Fracture Lecture 2/4 (General Notes)

Fracture - 2Fracture - 2
DR RAI M. AMMAR MADNIDR RAI M. AMMAR MADNI

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DR RAI M. AMMAR MADNIDR RAI M. AMMAR MADNI
( M.B.B.S , RMP )( M.B.B.S , RMP )

33
Principles of FracturePrinciples of Fracture
TreatmentTreatment
 Initial management—clinicalInitial management—clinical
assessmentassessment
Whole patient is required toWhole patient is required to
exclude injuries to other systemsexclude injuries to other systems
before examination of the skeletalbefore examination of the skeletal
injuryinjury
1. A wound communicating with the1. A wound communicating with the
fracturefracture
2. Evidence of a vascular injury2. Evidence of a vascular injury
3. Evidence of a nerve injury3. Evidence of a nerve injury

 Repetitive manual reduction (manipulation)Repetitive manual reduction (manipulation)
 Excessive stripping of the periosteum andExcessive stripping of the periosteum and
soft tissue in the open reductionsoft tissue in the open reduction
 Radical removal of the fragments in openRadical removal of the fragments in open
fracturefracture
 Excessive load in bone tractionExcessive load in bone traction
 Unstable fixationUnstable fixation
 Premature and improper function exercisePremature and improper function exercise
Factors depending on the treatmentFactors depending on the treatment

Management GoalsManagement Goals
 Prevent further injury.Prevent further injury.
 Obtain satisfactory (not alwaysObtain satisfactory (not always
anatomic) position of the fractureanatomic) position of the fracture
fragments.fragments.
 Obtain rapid union in the satisfactoryObtain rapid union in the satisfactory
position.position.
 Preserve and/or restore function.Preserve and/or restore function.
 Use the method with the least risk toUse the method with the least risk to
the patientthe patient

First AidFirst Aid
 Relief of discomfort, prevention ofRelief of discomfort, prevention of
further injury and control offurther injury and control of
bleeding until the patient reachesbleeding until the patient reaches
the site where definitive treatmentthe site where definitive treatment
will be institutedwill be instituted..

First aidFirst aid
 Shock treatmentShock treatment

coveringcovering open woundsopen wounds
 Proper splinting the partsProper splinting the parts
 Timely transportationTimely transportation

88
Initial management---resuscitationInitial management---resuscitation
Haemorrhagic shockHaemorrhagic shock
 The mainstay of treatment is theThe mainstay of treatment is the
immediate replenishment of theimmediate replenishment of the
circulating blood volume, withcirculating blood volume, with
transfused blood or alternativelytransfused blood or alternatively
by the use of plasma expandersby the use of plasma expanders
and blood substitutes.and blood substitutes.
Electrolytes are of little valueElectrolytes are of little value
in replacing lost blood. Colloidin replacing lost blood. Colloid
solutions are of more value andsolutions are of more value and
include dextran, a high-molecular-include dextran, a high-molecular-
weight polysaccharide. albuminweight polysaccharide. albumin
Blood loss from fracture
(ml)

First aidFirst aid
 Splinting the part and covering openSplinting the part and covering open
wounds with pressure bandages.wounds with pressure bandages.
 Splinting relieves pain and prevents sharpSplinting relieves pain and prevents sharp
bone ends from doing further damage tobone ends from doing further damage to
nerves, arteries, muscles, tendons andnerves, arteries, muscles, tendons and
skin.skin.
 Simple splints such as magazines, pillows,Simple splints such as magazines, pillows,
strapping the arm to the body, or binding astrapping the arm to the body, or binding a
leg to the opposite uninjured leg can beleg to the opposite uninjured leg can be
effectively devised at most accident sites.effectively devised at most accident sites.
 Transportation of the patient to the site forTransportation of the patient to the site for
definitive treatment must be done carefullydefinitive treatment must be done carefully
after first aid measures are completedafter first aid measures are completed

1010
Principles of FracturePrinciples of Fracture
TreatmentTreatment
 ReductionReduction of fractureof fracture
 ImmobilisationImmobilisation of the fractureof the fracture
fragments long enough to allowfragments long enough to allow
unionunion
 RehabiliationRehabiliation of the soft tissuesof the soft tissues
and jointsand joints

Preservation andPreservation and
restoration of functionrestoration of function
 During the immobilization of aDuring the immobilization of a
fracture, all nonimmobilizedfracture, all nonimmobilized
parts must be moved to avoidparts must be moved to avoid
stiffness, muscle atrophy andstiffness, muscle atrophy and
joint contractures.joint contractures.

ReductionReduction
 Reduction (Reduction (verbverb) is the process of) is the process of
apposing the fracture fragments.apposing the fracture fragments.
 Reduction (Reduction (nounnoun) also describes the) also describes the
apposition of the fragments.apposition of the fragments.
 It is usually described as anatomicIt is usually described as anatomic
reduction, near anatomic reduction,reduction, near anatomic reduction,
or non-anatomic reduction.or non-anatomic reduction.
 None of these degrees of reduction isNone of these degrees of reduction is
necessarily better than another but isnecessarily better than another but is
dependent on the specific fracture.dependent on the specific fracture.

1313
Methods of reduction (inMethods of reduction (in
three ways)three ways)
 a. by closed manipulationa. by closed manipulation
b. by mechanical tractionb. by mechanical traction
with or withoutwith or without
manipulationmanipulation
c. by open operationc. by open operation

AlignmentAlignment
 Alignment refers to the relative orientationAlignment refers to the relative orientation
or position of the fragments, or moreor position of the fragments, or more
specifically, the joints above and below thespecifically, the joints above and below the
fracture.fracture. Anatomic alignment is alwaysAnatomic alignment is always
strived for as this has a large bearing onstrived for as this has a large bearing on
function following healing.function following healing.
 Alignment can be anatomic withoutAlignment can be anatomic without
anatomic reduction, however, anatomicanatomic reduction, however, anatomic
reduction will always achieve anatomicreduction will always achieve anatomic
alignment.alignment.

AppositionApposition
 The amount of necessary contact (endThe amount of necessary contact (end
to end or side to side) of one fragmentto end or side to side) of one fragment
with the other varies depending uponwith the other varies depending upon
the site of the fracture. If the fracturethe site of the fracture. If the fracture
involves an articular surface, 100involves an articular surface, 100
percent apposition is needed. If thepercent apposition is needed. If the
bone is deep, such as the femur, nobone is deep, such as the femur, no
end to end apposition is necessary.end to end apposition is necessary.
Side to side (bayonet) apposition isSide to side (bayonet) apposition is
acceptable if alignment and lengthacceptable if alignment and length
have been corrected. Remodeling willhave been corrected. Remodeling will
correct the offset in the bone withcorrect the offset in the bone with
time.time.

Reduction of fractureReduction of fracture
 Reduction standardReduction standard
 Anatomical reduction: theAnatomical reduction: the
anatomical relation is restoredanatomical relation is restored
with excellent alignment andwith excellent alignment and
fully contact of fragmental endsfully contact of fragmental ends

 Functional reduction:Functional reduction:
 Axial rotation and seperation must beAxial rotation and seperation must be
correctedcorrected
 Lower extremity shortening less thanLower extremity shortening less than
1 cm in adult, or 2 cm in children is1 cm in adult, or 2 cm in children is
acceptableacceptable
 The contact of fragments must beThe contact of fragments must be
more than 1/3 in transverse fracturemore than 1/3 in transverse fracture
of long bone,3/4 in metaphysealof long bone,3/4 in metaphyseal
fracture.fracture.

Functional reductionFunctional reduction
 Rotatory Malalignment- the bone will not correctRotatory Malalignment- the bone will not correct
with time, bone will heal with residual deformity.with time, bone will heal with residual deformity.
 Angulatory Malalignment- The acceptable degree ofAngulatory Malalignment- The acceptable degree of
residual angulation depends upon:residual angulation depends upon:
 a) the age of the patient. In general, the youngera) the age of the patient. In general, the younger
the child, the more the angulation that will correctthe child, the more the angulation that will correct
with time;with time;
 b) the location- the nearer the end of a long bone,b) the location- the nearer the end of a long bone,
the more the angulation that will correct.the more the angulation that will correct.
 c) The direction of the angulation- it must be in thec) The direction of the angulation- it must be in the
plane of greatest motion of the joint. For example,plane of greatest motion of the joint. For example,
near the knee anterior-posterior angulation maynear the knee anterior-posterior angulation may
correct, but medial and lateral angulation will not.correct, but medial and lateral angulation will not.

 In displaced fractures the resultant muscle
spasm frequently produces significant
overriding of bone ends with shorting. This
must be corrected.
 Anatomic restoration of length is not always
necessary or perhaps not even desirable.
When fracture fragments of a long bone
displace, blood supply to the extremity
increases, and growth is stimulated. In such
instances, if bone ends are brought back end
to end, the extremity with the fracture may
eventually be longer by about 1 cm. Therefore
a 1 cm overlap with side to side union may be
acceptable.
Length Restoration

Reduction methodsReduction methods
 ManipulationManipulation
 Open reductionOpen reduction

AnesthesiaAnesthesia
 If the fracture fragments displace andIf the fracture fragments displace and
need to be replaced, sedation orneed to be replaced, sedation or
anesthesia becomes mandatory.anesthesia becomes mandatory.
Anesthesia can be local, regional, orAnesthesia can be local, regional, or
general, depending both upon the patientgeneral, depending both upon the patient
and fracture.and fracture.
 Local anesthesia : The fracture hematomaLocal anesthesia : The fracture hematoma
can be infiltrated with a local anestheticcan be infiltrated with a local anesthetic
agent.agent.
 If local anesthesia is not indicated oneIf local anesthesia is not indicated one
can use regional block such an axillarycan use regional block such an axillary
block for the upper extremity.block for the upper extremity.

Fixation of fractureFixation of fracture
 Fixation is the mechanism by which theFixation is the mechanism by which the
fracture fragments are stabilized untilfracture fragments are stabilized until
sufficient healing occurs.sufficient healing occurs. The combinationThe combination
of the fixation device and the fractureof the fixation device and the fracture
segments is called an osteosynthesis.segments is called an osteosynthesis. InIn
general, the fixation should allow neargeneral, the fixation should allow near
normal function during the healingnormal function during the healing
process.process.

Four basic fixationFour basic fixation
systemssystems
 External coaptation (casts andExternal coaptation (casts and
splints),splints),
 Intramedullary (IM) fixation (IM pinsIntramedullary (IM) fixation (IM pins
and IM nails),and IM nails),
 External skeletal fixation (linear andExternal skeletal fixation (linear and
ring fixators),ring fixators),
 Plates / screws.Plates / screws.
 Wire may be used with any of the surgicalWire may be used with any of the surgical
systems.systems.

External fixationExternal fixation
 SplinterSplinter
 PlasterPlaster
 BraceBrace
 Continuous tractionContinuous traction
 External fixaterExternal fixater

Indications for externalIndications for external
fixationfixation
 Acute trauma - open andAcute trauma - open and
unstable fracturesunstable fractures
 Non union of fracturesNon union of fractures
 ArthrodesisArthrodesis
 Correction of joint contractureCorrection of joint contracture
 Filling of segmental limb defectsFilling of segmental limb defects
- trauma, tumour and- trauma, tumour and
osteomyelitisosteomyelitis
 Limb lengtheningLimb lengthening

Complications ofComplications of
external fixationexternal fixation
 OverdistractionOverdistraction
 Pin-tract infectionPin-tract infection

Internal fixationInternal fixation
 IndicationsIndications
 Intra-articular fractures - to stabiliseIntra-articular fractures - to stabilise
anatomical reductionanatomical reduction
 Repair of blood vessels and nerves - toRepair of blood vessels and nerves - to
protect vascular and nerve repairprotect vascular and nerve repair
 Multiple injuriesMultiple injuries
 Elderly patients - to allow early mobilisationElderly patients - to allow early mobilisation
 Long bone fractures - tibia, femur andLong bone fractures - tibia, femur and
humerushumerus
 Failure of conservative managementFailure of conservative management
 Pathological fracturesPathological fractures
 Fractures that require open reductionFractures that require open reduction
 Unstable fracturesUnstable fractures

Advantages of theAdvantages of the
internal fixationinternal fixation
 The possibility of achieving andThe possibility of achieving and
maintaining a high qualitymaintaining a high quality
reductionreduction
 Earlier mobilisation of joints withEarlier mobilisation of joints with
less risk of permanent stiffness,less risk of permanent stiffness,
disuse osteoporosis, etc.disuse osteoporosis, etc.
 Earlier discharge from hospitalEarlier discharge from hospital
and earlier return to fulland earlier return to full
function.function.

Disadvantages of theDisadvantages of the
internal fixationinternal fixation
 The possibility of introducingThe possibility of introducing
infection.infection.
 Internal fixation techniques require aInternal fixation techniques require a
degree of mechanical aptitude anddegree of mechanical aptitude and
experience on the part of theexperience on the part of the
surgeonssurgeons
 To cover a wide range of fractureTo cover a wide range of fracture
situations, a fairly formidable numbersituations, a fairly formidable number
of instruments and fixation devicesof instruments and fixation devices
will be required.will be required.

Complications of internalComplications of internal
fixationfixation
 InfectionInfection
 Non-unionNon-union
 Implant failureImplant failure
 RefractureRefracture

Internal fixation devicesInternal fixation devices
 ScrewsScrews
 NailsNails
 PlatesPlates

Functional exerciseFunctional exercise
 First stage:First stage: within the first 1-within the first 1-
2weeks,improve the blood circulation,reduce the2weeks,improve the blood circulation,reduce the
swelling, prevent the muscle distrophy. Donswelling, prevent the muscle distrophy. Don ’’tt
move the adjacent jointsmove the adjacent joints
 Second stageSecond stage:2weeks later, move the:2weeks later, move the
adjacent joints.adjacent joints.
 Third stage:Third stage: most important stage, reachmost important stage, reach
the clinical bone union,the clinical bone union,

4040
Treatment of open fracturesTreatment of open fractures
 An open fracture always demandsAn open fracture always demands
urgent attention in a properlyurgent attention in a properly
equipped operation room. The soonerequipped operation room. The sooner
the wound can be dealt withthe wound can be dealt with
adequately, the smaller is the risk ofadequately, the smaller is the risk of
infection arising from contaminatinginfection arising from contaminating
organisms.organisms.

4141
Treatment of open fracturesTreatment of open fractures
 1.Principles of treatment1.Principles of treatment
2.Technique of operation for major wounds2.Technique of operation for major wounds
3. The question of skin closure3. The question of skin closure
4. Treatment of the fracture4. Treatment of the fracture
5. Supplementary treatment in cases of5. Supplementary treatment in cases of
openopen
fracture(repairing nerve , blood vessel,fracture(repairing nerve , blood vessel,
tendonstendons
injury)injury)

4242
Treatment of openTreatment of open
fracturesfractures
1.1. Preparation of the fieldPreparation of the field
2.2. Irrigation of the fractureIrrigation of the fracture
sitesite
3.3. Wound debridementWound debridement
4.4. Decontamination ofDecontamination of
bonebone
5.5. Closure of woundClosure of wound
OPERATIVE PROCEDURE

Gustillo Classification ofGustillo Classification of
Open fractureOpen fracture
 Grade I: - wound less than 1 cm w/ minimalGrade I: - wound less than 1 cm w/ minimal
soft tissue injury; - wound bed is clean -soft tissue injury; - wound bed is clean -
bone injury is simple w/ minimalbone injury is simple w/ minimal
comminution;comminution;

 Grade IIGrade II: - wound is greater than 1 cm w/: - wound is greater than 1 cm w/
moderate soft tissue injury; - wound bed ismoderate soft tissue injury; - wound bed is
moderatedly contaminated; - fracturemoderatedly contaminated; - fracture
contains moderate comminution;contains moderate comminution;

 Grade III: segmental frx w/ displacement -Grade III: segmental frx w/ displacement -
frx w/ diaphyseal segmental loss; - frx w/frx w/ diaphyseal segmental loss; - frx w/
associated vascular injury requiring repair;associated vascular injury requiring repair;
- farmyard injuries or highly contaminated- farmyard injuries or highly contaminated
wounds;wounds;

 Treat all open fractures as anTreat all open fractures as an
emergency;emergency;
 Perform thorough initial evaluation toPerform thorough initial evaluation to
find other life-threatening injuriesfind other life-threatening injuries
 antibiotics:antibiotics:
 Antibiotic prophylaxisAntibiotic prophylaxis
 Begin appropriate antibiotic therapyBegin appropriate antibiotic therapy
in the emergency room & continue forin the emergency room & continue for
two or three days only;two or three days only;
 Tetanus prophylaxisTetanus prophylaxis

Debridement andDebridement and
irrigationirrigation
 Ideally this should be performedIdeally this should be performed
within 6 hours of injurywithin 6 hours of injury
 Goal is to avoidGoal is to avoid infectioninfection; - sufficient; - sufficient
debridment & irrigation &debridment & irrigation &
preservation of periosteum arepreservation of periosteum are
essential;essential;
 Debridement of all devascularizedDebridement of all devascularized
bone & soft tissues;bone & soft tissues;

 Pressure irrigation:Pressure irrigation:
 Management of devascularized corticalManagement of devascularized cortical
fragments:fragments:
 Replace large free contaminated corticalReplace large free contaminated cortical
fragments in order to add to mechanicalfragments in order to add to mechanical
integrity of internal fixation;integrity of internal fixation;
 Remove small free devitalized tissueRemove small free devitalized tissue

Debridement of muscleDebridement of muscle
 Debridement was originally described byDebridement was originally described by
Napoleon's surgeon Baron Dominique JeanNapoleon's surgeon Baron Dominique Jean
Larrey;Larrey;

 Non-viable muscle can be identified by the 4 c'sNon-viable muscle can be identified by the 4 c's
(color, consistency, contraction, and circulation);(color, consistency, contraction, and circulation);
- the best indicator of viability is bleeding during- the best indicator of viability is bleeding during
debridement;debridement;
 Non viable muscle can be identified by its darkNon viable muscle can be identified by its dark
color, its mushy consistency, its failure tocolor, its mushy consistency, its failure to
contract when pinched with forceps (or cautery),contract when pinched with forceps (or cautery),
and the absence of bleeding from a cut surface;and the absence of bleeding from a cut surface;

Debridement of muscleDebridement of muscle
 The fascia should be incised parallel to theThe fascia should be incised parallel to the
muscle fibers in both directions; - themuscle fibers in both directions; - the
underlying muscle surrounding the muscleunderlying muscle surrounding the muscle
tract should be opened in the direction of itstract should be opened in the direction of its
fibers to the degree necessary to achievefibers to the degree necessary to achieve
exposure adequate to inspect the tract,exposure adequate to inspect the tract,
remove foreign bodies, and excise nonremove foreign bodies, and excise non
viable muscle;viable muscle;
 Staged surgical debridment may beStaged surgical debridment may be
necessary q24-48 hrs;necessary q24-48 hrs;
 Use of external fixators provides easyUse of external fixators provides easy
access to wounds during bone healing;access to wounds during bone healing;
 Soft tissue coverage may be necessary forSoft tissue coverage may be necessary for
large defects;large defects;

Stabilize the fractureStabilize the fracture
 Internal fixation: GustilloInternal fixation: Gustillo GradeGrade
II ,,Grade IIGrade II
 External fixation: GustilloExternal fixation: Gustillo Grade IIGrade II
>6-8 hours, Grade III>6-8 hours, Grade III

Wound closureWound closure
 Severe extremity wounds, early radicalSevere extremity wounds, early radical
debridement combined with early soft tissuedebridement combined with early soft tissue
coverage (regional or free flap) willcoverage (regional or free flap) will
decrease wound infection, flap loss, &decrease wound infection, flap loss, &
delayed bone healing;delayed bone healing;
 Early coverage will decrease infection,Early coverage will decrease infection,
wound desiccation, & necrosis of exposedwound desiccation, & necrosis of exposed
tendons and bone;tendons and bone;
 Note that tendon is the only type of tissueNote that tendon is the only type of tissue
in the extremities that is highly vulnerablein the extremities that is highly vulnerable
to dissecation, and therefore, exposedto dissecation, and therefore, exposed
tendons will not fair well with dressingtendons will not fair well with dressing
changes and secondary wound closurechanges and secondary wound closure

Tissue graftTissue graft
 Autograft = graft from one partAutograft = graft from one part
of body to another in the sameof body to another in the same
individualindividual
 Allograft = graft from oneAllograft = graft from one
individual to another in the sameindividual to another in the same
speciesspecies
 Xenograft = graft from oneXenograft = graft from one
species to anotherspecies to another

Open Joint InjuriesOpen Joint Injuries
 Classifaction of Open Joint Injuries:Classifaction of Open Joint Injuries:
 type 1: - single capsular perforationtype 1: - single capsular perforation
or laceration w/o extensive softor laceration w/o extensive soft
tissue injury;tissue injury;
 type 2: - single or multiple capsulartype 2: - single or multiple capsular
perforations or lacerations w/perforations or lacerations w/
extensive soft tissue injury; -extensive soft tissue injury; -
 type 3: - open periarticular frx w/type 3: - open periarticular frx w/
extension thru the adjacent intra-extension thru the adjacent intra-
articular surface;articular surface;

Treatment of the nonuion,Treatment of the nonuion,
delayed union anddelayed union and
malunionmalunion
 Union and consolidationUnion and consolidation
 Fracture repair is a continuous processFracture repair is a continuous process
 Union should be regarded as incomplete repairUnion should be regarded as incomplete repair
 Fracture site is still tenderFracture site is still tender
 Minimal movement at the fracture site isMinimal movement at the fracture site is
presentpresent
 Consolidation should be regarded as completeConsolidation should be regarded as complete
repairrepair
 Radiologically fracture line is obliteratedRadiologically fracture line is obliterated
 Fracture site is non-tenderFracture site is non-tender
 No movement is possible at the fracture siteNo movement is possible at the fracture site


Healing times ofHealing times of
fracturesfractures
 It is not possible to preciselyIt is not possible to precisely
estimate the time that it will take forestimate the time that it will take for
a fracture to heal. A rough estimatea fracture to heal. A rough estimate
is:is:
 Most upper limb fracture repairMost upper limb fracture repair
completely in 6-8 weekscompletely in 6-8 weeks
 lower limb fractures take twice aslower limb fractures take twice as
longlong
 children take half as longchildren take half as long
 Add 25% if the fracture involves theAdd 25% if the fracture involves the
femur or is not spiralfemur or is not spiral

Delayed unionDelayed union
 Delayed union is the prolongation ofDelayed union is the prolongation of
time to fracture uniontime to fracture union
 No definite timetable to defineNo definite timetable to define
delayed union existsdelayed union exists
 Delayed union is due toDelayed union is due to
– Inadequate blood supplyInadequate blood supply
– InfectionInfection
– Incorrect splintageIncorrect splintage

 Clinical featuresClinical features
 Fracture site remains tenderFracture site remains tender
 Bone may still move whenBone may still move when
stressedstressed
 On x-ray the fracture remainsOn x-ray the fracture remains
visiblevisible
 May be little callus formation orMay be little callus formation or
periosteal reactionperiosteal reaction

 ManagementManagement
 Usually continue previous treatment ofUsually continue previous treatment of
fracturefracture
 May need to replace cast or reduce tractionMay need to replace cast or reduce traction
 Functional bracing promotes bone unionFunctional bracing promotes bone union
 If union is delayed more than 6 months mayIf union is delayed more than 6 months may
need to considerneed to consider
– Internal fixationInternal fixation
– Bone graftingBone grafting

Non-unionNon-union
 Non-union has many causesNon-union has many causes
including:including:
– Bone or soft tissue lossBone or soft tissue loss
– Soft tissue interpositionSoft tissue interposition
– Poor blood supplyPoor blood supply
– InfectionInfection
– Pathological fracturePathological fracture
– Poor splintage or fixationPoor splintage or fixation
– Fracture distractionFracture distraction

Non-unionNon-union
 Clinical featuresClinical features
 Movement remains present at the fractureMovement remains present at the fracture
sitesite
 Movement is often relatively painlessMovement is often relatively painless
 Radiologically the fracture is still visibleRadiologically the fracture is still visible
 Bone ends on either side of the fracture areBone ends on either side of the fracture are
sclerosedsclerosed
 Non-union can be either hypertrophic orNon-union can be either hypertrophic or
atrophicatrophic

Non-union(10years)Non-union(10years)

Non-unionNon-union
 ManagementManagement
 Asymptomatic non-union may notAsymptomatic non-union may not
require active treatment exceptrequire active treatment except
splintagesplintage
 For hypertrophic non-union internalFor hypertrophic non-union internal
or external fixation may lead to unionor external fixation may lead to union
 For atrophic non-union bone graftingFor atrophic non-union bone grafting
is often requiredis often required

7676
Joint injuriesJoint injuries
 The stability of jointsThe stability of joints
Joint surfaces are held in contact byJoint surfaces are held in contact by
1. the shape of the articulating1. the shape of the articulating
surfacessurfaces
2. The ligaments2. The ligaments
3. The surrounding muscles3. The surrounding muscles
4. Atmospheric pressure4. Atmospheric pressure

7777
 Dislocation and subluxationDislocation and subluxation
A joint is dislocated or luxated when itsA joint is dislocated or luxated when its
articular surfaces are wholly displacedarticular surfaces are wholly displaced
one from the other, so that allone from the other, so that all
apposition between them is lost.apposition between them is lost.
A joint is subluxated when itsA joint is subluxated when its
articular surfaces are partly displacedarticular surfaces are partly displaced
but retain some contact one with thebut retain some contact one with the
otherother

7878
causation:causation:
1. Congenital1. Congenital
2. Spontaneous ( pathological)2. Spontaneous ( pathological)
3. Traumatic or recurrent3. Traumatic or recurrent

7979
Joint InjuriesJoint Injuries
 Traumatic dislocation or subluxationTraumatic dislocation or subluxation
1. The most common joint: shoulder,1. The most common joint: shoulder,
elbow,elbow,
hip ankle and interphalangeal joints ofhip ankle and interphalangeal joints of
thethe
fingersfingers
2.to be associated with a fracture: the2.to be associated with a fracture: the
injury is termed a fracture-dislocationinjury is termed a fracture-dislocation
or fracture-subluxationor fracture-subluxation

8080
3. To occur with some damage to the3. To occur with some damage to the
protective ligaments and joint capsuleprotective ligaments and joint capsule
4.Dislocation will occur most easily when4.Dislocation will occur most easily when
the muscles are off their guard. Thisthe muscles are off their guard. This
probably explains the high incidenceprobably explains the high incidence
of shoulder dislocations in patientsof shoulder dislocations in patients
suffering epileptic fits.suffering epileptic fits.

8181
DiagnosisDiagnosis
1.1. History of injuryHistory of injury
2.2. Clinical examinationClinical examination
3.3. X-rays and imaging techniquesX-rays and imaging techniques
4.4. Other specific clinical testOther specific clinical test

8282
 ComplicationsComplications
1. Infection( open dislocation)1. Infection( open dislocation)
2. Injury to important soft-tissue structure2. Injury to important soft-tissue structure
3. Persistent instability leading to recurrent3. Persistent instability leading to recurrent
dislocation or subluxationdislocation or subluxation
4.Joint stiffness from intra-articular or peri-4.Joint stiffness from intra-articular or peri-
articular adhesions, from reflexarticular adhesions, from reflex
sympathetic dystrophy or from post-sympathetic dystrophy or from post-
traumatic ossification about the jointtraumatic ossification about the joint
5.Osteoarthritis5.Osteoarthritis

8383
 TreatmentTreatment
1.1. Reduction: by manipulation or operationReduction: by manipulation or operation
2.2. Treatment of the ligamentous injuryTreatment of the ligamentous injury
a. Rupture of an important ligamenta. Rupture of an important ligament
b. a serious risk of post-traumaticb. a serious risk of post-traumatic
ossificationossification
c. severe painc. severe pain
3. Treatment of fracture-dislocations3. Treatment of fracture-dislocations

8484
 Recurrent dislocation or subluxationRecurrent dislocation or subluxation
Certain joints are liable to repeatedCertain joints are liable to repeated
dislocation or subluxation.dislocation or subluxation.
Clinical features:Clinical features:
1. A History of injury1. A History of injury
2. Local pain and tenderness2. Local pain and tenderness
3.moderate swelling3.moderate swelling
4. Sometimes a visible ecchymosis4. Sometimes a visible ecchymosis

8585
 TreatmentTreatment
Repair or reconstruct theRepair or reconstruct the
ligament that were damaged.ligament that were damaged.

Fracture Lecture 2/4 (General Notes)

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Fracture Lecture 2/4 (General Notes)