to maintain length.
Healing is likely to be slow. If the articular surfaces of the ankle joint have
not been properly realigned, disabling posttraumatic arthritis is apt to occur early.
Early arthrodesis may be indicated to shorten the period of disability.
INJURIES OF THE FOOT
1. FRACTURE & DISLOCATION OF THE TALUS
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Dislocation of the Subtalar Talonavicular Joints
Dislocation of the subtalar and talonavicular joints without fracture
occasionally occurs. Displacement of the foot can be by either inversion or
eversion. Reduction by closed manipulation is usually not difficult. Incarceration
of the posterior tibial tendon in the talonavicular joint may prevent reduction by
closed manipulation. After reduction, the extremity should be immobilized in a
plaster boot for 4 weeks.
Fractures of the Talus
Major fracture of the talus commonly occurs either through the body or
through the neck: the uncommon fracture of the head involves essentially a portion
of the neck with extension into the head. Indirect injury is usually the cause of
closed fracture as well as most open fractures: severe comminution is not
commonly present. Compression fracture or infraction of the tibial articular surface
may be caused by the initial injury or may occur later in association with
complicating avascular necrosis. The proximal or distal fragments may be
dislocated.
Fracture of the Neck: Forced dorsiflexion of the foot may cause this injury.
Undisplaced fracture of the neck can be treated adequately by a nonweightbearing plaster boot for 8-12 weeks. Dislocation of the body or the distal neck
fragment with the foot may complicate this injury. Fracture of the neck with
anterior and frequently medial dislocation of the distal fragment and foot can
usually be reduced by closed manipulation. Subsequent treatment is the same as
that of undisplaced fracture.
Dislocation of the proximal body fragment may occur separately or may be
associated with dislocation of the distal fragment. If dislocation of the body
fragment is complete, reduction by closed manipulation is not successful, open
reduction should be done as soon as possible to prevent or to minimize the extent
of the avascular necrosis. The blood supply to the talus enters in the neck area and
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likely to be disrupted with dislocation: therefore bone healing is likely to be
retarded, and some degree of avascular necrosis is possible.
Complete dislocation of the neck fragment from the talonavicular and
subtalar joints is rare, but if it does happen, avascular necrosis of the fragment may
occur even though anatomic reduction is promptly accomplished. If reduction by
closed manipulation is not possible, immediate open operation with reduction of
the fragment is advisable, since dalay may cause necrosis of overlying soft tissues.
2. FRACTURE OF THE CALCANEUS
Fracture of the calcaneus is commonly caused by direct trauma. Since this
fracture is likely to occur as a result of a fall from a height, fracture of the spine at
the thoracolumbar junction may also be present.
Comminution and impaction are general characteristics. Minor infractions or
impactions and fissure fractures are easy to miss on clinical examination, and xrays must be prepared in multiple projections to demonstrate adequately some
fracture clefts.
Various classifications have been advocated. Fractures that are generally
comminuted and disrupt the subtalar and
calcaneocuboid articulations ahould
be distnguished from those that do not: this differentiation has important
implications for treatment and prognosis.
Fracture of the Calcaneal Tuberosity
Isolated fracture of the tuberosity is not common. It may occur in a
horizontal or vertical direction.
A. Horizontal Fracture: Horizontal fracture may be limited to the superior
portion of the region of the former apophysis and represents an avulsion by the
Achilles tendon. Where the superior minor fragment is widely displaced
proximally with the tendon, open reduction and fixation with a stout wire suture
may be necessary to obtain the most satisfactory functional result.
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Further extension of the fracture cleft toward the subtalar joint in the
substance of the tuberosity creates the “beak” fracture.
The minor fragment may be displaced proximally by the action of the triceps
surae. If displacement is significant, reduction can be achieved by skeletal traction
to the proximal fragment with the foot in plantar flexion. Immobilization is
obtained by incorporation of the traction pin or wire in a full extremity plaster with
the knee flexed 30 degrees and the foot in plantar flexion. If adequate reduction
cannot be accomplished in this way, open reduction is advised.
B. Vertical Fracture: Vertical fracture occurs near the sagittal somewhat
medially through the tuberosity. Because the minor medial fragment normally is
not widely displaced, plaster immobilization is not required but will decrease pain.
Comfort can be enhanced by limitation of weight bearing with the aid of crutches.
Fracture of the Sustentaculum
Isolated fracture of the sustentaculum tali is a rare lesion that may be caused
by forced eversion of the foot. Where displacement of the larger body fragment
occurs, it is lateral. Incarceration of the tendon of the flexor hallucis longus in the
fracture cleft has been reported. Generally, this fracture occurs in association with
comminution of the body.
Fracture of the Anterior Process of the Calcaneus
Fracture of the anterior process is caused by forced inversion of the foot. It
must be differentiated from midtarsal and ankle joint sprains. The firmly attached
bifurcate ligament (calcaneonavicular and calcaneocuboid components) avulses a
bit of bone. Maximal tenderness and slight swelling occur midway between the tip
of the lateral malleolus and the base of the fifth metatarsal. The lateral x-ray view
projected obliquely demonstrates the fracture cleft. The treatment is by a nonweight-bearing plaster boot with the foot in neutral position for 4 weeks.
Fracture of the Body of the Calcaneus
Fracture of the body may occur posterior to the articular surfaces, in general
vertical but somewhat oblique plane, without disruption of the subtalar joint. Most
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severe fractures of the calcaneal body are comminuted and extend into the subtalar
and frequently the calcaneocuboid joints. Fissure fractures without significant
displacement cause minor disability and can be treated simply by protection from
weight bearing, either by crutches alone or in combination with a plaster boot until
bone healing is sufficiently sound to justify graded increments of loading.
Nonarticular Fracture: Where fracture of the body with comminution occurs
posterior to the articular surface, the direction of significant displacement of the
fragments attached to the tuberosity is proximal, causing diminution of the subtalar
joint angle. Since the subtalar joint is not disrupted, symptomatic posttraumatic
degenerative arthritis is not an important sequela even though some joint stiffness
persists permanently. Marked displacement should be corrected by skeletal traction
applied to the main posterior fragment to obtain an optimal cosmetic result.
Success of reduction can be judged by the adequacy of restoration of the subtalar
joint angle.
B. Articular Fracture: Articular fractures are of three general types:
1. Noncomminuted-Fracture of the body without comminution may involve
the posterior articular facet. Where displacement of the posterior fragment of the
tuberosity occurs, the direction is lateral. Fractures of this type with more than
minimal displacement should be treated by the method advocated for nonarticular
fracture of the body.
2.With minor comminution-In fractures with minor comminution, the main
cleft occurs vertically, in a somewhat oblique lateral deviation from the sagittal
plane. From emergence on the medial surface posterior to the sustentaculum it is
directed forward and rather obliquely laterally through the posterior articular facet.
The sustentaculum and the medial portion of the posterior articular facet remain
undisplaced with relation to the talus. The body below the remaining lateral
portion of the posterior articular facet, together with the tuberosity, is impacted
into the lateral portion of the posterior articular facet.
3.With extensive comminution- Fracture with extensive comminution
extending into the subtalar joint may involve the calcaneocuboid joint as well as
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the tuberosity. The multiple fracture clefts involve the entire posterior articular
surface, and the facet is impacted into the substance of the underlying body. There
are may variants; the clefts may extend across the calcaneal froove into the medial
and anterior articular surfaces, and detachment of the peroneal tubercle may be a
feature. This serious injury may cause disability in spite of the best treatment, since
the bursting nature of the injury may defy anatomic restoration.
Some surgeons advise nonintervention. Displacement of fragments is
disregarded. Initially, a compression dressing and splint are applied, and the
extremity is elevated for a week or so. After 3-5 days, as the intense pain begins to
subside, active exercises should be started, but weight bearing is avoided until
early bone healing has taken place. In spite of residual deformity of the heel,
varying degrees of weakness of the calf, and discomfort in the region of the
subtalar joint (which may be intensified by weight bearing), acceptable functional
results can be obtained, especially among vigorous young persons who are willing
to put up with the discomforts involved. Pain may persist for 6-12 months.
Other surgeons, notably Hermann and Bohler, advocate early closed
manipulation, which can partially restore the external anatomic of the heel region.
Open reduction and internal fixation may improve the alignment of the subtalar
joint, decreasing the chance of early arthritis.
Persistent and disabling painful symptoms originating in the deranged
subtalar joint may require arthrodesis for adequate relief. Concomitant
involvement of the calcaneocuboid joint is an indication for the more extensive
triple arthrodesis.
3.FRACTURE OF THE NAVICULAR
Minor avulsion fractures of the tarsal navicular may occur as a feature of
severe midtarsal sprain and require neither reduction nor elaborate treatment.
Avulsion fracture of the tuberosity near the insertion of the posterior tibialis
muscle is uncommon and must be differentiated from a persistent, ununited
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apophisis (accessory schaphoid) and from the supernumerary sesamoid bone, or
the os tibiale externum.
Major fracture occurs either through the middle in a horizontal or, more
rarely, in a vertical plane or is characterized by impaction of its substance. Only
noncomminuted fractures with displacement of the dorsal fragment can be reduced.
Closed manipulation by strong traction on the forefoot and simultaneous digital
pressure over the displaced fragment can restore it to its normal position. If a
tendency to redisplacement is apparent, this can be counteracted by temporary
fixation with a percutaneously inserted Kirschener wire. Non-weight-bearing
immobilization in a plaster cast is required for a minimum of 6 weeks.
Comminuted and impacted fractures cannot be anatomically reduced. Some
authorities offer a pessimistic prognosis for comminuted or impacted fractures. It is
their contention that even though partial reduction has been achieved,
posttraumatic arthritis supervenes, and that arthrodesis of the talonavicular and
cuneonavicular joints will be ultimately necessary to relieve painful symptoms.
4. FRACTURE OF THE CUNEIFORM&CUBOID BONES
Because of their relatively protected position in the mid tarsus, isolated
fracture of the cuboid and cuneiform bones is rarely encountered. Minor avulsion
fractures occur as a component of severe midtarsal sprains. Extensive fracture
usually occurs in association with other injuries of the foot and often is caused by
severe crushing. Simple classification is impractical because of the complex
caracter and the multiple combination of the whole injury.
5.TARSAL DISLOCATIONS
Midtarsal dislocation through the cuneonavicular and calcaneocuboid joints
or more proximally through the talocalcaneonavicular and calcaneocuboid joints
may occur as a result of twisting injury to the forefoot. Fractures of varying extent
of adjacent bones are frequent complications. When treatment is given soon after
the accident, closed reduction by traction on the forefoot and manipulation is
generally effective. If reduction is unstable and displacement tends to recur upon
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release of traction, stabilization for 4 weeks by percutaneously inserted Kirschner
wires is recommended.
6.FRACTURES& DISLOCATIONS OF THE METATARSALS
Fractures of the metatarsals and tarsometatarsal dislocations are likely to be caused
by direct crushing or indirect twisting injury to the forefoot. Besides osseous and
articular injury, complicating soft tissue lesions are often present. With severe
trauma, circulation may be compromised from injury to the dorsalis pedis artery,
which passes between the first and second metatarsal.
Tarsometatarsal Dislocations
Possibly because of strong ligamentous support and relative size,
dislocations of the first metatarsal at its base occirs less frequently than similar
involvement of the lesser bones. If dislocation occurs, fracture of the first
cuneiform is likely to be present also.More often, however, tarsometatarsal
dislocations involves the lesser metatarsal, and associated fractures are to be
expected. Dislocation is more commonly caused by direct injury but may be the
result of stress applied indirectly through the forefoot. The direction of
displacement is ordinarily dorsal, lateral, or a combination of both. Direct injuries
are frequently complicated by soft tissue damage, open wounds, and vascular
impairment.
Attempted closed reduction should not be deferred. Skeletal traction applied
to the involved bone by a Kirschner wire or a stout towel clamp can be a valuable
aid to manipulation. Even though persistent dislocation may not cause significant
disability, the resulting deformity can make shoe fitting difficult and the cosmetic
effect undesirable. Open reduction with Kirschener wire stabilization is a preferred
alternative to unsuccessful closed treatment. When effective treatment has been
deferred 3 weeks or longer, early healing will prevent satisfactory reduction of
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persisting displacement by closed techniques. Under such circumstances, it is
better to defer open reduction and direct treatment toward recovery of function.
Extensive operative procedures and continued immobilization can icrease joint
stiffness. Reconstructive operations can be planned more suitably after residual
disability becomes established.
Complications of this injury include local circulatory disturbance called
Sudeck’s atrophy and painful degenerative arthritis.
Fracture of the Metatarsal Shafts
Undisplaced fractures of the metatarsal shafts cause no permanent disability
unless failure of bone healing is encountered. Displacement is rarely significant
where of the middle metatarsals is oblique and the first and fifth are uninjured,
since they act as splints. Even fissure fractures should be treated by a stiff-sole
ahoe (with partial weight bearing) or, if pain is marked, by a plaster walking boot.
Great care should be taken in displaced fractures to correct angulation in the
longitudinal axis of the shaft. Persistent convex dorsal angulation causes
prominence of the head of the involved metatarsal on the plantar aspect, with the
implication of concetrated local pressure and production of painful skin callosities.
Deformity of the shaft of the first metatarsal due to convex plantar angulation can
transfer the stress of wieght bearing to the region of the head of the third
metatarsal. After correction of angular displacement, the plaster cast should be
molded well the plantar aspect of the foot to minimize recurrence of deformity and
to support the longitudinal and transverse arches.
If reduction is not reasonably accurate, fractures through the shafts near the
heads ( the “neck”) may cause great discomfort from concentrated pressure
beneath the head on the plantar surface and reactive skin callus formation. Every
effort should be made to correct convex dorsal angulation by disruption of
impaction and appropriate manipulation. Closed reduction is best achieved by use
of the Chinese fingertrap applied to the toes of the involved metatarsals. The
efficacy of closed treatment should be determined without delay: if success has not
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been achieved with closed treatment, open operation with Kirschner wire fixation
should be performed.
Fatique Fracture of the Metatarsal Shafts
Fatique fracture of the shafts of the metatarsals has been given various
names (eg, march, atress, and insufficiency fracture). Its protean clinical
manifestation cause difficulty in precise recognition, even to the point of confusion
with osteogenic sarcoma. Commonly, it occurs in active young adults, such as
military recruits, who are unaccustomed to vigorous and excessive walking. A
history of a single significant injury is lacking. Incipient pain of varying intensity
in the forefoot that is accentuated by walking, swelling, and localized tenderness of
the involved metatarsal are cardinal manifestations. Depending upon the stage of
progress, x-rays may not demonstrate the fracture cleft, and extracortical callus
formation may ultimately be the only clue. More striking findings may vary from
an incomplete fissure to an evident transverse cleft. Persistent unprocteted weight
bearing may cause arrest of bone healing and even displacement of the distal
fragment. The second and third metatarsals are most frequently involved near the
junction of the middle and distal thirds. The lesion can occur more proximally and
in other lesser metatarsals. Since weight bearing is likely to prolong and aggravate
symptoms, treatment is by protection in either a plaster walking boot or a heavy
shoe with the sole reinforced by a steel strut. Weight bearing should be restricted
until painful symptoms subside and restoration of bone continuity has been
demonstrated by x-ray examination, usually within 3-4 weeks.
Fracture of the Tuberosity of the Fifth Metatarsal
Forced adduction of the forefoot may cause avulsion fracture of the
tuberosity of the fifth metatarsal, and where suppoeting soft tissues have been torn,
activity of the peroneus brevis muscle may increase displacement of the avulsed
proximal fragment. If displacement of the minor is minimal, adhesive strapping or
a stiff-soled shoe is adequate treatment. If displacement is significant, treatment
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should be by a walking boot until bone healing occurs. Rarely does healing fail to
occur. Fracture should be differentiated from a separate ossific center of the
tuberosity in adolescence and supernumerary os vesalianum pedis adulthood.
7. FRACTURES& DISLOCATIONS OF THE PHALANGES OF THE TOES
Fractures of the phalanges of the toes are caused most commonly by direct
violence such as crushing or stubbing. Spiral or oblique fractures of the shafts of
the proximal phalanges of the lesser toes may occur as a result of indirect twisting
injury.
Comminuted fracture of the proximal phalanx of the great toe, alone or in
combination with fracture of the distal phalanx, is the most disabling injury. Since
wide displacement of fragments is not likely, correction of angulation and support
by an adhesive dressing and splint usually suffices. A weight-bearing plaster boot
may be useful for relief of symptoms arising from associated soft tissue injury.
Spiral or oblique fracture of the proximal phalanges of the lesser toes can be
treated adequately by binding the involved toe to the adjacent uninjured member.
Comminuted fracture of the distal phalanx is treated as a soft tissue injury.
Traumatic dislocation of the metatarsophalangeal joints and the uncommon
dislocation of the proximal interphalangeal joint usually can be reduced by closed
manipulation. These dislocations are rarely isolated and usually occur in
combination with other injuries to the forefoot.
8. FRACTURE OF THE SESAMOIDS OF THE GREAT TOE
Fracture of the sesamoid bones of the great toe is rare, but it may occur as a
result of crushing injury. It must be differentiated from a bipartite sesamoid.
Undisplaced fracture requires no treatment other than a foot support or a metatarsal
bar. Displaced fracture may require immobilization in a walking plaster boot, with
the toe strapped in flexion. Persistent delay of bone healing may cause disabling
pain arising from arthritis of the articulation between the sesamoid and the head of
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the first metatarsal. If a foot support and metatarsal bar do not provide adequate
relief, excision of the sesamoid may be necessary.
FRACTURES THAT FAIL TO UNITE
Prolonged delay in fracture healing is most common in long bone fractures
associated with severe tissue damage or infection. However, routine closed
fractures with minimal displacement occasionally fail to unite for reasons that
remain obscure. The tibia is the long bone most frequently affected by failure or
delay of healing. Nonution of the carpal scaphoid and the femoral neck is not
uncommon and is thought to be associated with damage to blood supply of the
fractured area at the time of injury.
If a fracture fails to unite in 1 ½ times the usual healing time for that bone, it
can be considered a delayed union, and some means of improving healing should
be sought. The atandard method has been the use of cancellous bone graft obtained
from the iliac crest and placed subperiosteally around the monution site. The stable
fibrous union of the unhealed bone does not have to be removed for successful
healing to occur. If there is instability of the fibrous union or significant
melalignment of the fracture, compresion plating for rigid fixation, with or without
bone graft, has proved successful. After bone grafting, the extremity must again be
immobilized in a cast for aproximately 3 months to allow the bone graft to mature
unless internal fixation provides rigid support.
A newer method of treatment of nonunion utilizes electrical current. Three
different methods have been developed: noninvasive, semi-invasive, and totally
invasive. In the noninvasive technique, electromagnetic coils are placed at a
measured distance on opposite sides of the cast at the fracture site. The coils are
are attached to a power source for 10-12 hours a day for 3 months. Weight bearing
is not allowed on the involved extremity. Immobilization with weight bearing is
continued for an additional 3 months after treatment with the coils. The semiinvasive technique uses Kirschner wire electrodes placed percutaneously into the
fracture site under sterile condition in the operating room. The electrodes are
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attached to a small portable battery incorporated into the cast. The electrodes are
left in place for 3 months, after which time immobilization in a weight-bearing
plaster cast is continued for an additional 3 months. In the totally invasive
technique, both the electrode and the battery are implanted in the involved
extremity. Postoperative care is similar to that given following noninvasive and
semi-invasive management.
The success rates of bone grafting and all forms of electrical treatment are
reported to approach 80%. If the first attempt is unsuccessful, repeat of any of the
tehniques has a significant chance of success.
Infection at the nonunion site is a contraindication to the use of the semiinvasive or totally invasive types of electrical treatment. Electromagnetic coils,
external fixators for rigid immobilization, and bone grafting (from posteriorly in
anteriorly infected tibial non-unions) have all been useful in treating infected
nonunions.
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