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0781791642 - Clinical Anatomy by Systems

0781791642 - Clinical Anatomy by Systems

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Crealer Tuberosilv Fraclures !

Lesser Tuberosilv Fraclures !52
Surgical Ñeck Fraclures !52
FracIures ø! Ihe Sha!I ø! Ihe Humerus 152
FracIures ø! Ihe D¡sIaí Enø ø! Ihe
Humerus 152
Bohes oI Ihe Forearm 152
FracIures ø! Ihe Paø¡us anø Uína 152
Oíecranøn Burs¡I¡s 154
Bohes oI Ihe Hahd 154
Ìn¡ur¡es Iø Ihe Bønes ø! Ihe Hanø 154
Bones of the Lower Limb 154
Bohes oI Ihe Pelvic Girdle 154
Cí¡n¡caí CøncepI: The Feív¡s ¡s a Bas¡n
v¡Ih Høíes ¡n ¡Is Waíís 154
Feív¡c NeasuremenIs ¡n ObsIeIr¡cs 155
ínlernal Pelvic Assessnenls !55
The Femaíe Feív¡s 155
FracIures ø! Ihe Feív¡s 156
Fraclures ol lhe False Pelvis !56
Fraclures ol lhe True Pelvis !56
Fraclures ol lhe Sacrun and Coccvx !53
íinor Fraclures ol lhe Pelvis !53
Analonv ol Conplicalions ol Pelvic
Fraclures !53
Bohes oI Ihe Thigh 158
Tenøerness ø! Ihe Heaø ø! Ihe Femur anø
ArIhr¡I¡s ø! Ihe H¡p Jø¡nI 158
Bíøøø Suppíy Iø Ihe Femøraí Heaø anø
Neck FracIures 159
The Neck ø! Ihe Femur anø Cø×a Vaíga
anø Cø×a Vara 159
FracIures ø! Ihe Femur 159
FaIeííar D¡síøcaI¡øns 161
FaIeííar FracIures 161
Bohes oI Ihe Leg 161
FracIures ø! Ihe T¡b¡a anø F¡buía 161
ÌnIerøsseøus Ìn!us¡øn ø! Ihe T¡b¡a ¡n Ihe
Ìn!anI 161
Bohes oI Ihe FooI 161
FracIures ø! Ihe Caícaneum 161
FracIures ø! Ihe Taíus 161
FracIures ø! Ihe NeIaIarsaí Bønes 162
CIinicaI ProbIem SoIving Ouestions 162
Answers and ExpIanations 165
Bones 147
Bone Fractures 147
Rickets 147
EpiphyseaI PIate Disorders 147
SkuII 147
Clihical FeaIures oI Ihe NeohaIal Skull 147
FønIaneííes 147
Tympan¡c Nembrane 147
Forceps Delivery ahd Ihe Facial Nerve 147
FracIures oI Ihe Skull 147
FracIures ø! Ihe AnIer¡ør Cran¡aí Føssa 148
FracIures ø! Ihe N¡øøíe Cran¡aí Føssa 148
FracIures ø! Ihe FøsIer¡ør Cran¡aí Føssa 148
Bøne Ìn¡ur¡es ø! Ihe Skuíí anø SkeíeIaí
DeveíøpmenI 148
AhaIomy oI Commoh Facial FracIures 148
Nasaí FracIures 148
Naסííø!ac¡aí FracIures 148
BíøvøuI FracIures ø! Ihe Naסíía 148
FracIures ø! Ihe Zygøma ør ZygømaI¡c
Arch 149
MandibIe 149
FracIures oI Ihe Mahdible 149
VertebraI CoIumn 149
E×amihaIioh oI Ihe Back 149
Abhormal Curves oI Ihe VerIebral Columh 150
ParIial Fusioh oI Ihe Sacral VerIebrae 150
FracIure oI Ihe Sacrum ih Trauma oI Ihe Pelvis 150
FracIures oI Ihe Coccy× ahd Coccydyhia 150
Thoracic Bones 150
Clihical ÌmporIahce oI Ihe SIerhal Ahgle
(Ahgle oI Louis) 150
SIerhum ahd Marrow Biopsy 150
Cervical Pib 150
Pib E×cisioh 151
Bones of the Upper Limb 151
Bohes oI Ihe Shoulder Girdle 151
FracIures ø! Ihe Cíav¡cíe 151
Cømpress¡øn ø! Ihe Brach¡aí Fíe×us,
Subcíav¡an ArIery, anø Subcíav¡an Ve¡n
by Ihe Cíav¡cíe 151
FracIures ø! Ihe Scapuía 151
Drøppeø Shøuíøer anø W¡ngeø Scapuía 151
Bohes oI Ihe Arm 152
FracIures ø! Ihe Frøסmaí Enø ø! Ihe
Humerus 152
Huneral Head Fraclures !52
Immedialelv aller a lraclure, lle palienl sullers severe local
pain and is nol alle lo use lle injured parl. Delormilv mav
le visille il lle lone lragmenls lave leen displaced relalive
lo eacl oller. 1le degree ol delormilv and lle direclions
laken lv lle lonv lragmenls depend nol onlv on lle mecl-
anism ol injurv lul also on lle pull ol lle muscles allacled
lo lle lragmenls. Iigamenlous allaclmenls also inlluence
lle delormilv. In cerlain silualions-lor example, lle
ileum-lraclures resull in no delormilv lecause lle inner
and ouler surlaces ol lle lone are splinled lv lle exlensive
origins ol muscles. In conlrasl, a lraclure ol lle neck ol lle
lemur produces consideralle displacemenl. 1le slrong
muscles ol lle lligl pull lle dislal lragmenl upward so llal
lle leg is slorlened. 1le verv slrong laleral rolalors rolale
lle dislal lragmenl lalerallv so llal lle lool poinls lalerallv.
Iraclure ol a lone is accompanied lv a consideralle
lemorrlage ol llood lelween lle lone ends and inlo lle
surrounding soll lissue. 1le llood vessels and lle lilrollasls
and osleollasls lrom lle periosleum and endosleum lake
parl in lle repair process.
Rickels is a deleclive mineralizalion ol lle carlilage malrix
in growing lones. 1lis produces a condilion in wlicl lle
carlilage cells conlinue lo grow, resulling in excess carlilage
and a widening ol lle epiplvseal plales. 1le poorlv miner-
alized carlilaginous malrix and lle osleoid malrix are soll,
and llev lend under lle slress ol learing weigll. 1le re-
sulling delormilies include enlarged cosloclondral junc-
lions, lowing ol lle long lones ol lle lower limls, and loss-
ing ol lle lronlal lones ol lle skull. Delormilies ol lle pelvis
mav also occur.
Ipiplvseal plale disorders allecl onlv clildren and adoles-
cenls. 1le epiplvseal plale is lle parl ol a growing lone
concerned primarilv will growll in lengll. 1rauma, inlec-
lion, diel, exercise, and endocrine disorders can dislurl lle
growll ol lle lvaline carlilaginous plale, leading lo delor-
milv and loss ol lunclion. In lle lemur, lor example, lle
proximal epiplvsis can slip lecause ol meclanical slress or
excessive loads. 1le lengll ol lle limls can increase exces-
sivelv lecause ol increased vascularilv in lle region ol lle
epiplvseal plale secondarv lo inleclion or in lle presence ol
lumors. Slorlening ol a liml can lollow lrauma lo lle epi-
plvseal plale resulling lrom a diminisled llood supplv lo
lle carlilage.
CIinicaI Features of the NeonataI SkuII
Ialpalion ol lle lonlanelles enalles lle plvsician lo deler-
mine lle progress ol growll in lle surrounding lones, lle
degree ol lvdralion ol lle lalv (e.g., il lle lonlanelles are
depressed lelow lle surlace, lle lalv is delvdraled), and
lle slale ol lle inlracranial pressure (a lulging lonlanelle
indicales raised inlracranial pressure).
Samples ol cerelrospinal lluid can le ollained lv pass-
ing a long needle olliquelv llrougl lle anlerior lonlanelle
inlo lle sularaclnoid space or even inlo lle laleral venlricle.
Clinicallv, il is usuallv nol possille lo palpale lle anle-
rior lonlanelle aller 18 monlls, lecause lle lronlal and
parielal lones lave enlarged lo close lle gap.
Tympahic Membrahe
Al lirll, lle lvmpanic memlrane laces more downward and
less lalerallv llan in malurilv, wlen examined will lle olo-
scope, il llerelore lies more olliquelv in lle inlanl llan in
lle adull.
Forceps DeIivery and the FaciaI Nerve
In lle newlorn inlanl, lle masloid process is nol developed,
and lle lacial nerve, as il emerges lrom lle slvlomasloid
loramen, is close lo lle surlace. 1lus, il can le damaged lv
lorceps in a dillicull deliverv.
Fractures of the SkuII
Iraclures ol lle skull are common in lle adull lul mucl
less so in lle voung clild. In lle inlanl skull, lle lones are
more resilienl llan in lle adull skull, and llev are separaled
lv lilrous sulural ligamenls. In lle adull, lle inner lalle ol
lle skull is parlicularlv lrillle. Moreover, lle sulural liga-
menls legin lo ossilv during middle age.
1le lvpe ol lraclure llal occurs in lle skull depends on
lle age ol lle palienl, lle severilv ol lle llow, and lle area
ol skull receiving lle lrauma. 1le aduIl skuII mav le
likened lo an eggslell in llal il possesses a cerlain limiled re-
silience levond wlicl il splinlers. A severe, localized llow
produces a local indenlalion, ollen accompanied lv splin-
lering ol lle lone. Blows lo lle vaull ollen resull in a series
ol linear lraclures, wlicl radiale oul llrougl lle llin areas
ol lone. 1le pelrous parls ol lle lemporal lones and lle oc-
cipilal cresls slronglv reinlorce lle lase ol lle skull and lend
lo dellecl linear lraclures.
In lle young chiId, lle skull mav le likened lo a lalle-
lennis lall in llal a localized llow produces a depression
willoul splinlering. 1lis common lvpe ol circumscriled
lesion is relerred lo as a ¨pond¨ Ftaclute.
Bones and CartiIage 147
skull is developed lrom memlrane (wlereas lle remainder
is developed lrom carlilage), llerelore, llis parl ol lle skull
in clildren is relalivelv llexille and can alsorl consideralle
lorce willoul resulling in a lraclure.
Signs ol lraclures ol lle lacial lones include delormilv,
ocular displacemenl, or alnormal movemenl accompanied
lv crepilalion and malocclusion ol lle leell. Anesllesia or
paresllesia ol lle lacial skin will lollow lraclure ol lones
llrougl wlicl lrancles ol lle lrigeminal nerve pass lo
lle skin.
1le muscles ol lle lace are llin and weak and cause lil-
lle displacemenl ol lle lone lragmenls. Once a lraclure ol
lle maxilla las leen reduced, lor example, prolonged lixa-
lion is nol needed. However, in lle case ol lle mandille,
lle slrong muscles ol maslicalion can creale consideralle
displacemenl, requiring long periods ol lixalion.
1le mosl common lacial lraclures involve lle nasal
lones, lollowed lv lle zvgomalic lone and llen lle
mandille. 1o lraclure lle maxillarv lones and lle supra-
orlilal ridges ol lle lronlal lones, an enormous lorce is
Nasal FracIures
Iraclures ol lle nasal lones, lecause ol lle prominence ol
lle nose, are lle mosl common lacial lraclures. Because lle
lones are lined will mucoperiosleum, lle lraclure is con-
sidered open, lle overlving skin mav also le laceraled. Al-
llougl mosl are simple lraclures and are reduced under
local anesllesia, some are associaled will severe injuries
lo lle nasal seplum and require carelul lrealmenl under
general anesllesia.
Ma×illoIacial FracIures
Maxillolacial lraclures usuallv occur as lle resull ol
massive lacial lrauma. 1lere is exlensive lacial swelling,
midlace molililv ol lle underlving lone on palpalion,
malocclusion ol lle leell will anlerior open lile, and pos-
sillv leakage ol cerelrospinal lluid (cerelrospinal rlinor-
rlea) secondarv lo lraclure ol lle crilrilorm plale ol lle
ellmoid lone. Doulle vision (diplopia) mav le presenl,
owing lo orlilal wall damage. Involvemenl ol lle inlraor-
lilal nerve will anesllesia or paresllesia ol lle skin ol lle
cleek and upper gum mav occur in lraclures ol lle lodv
ol lle maxilla. Nose lleeding mav also occur in maxillarv
lraclures. Blood enlers lle maxillarv air sinus and llen
leaks inlo lle nasal cavilv.
1le siles ol lle lraclures were classilied lv Ie Iorl
as lvpe I, II, or III, llese lraclures are summarized in
CD Iig. 11-1.
BlowouI FracIures oI Ihe Ma×illa
A severe llow lo lle orlil (as lrom a laselall) mav cause lle
conlenls ol lle orlilal cavilv lo explode downward llrougl
FracIures oI Ihe AhIerior Crahial Fossa
In lraclures ol lle anlerior cranial lossa, lle crilrilorm plale
ol lle ellmoid lone mav le damaged. 1lis usuallv resulls in
learing ol lle overlving meninges and underlving mucope-
riosleum. 1le palienl will lave lleeding lrom lle nose
(epislaxis) and leakage ol cerelrospinal lluid inlo lle nose
(cetebtospinaI thinotthea). Iraclures involving lle orlilal
plale ol lle lronlal lone resull in lemorrlage leneall lle
conjuncliva and inlo lle orlilal cavilv, causing exophlhaI-
mos. 1le lronlal air sinus mav le involved, will lemorrlage
inlo lle nose.
FracIures oI Ihe Middle Crahial Fossa
Iraclures ol lle middle cranial lossa are common, lecause
llis is lle weakesl parl ol lle lase ol lle skull. Analomi-
callv, llis weakness is caused lv lle presence ol numerous
loramina and canals in llis region, lle cavilies ol lle mid-
dle ear and lle splenoidal air sinuses are parlicularlv vul-
neralle. 1le leakage ol cerelrospinal lluid and llood lrom
lle exlernal audilorv mealus is common. 1le sevenll and
eiglll cranial nerves mav le involved as llev pass llrougl
lle pelrous parl ol lle lemporal lone. 1le llird, lourll,
and sixll cranial nerves mav le damaged il lle laleral wall
ol lle cavernous sinus is lorn. Blood and cerelrospinal
lluid mav leak inlo lle splenoidal air sinuses and llen inlo
lle nose.
FracIures oI Ihe PosIerior Crahial Fossa
In lraclures ol lle poslerior cranial lossa, llood mav escape
inlo lle nape ol lle neck deep lo lle poslverlelral muscles.
Some davs laler, il lracks lelween lle muscles and appears
in lle poslerior lriangle, close lo lle masloid process. 1le
mucous memlrane ol lle rool ol lle nasoplarvnx mav le
lorn, and llood mav escape llere. In lraclures involving lle
jugular loramen, lle ninll, lenll, and elevenll cranial
nerves mav le damaged. 1le slrong lonv walls ol lle lv-
poglossal canal usuallv prolecl lle lvpoglossal nerve lrom
Bohe Ìhiuries oI Ihe Skull ahd SkeleIal
1le developing lones ol a clild`s lace are more plialle llan
an adull`s, and lraclures mav le incomplele or greenslick. In
adulls, lle presence ol well-developed, air-lilled sinuses and
lle mucoperiosleal surlaces ol lle alveolar parls ol lle up-
per and lower jaws means llal mosl lacial lraclures slould
le considered lo le open lraclures, susceplille lo inleclion
and requiring anliliolic llerapv.
Anatomy of Common FaciaI Fractures
Aulomolile accidenls, lisliculls, and lalls are common
causes ol lacial lraclures. Iorlunalelv, lle upper parl ol lle
148 Chapter 11
lle lloor ol lle orlil inlo lle maxillarv sinus. Damage lo lle
inlraorlilal nerve, resulling in allered sensalion lo lle skin
ol lle cleek, upper lip, and gum, mav occur.
FracIures oI Ihe Zygoma
or ZygomaIic Arch
1le zvgoma or zvgomalic arcl can le lraclured lv a llow
lo lle side ol lle lace. Alllougl il can occur as an isolaled
lraclure, as lrom a llow lrom a clencled lisl, il mav le asso-
cialed will mulliple oller lraclures ol lle lace, as ollen seen
in aulomolile accidenls.
Fractures of the MandibIe
1le mandille is lorsesloe slaped and lorms parl ol a
lonv ring will lle lwo lemporomandilular joinls and lle
lase ol lle skull. 1raumalic impacl is lransmilled around
lle ring, causing a single lraclure or mulliple lraclures ol
lle mandille, ollen lar removed lrom lle poinl ol impacl.
Examination of the Back
Il is imporlanl llal lle wlole area ol lle lack and legs le
examined and llal lle sloes le removed. Unequal lengll ol
lle legs or disease ol lle lip joinls can lead lo alnormal cur-
valures ol lle verlelral column. 1le palienl slould le
asked lo walk up and down lle examinalion room so llal lle
normal lilling movemenl ol lle pelvis can le olserved. As
one side ol lle pelvis is raised, a coronal lumlar convexilv
develops on lle opposile side, will a compensalorv lloracic
convexilv on lle same side. Wlen a person assumes lle
silling posilion, il will le noled llal lle normal lumlar cur-
valure lecomes llallened, will an increase in lle inlerval
lelween lle lumlar spines.
Bones and CartiIage 149
CD Figure 11-1 Le ForI classiIicaIioh oI ma×illoIacial IracIures. The reø í¡ne dehoIes Ihe
IracIure lihe.
PartiaI Fusion of the SacraI Vertebrae
1le lirsl sacral verlelra can le parllv or complelelv sepa-
raled lrom lle second sacral verlelra. Occasionallv, on ra-
diograpls ol lle verlelral column, examples are seen in
wlicl lle lilll lumlar verlelra las lused will lle lirsl sacral
Fracture of the Sacrum in Trauma of
the PeIvis
1rauma lo lle lrue pelvis can resull in lraclure ol lle laleral
mass ol lle sacrum.
Fractures of the Coccyx
and Coccydynia
Iraclures ol lle coccvx are rare. However, coccydynia is
common and is usuallv caused lv direcl lrauma lo lle
coccvx, as in lalling down a lligll ol concrele sleps. 1le
anlerior surlace ol lle coccvx can le palpaled will a reclal
CIinicaI Importance of the SternaI
AngIe (AngIe of Louis)
Wlen one is examining lle clesl lrom lle lronl, lle sletnaI
angIe (angIe oF Louis) is an imporlanl landmark. Ils posi-
lion can easilv le lell and can ollen le seen lv lle presence
ol a lransverse ridge. 1le linger moved lo lle rigll or lo lle
lell passes direcllv onlo lle second coslal carlilage and llen
lle second ril. All oller rils can le counled lrom llis poinl.
1le lwellll ril can usuallv le lell lrom lelind, lul in some
olese persons llis mav prove dillicull.
Sternum and Marrow Biopsy
Since lle slernum possesses red lemalopoielic marrow
llrougloul lile, il is a common sile lor mattow biopsy.
Under a local anesllelic, a wide-lore needle is inlroduced
inlo lle marrow cavilv llrougl lle anlerior surlace ol lle
lone. 1le slernum mav also le splil al operalion lo allow
lle surgeon lo gain easv access lo lle learl, greal vessels,
and llvmus.
CervicaI Rib
A cervical ril (i.e., a ril arising lrom lle anlerior lulercle ol
lle lransverse process ol lle sevenll cervical verlelra) occurs
in aloul O.¯´ ol lumans (CD Iig. 11-2). Il mav lave a lree
anlerior end, mav le connecled lo lle lirsl ril lv a lilrous
land, or mav arliculale will lle lirsl ril. 1le imporlance ol
a cervical ril is llal il can cause pressure on lle lower lrunk
ol lle lraclial plexus in some palienls, producing pain down
1le normal range ol movemenl ol lle dillerenl parls ol
lle verlelral column slould le lesled. In lle cervical re-
gion, llexion, exlension, laleral rolalion, and laleral llexion
are possille. Rememler llal aloul lall ol lle movemenl re-
lerred lo as llexion is carried oul al lle allanlooccipilal
joinls. In llexion, lle palienl slould le alle lo loucl lis or
ler clesl will lle clin, and in exlension le or sle slould
le alle lo look direcllv upward. In laleral rolalion lle pa-
lienl slould le alle lo place lle clin nearlv in line will lle
sloulder. Hall ol laleral rolalion occurs lelween lle allas
and lle axis. In laleral llexion lle lead can normallv le
lilled 1¯° lo eacl sloulder. Il is imporlanl llal lle sloulder
is nol raised wlen llis movemenl is leing lesled.
In lle lloracic region lle movemenls are limiled lv lle
presence ol lle rils and slernum. Wlen lesling lor rolalion,
make sure llal lle palienl does nol rolale lle pelvis.
In lle lumlar region, llexion, exlension, laleral rola-
lion, and laleral llexion are possille. Ilexion and exlension
are lairlv lree. Ialeral rolalion, lowever, is limiled lv lle
inlerlocking ol lle arlicular processes. Ialeral llexion in
lle lloracic and lumlar regions is lesled lv asking lle pa-
lienl lo slide, in lurn, eacl land down lle laleral side ol
lle lligl.
AbnormaI Curves of the
VertebraI CoIumn
Kyphosis is an exaggeralion in lle sagillal curvalure presenl
in lle lloracic parl ol lle verlelral column. Il can le caused
lv muscular weakness or lv slruclural clanges in lle verle-
lral lodies or lv inlerverlelral discs. In sicklv adolescenls,
lor example, wlere lle muscle lone is poor, long lours ol
sludv or work over a low desk can lead lo a genllv curved
kvplosis ol lle upper lloracic region. 1le person is said lo
le ¨round-slouldered.` Crusl lraclures or lulerculous de-
slruclion ol lle verlelral lodies leads lo acule angular
kvplosis ol lle verlelral column. In lle aged, osleopotosis
(alnormal rarelaclion ol lone) and/or degeneralion ol lle
inlerverlelral discs leads lo seniIe kyphosis, involving lle
cervical, lloracic, and lumlar regions ol lle column.
Lotdosis is an exaggeralion in lle sagillal curvalure pre-
senl in lle lumlar region. Iordosis mav le caused lv an
increase in lle weigll ol lle aldominal conlenls, as will
lle gravid ulerus or a large ovarian lumor, or il mav le
caused lv disease ol lle verlelral column sucl as spondv-
lolisllesis. 1le possilililv llal il is a poslural compensalion
lor a kvplosis in lle lloracic region or a disease ol lle lip
joinl (congenilal dislocalion) musl nol le overlooked.
ScoIiosis is a laleral devialion ol lle verlelral column.
1lis is mosl commonlv lound in lle lloracic region and
mav le caused lv muscular or verlelral delecls. Iaralvsis ol
muscles caused lv poliomvelilis can cause severe scoliosis.
1le presence ol a congenilal lemiverlelra can cause scol-
iosis. Ollen scoliosis is compensalorv and mav le caused lv
a slorl leg or lip disease.
150 Chapter 11
lle medial side ol lle lorearm and land and wasling ol lle
small muscles ol lle land. Il can also exerl pressure on lle
overlving sulclavian arlerv and inlerlere will lle circulalion
ol lle upper liml.
Rib Excision
Ril excision is commonlv perlormed lv lloracic surgeons
wisling lo gain enlrance lo lle lloracic cavilv. A longiludi-
nal incision is made llrougl lle periosleum on lle ouler
surlace ol lle ril and a segmenl ol lle ril is removed. A sec-
ond longiludinal incision is llen made llrougl lle led ol
lle ril, wlicl is lle inner covering ol periosleum. Aller lle
operalion, lle ril regenerales lrom lle osleogenelic laver ol
lle periosleum.
Bones of the ShouIder GirdIe
FracIures oI Ihe Clavicle
1le clavicle is a slrul llal lolds lle arm lalerallv so llal il
can move lreelv on lle lrunk. Unlorlunalelv, lecause ol ils
posilion, il is exposed lo lrauma and lransmils lorces lrom
lle upper liml lo lle lrunk. I| is |bc mos| commonlv |rac-
|urcd bonc in |bc bodv. 1le lraclure usuallv occurs as a re-
sull ol a lall on lle sloulder or oulslrelcled land. 1le lorce
is lransmilled along lle clavicle, wlicl lreaks al ils weakesl
poinl, lle junclion ol lle middle and ouler llirds. Aller lle
lraclure, lle laleral lragmenl is depressed lv lle weigll
ol lle arm, and il is pulled mediallv and lorward lv lle
slrong adduclor muscles ol lle sloulder joinl, especiallv lle
pecloralis major. 1le medial end is lilled upward lv lle
slernocleidomasloid muscle.
1le close relalionslip ol lle supraclavicular nerves
lo lle clavicle mav resull in lleir involvemenl in callus lor-
malion aller lraclure ol lle lone. 1lis mav le lle cause ol
persislenl pain over lle side ol lle neck.
Compressioh oI Ihe Brachial Ple×us,
Subclaviah ArIery, ahd Subclaviah Veih
by Ihe Clavicle
1le inlerval lelween lle clavicle and lle lirsl ril in some
palienls mav lecome narrowed and llus is responsille lor
compression ol nerves and llood vessels.
FracIures oI Ihe Scapula
Iraclures ol lle scapula are usuallv lle resull ol severe
lrauma, sucl as occurs in run-over accidenl viclims or in
occupanls ol aulomoliles involved in crasles. Injuries
are usuallv associaled will lraclured rils. Mosl lraclures
ol lle scapula require lillle lrealmenl lecause lle muscles
on lle anlerior and poslerior surlaces adequalelv splinl lle
Dropped Shoulder ahd Wihged Scapula
1le posilion ol lle scapula on lle poslerior wall ol lle llo-
rax is mainlained lv lle lone and lalance ol lle muscles al-
lacled lo il. Il one ol llese muscles is paralvzed, lle lalance
is upsel, as in dropped sloulder, wlicl occurs will paralv-
sis ol lle lrapezius, or winged scapula (CD Iig. 11-²),
caused lv paralvsis ol lle serralus anlerior. Sucl imlalance
can le delecled lv carelul plvsical examinalion.
Bones and CartiIage 151
scalenus medius
brachial µlexus
scalenus anterior
subclavian arterv
cervical rib
lower trunk ol µlexus
librous band
cervical rib
CD Figure 11-2 Thoracic ouIleI as
seeh Irom above. NoIe Ihe
presehce oI Ihe cervical ribs (bíack)
oh boIh sides. Oh Ihe righI side oI
Ihe Ihora×, Ihe rib is almosI
compleIe ahd arIiculaIes ahIeriorly
wiIh Ihe IirsI rib. Oh Ihe leII side oI
Ihe Ihora×, Ihe rib is rudimehIary
buI is cohIihued Iorward as a
Iibrous bahd IhaI is aIIached Io Ihe
IirsI cosIal carIilage. NoIe IhaI Ihe
cervical rib may e×erI pressure oh
Ihe lower Iruhk oI Ihe brachial
ple×us ahd may kihk Ihe subclaviah
FracIures oI Ihe ShaII oI Ihe Humerus
Iraclures ol lle lumeral slall are common, displacemenl
ol lle lragmenls depends on lle relalion ol lle sile ol lle
lraclure lo lle inserlion ol lle delloid muscle (see CD Iig.
11-1). Wlen lle lraclure line is proximal lo lle delloid in-
serlion, lle proximal lragmenl is adducled lv lle pecloralis
major, lalissimus dorsi, and leres major muscles, lle dislal
lragmenl is pulled proximallv lv lle delloid, liceps, and lri-
ceps. Wlen lle lraclure is dislal lo lle delloid inserlion, lle
proximal lragmenl is alducled lv lle delloid, and lle dislal
lragmenl is pulled proximallv lv lle liceps and lriceps. 1le
radial nerve can le damaged wlere il lies in lle spiral
groove on lle poslerior surlace ol lle lumerus under cover
ol lle lriceps muscle.
FracIures oI Ihe DisIal Ehd
oI Ihe Humerus
Supracondvlar lraclures (see CD Iig. 11-1) are common in
clildren and occur wlen lle clild lalls on lle oulslrelcled
land will lle ellow parliallv llexed. Injuries lo lle medial,
radial, and ulnar nerves are nol uncommon, alllougl lunc-
lion usuallv quicklv relurns aller reduclion ol lle lraclure.
Damage lo or pressure on lle lraclial arlerv can occur al
lle lime ol lle lraclure or lrom swelling ol lle surrounding
lissues, lle circulalion lo lle lorearm mav le inlerlered
will, leading lo Volkmann`s isclemic conlraclure.
1le medial epicondvle (see CD Iig. 11-1) can le
avulsed lv lle medial collaleral ligamenl ol lle ellow joinl
il lle lorearm is lorcillv alducled. 1le ulnar nerve can le
injured al lle lime ol lle lraclure, can lecome involved
laler in lle repair process ol lle lraclure (in lle callus), or
can undergo irrilalion on lle irregular lonv surlace aller lle
lone lragmenls are reuniled.
Bones of the Forearm
FracIures oI Ihe Padius ahd Ulha
Iraclures oF lhe head oF lhe tadius can occur lrom lalls on
lle oulslrelcled land. As lle lorce is lransmilled along lle
radius, lle lead ol lle radius is driven slarplv againsl lle ca-
pilulum, splilling or splinlering lle lead (see CD Iig. 11-1).
Iraclures oF lhe neck oF lhe tadius occur in voung clil-
dren lrom lalls on lle oulslrelcled land (see CD Iig. 11-1).
Iraclures oF lhe shaFls oF lhe tadius and uIna mav or
mav nol occur logeller (see CD Iig. 11-1). Displacemenl ol
lle lragmenls is usuallv consideralle and depends on lle
pull ol lle allacled muscles. 1le proximal lragmenl ol lle
radius is supinaled lv lle supinalor and lle liceps lraclii
muscles (see CD Iig. 11-1). 1le dislal lragmenl ol lle
radius is pronaled and pulled mediallv lv lle pronalor
quadralus muscle. 1le slrengll ol lle lraclioradialis and
exlensor carpi radialis longus and lrevis slorlens and angu-
lales lle lorearm. In lraclures ol lle ulna, lle ulna angulales
Bones of the Arm
FracIures oI Ihe Pro×imal Ehd
oI Ihe Humerus
HumeraI Head Fractures
Iraclures ol lle lumeral lead (CD Iig. 11-1) can occur
during lle process ol anlerior and poslerior dislocalions ol
lle sloulder joinl. 1le lilrocarlilaginous glenoid lalrum
ol lle scapula produces lle lraclure, and lle lalrum can
lecome jammed in lle delecl, making reduclion ol lle
sloulder joinl dillicull.
Greater Tuberosity Fractures
1le grealer lulerosilv ol lle lumerus can le lraclured lv di-
recl lrauma, displaced lv lle glenoid lalrum during disloca-
lion ol lle sloulder joinl, or avulsed lv violenl conlraclions
ol lle supraspinalus muscle. 1le lone lragmenl will lave lle
allaclmenls ol lle supraspinalus, leres minor, and inlra-
spinalus muscles, wlose lendons lorm parl ol lle rolalor cull.
Wlen associaled will a sloulder dislocalion, severe learing ol
lle cull will lle lraclure can resull in lle grealer lulerosilv
remaining displaced posleriorlv aller lle sloulder joinl las
leen reduced. In llis silualion, open reduclion ol lle lraclure
is necessarv lo allacl lle rolalor cull lack inlo place.
Lesser Tuberosity Fractures
Occasionallv, a lesser lulerosilv lraclure accompanies pos-
lerior dislocalion ol lle sloulder joinl. 1le lone lragmenl
receives lle inserlion ol lle sulscapularis lendon (see CD
Iig. 11-1), a parl ol lle rolalor cull.
SurgicaI Neck Fractures
1le surgical neck ol lle lumerus (see CD Iig. 11-1),
wlicl lies immedialelv dislal lo lle lesser lulerosilv, can le
lraclured lv a direcl llow on lle laleral aspecl ol lle sloulder
or in an indirecl manner lv lalling on lle oulslrelcled land.
152 Chapter 11
CD Figure 11-3 Wihgihg oI Ihe righI scapula.
posleriorlv. 1o reslore lle normal movemenls ol pronalion
and supinalion, lle normal analomic relalionslip ol lle ra-
dius, ulna, and inlerosseous memlrane musl le regained.
A lraclure ol one lorearm lone mav le associaled will
a dislocalion ol lle oller lone. In Monleggia`s Ftaclute, lor
example, lle slall ol lle ulna is lraclured lv a lorce applied
lrom lelind. 1lere is a lowing lorward ol lle ulnar slall
and an anlerior dislocalion ol lle radial lead will ruplure
ol lle anular ligamenl. In CaIeazzi`s Ftaclute, lle proximal
llird ol lle radius is lraclured and lle dislal end ol lle ulna
is dislocaled al lle dislal radioulnar joinl.
Itaclutes oF lhe oIectanon ptocess can resull lrom a
lall on lle llexed ellow or lrom a direcl llow. Depending on
lle localion ol lle lraclure line, lle lonv lragmenl mav le
Bones and CartiIage 153
anatomical neck
suruical neck
shalt ol humerus
lateral eµicondvle
radial lossa
deltoid tuberositv
olecranon µrocess
trochlear notch
coronoid µrocess
biciµital tuberositv
shalt ol ulna
stvloid µrocess
stvloid µrocess
ol radius

ureater tuberositv
CD Figure 11-4  Commoh
IracIures oI Ihe humerus.
 Commoh IracIures oI Ihe
radius ahd ulha. The
displacemehI oI Ihe bohy
IragmehIs oh Ihe siIe oI Ihe
IracIure lihe ahd Ihe pull oI Ihe
muscles. CF pull oI commoh
Ile×ure muscles, D delIoid,
PM pecIoralis maior,
S supraspihaIus, SUB
subscapularis, ahd TP Iriceps.
1le llood vessels lo lle scaploid enler ils proximal and
dislal ends, alllougl lle llood supplv is occasionallv con-
lined lo ils dislal end. Il lle laller occurs, a lraclure de-
prives lle proximal lragmenl ol ils arlerial supplv, and llis
lragmenl undergoes avascular necrosis. Deep lenderness
in lle analomic snulllox aller a lall on lle oulslrelcled
land in a voung adull makes one suspicious ol a lraclured
DisIocalion oF lhe Iunale lone occasionallv occurs in
voung adulls wlo lall on lle oulslrelcled land in a wav llal
causes lvperexlension ol lle wrisl joinl. Involvemenl ol lle
median nerve is common.
Itaclutes oF lhe melacatpaI bones can occur as a re-
sull ol direcl violence, sucl as lle clencled lisl slriking a
lard oljecl. 1le lraclure alwavs angulales dorsallv. 1le
¨loxer`s lraclure` commonlv produces an ollique lraclure
ol lle neck ol lle lilll and somelimes lle lourll melacarpal
lones. 1le dislal lragmenl is commonlv displaced proxi-
mallv, llus slorlening lle linger posleriorlv.
Bennell`s Ftaclute is a lraclure ol lle lase ol lle
melacarpal ol lle lluml caused wlen violence is applied
along lle long axis ol lle lluml or lle lluml is lorcelullv
alducled. 1le lraclure is ollique and enlers lle car-
pomelacarpal joinl ol lle lluml, causing joinl inslalililv.
Itaclutes oF lhe phaIanges are common and usuallv
lollow direcl injurv.
Bones of the PeIvic GirdIe
Clihical CohcepI: The Pelvis Ìs a
Basih wiIh Holes ih ÌIs Walls
1le walls ol lle pelvis are lormed lv lones and ligamenls,
llese are parllv lined will muscles (olluralor inlernus and
pirilormis) covered will lascia and parielal periloneum. On
displaced lv lle pull ol lle lriceps muscle, wlicl is inserled
on lle olecranon process (see CD Iig. 11-1). Avulsion lrac-
lures ol parl ol lle olecranon process can le produced lv
lle pull ol lle lriceps muscle. Cood lunclional relurn aller
anv ol llese lraclures depends on lle accurale analomic re-
duclion ol lle lragmenl.
CoIIes` Ftaclute is a lraclure ol lle dislal end ol lle
radius resulling lrom a lall on lle oulslrelcled land. Il com-
monlv occurs in palienls older llan ¯O vears. 1le lorce dri-
ves lle dislal lragmenl posleriorlv and superiorlv, and lle
dislal arlicular surlace is inclined posleriorlv (CD Iig. 11-¯).
1lis poslerior displacemenl produces a poslerior lump,
somelimes relerred lo as lle ¨dinner-lork delormilv` le-
cause lle lorearm and wrisl resemlle lle slape ol llal eal-
ing ulensil. Iailure lo reslore lle dislal arlicular surlace lo ils
normal posilion will severelv limil lle range ol llexion ol lle
wrisl joinl.
Smilh`s Ftaclute is a lraclure ol lle dislal end ol lle
radius and occurs lrom a lall on lle lack ol lle land. Il is
a reversed Colles` lraclure lecause lle dislal lragmenl is
displaced anleriorlv (see CD Iig. 11-¯).
Olecrahoh BursiIis
A small sulculaneous lursa is presenl over lle olecranon
process ol lle ulna, and repealed lrauma ollen produces
clronic lursilis.
Bones of the Hand
Ìhiuries Io Ihe Bohes oI Ihe Hahd
Iraclure ol lle scaploid lone is common in voung adulls,
unless lrealed elleclivelv, lle lragmenls will nol unile, and
permanenl weakness and pain ol lle wrisl will resull, will
lle sulsequenl developmenl ol osleoarllrilis. 1le lraclure
line usuallv goes llrougl lle narrowesl parl ol lle lone,
wlicl lecause ol ils localion is lalled in svnovial lluid.
154 Chapter 11

CD Figure 11-5 FracIures oI Ihe disIal ehd oI Ihe radius.
 Colles' IracIure.  SmiIh's IracIure.
lle oulside ol lle pelvis are lle allaclmenls ol lle gluleal
muscles and lle olluralor exlernus muscle. 1le grealer parl
ol lle lonv pelvis is llus sandwicled lelween inner and
ouler muscles.
1le lasin las anlerior, poslerior, and laleral walls and
an inlerior wall or lloor lormed lv lle imporlanl levalor ani
and coccvgeus muscles and lleir covering lascia.
1le lasin las manv loles: 1le poslerior wall las loles
on lle anlerior surlace ol lle sacrum, lle anletiot sactaI
Fotamina, lor lle passage ol lle anlerior rami ol lle sacral
spinal nerves. 1le sactolubetous and sactospinous Iiga-
menls converl lle grealer and lesser scialic nolcles inlo lle
gtealet and Iesset scialic Fotamina. 1le grealer scialic lora-
men provides an exil lrom lle lrue pelvis inlo lle gluleal re-
gion lor lle scialic nerve, lle pudendal nerve, and lle gluleal
nerves and vessels, lle lesser scialic loramen provides an en-
lrance inlo lle perineum lrom lle gluleal region lor lle pu-
dendal nerve and lle inlernal pudendal vessels. (One can
make a lurller analogv lere: Ior lle wires lo gain enlrance
lo lle aparlmenl lelow, willoul going llrougl lle lloor,
llev lave lo pierce lle wall |grealer scialic loramen¹ lo gel
oulside lle luilding and llen relurn llrougl a second lole
|lesser scialic loramen¹. In lle case ol lle luman lodv, lle
pudendal nerve and inlernal pudendal vessels are lle wires
and lle levalor ani and lle coccvgeus muscles are lle lloor.)
1le laleral pelvic wall las a large lole, lle oblutalot
Fotamen, wlicl is closed lv lle oblutalot membtane, ex-
cepl lor a small opening llal permils lle olluralor nerve lo
leave lle pelvis and enler lle lligl.
Pelvic MeasuremehIs ih ObsIeIrics
1le capacilv and slape ol lle lemale pelvis are ol lunda-
menlal imporlance in olslelrics. 1le lemale pelvis is well
adapled lor lle process ol clildlirll. 1le pelvis is slallower
and lle lones are smooller llan in lle male. 1le size ol lle
pelvic inlel is similar in lle lwo sexes, lul in lle lemale, lle
cavilv is larger and cvlindrical and lle pelvic oullel is wider
in loll lle anleroposlerior and lle lransverse diamelers.
Iour lerms relaling lo areas ol lle pelvis are commonlv
used in clinical praclice:
1le peIvic inIel or btim ol lle lrue pelvis (CD Iig. 11-
6) is lounded anleriorlv lv lle svmplvsis pulis, lalerallv
lv lle iliopeclineal lines, and posleriorlv lv lle sacral
1le peIvic oulIel ol lle lrue pelvis (see CD Iig. 11-6) is
lounded in lronl lv lle pulic arcl, lalerallv lv lle is-
clial lulerosilies, and posleriorlv lv lle coccvx. 1le
sacrolulerous ligamenls also lorm parl ol lle margin ol
lle oullel.
1le peIvic cavily is lle space lelween lle inlel and lle
oullel (see CD Iig. 11-6).
1le axis oF lhe peIvis is an imaginarv line joining
lle cenlral poinls ol lle anleroposlerior diamelers lrom
lle inlel lo lle oullel and is lle curved course laken lv
lle lalv`s lead as il descends llrougl lle pelvis during
clildlirll (CD Iigs. 11-6 and 11-¯A).
InternaI PeIvic Assessments
Inlernal pelvic assessmenls are made lv vaginal examinalion
during lle laler weeks ol pregnancv, wlen lle pelvic lis-
sues are soller and more vielding llan in lle newlv pregnanl
Pubic atch: Spread lle lingers under lle pulic arcl and
examine ils slape. Is il lroad or angular¯ 1le examiner`s
lour lingers slould le alle lo resl comlorlallv in lle
angle lelow lle svmplvsis.
LaletaI waIIs: Ialpale lle laleral walls and delermine
wleller llev are concave, slraigll, or converging. 1le
prominence ol lle isclial spines and lle posilion ol lle
sacrospinous ligamenls are noled.
Posletiot waII: 1le sacrum is palpaled lo delermine
wleller il is slraigll or well curved. Iinallv, il lle palienl
las relaxed lle perineum sullicienllv, an allempl is made
lo palpale lle promonlorv ol lle sacrum. 1le second
linger ol lle examining land is placed on lle promon-
lorv, and lle index linger ol lle lree land, oulside lle
vagina, is placed al lle poinl on lle examining land
wlere il makes conlacl will lle lower lorder ol lle svm-
plvsis. 1le lingers are llen willdrawn and lle dislance
measured (CD Iig. 11-¯B), providing lle measuremenl
ol lle diagonaI conjugale, wlicl is normallv aloul ¯ in.
(1² cm). 1le anleroposlerior diameler lrom lle sacro-
coccvgeal joinl lo lle lower lorder ol lle svmplvsis is
llen eslimaled.
IschiaI lubetosilies: 1le dislance lelween lle isclial
lulerosilies mav le eslimaled lv using lle closed lisl
(CD Iig. 11-¯D). Il measures aloul 1 in. (1O cm), lul il
is dillicull lo measure exacllv.
Needless lo sav, consideralle clinical experience is re-
quired lo le alle lo assess lle slape and size ol lle pelvis lv
vaginal examinalion.
The Female Pelvis
Delormilies ol lle pelvis mav le responsille lor dyslocia
(dillicull lalor). A conlracled pelvis mav olslrucl lle nor-
mal passage ol lle lelus. Il mav le indirecllv responsille lor
dvslocia lv causing condilions sucl as malpresenlalion or
malposilion ol lle lelus, premalure ruplure ol lle lelal
memlranes, and ulerine inerlia.
1le cause ol pelvic delormilies mav le congenilal
(rare) or acquired lrom disease, poor poslure, or lraclures
caused lv injurv. Ielvic delormilies are more common in
women wlo lave grown up in a poor environmenl and are
undernourisled. Il is prolalle llal llese women sullered in
lleir voull lrom minor degrees ol rickels.
In 19²², Caldwell and Molov classilied pelves inlo lour
groups: gvnecoid, android, anllropoid, and plalvpelloid
Bones and CartiIage 155
FracIures oI Ihe Pelvis
Fractures of the FaIse PeIvis
Iraclures ol lle lalse pelvis caused lv direcl lrauma occa-
sionallv occur. 1le upper parl ol lle ilium is seldom dis-
placed lecause ol lle allaclmenl ol lle iliacus muscle on
lle inside and lle gluleal muscles on lle oulside.
Fractures of the True PeIvis
1le meclanism ol lraclures ol lle lrue pelvis can le leller
underslood il lle pelvis is regarded nol onlv as a lasin lul
also as a rigid ring (see CD Iig. 11-8). 1le ring is made up
(CD. Iig. 11-¯C).1le gynecoid lvpe, presenl in aloul 11´
ol women, is lle lvpical lemale pelvis, wlicl was previouslv
1le andtoid lvpe, presenl in aloul ²²´ ol wlile le-
males and 16´ ol llack lemales, is lle male or lunnel-
slaped pelvis will a conlracled oullel.
1le anlhtopoid lvpe, presenl in aloul 21´ ol wlile le-
males and 11´ ol llack lemales, is long, narrow, and oval
1le pIalypeIIoid lvpe, presenl in onlv aloul 2´ ol
women, is a wide pelvis llallened al lle lrim, will lle
promonlorv ol lle sacrum pusled lorward.
156 Chapter 11
µelvic inlet
diauonal conjuuate
axis ol µelvis
µelvic outlet
Female Male
µelvic inlet
µelvic outlet
µelvic cavitv
µubic arch
CD Figure 11-6 Pelvic ihleI, pelvic ouIleI, diagohal
cohiugaIe, ahd a×is oI Ihe pelvis. Some oI Ihe maih
diIIerehces beIweeh Ihe Iemale ahd Ihe male pelvis are
also showh.
ol lle pulic rami, lle isclium, lle acelalulum, lle ilium,
and lle sacrum, joined lv slrong ligamenls al lle sacroiliac
and svmplvseal joinls. Il lle ring lreaks al anv one poinl,
lle lraclure will le slalle and no displacemenl will occur.
However, il lwo lreaks occur in lle ring, lle lraclure will le
unslalle and displacemenl will occur, lecause lle poslver-
lelral and aldominal muscles will slorlen and elevale lle
laleral parl ol lle pelvis (see CD Iig. 11-8). 1le lreak in lle
ring mav occur nol as lle resull ol a lraclure lul as lle resull
ol disruplion ol lle sacroiliac or svmplvseal joinls. Iraclure
Bones and CartiIage 157
axis ol birth canal measurinu the diauonal conjuuate
measurinu transverse diameter ol µelvic outlet
 

CD Figure 11-7  BirIh cahal. ÌnIerrupIeø í¡ne ihdicaIes Ihe a×is oI Ihe cahal.
 Procedure used ih measurihg Ihe diagohal cohiugaIe.  DiIIerehI Iypes oI pelvic ihleIs,
accordihg Io Caldwell ahd Moloy.  EsIimaIioh oI Ihe widIh oI Ihe pelvic ouIleI by meahs
oI a closed IisI.
lascial leneall lle parielal periloneum can le lle source ol
a massive lemorrlage, wlicl mav le lile llrealening.
1le male urellra is ollen damaged, especiallv in verlical
slear lraclures llal mav disrupl lle urogenilal diaplragm.
1le lladder, wlicl lies immedialelv lelind lle pulis in
loll sexes, is occasionallv damaged lv spicules ol lone, a lull
lladder is more likelv lo le injured llan is an emplv lladder.
1le reclum lies willin lle concavilv ol lle sacrum and
is prolecled and rarelv damaged. Iraclures ol lle sacrum or
isclial spine mav le llrusl inlo lle pelvic cavilv, learing lle
Nerve injuries can lollow sacral lraclures, lle laving
down ol lilrous lissue around lle anlerior or poslerior nerve
rools or lle lrancles ol lle sacral spinal nerves can resull in
persislenl pain.
Damage lo lle scialic nerve mav occur in lraclures
involving lle loundaries ol lle grealer scialic nolcl. 1le
peroneal parl ol lle scialic nerve is mosl ollen involved, re-
sulling in lle inalililv ol a conscious palienl lo dorsillex lle
ankle joinl or lailure ol an unconscious palienl lo rellexlv
planlar-llex (ankle jerk) lle lool.
Bones of the Thigh
Tehderhess oI Ihe Head oI Ihe Femur
ahd ArIhriIis oI Ihe Hip JoihI
1le lead ol lle lemur-llal is, llal parl llal is nol inlraac-
elalular-can le palpaled on lle anlerior aspecl ol lle lligl
ol lone on eiller side ol lle joinl is more common llan dis-
ruplion ol lle joinl.
1le lorces responsille lor lle disruplion ol lle lonv
ring mav le anleroposlerior compression, laleral compres-
sion, or slearing.
A leavv lall on lle grealer lroclanler ol lle lemur
mav drive lle lead ol lle lemur llrougl lle lloor ol lle
acelalulum inlo lle pelvic cavilv.
Fractures of the Sacrum and Coccyx
Iraclures ol lle laleral mass ol lle sacrum mav occur as parl
ol a pelvic lraclure. Iraclures ol lle coccvx are rare.
Minor Fractures of the PeIvis
1le anlerior superior iliac spine mav le pulled oll lv lle
lorcille conlraclion ol lle sarlorius muscle in allleles (see
CD Iig. 11-8). In a similar manner lle anlerior inlerior il-
iac spine mav le avulsed lv lle conlraclion ol lle reclus
lemoris muscle (origin ol lle slraigll lead). 1le isclial
lulerosilv can le avulsed lv lle conlraclion ol lle lam-
slring muscles. Healing mav occur lv lilrous union, possi-
llv resulling in elongalion ol lle muscle unil and some
reduclion in muscular elliciencv.
Anatomy of CompIications of PeIvic Fractures
Iraclures ol lle lrue pelvis are commonlv associaled will
injuries lo lle soll pelvic lissues.
Il damaged, lle llin pelvic veins-namelv, lle inlernal
iliac veins and lleir lrilularies-llal lie in lle parielal pelvic
158 Chapter 11
anterior suµerior
iliac sµine
anterior inlerior
iliac sµine
ischial tuberositv
 
 
CD Figure 11-8  DiIIerehI Iypes oI
IracIures oI Ihe pelvic basih.  Avulsioh
IracIures oI Ihe pelvis. The sarIorius
muscle is respohsible Ior Ihe avulsioh oI
Ihe ahIerior superior iliac spihe, Ihe
sIraighI head oI Ihe recIus Iemoris muscle,
Ior Ihe avulsioh oI Ihe ahIerior ihIerior iliac
spihe, ahd Ihe hamsIrihg muscles, Ior Ihe
avulsioh oI Ihe ischial IuberosiIy.
jusl inlerior lo lle inguinal ligamenl and jusl laleral lo lle
pulsaling lemoral arlerv. 1enderness over lle lead ol lle le-
mur usuallv indicales lle presence ol arllrilis ol lle lip joinl.
Blood Supply Io Ihe Femoral Head
ahd Neck FracIures
Analomic knowledge ol lle llood supplv lo lle lemoral
lead explains wlv avascular necrosis ol lle lead can occur
aller lraclures ol lle neck ol lle lemur. In lle voung, lle
epiplvsis ol lle lead is supplied lv a small lrancl ol lle ol-
luralor arlerv, wlicl passes lo lle lead along lle ligamenl
ol lle lemoral lead. 1le upper parl ol lle neck ol lle lemur
receives a proluse llood supplv lrom lle medial lemoral cir-
cumllex arlerv (see lexl Iig. 12-2¯). 1lese lrancles pierce
lle capsule and ascend lle neck deep lo lle svnovial mem-
lrane. As long as lle epiplvseal carlilage remains, no
communicalion occurs lelween lle lwo sources ol llood.
In lle adull, aller lle epiplvseal carlilage disappears, an
anaslomosis lelween lle lwo sources ol llood supplv is es-
lallisled. Iraclures ol lle lemoral neck inlerlere will or
complelelv inlerrupl lle llood supplv lrom lle rool ol lle
lemoral neck lo lle lemoral lead. 1le scanl llood llow
along lle small arlerv llal accompanies lle round ligamenl
mav le insullicienl lo suslain lle vialililv ol lle lemoral
lead, and isclemic necrosis graduallv lakes place.
The Neck oI Ihe Femur ahd Co×a Valga
ahd Co×a Vara
1le neck ol lle lemur is inclined al an angle will lle slall,
lle angle is aloul 16O° in lle voung clild and aloul 12¯°
in lle adull. An increase in llis angle is relerred lo as coxa
vaIga, and il occurs, lor example, in cases ol congenilal dis-
localion ol lle lip. In llis condilion, adduclion ol lle lip
joinl is limiled. A decrease in llis angle is relerred lo as coxa
vata, and il occurs in lraclures ol lle neck ol lle lemur
and in slipping ol lle lemoral epiplvsis. In llis condilion,
alduclion ol lle lip joinl is limiled. Slenlon`s line is a use-
lul means ol assessing lle angle ol lle lemoral neck on a
radiograpl ol lle lip region (see lexl Iig. 11-66).
FracIures oI Ihe Femur
Itaclutes oF lhe neck oF lhe Femut are common and are ol
lwo lvpes, sulcapilal and lroclanleric. 1le subcapilaI Ftac-
lute occurs in lle elderlv and is usuallv produced lv a mi-
nor lrip or slumlle. Sulcapilal lemoral neck lraclures are
parlicularlv common in women aller menopause. 1lis gen-
der predisposilion is lecause ol a llinning ol lle corlical
and lralecular lone caused lv eslrogen deliciencv. Avascu-
lar necrosis ol lle lead is a common complicalion. Il lle
lragmenls are nol impacled, consideralle displacemenl oc-
curs. 1le slrong muscles ol lle lligl (CD Iig. 11-9), in-
cluding lle reclus lemoris, lle adduclor muscles, and lle
lamslring muscles, pull lle dislal lragmenl upward, so llal
lle leg is slorlened (as measured lrom lle anlerior superior
iliac spine lo lle adduclor lulercle or medial malleolus).
1le gluleus maximus, lle pirilormis, lle olluralor inler-
nus, lle gemelli, and lle quadralus lemoris rolale lle dislal
lragmenl lalerallv, as seen lv lle loes poinling lalerallv.
Ttochanletic Ftaclutes commonlv occur in lle voung
and middle-aged as a resull ol direcl lrauma. 1le lraclure
Bones and CartiIage 159
tvµe 8


tvµe 1
tvµe 2
tvµe 4
CD Figure 11-9  FracIures oI Ihe heck oI Ihe Iemur.
 DisplacemehI oI Ihe lower bohe IragmehI caused by Ihe
pull oI Ihe powerIul muscles. NoIe ih parIicular Ihe ouIward
roIaIioh oI Ihe leg so IhaI Ihe IooI characIerisIically poihIs
laIerally. GM gluIeus ma×imus, AM adducIor muscles,
GE gemelli, HS hamsIrihg muscles, OÌ obIuraIor
ihIerhus, PÌ piriIormis, OF quadraIus Iemoris,
PF recIus Iemoris.
quadriceps, and lalerallv rolaled lv lle adduclors and lle
weigll ol lle lool (see CD Iig. 11-1O).
In Ftaclutes oF lhe middIe lhitd oF lhe shaFl ol lle le-
mur, lle dislal lragmenl is pulled upward lv lle lamslrings
and lle quadriceps (see CD Iig. 11-1O), resulling in con-
sideralle slorlening. 1le dislal lragmenl is also rolaled
lackward lv lle pull ol lle lwo leads ol lle gaslrocnemius
(see CD Iig. 11-1O).
In Ftaclutes oF lhe dislaI lhitd oF lhe shaFl ol lle lemur,
lle same displacemenl ol lle dislal lragmenl occurs as seen
in lraclures ol lle middle llird ol lle slall. However, lle
dislal lragmenl is smaller and is rolaled lackward lv lle
line is exlracapsular, and loll lragmenls lave a proluse
llood supplv. Il lle lone lragmenls are nol impacled, lle
pull ol lle slrong muscles will produce slorlening and
laleral rolalion ol lle leg, as previouslv explained.
Itaclutes oF lhe shaFl oF lhe Femut usuallv occur in
voung and lealllv persons. In Ftaclutes oF lhe uppet lhitd
oF lhe shaFl ol lle lemur, lle proximal lragmenl is llexed lv
lle iliopsoas, alducled lv lle gluleus medius and minimus,
and lalerallv rolaled lv lle gluleus maximus, lle pirilormis,
lle olluralor inlernus, lle gemelli, and lle quadralus
lemoris (CD Iig. 11-1O). 1le lower lragmenl is adducled lv
lle adduclor muscles, pulled upward lv lle lamslrings and
160 Chapter 11

 


CD Figure 11-10 FracIures oI Ihe shaII
oI Ihe Iemur.  Upper Ihird oI Ihe
Iemoral shaII. NoIe Ihe displacemehI
caused by Ihe pull oI Ihe powerIul
muscles.  Middle Ihird oI Ihe Iemoral
shaII. NoIe Ihe posIerior displacemehI oI
Ihe lower IragmehI caused by Ihe
gasIrochemius muscle.  Lower Ihird oI
Ihe Iemoral shaII. NoIe Ihe e×cessive
displacemehI oI Ihe lower IragmehI
caused by Ihe pull oI Ihe gasIrochemius
muscle, IhreaIehihg Ihe ihIegriIy oI Ihe
popliIeal arIery. AM adducIor muscles,
GAST gasIrochemius, GE gemelli,
GM gluIeus ma×imus, GME gluIeus
medius, GMÌ gluIeus mihimus,
HAM hamsIrihgs, ÌP iliopsoas,
OÌ obIuraIor ihIerhus, PÌ piriIormis,
ODF quadriceps Iemoris,
OF quadraIus Iemoris.
gaslrocnemius muscle (see CD Iig. 11-1O) lo a grealer
degree and mav exerl pressure on lle poplileal arlerv and
inlerlere will lle llood llow llrougl lle leg and lool.
Irom llese accounls il is clear llal knowledge ol lle
dillerenl aclions ol lle muscles ol lle leg is necessarv lo un-
dersland lle displacemenl ol lle lragmenls ol a lraclured
lemur. Consideralle lraclion on lle dislal lragmenl is usu-
allv required lo overcome lle powerlul muscles and reslore
lle liml lo ils correcl lengll lelore manipulalion and oper-
alive llerapv lo lring lle proximal and dislal lragmenls inlo
correcl alignmenl.
PaIellar DislocaIiohs
1le palella is a sesamoid lone lving willin lle quadriceps
lendon. 1le imporlance ol lle lower lorizonlal lilers ol lle
vaslus medialis and lle large size ol lle laleral condvle ol
lle lemur in prevenling laleral displacemenl ol lle palella
lave leen emplasized. Congenilal recurrenl dislocalions
ol lle palella are caused lv underdevelopmenl ol lle laleral
lemoral condvle. 1raumalic dislocalion ol lle palella resulls
lrom direcl lrauma lo lle quadriceps allaclmenls ol
lle palella (especiallv lle vaslus medialis), will or willoul
lraclure ol lle palella.
PaIellar FracIures
A palella lraclured as a resull ol direcl violence, as in an au-
lomolile accidenl, is lroken inlo several small lragmenls.
Because lle lone lies willin lle quadriceps lemoris lendon,
lillle separalion ol lle lragmenls lakes place. 1le close rela-
lionslip ol lle palella lo lle overlving skin mav resull in lle
lraclure leing open. Iraclure ol lle palella as a resull ol in-
direcl violence is caused lv lle sudden conlraclion ol lle
quadriceps snapping lle palella across lle lronl ol lle
lemoral condvles. 1le knee is in lle semillexed posilion, and
lle lraclure line is lransverse. Separalion ol lle lragmenls
usuallv occurs.
Bones of the Leg
FracIures oI Ihe Tibia ahd Fibula
Iraclures ol lle lilia and lilula are common. Il onlv one
lone is lraclured, lle oller acls as a splinl and displacemenl
is minimal. Iraclures ol lle slall ol lle lilia are ollen open
lecause lle enlire lengll ol lle medial surlace is covered
onlv lv skin and superlicial lascia. Iraclures ol lle dislal
llird ol lle slall ol lle lilia are prone lo delaved union or
nonunion. 1lis can le lecause lle nulrienl arlerv is lorn al
lle lraclure line, will a consequenl reduclion in llood llow
lo lle dislal lragmenl, il is also possille llal lle splinl-like
aclion ol lle inlacl lilula prevenls lle proximal and dislal
lragmenls lrom coming inlo apposilion.
Iraclures ol lle ptoximaI end oF lhe libia, al lle lil-
ial condvles (lilial plaleau), are common in lle middle-
aged and elderlv, llev usuallv resull lrom direcl violence lo
lle laleral side ol lle knee joinl, as wlen a person is lil lv
lle lumper ol an aulomolile. 1le lilial condvle mav
slow a splil lraclure or le lroken up, or lle lraclure line
mav pass lelween loll condvles in lle region ol lle inler-
condvlar eminence. As a resull ol lorced alduclion ol lle
knee joinl, lle medial collaleral ligamenl can also le lorn
or ruplured.
Iraclures ol lle dislaI end oF lhe libia are considered
will lle ankle joinl.
ÌhIraosseous ÌhIusioh oI Ihe Tibia
ih Ihe ÌhIahI
1le leclnique mav le used lor lle inlusion ol lluids and
llood wlen il las leen lound impossille lo ollain an inlra-
venous line. 1le procedure is easv and rapid lo perlorm, as
1. Will lle dislal leg adequalelv supporled, lle anlerior
sulculaneous surlace ol lle lilia is palpaled.
2. 1le skin is anesllelized aloul 1 in. (2.¯ cm) dislal lo
lle lilial lulerosilv, llus llocking lle inlrapalellar
lrancl ol lle saplenous nerve.
². 1le lone marrow needle is direcled al rigll angles
llrougl lle skin, superlicial lascia, deep lascia, and lil-
ial periosleum and lle corlex ol lle lilia. Once lle nee-
dle lip reacles lle medulla and lone marrow, lle
operalor senses a leeling ol ¨give.` 1le posilion ol lle
needle in lle marrow can le conlirmed lv aspiralion.
1le needle slould le direcled sliglllv caudad lo avoid
injurv lo lle epiplvseal plale ol lle proximal end ol lle
lilia. 1le lranslusion mav llen commence.
Bones of the Foot
FracIures oI Ihe Calcaheum
Compression lraclures ol lle calcaneum resull lrom lalls
lrom a leigll. 1le weigll ol lle lodv drives lle lalus down-
ward inlo lle calcaneum, crusling il in sucl a wav llal il
loses verlical leigll and lecomes wider lalerallv. 1le pos-
lerior porlion ol lle calcaneum alove lle inserlion ol lle
lendo calcaneus can le lraclured lv poslerior displacemenl
ol lle lalus. 1le suslenlaculum lali can le lraclured lv
lorced inversion ol lle lool.
FracIures oI Ihe Talus
Iraclures occur al lle neck or lodv ol lle lalus. Neck lrac-
lures occur during violenl dorsillexion ol lle ankle joinl
wlen lle neck is driven againsl lle anlerior edge ol lle dis-
lal end ol lle lilia. 1le lodv ol lle lalus can le lraclured lv
jumping lrom a leigll, alllougl lle lwo malleoli prevenl
displacemenl ol lle lragmenls.
Bones and CartiIage 161
Slress lraclure ol a melalarsal lone is common in jog-
gers and in soldiers aller long marcles, il can also occur in
nurses and likers. Il occurs mosl lrequenllv in lle dislal
llird ol lle second, llird, or lourll melalarsal lone. Mini-
mal displacemenl occurs lecause ol lle allaclmenl ol lle
inlerosseous muscles.
FracIures oI Ihe MeIaIarsal Bohes
1le lase ol lle lilll melalarsal can le lraclured during
lorced inversion ol lle lool, al wlicl lime lle lendon ol in-
serlion ol lle peroneus lrevis muscle pulls oll lle lase ol
lle melalarsal.
162 Chapter 11
Read the foIIowing case histories/questions and give
the best answer for each.
A 19-vear-old lov was suspecled ol laving leukemia. Il
was decided lo conlirm lle diagnosis lv perlorming a
lone marrow liopsv.
1. 1le lollowing slalemenls concerning llis procedure
are correcl excepl wlicl¯
A. 1le liopsv was laken lrom lle lower end ol lle
B. Red lone marrow specimens can le ollained lrom
lle slernum or lle iliac cresls.
C. Al lirll, lle marrow ol all lones ol lle lodv is red
and lemalopoielic.
D. 1le llood-lorming aclivilv ol lone marrow in manv
long lones graduallv lessens will age, and lle red
marrow is graduallv replaced lv vellow marrow.
A 1¯-vear-old man will exlensive maxillolacial injuries
aller an aulomolile accidenl was lrougll lo lle emer-
gencv deparlmenl. Ivalualion ol lle airwav revealed
parlial olslruclion. Despile an olvious lraclured
mandille, an allempl was made lo move lle longue lor-
ward lrom lle poslerior plarvngeal wall lv pusling lle
angles ol lle mandille lorward. 1lis maneuver lailed lo
move lle longue, and il lecame necessarv lo lold lle
longue lorward direcllv lo pull il awav lrom lle poslerior
plarvngeal wall.
2. 1le mosl IikeIy reason lle plvsician was unalle lo pull
lle longue lorward in llis palienl is wlicl¯
A. 1le lvpoglossal nerves were damaged on loll sides
ol lle neck.
B. Spasm ol lle slvloglossus muscles
C. 1le mandilular origin ol lle genioglossus muscles
was lloaling lecause ol lilaleral lraclures ol lle lodv
ol lle mandille.
D. 1le presence ol a llood clol in lle moull
I. 1le resislance ol lle palienl
A 16-vear-old man was seen in lle emergencv deparl-
menl aller leing knocked down in a slreel lrawl. He
lad received a llow on lle lead will an emplv lollle.
On examinalion, lle palienl was conscious and lad a
large dougl-like swelling over lle lack ol lle lead
llal was reslricled lo lle area over lle occipilal lone.
1le skin was inlacl, and lle swelling lluclualed on
². 1le lollowing slalemenls concerning llis palienl are
correcl excepl wlicl¯
A. 1le lemaloma, alllougl large, did nol exlend lor-
ward lo lle orlilal margins and did nol exlend laler-
allv as lar as lle lemporal lines.
B. 1le lemaloma was localed jusl leneall lle scalp
and was superlicial lo lle periosleum ol lle occipi-
lal lone.
C. 1le swelling did nol occupv lle sulculaneous lis-
sue ol lle scalp.
D. 1le lemaloma was reslricled lo one skull lone and
was silualed leneall lle periosleum.
A 1¯-vear-old woman visiled ler plvsician lecause ol a
low lack pain ol ² monlls` duralion. Sle was ollerwise
verv lil. On examinalion ol ler lack, nolling alnormal
was discovered. 1le plvsician llen lislened lo ler
clesl, examined ler llvroid gland, and linallv exam-
ined loll lreasls. A large, lard mass was lound in lle
lell lreasl.
1. 1le lollowing lacls supporled lle diagnosis ol carci-
noma ol lle lell lreasl will secondaries in lle verlelral
column excepl wlicl¯
A. 1le lump in lle lreasl was painless and lle pa-
lienl lad noliced il wlile slowering 6 monlls
B. Several large, lard, pecloral lvmpl nodes were
lound in lle lell axilla.
C. A laleral radiograpl ol lle lumlar verlelral column
slowed exlensive melaslases in lle lodies ol lle
second and llird lumlar verlelrae.
D. 1le lump was silualed in lle upper ouler quadranl
ol lle lell lreasl and was lixed lo surrounding
I. Alllougl lle cancer lad spread lv lle lvmpl ves-
sels, no evidence ol spread via lle lloodslream was
A 6¯-vear-old man and a 1O-vear-old lov were involved
in a severe aulomolile accidenl. In loll palienls lle
llorax lad leen ladlv crusled. Radiograplic examina-
lion revealed llal lle man lad live lraclured rils lul
lle lov lad no lraclures.
¯. Wlal is lle mosl IikeIy explanalion lor llis dillerence
in medical lindings¯
A. 1le palienls were in dillerenl seals in lle velicle.
B. 1le lov was wearing lis seal lell and lle man was
C. 1le clesl wall ol a clild is verv elaslic, and lraclures
ol rils in clildren are rare.
D. 1le man anlicipaled lle impacl and lensed lis
muscles, including llose ol lle sloulder girdle and
An 18-vear-old woman was llrown lrom a lorse wlile
allempling lo jump a lence. Sle landed leavilv on
lle ground, slriking lle lower parl ol ler clesl on
lle lell side. On examinalion in lle emergencv de-
parlmenl sle was conscious lul lreallless. 1le lower
lell side ol ler clesl was ladlv lruised, and lle ninll
and lenll rils were exlremelv lender lo loucl. Sle
lad severe laclvcardia, and ler svslolic llood pressure
was low.
6. 1le lollowing slalemenls are possillv correcl excepl
A. 1lere was evidence ol lenderness and muscle spasm
in lle lell upper quadranl ol lle anlerior aldominal
B. A posleroanlerior radiograpl ol lle clesl revealed
lraclures ol lle lell ninll and lenll rils near lleir
C. 1le llunl lrauma lo lle rils could nol resull in
injurv lo lle underlving spleen.
D. 1le presence ol llood in lle periloneal cavilv lad
irrilaled lle parielal periloneum, producing rellex
spasm ol lle upper aldominal muscles.
I. 1le muscles ol lle anlerior aldominal wall are
supplied lv lloracic spinal nerves.
A 1¯-vear-old girl, wlile demonslraling lo ler lriends
ler proliciencv al slanding on ler lands, suddenlv
wenl oll lalance and pul all ler lodv weigll on ler lell
oulslrelcled land. A dislinclive cracking noise was
leard, and sle lell a sudden pain in ler lell sloulder re-
gion. On examinalion in lle emergencv deparlmenl,
lle smooll conlour ol ler lell sloulder was alsenl. 1le
clavicle was olviouslv lraclured, and lle edges ol lle
lonv lragmenls could le palpaled.
¯. 1le lollowing slalemenls concerning llis case are
correcl excepl wlicl¯
A. 1le clavicle is one ol lle mosl common lones in
lle lodv lo le lraclured.
B. Analomicallv, lle weakesl parl ol lle clavicle is lle
junclion ol lle medial and middle llirds, and llis is
wlere lle lraclure commonlv occurs.
C. 1le laleral lonv lragmenl is depressed downward lv
lle weigll ol lle arm.
D. 1le laleral lragmenl is pulled lorward and mediallv
lv lle pecloral muscles.
I. 1le medial lragmenl is elevaled lv lle slernoclei-
domasloid muscle.
I. 1le supraclavicular nerves or a communicaling
vein lelween lle ceplalic and inlernal jugular vein
mav le damaged lv lle lone lragmenls.
A 22-vear-old medical sludenl lell oll ler licvcle onlo
ler oulslrelcled land. Sle llougll sle lad sprained
ler rigll wrisl joinl and lrealed lersell lv linding ler
wrisl will an elaslic landage. 1lree weeks laler, low-
ever, sle was slill experiencing pain on moving ler
wrisl and so decided lo visil lle emergencv deparlmenl.
On examinalion ol lle dorsal surlaces ol loll lands,
will lle lingers and llumls lullv exlended, a localized
lenderness could le lell in lle analomic snulllox ol ler
rigll land. A diagnosis ol lraclure ol lle rigll scaploid
lone was made.
8. 1le lollowing slalemenls concerning llis palienl are
correcl excepl wlicl¯
A. 1le lraclure line on lle scaploid lone mav deprive
lle proximal lragmenl ol ils arlerial supplv.
B. A lonv lragmenl deprived ol ils llood supplv mav
undergo isclemic necrosis.
C. Because lle scaploid lone arliculales will oller
lones, lle lraclure line mav enler a joinl cavilv and
lecome lalled in svnovial lluid, wlicl would in-
lilil repair.
D. 1le scaploid lone is an easv lone lo immolilize
lecause ol ils small size.
I. Iraclures ol lle scaploid lone lave a ligl incidence
ol nonunion.
A leavilv luill, middle-aged man running down a lligll
ol slone sleps misjudged lle posilion ol one ol lle sleps
and lell suddenlv onlo lis lullocks. Iollowing lle lall,
le complained ol severe lruising ol lle area ol lle clell
lelween lle lullocks and persislenl pain in llis area.
9. 1le lollowing slalemenls concerning llis palienl are
correcl excepl wlicl¯
A. 1le lower end ol lle verlelral column was lrauma-
lized lv lle slone slep.
B. 1le coccvx can le palpaled leneall lle skin in lle
nalal clell.
Bones and CartiIage 163
1². Iraclure ol lle neck ol lle lemur in lle adull com-
monlv resulls in avascular necrosis ol parl ol lle
lemoral lead. Can vou explain llis on analomic
grounds¯ 1roclanleric lraclures are never accompa-
nied lv avascular necrosis. Wlv¯
A ²¯-vear-old woman was involved in a ligll plane
accidenl. Sle and ler lusland were llving lome lrom
a lusiness lrip wlen llev lad lo make a lorced land-
ing in a lield due lo log. On landing, lle plane lil
a lree and came lo resl on ils nose. Her lusland
was killed on impacl and sle was llrown lrom lle
cockpil. Sle was evalualed in lle emergencv deparl-
menl will mulliple injuries. Radiograplic examina-
lion ol ler pelvis slowed a lraclure ol ler lell ilium
and iliac cresl.
11. Irom vour knowledge ol analomv, would vou expecl
mucl displacemenl ol lle lonv lragmenls¯
A 2¯-vear-old man was running across a lield wlen
le caugll lis rigll lool in a rallil lole. As le lell,
lle rigll lool was violenllv rolaled lalerallv and
overeverled. On allempling lo sland, le could place
no weigll on lis rigll lool. On examinalion lv a
plvsician, lle rigll ankle was considerallv swollen,
especiallv on lle laleral side. Aller lurller exami-
nalion, including a radiograpl ol lle ankle, a diag-
nosis ol severe lraclure dislocalion ol lle ankle joinl
was made.
1¯. 1le lollowing slalemenls concerning llis palienl are
correcl excepl wlicl¯
A. 1lis lvpe ol lraclure dislocalion is caused lv lorced
exlernal rolalion and overeversion ol lle lool.
B. 1le lalus is exlernallv rolaled againsl lle laleral
malleolus ol lle lilula, causing il lo lraclure.
C. 1le lorsion ellecl on lle laleral malleolus produces
a spiral lraclure.
D. 1le medial ligamenl ol lle ankle joinl is slrong and
never ruplures.
I. Il lle lalus is lorced lo move larller lalerallv and
conlinues lo rolale, lle poslerior inlerior margin ol
lle lilia will le sleared oll.
16. A ²2-vear-old woman was rock climling wlen sle de-
cided lo jump lrom a ledge down lo a llal rock some live
leel lelow. On landing sle mainlained ler lalance lul
experienced a severe pain in ler rigll lool in lle region
ol lle leel. On examinalion laler in lle emergencv de-
parlmenl ol lle local lospilal, lle plvsician`s assislanl
noled lle exlreme lenderness lell over lle sides and in-
lerior surlace ol lle rigll calcaneum. Sle also noled
llal lle rigll calcaneum appeared wider llan lle one
on lle lell. Using vour knowledge ol analomv, make lle
C. 1le anlerior surlace ol lle coccvx cannol le lell
D. 1le coccvx is usuallv severelv lruised or lraclured.
I. 1le pain is lell in lle dislrilulion ol dermalomes S1
and S¯.
An elderlv woman was run over lv an aulomolile as sle
was crossing lle road. Radiograplic examinalion ol lle
pelvis in lle emergencv deparlmenl ol lle local lospi-
lal revealed a lraclure ol lle ilium and iliac cresl on lle
lell side.
1O. 1le lollowing slalemenls aloul lraclures ol lle pelvis
are correcl excepl wlicl¯
A. Iraclures ol lle ilium lave lillle displacemenl.
B. Displacemenl is prevenled lv lle presence ol lle il-
iacus and lle gluleal muscles on lle inner and ouler
surlaces ol llis lone, respeclivelv.
C. Il lwo lraclures occur in lle ring lorming lle lrue
pelvis, lle lraclure will le unslalle and displace-
menl will occur.
D. Iraclures ol lle lrue pelvis do nol cause injurv lo lle
pelvic viscera.
I. 1le poslverlelral and aldominal muscles are re-
sponsille lor elevaling lle laleral parl ol lle pelvis
slould lwo lraclures occur.
I. A leavv lall on lle grealer lroclanler ol lle lemur
mav drive lle lead ol lle lemur llrougl lle lloor ol
lle acelalulum and inlo lle pelvic cavilv.
A pregnanl woman visiled an anlenalal clinic. A vaginal
examinalion revealed llal lle sacral promonlorv could
le easilv palpaled and llal lle diagonal conjugale
measured less llan 1 in. (1O cm).
11. 1le lollowing slalemenls concerning llis examinalion
are correcl excepl wlicl¯
A. Normallv il is dillicull or impossille lo leel lle
sacral promonlorv lv means ol a vaginal examina-
B. 1le normal diagonal conjugale measures aloul 1O
in. (2¯ cm).
C. 1lis palienl`s pelvis was llallened anleroposleriorlv,
and lle sacral promonlorv projecled loo lar lorward.
D. Il is likelv llal llis palienl would lave an olslrucled
I. 1lis palienl was advised lo lave a cesarean seclion.
On a rouline anleroposlerior radiograplic examinalion
ol a palienl`s rigll lip joinl, lle long axis ol lle neck ol
lle lemur was lound lo le al an angle ol 16O° will lle
long axis ol lle lemoral slall.
12. Is llis angle normal in a ¯-vear-old clild¯ In a ²¯-vear-
old man¯ Wlal is lle clinical condilion called in wlicl
lle angle is smaller llan normal¯ Wlicl movemenl ol
lle lip joinl is limiled lv llis condilion¯
164 Chapter 11
1. A is lle correcl answer. In a 19-vear-old lov, lle lone
marrow al lle lower end ol lle lilia is vellow.
2. C is lle correcl answer. 1le genioglossus muscle arises
lrom lle superior menlal spines lelind lle svmplvsis
menli ol lle mandille (see lexl Iig. 11-1O).
². B is lle correcl answer. 1le lemaloma was localed
deep lo lle periosleum ol lle occipilal lone.
1. I is lle correcl answer. 1le carcinoma ol lle lell lreasl
was in an advanced slage and lad spread lv wav ol lle
lvmpl vessels lo lle axillarv lvmpl nodes and lv lle
lloodslream lo lle lodies ol lle second and llird lum-
lar verlelrae. Carcinoma ol lle llvroid, lronclus,
lreasl, kidnev, and proslale lend lo melaslasize via lle
lloodslream lo lones.
¯. C is lle correcl answer. 1le clesl wall ol a clild is verv
elaslic, and lraclures ol rils in clildren are rare.
6. C is lle correcl answer. 1rauma lo lle lower parl ol lle
woman`s lell clesl could easilv severelv damage lle
spleen in lle aldomen, resulling in lemorrlage inlo
lle periloneal cavilv.
¯. B is lle correcl answer. Analomicallv, lle weakesl parl ol
lle clavicle is lle junclion ol lle middle and laleral llirds,
and llal is wlere lle lraclure occurred in llis palienl.
8. D is lle correcl answer. 1le scaploid lone is a dillicull
lone lo immolilize lecause ol ils posilion and small
9. C is lle correcl answer. 1le anlerior surlace ol lle coc-
cvx can le palpaled will a gloved linger placed in lle
anal canal.
1O. D is lle correcl answer. Iraclures ol lle lrue pelvis are
commonlv associaled will injuries lo lle soll pelvic vis-
cera, especiallv lle lladder and lle urellra.
11. B is lle correcl answer. 1le normal diagonal conjugale
measures aloul ¯ in. (11.¯ cm) (see CD Iig. 11-6).
12. 1lis angle is willin normal limils in a ¯-vear-old clild.
Il is loo greal in a ²¯-vear-old man, lle condilion is
called coxa valga, in wlicl adduclion ol lle lip joinl is
limiled. Wlen lle angle ol lle lemoral neck is smaller
llan normal (coxa vara), alduclion ol lle lip joinl is
1². Iraclures ol lle neck ol lle lemur in lle adull com-
monlv resull in avascular necrosis ol parl ol lle lemoral
lead. 1le lemoral lead receives ils llood supplv lrom
lwo sources-a small arlerv, a lrancl ol lle olluralor
arlerv, llal runs will lle round ligamenl ol lle lemoral
lead and a proluse llood supplv lrom lle medial
lemoral circumllex lemoral arlerv, lrancles llal as-
cend lle lemoral neck leneall lle svnovial memlrane.
Iraclure ol lle lemoral neck mav deprive lle lemoral
lead ol parl or all ol lle llood lrom lle medial lemoral
circumllex lemoral arlerv, and avascular necrosis will
occur. In lroclanleric lraclures, loll lragmenls lave a
proluse llood supplv.
11. Mosl lraclures ol lle upper parl ol lle ilium lave lillle
displacemenl ol lle lone lragmenls. 1lis is lecause
lle iliacus muscle is allacled lo lle inner surlace and
lle gluleal muscles are allacled lo lle ouler surlace
(see lexl Iig. 11-¯1). Splinling lle lones is unnecessarv
lecause ol lle allaclmenl ol llese muscles.
1¯. D is lle correcl answer. Alllougl lle medial ligamenl
ol lle ankle joinl is slrong, exlreme lorce can resull in
ruplure ol lle ligamenl, or lle ligamenl can le lorn
lrom lle medial malleolus, or lle pull on lle ligamenl
can lraclure lle medial malleolus.
16. 1lis woman lad sullered a compression lraclure
ol lle rigll calcaneum as a resull ol lle lall lrom a
leigll. 1le weigll ol lle lodv drives lle lalus down-
ward inlo lle calcaneum, crusling il in sucl a wav llal
il loses verlical leigll and lecomes wider lalerallv. 1le
diagnosis was conlirmed on an anleroposlerior and a
laleral radiograpl ol lle rigll ankle.
Bones and CartiIage 165

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