Principles of fractures

23
Selvadurai Nayagam

Fractures result from: (1) injury; (2) repetitive stress;

INTRODUCTION
A fracture is a break in the structural continuity of
bone. It may be no more than a crack, a crumpling or
a splintering of the cortex; more often the break is
complete and the bone fragments are displaced. If the
overlying skin remains intact it is a closed (or simple)
fracture; if the skin or one of the body cavities is
breached it is an open (or compound) fracture, liable to
contamination and infection.
HOW FRACTURES HAPPEN
Bone is relatively brittle, yet it has sufficient strength
and resilience to withstand considerable stress.
or (3) abnormal weakening of the bone (a ‘patholog-
ical’ fracture).
FRACTURES DUE TO INJURY
Most fractures are caused by sudden and excessive
force, which may be direct or indirect.
With a direct force the bone breaks at the point of
impact; the soft tissues also are damaged. A direct
blow usually splits the bone transversely or may bend
it over a fulcrum so as to create a break with a ‘but-
terfly’ fragment. Damage to the overlying skin is com-
mon; if crushing occurs, the fracture pattern will be
comminuted with extensive soft-tissue damage.
With an indirect force the bone breaks at a distance
from where the force is applied; soft-tissue damage at

(a) (b) (c) (d)

23.1 Mechanism of injury Some fracture patterns suggest the causal mechanism: (a) spiral pattern (twisting); (b) short
oblique pattern (compression); (c) triangular ‘butterfly’ fragment (bending) and (d) transverse pattern (tension). Spiral and
some (long) oblique patterns are usually due to low-energy indirect injuries; bending and transverse patterns are caused by
high-energy direct trauma.
23 the fracture site is not inevitable. Although most
fractures are due to a combination of forces (twisting,
bending, compressing or tension), the x-ray pattern
reveals the dominant mechanism:
• Twisting causes a spiral fracture;
FRACTURES AND JOINT INJURIES
• Compression causes a short oblique fracture.
• Bending results in fracture with a triangular ‘but-
terfly’ fragment;
• Tension tends to break the bone transversely; in
some situations it may simply avulse a small frag-
ment of bone at the points of ligament or tendon
insertion.
NOTE: The above description applies mainly to the
long bones. A cancellous bone, such as a vertebra or
the calcaneum, when subjected to sufficient force, will
split or be crushed into an abnormal shape.
FATIGUE OR STRESS FRACTURES
These fractures occur in normal bone which is subject
to repeated heavy loading, typically in athletes,
dancers or military personnel who have gruelling
exercise programmes. These high loads create minute
deformations that initiate the normal process of
remodelling – a combination of bone resorption and
new bone formation in accordance with Wolff’s law.
When exposure to stress and deformation is repeated
and prolonged, resorption occurs faster than replace-
ment and leaves the area liable to fracture. A similar
problem occurs in individuals who are on medication
that alters the normal balance of bone resorption and
replacement; stress fractures are increasingly seen in
patients with chronic inflammatory diseases who are
on treatment with steroids or methotrexate.
(a) (b) (c)
23.2 Varieties of fracture Complete fractures: (a) transverse; (b) segmental and (c) spiral. Incomplete fractures:
688 (d) buckle or torus and (e,f) greenstick.
PATHOLOGICAL FRACTURES
Fractures may occur even with normal stresses if the
bone has been weakened by a change in its structure
(e.g. in osteoporosis, osteogenesis imperfecta or
Paget’s disease) or through a lytic lesion (e.g. a bone
cyst or a metastasis).
TYPES OF FRACTURE
Fractures are variable in appearance but for practical
reasons they are divided into a few well-defined
groups.
COMPLETE FRACTURES
The bone is split into two or more fragments. The
fracture pattern on x-ray can help predict behaviour
after reduction: in a transverse fracture the fragments
usually remain in place after reduction; if it is oblique
or spiral, they tend to shorten and re-displace even if
the bone is splinted. In an impacted fracture the frag-
ments are jammed tightly together and the fracture
line is indistinct. A comminuted fracture is one in
which there are more than two fragments; because
there is poor interlocking of the fracture surfaces,
these are often unstable.
INCOMPLETE FRACTURES
Here the bone is incompletely divided and the perios-
teum remains in continuity. In a greenstick fracture
the bone is buckled or bent (like snapping a green
(d) (e) (f)
twig); this is seen in children, whose bones are more
springy than those of adults. Children can also sustain
injuries where the bone is plastically deformed (mis-
shapen) without there being any crack visible on the
x-ray. In contrast, compression fractures occur when
cancellous bone is crumpled. This happens in adults
and typically where this type of bone structure is pres-
ent, e.g. in the vertebral bodies, calcaneum and tibial
plateau.
CLASSIFICATION OF FRACTURES
Sorting fractures into those with similar features
brings advantages: it allows any information about a
fracture to be applied to others in the group (whether
this concerns treatment or prognosis) and it facilitates
a common dialogue between surgeons and others
involved in the care of such injuries.
Traditional classifications, which often bear the
originator’s name, are hampered by being applicable
to that type of injury only; even then the term is often
inaccurately applied, famously in the case of Pott’s
fracture, which is often applied to any fracture around
the ankle though that is not what Sir Percival Pott
implied when he described the injury in 1765.
A universal, anatomically based system facilitates
communication and the sharing of data from a variety
of countries and populations, thus contributing to
advances in research and treatment. An alphanumeric
classification developed by Müller and colleagues has
now been adapted and revised (Muller et al., 1990;
(b) (c) (d)
(a) (e) (f) (g)
23.3 Müller’s classification (a) Each long bone has three
segments – proximal, diaphyseal and distal; the proximal
and distal segments are each defined by a square based on
the widest part of the bone. (b,c,d) Diaphyseal fractures
may be simple, wedge or complex.
(e,f,g) Proximal and distal fractures may be extra-articular,
partial articular of complete articular.
Marsh et al., 2007; Slongo and Audige 2007). Whilst 23
it has yet to be fully validated for reliability and repro-
ducibility, it fulfils the objective of being comprehen-
sive. In this system, the first digit specifies the bone
(1 = humerus, 2 = radius/ulna, 3 = femur,
4 = tibia/fibula) and the second the segment
Principles of fractures
(1 = proximal, 2 = diaphyseal, 3 = distal, 4 = malleo-
lar). A letter specifies the fracture pattern (for the dia-
physis: A = simple, B = wedge, C = complex; for the
metaphysis: A = extra-articular, B = partial articular,
C = complete articular). Two further numbers specify
the detailed morphology of the fracture (Fig. 23.3).
HOW FRACTURES ARE DISPLACED
After a complete fracture the fragments usually become
displaced, partly by the force of the injury, partly by
gravity and partly by the pull of muscles attached to
them. Displacement is usually described in terms of
translation, alignment, rotation and altered length:
• Translation (shift) – The fragments may be shifted
sideways, backward or forward in relation to each
other, such that the fracture surfaces lose contact.
The fracture will usually unite as long as sufficient
contact between surfaces is achieved; this may occur
even if reduction is imperfect, or indeed even if the
fracture ends are off-ended but the bone segments
come to lie side by side.
• Angulation (tilt) – The fragments may be tilted or
angulated in relation to each other. Malalignment,
if uncorrected, may lead to deformity of the limb.
• Rotation (twist) – One of the fragments may be
twisted on its longitudinal axis; the bone looks
straight but the limb ends up with a rotational
deformity.
• Length – The fragments may be distracted and sep-
arated, or they may overlap, due to muscle spasm,
causing shortening of the bone.
HOW FRACTURES HEAL
It is commonly supposed that, in order to unite, a
fracture must be immobilized. This cannot be so
since, with few exceptions, fractures unite whether
they are splinted or not; indeed, without a built-in
mechanism for bone union, land animals could
scarcely have evolved. It is, however, naive to suppose
that union would occur if a fracture were kept moving
indefinitely; the bone ends must, at some stage, be
brought to rest relative to one another. But it is not
mandatory for the surgeon to impose this immobility
artificially – nature can do it with callus, and callus
forms in response to movement, not to splintage. 689
23 Most fractures are splinted, not to ensure union but
to: (1) alleviate pain; (2) ensure that union takes place
in good position and (3) permit early movement of
the limb and a return of function.
The process of fracture repair varies according to
the type of bone involved and the amount of move-
FRACTURES AND JOINT INJURIES
ment at the fracture site.
HEALING BY CALLUS
This is the ‘natural’ form of healing in tubular bones;
in the absence of rigid fixation, it proceeds in five
stages:
1. Tissue destruction and haematoma formation –
Vessels are torn and a haematoma forms around
and within the fracture. Bone at the fracture
surfaces, deprived of a blood supply, dies back for
a millimetre or two.
2. Inflammation and cellular proliferation – Within 8
hours of the fracture there is an acute
inflammatory reaction with migration of
inflammatory cells and the initiation of
proliferation and differentiation of mesenchymal
stem cells from the periosteum, the breached
medullary canal and the surrounding muscle. The
fragment ends are surrounded by cellular tissue,
which creates a scaffold across the fracture site. A
vast array of inflammatory mediators (cytokines
and various growth factors) is involved. The
clotted haematoma is slowly absorbed and fine
new capillaries grow into the area.
3. Callus formation – The differentiating stem cells
provide chrondrogenic and osteogenic cell
populations; given the right conditions – and this is
usually the local biological and biomechanical
environment – they will start forming bone and, in
some cases, also cartilage. The cell population now
also includes osteoclasts (probably derived from
the new blood vessels), which begin to mop up
dead bone. The thick cellular mass, with its islands
of immature bone and cartilage, forms the callus or
splint on the periosteal and endosteal surfaces. As
the immature fibre bone (or ‘woven’ bone)
becomes more densely mineralized, movement at
the fracture site decreases progressively and at
about 4 weeks after injury the fracture ‘unites’.
4. Consolidation – With continuing osteoclastic and
osteoblastic activity the woven bone is transformed
into lamellar bone. The system is now rigid
enough to allow osteoclasts to burrow through
the debris at the fracture line, and close behind
them. Osteoblasts fill in the remaining gaps
between the fragments with new bone. This is a
slow process and it may be several months before
690 the bone is strong enough to carry normal loads.
5. Remodelling – The fracture has been bridged by a
cuff of solid bone. Over a period of months, or
even years, this crude ‘weld’ is reshaped by a
continuous process of alternating bone resorption
and formation. Thicker lamellae are laid down
where the stresses are high, unwanted buttresses are
carved away and the medullary cavity is reformed.
Eventually, and especially in children, the bone
reassumes something like its normal shape.
HEALING BY DIRECT UNION
Clinical and experimental studies have shown that cal-
lus is the response to movement at the fracture site
(McKibbin, 1978). It serves to stabilize the fragments
as rapidly as possible – a necessary precondition for
bridging by bone. If the fracture site is absolutely
immobile – for example, an impacted fracture in can-
cellous bone, or a fracture rigidly immobilized by a
metal plate – there is no stimulus for callus (Sarmiento
et al., 1980). Instead, osteoblastic new bone forma-
tion occurs directly between the fragments. Gaps
between the fracture surfaces are invaded by new cap-
illaries and osteoprogenitor cells growing in from the
edges, and new bone is laid down on the exposed sur-
face (gap healing). Where the crevices are very narrow
(less than 200 μm), osteogenesis produces lamellar
bone; wider gaps are filled first by woven bone, which
is then remodelled to lamellar bone. By 3–4 weeks the
fracture is solid enough to allow penetration and
bridging of the area by bone remodelling units, i.e.
osteoclastic ‘cutting cones’ followed by osteoblasts.
Where the exposed fracture surfaces are in intimate
contact and held rigidly from the outset, internal
bridging may occasionally occur without any interme-
diate stages (contact healing).
Healing by callus, though less direct (the term
‘indirect’ could be used) has distinct advantages: it
ensures mechanical strength while the bone ends heal,
and with increasing stress the callus grows stronger
and stronger (an example of Wolff’s law). With rigid
metal fixation, on the other hand, the absence of cal-
lus means that there is a long period during which the
bone depends entirely upon the metal implant for its
integrity. Moreover, the implant diverts stress away
from the bone, which may become osteoporotic and
not recover fully until the metal is removed.
UNION, CONSOLIDATION AND
NON-UNION
Repair of a fracture is a continuous process: any stages
into which it is divided are necessarily arbitrary. In this
book the terms ‘union’ and ‘consolidation’ are used,
and they are defined as follows:
 23.4 Fracture healing Five stages of healing: (a) 23
Haematoma: there is tissue damage and bleeding
at the fracture site; the bone ends die back for a
few millimetres. (b) Inflammation: inflammatory
cells appear in the haematoma. (c) Callus: the cell
population changes to osteoblasts and osteoclasts;
dead bone is mopped up and woven bone appears

Principles of fractures
in the fracture callus. (d) Consolidation: woven
bone is replaced by lamellar bone and the fracture
is solidly united. (e) Remodelling: the newly formed
bone is remodelled to resemble the normal
(a) (b) (c) (d) (e)
structure.

(a) (b)

23.5 Fracture healing – histology Experimental fracture

healing: (a) by bridging callus and (b) by direct penetration
of the fracture gap by a cutting cone.
(a) (b) (c)
23.6 Callus and movement Three patients with femoral
shaft fractures. (a) and (b) are both 6 weeks after fixation:
in (a) the Kuntscher nail fitted tightly, preventing
movement, and there is no callus; in (b) the nail fitted
loosely, permitting some movement, so there is callus.
(c) This patient had cerebral irritation and thrashed around
wildly; at 3 weeks callus is excessive.

23.7 Fracture repair (a) Fracture;

(b) union; (c) consolidation; (d) bone
remodelling. The fracture must be
protected until consolidated.
(a) (b) (c) (d) 691
23
FRACTURES AND JOINT INJURIES
(a) (b) (c) (d)
• Union – Union is incomplete repair; the ensheath-
ing callus is calcified. Clinically the fracture site is
still a little tender and, though the bone moves in
one piece (and in that sense is united), attempted
angulation is painful. X-Rays show the fracture line
still clearly visible, with fluffy callus around it.
Repair is incomplete and it is not safe to subject the
unprotected bone to stress.
• Consolidation – Consolidation is complete repair;
the calcified callus is ossified. Clinically the fracture
site is not tender, no movement can be obtained
and attempted angulation is painless. X-rays show
the fracture line to be almost obliterated and
crossed by bone trabeculae, with well-defined callus
around it. Repair is complete and further protec-
tion is unnecessary.
• Timetable – How long does a fracture take to unite
and to consolidate? No precise answer is possible
because age, constitution, blood supply, type of frac-
ture and other factors all influence the time taken.
Approximate prediction is possible and Perkins’
timetable is delightfully simple. A spiral fracture in
the upper limb unites in 3 weeks; for consolidation
multiply by 2; for the lower limb multiply by 2
again; for transverse fractures multiply again by 2. A
more sophisticated formula is as follows. A spiral
fracture in the upper limb takes 6–8 weeks to con-
solidate; the lower limb needs twice as long. Add
25% if the fracture is not spiral or if it involves the
femur. Children’s fractures, of course, join more
quickly. These figures are only a rough guide; there
must be clinical and radiological evidence of con-
solidation before full stress is permitted without
splintage.
• Non-union – Sometimes the normal process of frac-
ture repair is thwarted and the bone fails to unite.
Causes of non-union are: (1) distraction and sepa-
ration of the fragments, sometimes the result of
interposition of soft tissues between the fragments;
(2) excessive movement at the fracture line; (3) a
severe injury that renders the local tissues non-
692 viable or nearly so; (4) a poor local blood supply
23.8 Non-unions Aseptic non-unions are generally
divided into hypertrophic and atrophic types.
Hypertrophic non-unions often have florid streams of
callus around the fracture gap – the result of insufficient
stability. They are sometimes given colourful names, such
as: (a) elephant’s foot. In contrast, atrophic non-unions
usually arise from an impaired repair process; they are
classified according to the x-ray appearance as (b)
necrotic, (c) gap and (d) atrophic.
and (5) infection. Of course surgical intervention, if
ill-judged, is another cause!
Non-unions are septic or aseptic. In the latter group,
they can be either stiff or mobile as judged by clinical
examination. The mobile ones can be as free and pain-
less as to give the impression of a false joint
(pseudoarthrosis). On x-ray, non-unions are typified by
a lucent line still present between the bone fragments;
sometimes there is exuberant callus trying – but fail-
ing – to bridge the gap (hypertrophic non-union) or at
times none at all (atrophic non-union) with a sorry,
withered appearance to the fracture ends.
CLINICAL FEATURES
HISTORY
There is usually a history of injury, followed by inabil-
ity to use the injured limb – but beware! The fracture
is not always at the site of the injury: a blow to the
knee may fracture the patella, femoral condyles, shaft
of the femur or even acetabulum. The patient’s age
and mechanism of injury are important. If a fracture
occurs with trivial trauma, suspect a pathological
lesion. Pain, bruising and swelling are common symp-
toms but they do not distinguish a fracture from a
soft-tissue injury. Deformity is much more suggestive.
Always enquire about symptoms of associated
injuries: pain and swelling elsewhere (it is a common
mistake to get distracted by the main injury, particu-
larly if it is severe), numbness or loss of movement,
skin pallor or cyanosis, blood in the urine, abdominal
pain, difficulty with breathing or transient loss of con-
sciousness.
Once the acute emergency has been dealt with, ask
about previous injuries, or any other musculoskeletal
abnormality that might cause confusion when the
x-ray is seen. Finally, a general medical history is im-
portant, in preparation for anaesthesia or operation.
GENERAL SIGNS
Unless it is obvious from the history that the patient has
sustained a localized and fairly modest injury, priority
must be given to dealing with the general effects of
trauma (see Chapter 22). Follow the ABCs: look for,
and if necessary attend to, Airway obstruction, Breath-
ing problems, Circulatory problems and Cervical spine
injury. During the secondary survey it will also be nec-
essary to exclude other previously unsuspected injuries
and to be alert to any possible predisposing cause (such
as Paget’s disease or a metastasis).
LOCAL SIGNS
Injured tissues must be handled gently. To elicit crepi-
tus or abnormal movement is unnecessarily painful; x-ray
diagnosis is more reliable. Nevertheless the familiar head-
ings of clinical examination should always be considered,
or damage to arteries, nerves and ligaments may be
overlooked. A systematic approach is always helpful:
• Examine the most obviously injured part.
• Test for artery and nerve damage.
• Look for associated injuries in the region.
• Look for associated injuries in distant parts.
Look
Swelling, bruising and deformity may be obvious, but
the important point is whether the skin is intact; if the
skin is broken and the wound communicates with the
fracture, the injury is ‘open’ (‘compound’). Note also
the posture of the distal extremity and the colour of
the skin (for tell-tale signs of nerve or vessel damage).
Feel
The injured part is gently palpated for localized ten-
derness. Some fractures would be missed if not specifi-
cally looked for, e.g. the classical sign (indeed the only
clinical sign!) of a fractured scaphoid is tenderness on
pressure precisely in the anatomical snuff-box. The
common and characteristic associated injuries should
also be felt for, even if the patient does not complain
of them. For example, an isolated fracture of the prox-
imal fibula should always alert to the likelihood of an
associated fracture or ligament injury of the ankle, and
in high-energy injuries always examine the spine and
pelvis. Vascular and peripheral nerve abnormalities
should be tested for both before and after treatment.
Move
Crepitus and abnormal movement may be present,
but why inflict pain when x-rays are available? It is
more important to ask if the patient can move the 23
joints distal to the injury.
X-RAY
Principles of fractures
X-ray examination is mandatory. Remember the rule
of twos:
• Two views – A fracture or a dislocation may not be
seen on a single x-ray film, and at least two views
(anteroposterior and lateral) must be taken.
• Two joints – In the forearm or leg, one bone may be
fractured and angulated. Angulation, however, is
impossible unless the other bone is also broken, or
a joint dislocated. The joints above and below the
fracture must both be included on the x-ray films.
• Two limbs – In children, the appearance of imma-
ture epiphyses may confuse the diagnosis of a frac-
ture; x-rays of the uninjured limb are needed for
comparison.
• Two injuries – Severe force often causes injuries at
more than one level. Thus, with fractures of the cal-
caneum or femur it is important to also x-ray the
pelvis and spine.
• Two occasions – Some fractures are notoriously diffi-
cult to detect soon after injury, but another x-ray
examination a week or two later may show the
lesion. Common examples are undisplaced fractures
of the distal end of the clavicle, scaphoid, femoral
neck and lateral malleolus, and also stress fractures
and physeal injuries wherever they occur.
SPECIAL IMAGING
Sometimes the fracture – or the full extent of the frac-
ture – is not apparent on the plain x-ray. Computed
tomography may be helpful in lesions of the spine or
for complex joint fractures; indeed, these cross-
sectional images are essential for accurate visualization
of fractures in ‘difficult’ sites such as the calcaneum or
acetabulum. Magnetic resonance imaging may be the
only way of showing whether a fractured vertebra is
threatening to compress the spinal cord. Radioisotope
scanning is helpful in diagnosing a suspected stress
fracture or other undisplaced fractures.
DESCRIPTION
Diagnosing a fracture is not enough; the surgeon
should picture it (and describe it) with its properties:
(1) Is it open or closed? (2) Which bone is broken,
and where? (3) Has it involved a joint surface? (4)
What is the shape of the break? (5) Is it stable or
unstable? (6) Is it a high-energy or a low-energy 693
23
FRACTURES AND JOINT INJURIES

(a) (b) (c) (d)

(e)

(g) (h)

(f)
23.9 X-ray examination must be ‘adequate’ (a,b) Two films of the same tibia: the fracture may be ‘invisible’ in one
view and perfectly plain in a view at right angles to that. (c,d) More than one occasion: A fractured scaphoid may not be
obvious on the day of injury, but clearly seen 2 weeks later. (e,f) Two joints: The first x-ray (e) did not include the elbow.
This was, in fact, a Monteggia fracture – the head of the radius is dislocated; (f) shows the dislocated radiohumeral joint.
(g,h) Two limbs: Sometimes the abnormality can be appreciated only by comparision with the normal side; in this case
there is a fracture of the lateral condyle on the left side (h).

injury? And last but not least (7) who is the person
with the injury? In short, the examiner must learn to
recognize what has been aptly described as the ‘per-
sonality’ of the fracture.
Shape of the fracture
A transverse fracture is slow to join because the area
of contact is small; if the broken surfaces are accu-
rately apposed, however, the fracture is stable on com-
pression. A spiral fracture joins more rapidly (because
the contact area is large) but is not stable on com-
pression. Comminuted fractures are often slow to join
because: (1) they are associated with more severe soft-
tissue damage and (2) they are likely to be unstable.
Displacement
For every fracture, three components must be
694 assessed:
1. Shift or translation – backwards, forwards,
sideways, or longitudinally with impaction or
overlap.
2. Tilt or angulation – sideways, backwards or
forwards.
3. Twist or rotation – in any direction.
A problem often arises in the description of angula-
tion. ‘Anterior angulation’ could mean that the apex
of the angle points anteriorly or that the distal frag-
ment is tilted anteriorly: in this text it is always the lat-
ter meaning that is intended (‘anterior tilt of the distal
fragment’ is probably clearer).
SECONDARY INJURIES
Certain fractures are apt to cause secondary injuries
and these should always be assumed to have occurred
until proved otherwise:
• Thoracic injuries – Fractured ribs or sternum may
be associated with injury to the lungs or heart. It is
essential to check cardiorespiratory function.
• Spinal cord injury – With any fracture of the spine,
neurological examination is essential to: (1) estab-
lish whether the spinal cord or nerve roots have
been damaged and (2) obtain a baseline for later
comparison if neurological signs should change.
• Pelvic and abdominal injuries – Fractures of the pelvis
may be associated with visceral injury. It is especially
important to enquire about urinary function; if a
urethral or bladder injury is suspected, diagnostic
urethrograms or cystograms may be necessary.
• Pectoral girdle injuries – Fractures and dislocations
around the pectoral girdle may damage the brachial
plexus or the large vessels at the base of the neck.
Neurological and vascular examination is essential.
TREATMENT OF CLOSED
FRACTURES
General treatment is the first consideration: treat the
patient, not only the fracture. The principles are dis-
cussed in Chapter 22.
Treatment of the fracture consists of manipulation
to improve the position of the fragments, followed by
splintage to hold them together until they unite;
meanwhile joint movement and function must be pre-
served. Fracture healing is promoted by physiological
loading of the bone, so muscle activity and early
weightbearing are encouraged. These objectives are
covered by three simple injunctions:
• Reduce.
• Hold.
• Exercise.
Two existential problems have to be overcome. The
first is how to hold a fracture adequately and yet per-
mit the patient to use the limb sufficiently; this is a
conflict (Hold versus Move) that the surgeon seeks to
resolve as rapidly as possible (e.g. by internal fixation).
However the surgeon also wants to avoid unnecessary
risks – here is a second conflict (Speed versus Safety).
This dual conflict epitomizes the four factors that
dominate fracture management (the term ‘fracture
quartet’ seems appropriate).
The fact that the fracture is closed (and not open)
is no cause for complacency. The most important
factor in determining the natural tendency to heal is
the state of the surrounding soft tissues and the local
blood supply. Low-energy (or low-velocity) fractures
cause only moderate soft-tissue damage; high-energy
(velocity) fractures cause severe soft-tissue damage,
no matter whether the fracture is open or closed.
Tscherne (Oestern and Tscherne, 1984) has 23
devised a helpful classification of closed injuries:
• Grade 0 – a simple fracture with little or no soft-
tissue injury.
• Grade 1 – a fracture with superficial abrasion or
bruising of the skin and subcutaneous tissue.
Principles of fractures
• Grade 2 – a more severe fracture with deep soft-
tissue contusion and swelling.
• Grade 3 – a severe injury with marked soft-tissue
damage and a threatened compartment syndrome.
The more severe grades of injury are more likely to
require some form of mechanical fixation; good skele-
tal stability aids soft-tissue recovery.
REDUCTION
Although general treatment and resuscitation must
always take precedence, there should not be undue
delay in attending to the fracture; swelling of the soft
parts during the first 12 hours makes reduction
increasingly difficult. However, there are some situa-
tions in which reduction is unnecessary: (1) when
there is little or no displacement; (2) when displace-
ment does not matter initially (e.g. in fractures of the
clavicle) and (3) when reduction is unlikely to succeed
(e.g. with compression fractures of the vertebrae).
Reduction should aim for adequate apposition and
normal alignment of the bone fragments. The greater
the contact surface area between fragments the more
likely healing is to occur. A gap between the fragment
ends is a common cause of delayed union or non-
union. On the other hand, so long as there is contact
and the fragments are properly aligned, some overlap
at the fracture surfaces is permissible. The exception is
a fracture involving an articular surface; this should be
reduced as near to perfection as possible because any
irregularity will cause abnormal load distribution
between the surfaces and predispose to degenerative
changes in the articular cartilage.
There are two methods of reduction: closed and
open.
CLOSED REDUCTION
Under appropriate anaesthesia and muscle relaxation,
the fracture is reduced by a three-fold manoeuvre: (1)
the distal part of the limb is pulled in the line of the
bone; (2) as the fragments disengage, they are reposi-
tioned (by reversing the original direction of force if
this can be deduced) and (3) alignment is adjusted in
each plane. This is most effective when the perios-
teum and muscles on one side of the fracture remain
intact; the soft-tissue strap prevents over-reduction 695
23 better alignment to be obtained; this practice is help-
ful for femoral and tibial shaft fractures and even
supracondylar humeral fractures in children.
In general, closed reduction is used for all mini-
mally displaced fractures, for most fractures in chil-
dren and for fractures that are not unstable after
FRACTURES AND JOINT INJURIES

reduction and can be held in some form of splint or

cast. Unstable fractures can also be reduced using
closed methods prior to stabilization with internal or
(a) external fixation. This avoids direct manipulation of
the fracture site by open reduction, which damages
the local blood supply and may lead to slower healing
times; increasingly, surgeons resort to reduction
manoeuvres that avoid fracture-site exposure, even
when the aim is some form of internal or external fix-
ation. Traction, which reduces fracture fragments
through ligamentotaxis (ligament pull), can usually be
applied by using a fracture table or bone distractor.

(b)
(c)
23.10 Closed reduction (a) Traction in the line of the
bone. (b) Disimpaction. (c) Pressing fragment into reduced
position.
and stabilizes the fracture after it has been reduced
(Charnley 1961).
Some fractures are difficult to reduce by manipula-
tion because of powerful muscle pull and may need
prolonged traction. Skeletal or skin traction for several
days allows for soft-tissue tension to decrease and a
OPEN REDUCTION
Operative reduction of the fracture under direct vision
is indicated: (1) when closed reduction fails, either
because of difficulty in controlling the fragments or
because soft tissues are interposed between them; (2)
when there is a large articular fragment that needs
accurate positioning or (3) for traction (avulsion) frac-
tures in which the fragments are held apart. As a rule,
however, open reduction is merely the first step to
internal fixation.
HOLD REDUCTION
The word ‘immobilization’ has been deliberately
avoided because the objective is seldom complete
immobility; usually it is the prevention of displace-
ment. Nevertheless, some restriction of movement is
needed to promote soft-tissue healing and to allow
free movement of the unaffected parts.

23.11 Closed
reduction These two
ankle fractures look
somewhat similar but
are caused by different
forces. The causal force
must be reversed to
(b) (c) achieve reduction:
(a) requires internal
rotation (b); an
adduction force (c) is
needed for (d).

696 (a) (d)


23.12 Hold reduction Showing how, if the soft tissues
around a fracture are intact, traction will align the bony
fragments.
HOLD
SPEED
SAFETY
MOVE
23.13 Continuous traction ‘Speed’ is the weak member
of the quartet.
The available methods of holding reduction are:
• Continuous traction.
• Cast splintage.
• Functional bracing.
• Internal fixation.
• External fixation.
In the modern technological age, ‘closed’ methods
are often scorned – an attitude arising from ignorance
rather than experience. The muscles surrounding a
fracture, if they are intact, act as a fluid compartment;
traction or compression creates a hydraulic effect that
is capable of splinting the fracture. Therefore closed
methods are most suitable for fractures with intact
soft tissues, and are liable to fail if they are used as the
primary method of treatment for fractures with severe
soft-tissue damage. Other contraindications to non-
operative methods are inherently unstable fractures,
multiple fractures and fractures in confused or unco-
operative patients. If these constraints are borne in
mind, closed reduction can be sensibly considered in
choosing the most suitable method of fracture splin-
tage. Remember, too, that the objective is to splint
the fracture, not the entire limb!
CONTINUOUS TRACTION
Traction is applied to the limb distal to the fracture,
so as to exert a continuous pull in the long axis of the
bone, with a counterforce in the opposite direction
(to prevent the patient being merely dragged along
the bed). This is particularly useful for shaft fractures
that are oblique or spiral and easily displaced by mus-
cle contraction.
Traction cannot hold a fracture still; it can pull a 23
long bone straight and hold it out to length but to
maintain accurate reduction is sometimes difficult.
Meanwhile the patient can move the joints and exer-
cise the muscles.
Traction is safe enough, provided it is not excessive
Principles of fractures
and care is taken when inserting the traction pin. The
problem is speed: not because the fracture unites
slowly (it does not) but because lower limb traction
keeps the patient in hospital. Consequently, as soon as
the fracture is ‘sticky’ (deformable but not displace-
able), traction should be replaced by bracing, if this
method is feasible. Traction includes:
• Traction by gravity – This applies only to upper
limb injuries. Thus, with a wrist sling the weight of
the arm provides continuous traction to the
humerus. For comfort and stability, especially with
a transverse fracture, a U-slab of plaster may be
bandaged on or, better, a removable plastic sleeve
from the axilla to just above the elbow is held on
with Velcro.
• Skin traction – Skin traction will sustain a pull of no
more than 4 or 5 kg. Holland strapping or one-
way-stretch Elastoplast is stuck to the shaved skin
and held on with a bandage. The malleoli are pro-
tected by Gamgee tissue, and cords or tapes are
used for traction.
• Skeletal traction – A stiff wire or pin is inserted –
usually behind the tibial tubercle for hip, thigh and
knee injuries, or through the calcaneum for tibial
fractures – and cords tied to them for applying trac-
tion. Whether by skin or skeletal traction, the frac-
ture is reduced and held in one of three ways: fixed
traction, balanced traction or a combination of the
two.
Fixed traction
The pull is exerted against a fixed point. The usual
method is to tie the traction cords to the distal end of
a Thomas’ splint and pull the leg down until the prox-
imal, padded ring of the splint abuts firmly against the
pelvis.
Balanced traction
Here the traction cords are guided over pulleys at the
foot of the bed and loaded with weights; counter-trac-
tion is provided by the weight of the body when the
foot of the bed is raised.
Combined traction
If a Thomas’ splint is used, the tapes are tied to the
end of the splint and the entire splint is then sus-
pended, as in balanced traction. 697
23
FRACTURES AND JOINT INJURIES
(a) (b) (c)
(d)
Complications of traction
Circulatory embarrassment In children especially,
traction tapes and circular bandages may constrict the
circulation; for this reason ‘gallows traction’, in which
the baby’s legs are suspended from an overhead beam,
should never be used for children over 12 kg in weight.
Nerve injury In older people, leg traction may
predispose to peroneal nerve injury and cause a drop-
foot; the limb should be checked repeatedly to see that
it does not roll into external rotation during traction.
Pin sites must be kept clean and
Pin site infection
should be checked daily.
CAST SPLINTAGE
Plaster of Paris is still widely used as a splint, especially
for distal limb fractures and for most children’s frac-
tures. It is safe enough, so long as the practitioner is
alert to the danger of a tight cast and provided pres-
sure sores are prevented. The speed of union is neither
greater nor less than with traction, but the patient can
go home sooner. Holding reduction is usually no
problem and patients with tibial fractures can bear
698 weight on the cast. However, joints encased in plaster
23.14 Methods of
traction (a) Traction by
gravity. (b,c,d) Skin traction:
(b) fixed; (c) balanced;
(d) Russell. (e) Skeletal
traction with a splint and a
knee-flexion piece.
(e)
HOLD
SPEED SAFETY
MOVE
23.15 Casts ‘Move’ is the weakest member of the
quartet.
cannot move and are liable to stiffen; stiffness, which
has earned the sobriquet ‘fracture disease’, is the
problem with conventional casts. While the swelling
and haematoma resolve, adhesions may form that
bind muscle fibres to each other and to the bone; with
articular fractures, plaster perpetuates surface irregu-
larities (closed reduction is seldom perfect) and lack of
movement inhibits the healing of cartilage defects.
Newer substitutes have some advantages over plaster
(they are impervious to water, and also lighter) but as
long as they are used as full casts the basic drawback
is the same.
Stiffness can be minimized by: (1) delayed splintage
– that is, by using traction until movement has been
regained, and only then applying plaster; or (2)
 23

Principles of fractures
(a) (b) (c)

(d) (e) (f)

(g) (h) (i)

23.16 Plaster technique Applying a well-fitting and effective plaster needs experience and
attention to detail. (a) A well-equipped plaster trolley is invaluable. (b) Adequate anaesthesia and
careful study of the x-ray films are both indispensable. (c) For a below-knee plaster the thigh is
best supported on a padded block. (d) Stockinette is threaded smoothly onto the leg. (e) For a
padded plaster the wool is rolled on and it must be even. (f) Plaster is next applied smoothly,
taking a tuck with each turn, and (g) smoothing each layer firmly onto the one beneath. (h)
While still wet the cast is moulded away from the point points. (i) With a recent injury the plaster
is then split.

starting with a conventional cast but, after a few
weeks, when the limb can be handled without too
much discomfort, replacing the cast by a functional
brace which permits joint movement.
Technique
After the fracture has been reduced, stockinette is
threaded over the limb and the bony points are pro-
tected with wool. Plaster is then applied. While it is
setting the surgeon moulds it away from bony promi-
nences; with shaft fractures three-point pressure can
be applied to keep the intact periosteal hinge under
tension and thereby maintain reduction.
If the fracture is recent, further swelling is likely;
the plaster and stockinette are therefore split from top
to bottom, exposing the skin. Check x-rays are essen-
tial and the plaster can be wedged if further correction
of angulation is necessary.
With fractures of the shafts of long bones, rotation
is controlled only if the plaster includes the joints
above and below the fracture. In the lower limb, the
knee is usually held slightly flexed, the ankle at a right
angle and the tarsus and forefoot neutral (this ‘planti-
grade’ position is essential for normal walking). In the
upper limb the position of the splinted joints varies
with the fracture. Splintage must not be discontinued
(though a functional brace may be substituted) until
the fracture is consolidated; if plaster changes are
needed, check x-rays are essential.
Complications
Plaster immobilization is safe, but only if care is taken
to prevent certain complications. These are tight cast,
pressure sores and abrasion or laceration of the skin.
Tight cast The cast may be put on too tightly, or it may
become tight if the limb swells. The patient complains
of diffuse pain; only later – sometimes much later – do
the signs of vascular compression appear. The limb
should be elevated, but if the pain persists, the only safe
course is to split the cast and ease it open: (1)
throughout its length and (2) through all the padding
down to skin. Whenever swelling is anticipated the cast
should be applied over thick padding and the plaster 699
23
FRACTURES AND JOINT INJURIES
23.17 Functional bracing (cast bracing) Despite plaster the patient has
excellent joint movement. (Courtesy of Dr John A Feagin).
should be split before it sets, so as to provide a firm
but not absolutely rigid splint.
Pressure sores Even a well-fitting cast may press upon
the skin over a bony prominence (the patella, heel,
elbow or head of the ulna). The patient complains of
localized pain precisely over the pressure spot. Such
localized pain demands immediate inspection through
a window in the cast.
Skin abrasion or laceration This is really a complication
of removing plasters, especially if an electric saw is
used. Complaints of nipping or pinching during plas-
ter removal should never be ignored; a ripped forearm
is a good reason for litigation.
Loose cast Once the swelling has subsided, the cast
may no longer hold the fracture securely. If it is loose,
the cast should be replaced.
FUNCTIONAL BRACING
Functional bracing, using either plaster of Paris or one
of the lighter thermoplastic materials, is one way of
preventing joint stiffness while still permitting fracture
splintage and loading. Segments of a cast are applied
only over the shafts of the bones, leaving the joints
free; the cast segments are connected by metal or plas-
tic hinges that allow movement in one plane. The
splints are ‘functional’ in that joint movements are
much less restricted than with conventional casts.
Functional bracing is used most widely for fractures
of the femur or tibia, but since the brace is not very
rigid, it is usually applied only when the fracture is
beginning to unite, i.e. after 3–6 weeks of traction or
conventional plaster. Used in this way, it comes out
well on all four of the basic requirements: the fracture
can be held reasonably well; the joints can be moved;
the fracture joins at normal speed (or perhaps slightly
quicker) without keeping the patient in hospital and
700 the method is safe.
Technique
Considerable skill is needed to apply an effective
brace. First the fracture is ‘stabilized’: by a few days on
traction or in a conventional plaster for tibial frac-
tures; and by a few weeks on traction for femoral frac-
tures (until the fracture is sticky, i.e. deformable but
not displaceable). Then a hinged cast or splint is
applied, which holds the fracture snugly but permits
joint movement; functional activity, including weight-
bearing, is encouraged. Unlike internal fixation, func-
tional bracing holds the fracture through compression
of the soft tissues; the small amount of movement that
occurs at the fracture site through using the limb
encourages vascular proliferation and callus forma-
tion. Details of the rationale, technique and applica-
tions are given by Sarmiento and Latta (Sarmiento
and Latta 1999, 2006).
INTERNAL FIXATION
Bone fragments may be fixed with screws, a metal
plate held by screws, a long intramedullary rod or nail
(with or without locking screws), circumferential
bands or a combination of these methods.
Properly applied, internal fixation holds a fracture
securely so that movement can begin at once; with
early movement the ‘fracture disease’ (stiffness and
HOLD
SAFETY
SPEED
MOVE
23.18 Internal fixation ‘Safety’ is the weak member of
the quartet.
 23

COULD be fixed

Principles of fractures
P
SHOULD be fixed -U
K
C
A
B (a) (b)
MUST be fixed L
IL
K
S

23.19 Indications staircase The indications for fixation

are not immutable; thus, if the surgical skill or back-up
facilities (staff, sterility and equipment) are of a low order,
internal fixation is indicated only when the alternative is
unacceptable (e.g. with femoral neck fractures). With
average skill and facilities, fixation is indicated when
alternative methods are possible but very difficult or
unwise (e.g. multiple injuries). With the highest levels of
skill and facilities, fixation is reasonable if it saves time,
money or beds.
oedema) is abolished. As far as speed is concerned,
the patient can leave hospital as soon as the wound
is healed, but he must remember that, even though
the bone moves in one piece, the fracture is not
united – it is merely held by a metal bridge and
unprotected weightbearing is, for some time,
unsafe.
The greatest danger, however, is sepsis; if infection
supervenes, all the manifest advantages of internal fix-
ation (precise reduction, immediate stability and early
movement) may be lost. The risk of infection depends
upon: (1) the patient – devitalized tissues, a dirty
wound and an unfit patient are all dangerous; (2) the
surgeon – thorough training, a high degree of surgi-
cal dexterity and adequate assistance are all essential
and (3) the facilities – a guaranteed aseptic routine, a
full range of implants and staff familiar with their use
are all indispensable.
Indications
Internal fixation is often the most desirable form of
treatment. The chief indications are:
1. Fractures that cannot be reduced except by
operation.
2. Fractures that are inherently unstable and prone to
re-displace after reduction (e.g. mid-shaft fractures
of the forearm and some displaced ankle
(b) (d)
23.20 Indications for internal fixation (a) This patella
has been pulled apart and can be held together only be
internal fixation. (b) Fracture dislocation of the ankle is
often unstable after reduction and usually requires fixation.
(c) This patient was considered to be too ill for operation;
her femoral neck fracture has failed to unite without rigid
fixation. (d) Pathological fracture in Paget bone; without
fixation, union may not occur.
fractures). Also included are those fractures liable
to be pulled apart by muscle action (e.g. transverse
fracture of the patella or olecranon).
3. Fractures that unite poorly and slowly, principally
fractures of the femoral neck.
4. Pathological fractures in which bone disease may
prevent healing.
5. Multiple fractures where early fixation (by either
internal or external fixation) reduces the risk of
general complications and late multisystem organ
failure (Pape et al., 2005; Roberts et al., 2005).
6. Fractures in patients who present nursing
difficulties (paraplegics, those with multiple
injuries and the very elderly).
Types of internal fixation
Interfragmentary screws Screws that are only partially
threaded (a similar effect is achieved by overdrilling the
‘near’ cortex of bone) exert a compression or ‘lag’
effect when inserted across two fragments. The 701
23 technique is useful for reducing single fragments onto 1. Neutralization – when used to bridge a
the main shaft of a tubular bone or fitting together fracture and supplement the effect of
fragments of a metaphyseal fracture. interfragmentary lag screws; the plate is to
resist torque and shortening.
Wires (transfixing, cerclage and tension-band) Transfixing
2. Compression – often used in metaphyseal
wires, often passed percutaneously, can hold major
fractures where healing across the cancellous
fracture fragments together. They are used in situations
FRACTURES AND JOINT INJURIES

fracture gap may occur directly, without

where fracture healing is predictably quick (e.g. in
periosteal callus. This technique is less
children or for distal radius fractures), and some form
appropriate for diaphyseal fractures and there
of external splintage (usually a cast) is applied as
has been a move towards the use of long plates
supplementary support.
that span the fracture, thus achieving some
Cerclage and tension-band wires are essentially
stability without totally sacrificing the
loops of wire passed around two bone fragments and
biological (and callus producing) effect of
then tightened to compress the fragments together.
movement.
When using cerclage wires, make sure that the wires
3. Buttressing – here the plate props up the
hug the bone and do not embrace any of the close-
‘overhang’ of the expanded metaphyses of long
lying nerves or vessels.
bones (e.g. in treating fractures of the proximal
Both techniques are used for patellar fractures: the
tibial plateau).
tension-band wire is placed such that the maximum
4. Tension-band – using a plate in this manner,
compressive force is over the tensile surface, which is
again on the tensile surface of the bone, allows
usually the convex side of the bone.
compression to be applied to the biomechanically
Plates and screws This form of fixation is useful for more advantageous side of the fracture.
treating metaphyseal fractures of long bones and 5. Anti-glide – by fixing a plate over the tip of a
diaphyseal fractures of the radius and ulna. Plates have spiral or oblique fracture line and then using
five different functions: the plate as a reduction aid, the anatomy is

23.21 Internal fixation The method used

must be appropriate to the situation:
(a) screws – interfragmentary compression;
(b) plate and screws – most suitable in the
forearm or around the metaphysis; (c) flexible
intramedullary nails – for long bones in
children, particularly forearm bones and the
femur; (d) interlocking nail and screws – ideal
for the femur and tibia; (e) dynamic
compression screw and plate – ideal for the
proximal and distal ends of the femur;
(f) simple K-wires – for fractures around the
elbow and wrist and (g) tension-band wiring
– for olecranon or fractures of the patella.

(a) (b) (c)

702 (d) (e) (f) (g)


(a) (b) (c)
restored with minimal stripping of soft tissues.
The position of the plate acts to prevent
shortening and recurrent displacement of the
fragments.
Intramedullary nails These are suitable for long bones.
A nail (or long rod) is inserted into the medullary canal
to splint the fracture; rotational forces are resisted by
introducing transverse interlocking screws that transfix
the bone cortices and the nail proximal and distal to
the fracture. Nails are used with or without prior
reaming of the medullary canal; reamed nails achieve
an interference fit in addition to the added stability
from interlocking screws, but at the expense of
temporary loss of the intramedullary blood supply.
Complications of internal fixation
Most of the complications of internal fixation are due
to poor technique, poor equipment or poor operating
conditions:
Infection Iatrogenic infection is now the most com-
mon cause of chronic osteomyelitis; the metal does
not predispose to infection but the operation and
quality of the patient’s tissues do.
Non-union If the bones have been fixed rigidly with a
gap between the ends, the fracture may fail to unite.
This is more likely in the leg or the forearm if one
bone is fractured and the other remains intact. Other
causes of non-union are stripping of the soft tissues
and damage to the blood supply in the course of oper-
ative fixation.
Implant failure Metal is subject to fatigue and can fail
unless some union of the fracture has occurred. Stress
must therefore be avoided and a patient with a broken
tibia internally fixed should walk with crutches and stay
23.22 Bad fixation (how not to do it) 23
(a) Too little. (b) Too much. (c) Too weak.
Principles of fractures
away from partial weightbearing for 6 weeks or longer,
until callus or other radiological sign of fracture healing
is seen on x-ray. Pain at the fracture site is a danger sig-
nal and must be investigated.
Refracture It is important not to remove metal
implants too soon, or the bone may refracture. A year
is the minimum and 18 or 24 months safer; for several
weeks after removal the bone is weak, and care or pro-
tection is needed.
EXTERNAL FIXATION
A fracture may be held by transfixing screws or tensioned
wires that pass through the bone above and below the
fracture and are attached to an external frame. This is
especially applicable to the tibia and pelvis, but the
method is also used for fractures of the femur, humerus,
lower radius and even bones of the hand.
Indications
External fixation is particularly useful for:
1. Fractures associated with severe soft-tissue damage
(including open fractures) or those that are
contaminated, where internal fixation is risky and
repeated access is needed for wound inspection,
dressing or plastic surgery.
2. Fractures around joints that are potentially suitable
for internal fixation but the soft tissues are too
swollen to allow safe surgery; here, a spanning
external fixator provides stability until soft-tissue
conditions improve.
3. Patients with severe multiple injuries, especially if
there are bilateral femoral fractures, pelvic
fractures with severe bleeding, and those with limb
and associated chest or head injuries. 703
23 23.23 External fixation
of fractures External
fixation is widely used for
‘damage control’
(a,b) temporary
stabilization of fractures in
order to allow the patient’s
FRACTURES AND JOINT INJURIES

general condition or the

state of soft tissues to
improve prior to definitive
surgery or
(c–f) reconstruction of
limbs using distraction
(a) (b) osteogenesis.
(c) A bone defect after
surgical resection with
gentamicin beads used to
fill the space temporarily.
(d) Bone transport from a
more proximal osteotomy.
(e) ‘Docking’ of the
transported segment and
(f) final union and
restoration of structural
integrity.

(c) (d) (e) (f)

4. Ununited fractures, which can be excised and
compressed; sometimes this is combined with
bone lengthening to replace the excised segment.
5. Infected fractures, for which internal fixation
might not be suitable.
Technique
The principle of external fixation is simple: the bone is
transfixed above and below the fracture with screws or
tensioned wires and these are then connected to each
other by rigid bars. There are numerous types of
external fixation devices; they vary in the technique of
application and each type can be constructed to pro-
vide varying degrees of rigidity and stability. Most of
them permit adjustment of length and alignment after
application on the limb.
The fractured bone can be thought of as broken into
segments – a simple fracture has two segments whereas
a two-level (segmental) fracture has three and so on. Each
segment should be held securely, ideally with the half-pins
or tensioned wires straddling the length of that segment.
The wires and half-pins must be inserted with care.
Knowledge of ‘safe corridors’ is essential so as to avoid
injuring nerves or vessels; in addition, the entry sites
should be irrigated to prevent burning of the bone (a
temperature of only 50ºC can cause bone death).
The fracture is then reduced by connecting the var-
ious groups of pins and wires by rods.
Depending on the stability of fixation and the
704 underlying fracture pattern, weightbearing is started
as early as possible to ‘stimulate’ fracture healing.
Some fixators incorporate a telescopic unit that allows
‘dynamization’; this will convert the forces of weight-
bearing into axial micromovement at the fracture site,
thus promoting callus formation and accelerating
bone union (Kenwright et al., 1991).
Complications
Damage to soft-tissue structures Transfixing pins or
wires may injure nerves or vessels, or may tether
ligaments and inhibit joint movement. The surgeon
must be thoroughly familiar with the cross-sectional
anatomy before operating.
OverdistractionIf there is no contact between the
fragments, union is unlikely.
Pin-track infection This is less likely with good
operative technique. Nevertheless, meticulous pin-site
care is essential, and antibiotics should be administered
immediately if infection occurs.
EXERCISE
More correctly, restore function – not only to the
injured parts but also to the patient as a whole. The
objectives are to reduce oedema, preserve joint move-
ment, restore muscle power and guide the patient
back to normal activity:
 23

Principles of fractures
(a) (b)
23.24 Some aspects of soft tissue
treatment Swelling is minimized by
improving venous drainage. This can be
accomplished by: (1) elevation and (2)
firm support. Stiffness is minimized by
exercise. (a,c) Intermittent venous plexus
pumps for use on the foot or palm to
help reduce swelling. (b) A made-to-
measure pressure garment that helps
reduce swelling and scarring after
treatment. (d) Coban wrap around a
limb to control swelling during
treatment.

(c) (d)

Prevention of oedema Swelling is almost inevitable after exercise the limb actively, but not to let it dangle.
a fracture and may cause skin stretching and blisters. When the plaster is finally removed, a similar routine of
Persistent oedema is an important cause of joint activity punctuated by elevation is practised until
stiffness, especially in the hand; it should be prevented circulatory control is fully restored.
if possible, and treated energetically if it is already Injuries of the upper limb also need elevation. A
present, by a combination of elevation and exercise. sling must not be a permanent passive arm-holder; the
Not every patient needs admission to hospital, and less limb must be elevated intermittently or, if need be,
severe injuries of the upper limb are successfully continuously.
managed by placing the arm in a sling; but it is then
essential to insist on active use, with movement of all
the joints that are free. As with most closed fractures,
in all open fractures and all fractures treated by internal
fixation it must be assumed that swelling will occur;
the limb should be elevated and active exercise begun
as soon as the patient will tolerate this. The essence of
soft-tissue care may be summed up thus: elevate and
exercise; never dangle, never force.
Elevation An injured limb usually needs to be elevated;
after reduction of a leg fracture the foot of the bed is
raised and exercises are begun. If the leg is in plaster
the limb must, at first, be dependent for only short
periods; between these periods, the leg is elevated on 23.25 Continuous passive motion The motorized frame
a chair. The patient is allowed, and encouraged, to provides continuous flexion and extension to pre-set limits. 705
23 Active exercise Active movement helps to pump away
oedema fluid, stimulates the circulation, prevents soft-
tissue adhesion and promotes fracture healing. A limb
encased in plaster is still capable of static muscle
contraction and the patient should be taught how to
do this. When splintage is removed the joints are
FRACTURES AND JOINT INJURIES
mobilized and muscle-building exercises are steadily
increased. Remember that the unaffected joints need
exercising too; it is all too easy to neglect a stiffening
shoulder while caring for an injured wrist or hand.
Assisted movement It has long been taught that passive
movement can be deleterious, especially with injuries
around the elbow, where there is a high risk of
developing myositis ossificans. Certainly forced
movements should never be permitted, but gentle
assistance during active exercises may help to retain
function or regain movement after fractures involving
the articular surfaces. Nowadays this is done with
machines that can be set to provide a specified range
and rate of movement (‘continuous passive motion’).
Functional activity As the patient’s mobility improves,
an increasing amount of directed activity is included in
the programme. He may need to be taught again how
to perform everyday tasks such as walking, getting in
and out of bed, bathing, dressing or handling eating
utensils. Experience is the best teacher and the patient
is encouraged to use the injured limb as much as
possible. Those with very severe or extensive injuries
may benefit from spending time in a special
rehabilitation unit, but the best incentive to full
recovery is the promise of re-entry into family life,
recreational pursuits and meaningful work.
TREATMENT OF OPEN
FRACTURES
INITIAL MANAGEMENT
Patients with open fractures may have multiple injuries;
a rapid general assessment is the first step and any life-
threatening conditions are addressed (see Chapter 22).
The open fracture may draw attention away from
other more important conditions and it is essential
that the step-by-step approach in advanced trauma life
support not be forgotten.
When the fracture is ready to be dealt with, the
wound is first carefully inspected; any gross contami-
nation is removed, the wound is photographed with a
Polaroid or digital camera to record the injury and the
area then covered with a saline-soaked dressing under
an impervious seal to prevent desiccation. This is left
706 undisturbed until the patient is in the operating the-
atre. The patient is given antibiotics, usually co-amox-
iclav or cefuroxime, but clindamycin if the patient is
allergic to penicillin. Tetanus prophylaxis is adminis-
tered: toxoid for those previously immunized, human
antiserum if not. The limb is then splinted until sur-
gery is undertaken.
The limb circulation and distal neurological status
will need checking repeatedly, particularly after any
fracture reduction manoeuvres. Compartment syn-
drome is not prevented by there being an open frac-
ture; vigilance for this complication is wise.
CLASSIFYING THE INJURY
Treatment is determined by the type of fracture, the
nature of the soft-tissue injury (including the wound
size) and the degree of contamination. Gustilo’s clas-
sification of open fractures is widely used (Gustilo et
al., 1984):
Type 1 – The wound is usually a small, clean puncture
through which a bone spike has protruded. There is
little soft-tissue damage with no crushing and the
fracture is not comminuted (i.e. a low-energy
fracture).
Type II – The wound is more than 1 cm long, but
there is no skin flap. There is not much soft-tissue
damage and no more than moderate crushing or
comminution of the fracture (also a low- to
moderate-energy fracture).
Type III – There is a large laceration, extensive
damage to skin and underlying soft tissue and, in the
most severe examples, vascular compromise. The
injury is caused by high-energy transfer to the bone
and soft tissues. Contamination can be significant.
There are three grades of severity. In type III A the
fractured bone can be adequately covered by soft tis-
sue despite the laceration. In type III B there is exten-
sive periosteal stripping and fracture cover is not
possible without use of local or distant flaps. The frac-
ture is classified as type III C if there is an arterial
injury that needs to be repaired, regardless of the
amount of other soft-tissue damage.
The incidence of wound infection correlates
directly with the extent of soft-tissue damage, rising
from less than 2 per cent in type I to more than 10 per
cent in type III fractures.
PRINCIPLES OF TREATMENT
All open fractures, no matter how trivial they may
seem, must be assumed to be contaminated; it is
important to try to prevent them from becoming
infected. The four essentials are:
• Antibiotic prophylaxis. and Pseudomonas, both of which are near the top of 23
• Urgent wound and fracture debridement. the league table of responsible bacteria. The total
• Stabilization of the fracture. period of antibiotic use for these fractures should not
• Early definitive wound cover. be greater than 72 hours (Table 23.1).

Sterility and antibiotic cover Debridement

The wound should be kept covered until the patient
reaches the operating theatre. In most cases co-amox-
iclav or cefuroxime (or clindamycin if penicillin allergy
is an issue) is given as soon as possible, often in the
Accident and Emergency department. At the time of
debridement, gentamicin is added to a second dose of
the first antibiotic. Both antibiotics provide prophy-
laxis against the majority of Gram-positive and Gram-
negative bacteria that may have entered the wound at
the time of injury. Only co-amoxiclav or cefuroxime
(or clindamycin) is continued thereafter; as wounds of
Gustilo grade I fractures can be closed at the time of
debridement, antibiotic prophylaxis need not be for
more than 24 hours. With Gustilo grade II and IIIA
fractures, some surgeons prefer to delay closure after
a ‘second look’ procedure. Delayed cover is also usu-
ally practised in most cases of Grade IIIB and IIIC
injuries. As the wounds have now been present in a
hospital environment for some time, and there are
data to indicate infections after such open fractures
are caused mostly by hospital-acquired bacteria and
not seeded at the time of injury, gentamicin and van-
comycin (or teicoplanin) are given at the time of
definitive wound cover. These antibiotics are effective
against methicillin-resistant Staphylococcus aureus
Principles of fractures
The operation aims to render the wound free of for-
eign material and of dead tissue, leaving a clean surgi-
cal field and tissues with a good blood supply
throughout. Under general anaesthesia the patient’s
clothing is removed, while an assistant maintains trac-
tion on the injured limb and holds it still. The dress-
ing previously applied to the wound is replaced by a
sterile pad and the surrounding skin is cleaned. The
pad is then taken off and the wound is irrigated thor-
oughly with copious amounts of physiological saline.
The wound is covered again and the patient’s limb
then prepped and draped for surgery.
Many surgeons prefer to use a tourniquet as this
provides a bloodless field. However this induces
ischaemia in an already badly injured leg and can make
it difficult to recognize which structures are devital-
ized. A compromise is to apply the tourniquet but not
to inflate it during the debridement unless absolutely
necessary.
Because open fractures are often high-energy
injuries with severe tissue damage, the operation
should be performed by someone skilled in dealing
with both skeletal and soft tissues; ideally this will be
a joint effort by orthopaedic and plastic surgeons. The
following principles must be observed:

Table 23.1 Antibiotics for open fractures1

Grade I Grade II Grade IIIA Grade IIIB/IIIC

2 2 2
As soon as possible Co-amoxiclav Co-amoxiclav Co-amoxiclav Co-amoxiclav2
(within 3 hours of
injury)

At debridement Co-amoxiclav2 and Co-amoxiclav2 and Co-amoxiclav2 and Co-amoxiclav2 and

gentamicin gentamicin gentamicin gentamicin

At definitive fracture Wound cover is usually Wound cover is usually Wound cover is usually Gentamicin and
cover possible at debridement; possible at debridement. possible at debridement. vancomycin (or
delayed closure If delayed, gentamicin If delayed, gentamicin teicoplanin)
unnecessary and vancomycin (or and vancomycin (or
teicoplanin) at the time teicoplanin) at the time
of cover of cover

Continued prophylaxis Only co-amoxiclav2* Only co-amoxiclav2 Only co-amoxiclav2 Only co-amoxiclav2
continued after surgery continued between continued between continued between
procedures and after final procedures and after final procedures and after final
surgery surgery surgery

Maximum period 24 hours 72 hours 72 hours 72 hours

1
Based on the Standards for the Management of Open Fractures of the Lower Limb, British Orthopaedic Association and British
Association of Plastic, Reconstructive and Aesthetic Surgeons, 2009
2
Or cefuroxime (clindamycin for those with penicillin allergy). 707
23
FRACTURES AND JOINT INJURIES
(a) (b)
(c) (d)
23.26 Wound extensions for access in open fractures
of the tibia Wound incisions (extensions) for adequate
access to an open tibial fracture are made along standard
fasciotomy incisions: 1 cm behind the posteromedial
border of the tibia and 2–3 cm lateral to the crest of the
tibia as shown in this example of a two-incision fasciotomy.
The dotted lines mark out the crest (C) and posteromedial
corner (PM) of the tibia (a). These incisions avoid injury to
the perforating branches that supply areas of skin that can
be used as flaps to cover the exposed fracture (b). This
clinical example shows how local skin necrosis around an
open fracture is excised and the wound extended
proximally along a fasciotomy incision (c,d).
Wound excision The wound margins are excised, but
only enough to leave healthy skin edges.
Wound extension Thorough cleansing necessitates
adequate exposure; poking around in a small wound
to remove debris can be dangerous. If extensions are
needed they should not jeopardize the creation of skin
flaps for wound cover if this should be needed. The
safest extensions are to follow the line of fasciotomy
incisions; these avoid damaging important perforator
vessels that can be used to raise skin flaps for eventual
fracture cover.
Delivery of the fracture Examination of the fracture sur-
faces cannot be adequately performed without extract-
ing the bone from within the wound. The simplest (and
708 gentlest) method is to bend the limb in the manner in
23.27 Delivering the fracture Debridement is only
possible if the fracture is adequately seen; for this, the
fracture ends have to be delivered from within.
which it was forced at the moment of injury; the frac-
ture surfaces will be exposed through the wound with-
out any additional damage to the soft tissues. Large
bone levers and retractors should not be used.
Removal of devitalized tissue Devitalized tissue provides
a nutrient medium for bacteria. Dead muscle can be
recognized by its purplish colour, its mushy
consistency, its failure to contract when stimulated and
its failure to bleed when cut. All doubtfully viable
tissue, whether soft or bony, should be removed. The
fracture ends can be nibbled away until seen to bleed.
Wound cleansing All foreign material and tissue debris
is removed by excision or through a wash with copious
quantities of saline. A common mistake is to inject
syringefuls of fluid through a small aperture – this only
serves to push contaminants further in; 6–12 L of
saline may be needed to irrigate and clean an open
fracture of a long bone. Adding antibiotics or
antiseptics to the solution has no added benefit.
Nerves and tendons As a general rule it is best to leave
cut nerves and tendons alone, though if the wound is
absolutely clean and no dissection is required – and pro-
vided the necessary expertise is available – they can be
sutured.
Wound closure
A small, uncontaminated wound in a Grade I or II
fracture may (after debridement) be sutured, provided
this can be done without tension. In the more severe
grades of injury, immediate fracture stabilization and
wound cover using split-skin grafts, local or distant
 23.28 Covering the 23
fracture The best fracture
cover is skin or muscle – with
the help of a plastic surgeon
(a–c). If none is available,
gentamicin beads can be
inserted and sealed with an

Principles of fractures
impervious dressing until the
second operation, where a
further debridement and,
ideally, definitive fracture
(a) (b) (c) cover is obtained (d,e).

(d) (e)

flaps is ideal, provided both orthopaedic and plastic
surgeons are satisfied that a clean, viable wound has
been achieved after debridement. In the absence of
this combined approach at the time of debridement,
the fracture is stabilized and the wound left open and
dressed with an impervious dressing. Adding gentam-
icin beads under the dressing has been shown to help,
as has the use of vacuum dressings. Return to surgery
for a ‘second look’ should have definitive fracture
cover as an objective. It should be done by 48–
72 hours, and not later than 5 days. Open fractures do
not fare well if left exposed for long and multiple
debridement can be self-defeating.
Stabilizing the fracture
Stabilizing the fracture is important in reducing the
likelihood of infection and assisting recovery of
the soft tissues. The method of fixation depends
on the degree of contamination, length of time from
injury to operation and amount of soft-tissue damage.
If there is no obvious contamination and definitive
wound cover can be achieved at the time of debride-
ment, open fractures of all grades can be treated as for
a closed injury; internal or external fixation may be
appropriate depending on the individual characteris-
tics of the fracture and wound. This ideal scenario of
judicious soft-tissue and bone debridement, wound
cleansing, immediate stabilization and cover is only
possible if orthopaedic and plastic surgeons are pres-
ent at the time of initial surgery.
If wound cover is delayed, then external fixation is
safer; however, the surgeon must take care to insert
the fixator pins away from potential flaps needed by
the plastic surgeon!
The external fixator may be exchanged for internal

23.29 Stabilizing the limb

in open fractures Spanning
external fixation is a useful
method of holding the
fracture in the first instance
(a,b). When definitive fracture
cover is carried out, this can
be substituted with internal
fixation, provided the wound
is clean and the interval
between the two procedures
is less than 7 days.

(a) (b) 709

23
FRACTURES AND JOINT INJURIES
(a) (b)
23.30 Complications of fractures Fractures can become infected (a,b), fail to unite (c) or (d) unite in poor alignment.
fixation at the time of definitive wound cover as long
as (1) the delay to wound cover is less than 7 days; (2)
wound contamination is not visible and (3) internal
fixation can control the fracture as well as the external
fixator. This approach is less risky than introducing
internal fixation at the time of initial surgery and leav-
ing both metalwork and bone exposed until definitive
cover several days later.
Aftercare
In the ward, the limb is elevated and its circulation
carefully watched. Antibiotic cover is continued but
only for a maximum of 72 hours in the more severe
grades of injury. Wound cultures are seldom helpful as
osteomyelitis, if it were to ensue, is often caused by
hospital-derived organisms; this emphasizes the need
for good debridement and early fracture cover.
SEQUELS TO OPEN FRACTURES
Skin
If split-thickness skin grafts are used inappropriately,
particularly where flap cover is more suited, there can
be areas of contracture or friable skin that breaks
down intermittently. Reparative or reconstructive sur-
710 gery by a plastic surgeon is desirable.
(c) (d)
Bone
Infection involves the bone and any implants that may
have been used. Early infection may present as wound
inflammation without discharge. Identifying the
causal organism without tissue samples is difficult but,
at best guess, it is likely to be S. aureus (including
methicillin-resistant varieties) or Pseudomonas. Sup-
pression by appropriate antibiotics, as long as the fix-
ation remains stable, may allow the fracture to
proceed to union, but further surgery is likely later,
when the antibiotics are stopped.
Late presentation may be with a sinus and x-ray ev-
idence of sequestra. The implants and all avascular
pieces of bone should be removed; robust soft tissue
cover (ideally a flap) is needed. An external fixator can
be used to bridge the fracture. If the resulting defect is
too large for bone grafting at a later stage, the patient
should be referred to a centre with the necessary
experience and facilities for limb reconstruction.
Joints
When an infected fracture communicates with a joint,
the principles of treatment are the same as with bone
infection, namely debridement and drainage, drugs and
splintage. On resolution of the infection, attention
can be given to stabilizing the fracture so that joint
movement can recommence. Permanent stiffness is a real
threat; where fracture stabilization cannot be achieved to
allow movement, the joint should be splinted in the
optimum position for ankylosis, lest this should occur.

GUNSHOT INJURIES
Missile wounds are looked upon as a special type of
open injury. Tissue damage is produced by: (1) direct
injury in the immediate path of the missile; (2) con-
tusion of muscles around the missile track and (3)
bruising and congestion of soft tissues at a greater dis-
tance from the primary track. The exit wound (if any)
is usually larger than the entry wound.
With high-velocity missiles (bullets, usually from
rifles, travelling at speeds above 600 m/s) there is
marked cavitation and tissue destruction over a wide
area. The splintering of bone resulting from the trans-
fer of large quantities of energy creates secondary mis-
siles, causing greater damage. With low-velocity
missiles (bullets from civilian hand-guns travelling at
speeds of 300–600 m/s) cavitation is much less, and
with smaller weapons tissue damage may be virtually
confined to the bullet track. However, with all gun-
shot injuries debris is sucked into the wound, which is
therefore contaminated from the outset.
Emergency treatment
As always, the arrest of bleeding and general resusci-
tation take priority. The wounds should each be
covered with a sterile dressing and the area examined
for artery or nerve damage. Antibiotics should be
given immediately, following the recommendations
for open fractures (see Table 23.1).
Definitive treatment
Traditionally, all missile injuries were treated as severe
open injuries, by exploration of the missile track and
formal debridement. However, it has been shown that
low-velocity wounds with relatively clean entry and
exit wounds can be treated as Gustilo type I injuries,
by superficial debridement, splintage of the limb and
antibiotic cover; the fracture is then treated as for
(a) (b)
similar open fractures. If the injury is to soft tissues 23
only with minimal bone splinters, the wound may be
safely treated without surgery but with local wound
care and antibiotics.
High-velocity injuries demand thorough cleansing
of the wound and debridement, with excision of deep
Principles of fractures
damaged tissues and, if necessary, splitting of fascial
compartments to prevent ischaemia; the fracture is
stabilized and the wound is treated as for a Gustilo
type III fracture. If there are comminuted fractures,
these are best managed by external fixation. The
method of wound closure will depend on the state of
tissues after several days; in some cases delayed pri-
mary suture is possible but, as with other open
injuries, close collaboration between plastic and
orthopaedic surgeons is needed (Dicpinigaitis et al.,
2006).
Close-range shotgun injuries, although the missiles
may be technically low velocity, are treated as high-
velocity wounds because the mass of shot transfers
large quantities of energy to the tissues.
COMPLICATIONS OF
FRACTURES
The general complications of fractures (blood loss,
shock, fat embolism, cardiorespiratory failure etc.) are
dealt with in Chapter 22.
Local complications can be divided into early (those
that arise during the first few weeks following injury)
and late.
EARLY COMPLICATIONS
Early complications may present as part of the primary
injury or may appear only after a few days or weeks.
23.31 Gunshot
injuries (a) Close-
range shotgun blasts,
although technically
low velocity, transfer
large quantities of
destructive force to
the tissues due to the
mass of shot. They
should be treated like
high-energy open
fractures (b,c).
(c) 711
23 Table 23.2 Local complications of fractures either by the initial injury or subsequently by jagged
bone fragments. Even if its outward appearance is
Urgent Less urgent Late
normal, the intima may be detached and the vessel
Local visceral injury Fracture blisters Delayed union blocked by thrombus, or a segment of artery may be
Vascular injury Plaster sores Malunion in spasm. The effects vary from transient diminution
Nerve injury Pressure sores Non-union
Compartment Nerve entrapment Avascular
of blood flow to profound ischaemia, tissue death and
FRACTURES AND JOINT INJURIES

syndrome Myositis ossificans necrosis peripheral gangrene.

Haemarthrosis Ligament injury Muscle
Infection Tendon lesions contracture
Gas gangrene Joint stiffness Joint instability Clinical features
Algodystrophy Osteoarthritis
The patient may complain of paraesthesia or numb-
ness in the toes or the fingers. The injured limb is cold
and pale, or slightly cyanosed, and the pulse is weak or
VISCERAL INJURY absent. X-rays will probably show one of the ‘high-
Fractures around the trunk are often complicated by risk’ fractures listed above. If a vascular injury is sus-
injuries to underlying viscera, the most important pected an angiogram should be performed
being penetration of the lung with life-threatening immediately; if it is positive, emergency treatment
pneumothorax following rib fractures and rupture of must be started without further delay.
the bladder or urethra in pelvic fractures. These
injuries require emergency treatment. Treatment
All bandages and splints should be removed. The frac-
Table 23.3 Common vascular injuries ture is re-x-rayed and, if the position of the bones sug-
Injury Vessel gests that the artery is being compressed or kinked,
prompt reduction is necessary. The circulation is then re-
First rib fracture Subclavian
Shoulder dislocation Axillary
assessed repeatedly over the next half hour. If there is no
Humeral supracondylar fracture Brachial improvement, the vessels must be explored by operation
Elbow dislocation Brachial – preferably with the benefit of preoperative or perop-
Pelvic fracture Presacral and internal iliac erative angiography. A cut vessel can be sutured, or a seg-
Femoral supracondylar fracture Femoral ment may be replaced by a vein graft; if it is thrombosed,
Knee dislocation Popliteal
Proximal tibial Popliteal or its branches
endarterectomy may restore the blood flow. If vessel re-
pair is undertaken, stable fixation is a must and where it
is practicable, the fracture should be fixed internally.

VASCULAR INJURY
The fractures most often associated with damage to a
major artery are those around the knee and elbow,
and those of the humeral and femoral shafts. The
artery may be cut, torn, compressed or contused,
NERVE INJURY
Nerve injury is particularly common with fractures of
the humerus or injuries around the elbow or the knee

23.32 Vascular injury This patient was

brought into hospital with a fractured femur
and early signs of vascular insufficiency. The
plain x-ray (a) looked as if the proximal bone
fragment might have speared the popliteal
artery. The angiogram (b) confirmed these
fears. Despite vein grafting the patient
developed peripheral gangrene (c).

712 (a) (b) (c)

Table 23.4 Common nerve injuries COMPARTMENT SYNDROME 23
Injury Nerve
Fractures of the arm or leg can give rise to severe
Shoulder dislocation Axillary ischaemia, even if there is no damage to a major ves-
Humeral shaft fracture Radial
sel. Bleeding, oedema or inflammation (infection)
Humeral supracondylar fracture Radial or median
Elbow medial condyle Ulnar may increase the pressure within one of the osseofas-

Principles of fractures
Monteggia fracture–dislocation Posterior-interosseous cial compartments; there is reduced capillary flow,
Hip dislocation Sciatic which results in muscle ischaemia, further oedema,
Knee dislocation Peroneal still greater pressure and yet more profound ischaemia
– a vicious circle that ends, after 12 hours or less, in
necrosis of nerve and muscle within the compartment.
Nerve is capable of regeneration but muscle, once
infarcted, can never recover and is replaced by inelas-
(see also Chapter 11). The telltale signs should be tic fibrous tissue (Volkmann’s ischaemic contracture).
looked for (and documented) during the initial exam- A similar cascade of events may be caused by swelling
ination and again after reduction of the fracture. of a limb inside a tight plaster cast.

Closed nerve injuries Clinical features

In closed injuries the nerve is seldom severed, and High-risk injuries are fractures of the elbow, forearm
spontaneous recovery should be awaited – it occurs in bones, proximal third of the tibia, and also multiple
90 per cent within 4 months. If recovery has not
occurred by the expected time, and if nerve conduc-
tion studies and EMG fail to show evidence of recov-
ery, the nerve should be explored.

Open nerve injuries

With open fractures the nerve injury is more likely to
be complete. In these cases the nerve should be
explored at the time of debridement and repaired at
the time or at wound closure.

Acute nerve compression

Nerve compression, as distinct from a direct injury,
sometimes occurs with fractures or dislocations
around the wrist. Complaints of numbness or paraes- (a) (b)
thesia in the distribution of the median or ulnar
nerves should be taken seriously and the patient mon-
itored closely; if there is no improvement within 48
hours of fracture reduction or splitting of bandages
around the splint, the nerve should be explored and
decompressed.

INDICATIONS FOR EARLY EXPLORATION

Nerve injury associated with open fracture
Nerve injury with fractures that need internal
fixation
Presence of a concomitant vascular injury
Nerve damage diagnosed after manipulation of the
fracture
(c)
23.33 Compartment syndrome (a) A fracture at this
level is always dangerous. This man was treated in plaster.
Pain became intense and when the plaster was split (which
should have been done immediately after its application),
the leg was swollen and blistered (b). Tibial compartment
decompression (c) requires fasciotomies of all the
compartments in the leg. 713
23 fractures of the hand or foot, crush injuries and cir-
cumferential burns. Other precipitating factors are
operation (usually for internal fixation) or infection.
The classic features of ischaemia are the five Ps:
• Pain
• Paraesthesia
FRACTURES AND JOINT INJURIES
• Pallor
• Paralysis
• Pulselessness.
However in compartment syndrome the ischaemia
occurs at the capillary level, so pulses may still be felt
and the skin may not be pale! The earliest of the ‘clas-
sic’ features are pain (or a ‘bursting’ sensation),
altered sensibility and paresis (or, more usually, weak-
ness in active muscle contraction). Skin sensation
should be carefully and repeatedly checked.
Ischaemic muscle is highly sensitive to stretch. If
the limb is unduly painful, swollen or tense, the muscles
(which may be tender) should be tested by stretching
them. When the toes or fingers are passively hyperex-
tended, there is increased pain in the calf or forearm.
Confirmation of the diagnosis can be made by meas-
uring the intracompartmental pressures. So important
is the need for early diagnosis that some surgeons ad-
vocate the use of continuous compartment pressure
monitoring for high-risk injuries (e.g. fractures of the
tibia and fibula) and especially for forearm or leg frac-
tures in patients who are unconscious. A split catheter
is introduced into the compartment and the pressure is
measured close to the level of the fracture. A differen-
tial pressure (ΔP) – the difference between diastolic
pressure and compartment pressure – of less than
30 mmHg (4.00 kilopascals) is an indication for im-
mediate compartment decompression.
Treatment
The threatened compartment (or compartments)
must be promptly decompressed. Casts, bandages and
dressings must be completely removed – merely split-
ting the plaster is utterly useless – and the limb should
be nursed flat (elevating the limb causes a further
decrease in end capillary pressure and aggravates the
muscle ischaemia). The ΔP should be carefully moni-
tored; if it falls below 30 mmHg, immediate open fas-
ciotomy is performed. In the case of the leg,
‘fasciotomy’ means opening all four compartments
through medial and lateral incisions. The wounds
should be left open and inspected 2 days later: if there
is muscle necrosis, debridement can be carried out; if
the tissues are healthy, the wounds can be sutured
(without tension) or skin-grafted.
NOTE: If facilities for measuring compartmental
pressures are not available, the decision to operate will
have to be made on clinical grounds. If three or more
714 signs are present, the diagnosis is almost certain
(Ulmer, 2002). If the clinical signs are ‘soft’, the limb
should be examined at 30-minute intervals and if
there is no improvement within 2 hours of splitting
the dressings, fasciotomy should be performed. Mus-
cle will be dead after 4–6 hours of total ischaemia –
there is no time to lose!
HAEMARTHROSIS
Fractures involving a joint may cause acute
haemarthrosis. The joint is swollen and tense and the
patient resists any attempt at moving it. The blood
should be aspirated before dealing with the fracture.
INFECTION
Open fractures may become infected; closed fractures
hardly ever do unless they are opened by operation.
Post-traumatic wound infection is now the most
common cause of chronic osteitis. The management
of early and late infection is summarized under the
section Sequels to open fractures (page 710).
GAS GANGRENE
This terrifying condition is produced by clostridial
infection (especially Clostridium welchii). These are
anaerobic organisms that can survive and multiply
only in tissues with low oxygen tension; the prime site
for infection, therefore, is a dirty wound with dead
muscle that has been closed without adequate
debridement. Toxins produced by the organisms
destroy the cell wall and rapidly lead to tissue necro-
sis, thus promoting the spread of the disease.
Clinical features appear within 24 hours of the
injury: the patient complains of intense pain and
swelling around the wound and a brownish discharge
may be seen; gas formation is usually not very marked.
There is little or no pyrexia but the pulse rate is
increased and a characteristic smell becomes evident
(once experienced this is never forgotten). Rapidly the
patient becomes toxaemic and may lapse into coma
and death.
It is essential to distinguish gas gangrene, which is
characterized by myonecrosis, from anaerobic celluli-
tis, in which superficial gas formation is abundant but
toxaemia usually slight. Failure to recognize the dif-
ference may lead to unnecessary amputation for the
non-lethal cellulitis.
Prevention
Deep, penetrating wounds in muscular tissue are dan-
gerous; they should be explored, all dead tissue

(b)
23.34 Infection after fracture treatment Operative fixation is one of the commonest causes
of infection in closed fractures. Fatigue failure of implants is inevitable if infection hinders union
(a). Deep infection can lead to development of discharging sinuses (b,c).
(a)
should be completely excised and, if there is the
slightest doubt about tissue viability, the wound
should be left open. Unhappily there is no effective
antitoxin against C. welchii.
Treatment
The key to life-saving treatment is early diagnosis.
General measures, such as fluid replacement and intra-
venous antibiotics, are started immediately. Hyper-
baric oxygen has been used as a means of limiting the
spread of gangrene. However, the mainstay of treat-
ment is prompt decompression of the wound and
removal of all dead tissue. In advanced cases, amputa-
tion may be essential.
(a) (b)
23.35 Gas gangrene (a) Clinical picture of gas gangrene.
(b) X-rays show diffuse gas in the muscles of the calf.
23
Principles of fractures
(c)
FRACTURE BLISTERS
Two distinct blister types are sometimes seen after
fractures: clear fluid-filled vesicles and blood-stained
ones. Both occur during limb swelling and are due to
elevation of the epidermal layer of skin from the der-
mis (Giordano et al., 1994). There is no advantage to
puncturing the blisters (it may even lead to increased
local infection) and surgical incisions through blisters,
whilst generally safe, should be undertaken only when
limb swelling has decreased.
PLASTER AND PRESSURE SORES
Plaster sores occur where skin presses directly onto
bone. They should be prevented by padding the bony
points and by moulding the wet plaster so that
pressure is distributed to the soft tissues around the
bony points. While a plaster sore is developing the
patient feels localized burning pain. A window must
(a) (b)
23.36 Pressure sores Pressure sores are a sign of
carelessness. (a,b) Sores from poorly supervised treatment
in a Thomas splint. 715
23 immediately be cut in the plaster, or warning pain
quickly abates and skin necrosis proceeds unnoticed.
Even traction on a Thomas splint requires skill in
nursing care; careless selection of ring size, excessive
fixed (as opposed to balanced) traction, and neglect can
lead to pressure sores around the groin and iliac crest.
FRACTURES AND JOINT INJURIES
LATE COMPLICATIONS
DELAYED UNION
The timetable on page 692 is no more than a rough
guide to the period in which a fracture may be
expected to unite and consolidate. It must never be
relied upon in deciding when treatment may be dis-
continued. If the time is unduly prolonged, the term
‘delayed union’ is used.
Causes
Factors causing delayed union can be summarized as:
biological, biomechanical or patient-related.
BIOLOGICAL
Inadequate blood supply A badly displaced fracture of a
long bone will cause tearing of both the periosteum
and interruption of the intramedullary blood supply.
The fracture edges will become necrotic and
dependent on the formation of an ensheathing callus
mass to bridge the break. If the zone of necrosis is
extensive, as might occur in highly comminuted
fractures, union may be hampered.
Severe soft tissue damage Severe damage to the soft
tissues affects fracture healing by: (1) reducing the
effectiveness of muscle splintage; (2) damaging the
local blood supply and (3) diminishing or eliminating
the osteogenic input from mesenchymal stem cells
within muscle.
Periosteal stripping Over-enthusiastic stripping of
periosteum during internal fixation is an avoidable
cause of delayed union.
BIOMECHANICAL
Imperfect splintage Excessive traction (creating a
fracture gap) or excessive movement at the fracture site
will delay ossification in the callus. In the forearm and
leg a single-bone fracture may be held apart by an
intact fellow bone.
Over-rigid fixation Contrary to popular belief, rigid fix-
ation delays rather than promotes fracture union. It is
only because the fixation device holds the fragments so
securely that the fracture seems to be ‘uniting’. Union
by primary bone healing is slow, but provided stability
716 is maintained throughout, it does eventually occur.
Infection Both biology and stability are hampered by
active infection: not only is there bone lysis, necrosis
and pus formation, but implants which are used to
hold the fracture tend to loosen.
PATIENT RELATED
In a less than ideal world, there are patients who are:
• Immense
• Immoderate
• Immovable
• Impossible.
These factors must be accommodated in an appro-
priate fashion.
Clinical features
Fracture tenderness persists and, if the bone is sub-
jected to stress, pain may be acute.
On x-ray, the fracture line remains visible and there
is very little or incomplete callus formation or
periosteal reaction. However, the bone ends are not
sclerosed or atrophic. The appearances suggest that,
although the fracture has not united, it eventually will.
Treatment
CONSERVATIVE
The two important principles are: (1) to eliminate any
possible cause of delayed union and (2) to promote
healing by providing the most appropriate environ-
ment. Immobilization (whether by cast or by internal
fixation) should be sufficient to prevent shear at the
fracture site, but fracture loading is an important stim-
ulus to union and can be enhanced by: (1) encourag-
ing muscular exercise and (2) by weightbearing in the
cast or brace. The watchword is patience; however,
there comes a point with every fracture where the ill-
effects of prolonged immobilization outweigh the
advantages of non-operative treatment, or where the
risk of implant breakage begins to loom.
OPERATIVE
Each case should be treated on its merits; however, if
union is delayed for more than 6 months and there is
no sign of callus formation, internal fixation and bone
grafting are indicated. The operation should be
planned in such a way as to cause the least possible
damage to the soft tissues.
NON-UNION
In a minority of cases delayed union gradually turns
into non-union – that is it becomes apparent that the
fracture will never unite without intervention. Move-
ment can be elicited at the fracture site and pain
 23.37 Non-union 23
(a) This patient has an
obvious pseudarthrosis
of the humerus. The
x-ray (b) shows a typical
hypertrophic non-union.
(c,d) Examples of

Principles of fractures
atrophic non-union.

(a) (b) (c) (d)

diminishes; the fracture gap becomes a type of
pseudoarthrosis.
X-ray The fracture is clearly visible but the bone on
either side of it may show either exuberant callus or
atrophy. This contrasting appearance has led to non-
union being divided into hypertrophic and atrophic
types. In hypertrophic non-union the bone ends are
enlarged, suggesting that osteogenesis is still active
but not quite capable of bridging the gap. In atrophic
non-union, osteogenesis seems to have ceased. The
bone ends are tapered or rounded with no suggestion
of new bone formation.
2. Alignment – Was the fracture adequately aligned,
to reduce shear?
3. Stability – Was the fracture held with sufficient
stability?
4. Stimulation – Was the fracture sufficiently ‘stimu-
lated’? (e.g. by encouraging weightbearing).
There are, of course, also biological and patient-
related reasons that may lead to non-union: (1) poor
soft tissues (from either the injury or surgery); (2)
local infection; (3) associated drug abuse, anti-inflam-
matory or cytotoxic immunosuppressant medication
and (4) non-compliance on the part of the patient.

Causes
When dealing with the problem of non-union, four
questions must be addressed. They have given rise to
the acronym CASS:
1. Contact – Was there sufficient contact between
the fragments?
Treatment
CONSERVATIVE
Non-union is occasionally symptomless, needing no
treatment or, at most, a removable splint. Even if
symptoms are present, operation is not the only

23.38 Non-union –
treatment (a) This
patient with fractures of
the tibia and fibula was
initially treated by internal
fixation with a plate and
screws. The fracture failed
to heal, and developed the
typical features of
hypertrophic non-union.
(b) After a further
operation, using more
rigid fixation (and no bone
grafts), the fractures
healed solidly. (c,d) This
patient with atrophic non-
union needed both
internal fixation and bone
grafts to stimulate bone
formation and union (e).
(a) (b) (c) (d) (e) 717
23
FRACTURES AND JOINT INJURIES
(a) (b) (c)
(e) (f) (g)
answer; with hypertrophic non-union, functional
bracing may be sufficient to induce union, but splin-
tage often needs to be prolonged. Pulsed electromag-
netic fields and low-frequency, pulsed ultrasound can
also be used to stimulate union.
OPERATIVE
With hypertrophic non-union and in the absence of
deformity, very rigid fixation alone (internal or exter-
nal) may lead to union. With atrophic non-union, fix-
ation alone is not enough. Fibrous tissue in the
fracture gap, as well as the hard, sclerotic bone ends is
excised and bone grafts are packed around the frac-
ture. If there is significant ‘die-back’, this will require
more extensive excision and the gap is then dealt with
by bone advancement using the Ilizarov technique.
MALUNION
When the fragments join in an unsatisfactory position
718 (unacceptable angulation, rotation or shortening) the
23.39 Non-union –
treatment by the
Ilizarov technique
Hypertrophic non-unions
can be treated by gradual
distraction and
realignment in an external
fixator (a–d). Atrophic
non-unions will need
more surgery; the poor
tissue is excised (e,f) and
replaced through bone
transport (g,h).
(d)
(h)
fracture is said to be malunited. Causes are failure to
reduce a fracture adequately, failure to hold reduction
while healing proceeds, or gradual collapse of com-
minuted or osteoporotic bone.
Clinical features
The deformity is usually obvious, but sometimes the
true extent of malunion is apparent only on x-ray.
Rotational deformity of the femur, tibia, humerus or
forearm may be missed unless the limb is compared
with its opposite fellow. Rotational deformity of a
metacarpal fracture is detected by asking the patient
to flatten the fingers onto the palm and seeing
whether the normal regular fan-shaped appearance is
reproduced (Chapter 26).
X-rays are essential to check the position of the frac-
ture while it is uniting. This is particularly important
during the first 3 weeks, when the situation may
change without warning. At this stage it is sometimes
difficult to decide what constitutes ‘malunion’;
acceptable norms differ from one site to another and
these are discussed under the individual fractures.
 23

Principles of fractures
(a) (b) (c) (d) (e)

(f) (g) (h) (i)

23.40 Malunion – treatment by internal fixation An osteotomy, correction of deformity and internal fixation can be
used to treat both intra-articular deformities (a–e) and those in the shaft of a long bone (f–i).

Treatment 2. In children, angular deformities near the bone

Incipient malunion may call for treatment even before
the fracture has fully united; the decision on the need
for re-manipulation or correction may be extremely
difficult. A few guidelines are offered:
1. In adults, fractures should be reduced as near to the
anatomical position as possible. Angulation of more
than 10–15 degrees in a long bone or a noticeable
rotational deformity may need correction by re-
manipulation, or by osteotomy and fixation.
ends (and especially if the deformity is in the same
plane as that of movement of the nearby joint) will
usually remodel with time; rotational deformities
will not.
3. In the lower limb, shortening of more than 2.0 cm
is seldom acceptable to the patient and a limb
length equalizing procedure may be indicated.
4. The patient’s expectations (often prompted by
cosmesis) may be quite different from the
surgeon’s; they are not to be ignored.

(a) (b) (c)

23.41 Avascular necrosis (a) Displaced fractures of the femoral neck are at considerable risk of
developing avascular necrosis. Despite internal fixation within a few hours of the injury (b), the
head-fragment developed avascular necrosis. (c) X-ray after removal of the fixation screws. 719
23 5. Early discussion with the patient, and a guided
view of the x-rays, will help in deciding the need
for treatment and may prevent later
misunderstanding.
6. Very little is known of the long-term effects of
small angular deformities on joint function.
FRACTURES AND JOINT INJURIES
However, it seems likely that malalignment of
more than 15 degrees in any plane may cause
asymmetrical loading of the joint above or below
and the late development of secondary
osteoarthritis; this applies particularly to the large
weightbearing joints.
AVASCULAR NECROSIS
Certain regions are notorious for their propensity to
develop ischaemia and bone necrosis after injury (see
also Chapter 6). They are: (1) the head of the femur
(after fracture of the femoral neck or dislocation of
the hip); (2) the proximal part of the scaphoid (after
fracture through its waist); (3) the lunate (following
dislocation) and (4) the body of the talus (after frac-
ture of its neck).
Accurately speaking, this is an early complication of
bone injury, because ischaemia occurs during the first
few hours following fracture or dislocation. However,
the clinical and radiological effects are not seen until
weeks or even months later.
Clinical features
There are no symptoms associated with avascular
necrosis, but if the fracture fails to unite or if the bone
collapses the patient may complain of pain. X-ray
shows the characteristic increase in x-ray density,
which occurs as a consequence of two factors: disuse
osteoporosis in the surrounding parts gives the
impression of ‘increased density’ in the necrotic seg-
ment, and collapse of trabeculae compacts the bone
and increases its density. Where normal bone meets
the necrotic segment a zone of increased radiographic
density may be produced by new bone formation.
Treatment
Treatment usually becomes necessary when joint
function is threatened. In old people with necrosis of
the femoral head an arthroplasty is the obvious
choice; in younger people, realignment osteotomy
(or, in some cases, arthrodesis) may be wiser. Avascu-
lar necrosis in the scaphoid or talus may need no more
than symptomatic treatment, but arthrodesis of the
720 wrist or ankle is sometimes needed.
GROWTH DISTURBANCE
In children, damage to the physis may lead to abnor-
mal or arrested growth. A transverse fracture through
the growth plate is not always disastrous; the fracture
runs through the hypertrophic and calcified layers and
not through the germinal zone, so provided it is accu-
rately reduced, there may not be any disturbance of
growth. However fractures that split the epiphysis
inevitably traverse the growing portion of the physis,
and so further growth may be asymmetrical and the
bone end characteristically angulated; if the entire
physis is damaged, there may be slowing or complete
cessation of growth. The subject is dealt with in more
detail on page 727.
BED SORES
Bed sores occur in elderly or paralysed patients. The
skin over the sacrum and heels is especially vulnerable.
Careful nursing and early activity can usually prevent
bed sores; once they have developed, treatment is dif-
ficult – it may be necessary to excise the necrotic tis-
sue and apply skin grafts. In recent years
vacuum-assisted closure (a form of negative pressure
dressing) has been used for sacral bed sores.
MYOSITIS OSSIFICANS
Heterotopic ossification in the muscles sometimes
occurs after an injury, particularly dislocation of the
elbow or a blow to the brachialis, deltoid or quadri-
ceps. It is thought to be due to muscle damage, but it
also occurs without a local injury in unconscious or
paraplegic patients.
Clinical features
Soon after the injury, the patient (usually a fit young
man) complains of pain; there is local swelling and
23.42 Bed sores Bed sores in an elderly patient, which
kept her in hospital for months.

23.43 Myositis ossificans This followed a fractured head
of the radius.
soft-tissue tenderness. X-ray is normal but a bone scan
may show increased activity. Over the next 2–3 weeks
the pain gradually subsides, but joint movement is
limited; x-ray may show fluffy calcification in the soft
tissues. By 8 weeks the bony mass is easily palpable
and is clearly defined in the x-ray.
Treatment
The worst treatment is to attack an injured and
slightly stiff elbow with vigorous muscle-stretching
exercises; this is liable to precipitate or aggravate the
condition. The joint should be rested in the position
of function until pain subsides; gentle active move-
ments are then begun.
Months later, when the condition has stabilized, it
may be helpful to excise the bony mass. Indomethacin
or radiotherapy should be given to help prevent a
recurrence.
TENDON LESIONS
Tendinitis may affect the tibialis posterior tendon fol-
lowing medial malleolar fractures. It should be pre-
vented by accurate reduction, if necessary at surgery.
Rupture of the extensor pollicis longus tendon may
occur 6–12 weeks after a fracture of the lower radius.
Direct suture is seldom possible and the resulting dis-
ability is treated by transferring the extensor indicis
proprius tendon to the distal stump of the ruptured
thumb tendon. Late rupture of the long head of
biceps after a fractured neck of humerus usually
requires no treatment.
NERVE COMPRESSION
Nerve compression may damage the lateral popliteal
nerve if an elderly or emaciated patient lies with the
leg in full external rotation. Radial palsy may follow 23
the faulty use of crutches. Both conditions are due to
lack of supervision.
Bone or joint deformity may result in local nerve
entrapment with typical features such as numbness or
paraesthesia, loss of power and muscle wasting in the
Principles of fractures
distribution of the affected nerve. Common sites are:
(1) the ulnar nerve, due to a valgus elbow following a
malunited lateral condyle or supracondylar fracture;
(2) the median nerve, following injuries around the
wrist and (3) the posterior tibial nerve, following frac-
tures around the ankle. Treatment is by early decom-
pression of the nerve; in the case of the ulnar nerve
this may require anterior transposition.
MUSCLE CONTRACTURE
Following arterial injury or compartment syndrome,
the patient may develop ischaemic contractures of the
affected muscles (Volkmann’s ischaemic contracture).
Nerves injured by ischaemia sometimes recover, at
least partially; thus the patient presents with deformity
and stiffness, but numbness is inconstant. The sites
most commonly affected are the forearm and hand,
leg and foot.
In a severe case affecting the forearm, there will be
wasting of the forearm and hand, and clawing of the
fingers. If the wrist is passively flexed, the patient can
extend the fingers, showing that the deformity is
largely due to contracture of the forearm muscles.
Detachment of the flexors at their origin and along
the interosseous membrane in the forearm may
improve the deformity, but function is no better if
sensation and active movement are not restored. A
pedicle nerve graft, using the proximal segments of
the median and ulnar nerves may restore protective
sensation in the hand, and tendon transfers (wrist
extensors to finger and thumb flexors) will allow
active grasp. In less severe cases, median nerve sensi-
bility may be quite good and, with appropriate tendon
releases and transfers, the patient regains a consider-
able degree of function.
Ischaemia of the hand may follow forearm injuries,
or swelling of the fingers associated with a tight fore-
arm bandage or plaster. The intrinsic hand muscles
fibrose and shorten, pulling the fingers into flexion at
the metacarpophalangeal joints, but the interpha-
langeal joints remain straight. The thumb is adducted
across the palm (Bunnell’s ‘intrinsic-plus’ position).
Ischaemia of the calf muscles may follow injuries or
operations involving the popliteal artery or its divi-
sions. This is more common than is usually supposed.
The symptoms, signs and subsequent contracture are
similar to those following ischaemia of the forearm.
One of the causes of late claw-toe deformity is an
undiagnosed compartment syndrome. 721
23
FRACTURES AND JOINT INJURIES
(b)
(a) (c)
23.44 Volkmann’s ischaemia (a) Kinking of the main artery is an important cause, but intimal tears
may also lead to blockage from thrombosis. A delayed diagnosis of compartment syndrome carries the
same sorry fate. (b,c) Volkmann’s contracture of the forearm. The fingers can be straightened only
when the wrist is flexed (the constant length phenomenon). (d) Ischaemic contracture of the small
muscles of the hand. (e) Ischaemic contracture of the calf muscles with clawing of the toes.
JOINT INSTABILITY
Following injury a joint may give way. Causes include
the following:
• Ligamentous laxity – especially at the knee, ankle
and metacarpophalangeal joint of the thumb.
• Muscle weakness – especially if splintage has been
excessive or prolonged, and exercises have been
inadequate (again the knee and ankle are most
often affected).
• Bone loss – especially after a gunshot fracture or
severe compound injury, or from crushing of meta-
physeal bone in joint depression fractures.
Injury may also lead to recurrent dislocation. The
commonest sites are: (1) the shoulder – if the glenoid
labrum has been detached (a Bankart lesion) and (2)
the patella – if, after traumatic dislocation, the
restraining patellofemoral ligament heals poorly.
A more subtle form of instability is seen after frac-
tures around the wrist. Patients complaining of per-
sistent discomfort or weakness after wrist injury
should be fully investigated for chronic carpal instabil-
ity (see Chapters 15 and 25).
JOINT STIFFNESS
Joint stiffness after a fracture commonly occurs in the
knee, elbow, shoulder and (worst of all) small joints of
722 the hand. Sometimes the joint itself has been injured;
(d)
(e)
a haemarthrosis forms and leads to synovial adhesions.
More often the stiffness is due to oedema and fibrosis
of the capsule, ligaments and muscles around the
joint, or adhesions of the soft tissues to each other or
to the underlying bone. All these conditions are made
worse by prolonged immobilization; moreover, if the
joint has been held in a position where the ligaments
are at their shortest, no amount of exercise will after-
wards succeed in stretching these tissues and restoring
the lost movement completely.
In a small percentage of patients with fractures of the
forearm or leg, early post-traumatic swelling is accom-
panied by tenderness and progressive stiffness of the
distal joints. These patients are at great risk of devel-
oping a complex regional pain syndrome; whether this is
an entirely separate entity or merely an extension of the
‘normal’ post-traumatic soft-tissue reaction is uncertain.
What is important is to recognize this type of ‘stiffness’
when it occurs and to insist on skilled physiotherapy un-
til normal function is restored.
Treatment
The best treatment is prevention – by exercises that keep
the joints mobile from the outset. If a joint has to be
splinted, make sure that it is held in the ‘position of
safety’ (page 431).
Joints that are already stiff take time to mobilize, but
prolonged and patient physiotherapy can work wonders.
If the situation is due to intra-articular adhesions,
arthroscopic-guided releases may free the joint suffi-
ciently to permit a more pliant response to further ex-
ercise. Occasionally, adherent or contracted tissues need
to be released by operation (e.g. when knee flexion is
prevented by adhesions in and around the quadriceps).
COMPLEX REGIONAL PAIN SYNDROME
(ALGODYSTROPHY)
Sudeck, in 1900, described a condition characterized
by painful osteoporosis of the hand. The same condi-
tion sometimes occurs after fractures of the extremi-
ties and for many years it was called Sudeck’s atrophy.
It is now recognized that this advanced atrophic dis-
order is the late stage of a post-traumatic reflex sym-
pathetic dystrophy (also known as algodystrophy), which
is much more common than originally believed
(Atkins, 2003) and that it may follow relatively trivial
injury. Because of continuing uncertainty about its
nature, the term complex regional pain syndrome
(CRPS) has been introduced (see page 261).
Two types of CRPS are recognized:
• Type 1 –a reflex sympathetic dystrophy that devel-
ops after an injurious or noxious event.
• Type 2 – causalgia that develops after a nerve injury.
(a) (b) (c)
(d) (e)
The patient complains of continuous pain, often 23
described as ‘burning’ in character. At first there is
local swelling, redness and warmth, as well as tender-
ness and moderate stiffness of the nearby joints. As
the weeks go by the skin becomes pale and atrophic,
movements are increasingly restricted and the patient
Principles of fractures
may develop fixed deformities. X-rays characteristi-
cally show patchy rarefaction of the bone.
The earlier the condition is recognized and treat-
ment begun, the better the prognosis. Elevation and
active exercises are important after all injuries, but in
CRPS they are essential. In the early stage of the con-
dition anti-inflammatory drugs and adequate analge-
sia are helpful. Involvement of a pain specialist who
has familiarity with desensitization methods, regional
anaesthesia, and use of drugs like amitriptyline, carba-
mazepine and gabapentin may help; this, combined
with prolonged and dedicated physiotherapy, is the
mainstay of treatment.
OSTEOARTHRITIS
A fracture involving a joint may severely damage the
articular cartilage and give rise to post-traumatic
osteoarthritis within a period of months. Even if the
cartilage heals, irregularity of the joint surface may
23.45 Complex regional pain
syndrome (a) Regional osteoporosis is
common after fractures of the extremities.
The radiolucent bands seen here are
typical. (b) In algodystrophy the picture is
exaggerated and the soft tissues are also
involved: here the right foot is somewhat
swollen and the skin has become dusky,
smooth and shiny. (c) In the full-blown
case, x-rays show a typical patchy
osteoporosis. (d) Similar changes may
occur in the wrist and hand; they are
always accompanied by (e) increased
activity in the radionuclide scan.
723
23 cause localized stress and so predispose to secondary
osteoarthritis years later. If the step-off in the articu-
lar surface involves a large fragment in a joint that is
readily accessible to surgery, intra-articular
osteotomies and re-positioning of the fragment may
help. Often though the problem arises from areas that
FRACTURES AND JOINT INJURIES
were previously comminuted and depressed – little
can be done once the fracture has united.
Malunion of a metaphyseal fracture may radically
alter the mechanics of a nearby joint and this, too, can
give rise to secondary osteoarthritis. It is often
asserted that malunion in the shaft of a long bone
(e.g. the tibia) may act in a similar manner; however,
there is little evidence to show that residual angula-
tion of less than 15 degrees can cause proximal or dis-
tal osteoarthritis.
STRESS FRACTURES
A stress or fatigue fracture is one occurring in the nor-
mal bone of a healthy patient, due not to any specific
traumatic incident but to small repetitive stresses of
two main types: bending and compression.
Bending stress causes deformation and bone
responds by changing the pattern of remodelling.
With repeated stress, osteoclastic resorption exceeds
osteoblastic formation and a zone of relative weakness
develops – ultimately leading to a breach in the cor-
tex. This process affects young adults undertaking
strenuous physical routines and is probably due to
muscular forces acting on bone. Athletes in training,
dancers and military recruits build up muscle power
quickly but bone strength only slowly; this accounts
for the high incidence of stress fractures in these
groups.
Compressive stresses act on soft cancellous bone; with
frequent repetition an impacted fracture may result.
A combination of compression and shearing stresses
may account for the osteochondral fracures that char-
acterize some of the so-called osteochondritides.
‘Spontaneous fractures’ occur with even greater ease
in people with osteoporosis or osteomalacia and in
patients treated with drugs that affect bone remodel-
ling in a similar way (e.g. corticosteroids and
methotrexate). These are often referred to as insuffi-
ciency fractures.
Sites affected
Least rare are the following: shaft of humerus (ado-
lescent cricketers); pars interarticularis of fifth lumbar
vertebra (causing spondylolysis); pubic rami (inferior
in children, both rami in adults); femoral neck (at any
age); femoral shaft (chiefly lower third); patella (chil-
724 dren and young adults); tibial shaft (proximal third in
children, middle third in athletes and trainee para-
troopers, distal third in the elderly); distal shaft of the
fibula (the ‘runner’s fracture’); calcaneum (adults);
navicular (athletes) and metatarsals (especially the sec-
ond).
Clinical features
There may be a history of unaccustomed and repeti-
tive activity or one of a strenuous physical exercise
programme. A common sequence of events is: pain
after exercise – pain during exercise – pain without
exercise. Occasionally the patient presents only after
the fracture has healed and may then complain of a
lump (the callus).
The patient is usually healthy. The affected site may
be swollen or red. It is sometimes warm and usually
tender; the callus may be palpable. ‘Springing’ the
bone (attempting to bend it) is often painful.
Imaging
X-RAY
Early on, the fracture is difficult to detect, but
radioscintigraphy will show increased activity at the
painful spot. Plain x-rays taken a few weeks later may
show a small transverse defect in the cortex and/or
localized periosteal new-bone formation. These
appearances have, at times, been mistaken for those of
an osteosarcoma, a horrifying trap for the unwary.
Compression stress fractures (especially of the femoral
neck and upper tibia) may show as a hazy transverse
band of sclerosis with (in the tibia) peripheral callus.
Another typical picture is that of a small osteoartic-
ular fracture – most commonly of the dome of the
medial femoral condyle at the knee or the upper sur-
face of the talus at the ankle. Later, ischaemic necro-
sis of the detached fragment may render the lesion
even more obvious.
(a) (b)
23.46 Stress fracture (a) The stress fracture in this tibia
is only just visible on x-ray, but it had already been
suspected 2 weeks earlier when the patient first com-
plained of pain and a radioisotope scan revealed a ‘hot’
area just above the ankle (b).
 23.47 Stress fractures Stress 23
fractures are often missed or
wrongly diagnosed. (a) This tibial
fracture was at first thought to be
an osteosarcoma. (b) Stress
fractures of the pubic rami in
elderly women can be mistaken

Principles of fractures
for metastases.

(a) (b)

MRI Table 23.5 Causes of pathological fracture

The earliest changes, particularly in ‘spontaneous’
Generalized bone disease Primary malignant tumours
undisplaced osteoarticular fractures, are revealed by
MRI. This investigation should be requested in older 1. Osteogenesis imperfecta 1. Chondrosarcoma
patients (possibly with osteoporosis) complaining of 2. Postmenopausal 2. Osteosarcoma
osteoporosis 3. Ewing’s tumour
sudden onset of pain over the anteromedial part of the 3. Metabolic bone disease
knee. 4. Myelomatosis
5. Polyostotic fibrous dysplasia
6. Paget’s disease
Diagnosis
Local benign conditions Metastatic tumours
Many disorders, including osteomyelitis, scurvy and 1. Chronic infection Carcinoma in breast, lung,
battered baby syndrome, may be confused with stress 2. Solitary bone cyst kidney, thyroid, colon
fractures. The great danger, however, is a mistaken 3. Fibrous cortical defect and prostate
diagnosis of osteosarcoma; scanning shows increased 4. Chondromyxoid fibroma
uptake in both conditions and even biopsy may be 5. Aneurysmal bone cyst
6. Chondroma
misleading. 7. Monostotic fibrous dysplasia

Treatment
Most stress fractures need no treatment other than an
elastic bandage and avoidance of the painful activity
until the lesion heals; surprisingly, this can take many
months and the forced inactivity is not easily accepted
by the hard-driving athlete or dancer.
An important exception is stress fracture of the
femoral neck. This should be suspected in all elderly
people who complain of pain in the hip for which no
obvious cause can be found. If the diagnosis is con-
firmed by bone scan, the femoral neck should be
internally fixed with screws as a prophylactic measure.
PATHOLOGICAL FRACTURES
When abnormal bone gives way this is referred to as a
pathological fracture. The causes are numerous and
varied; often the diagnosis is not made until a biopsy
is examined (Table 23.5).
HISTORY
Bone that fractures spontaneously, or after trivial
injury, must be regarded as abnormal until proved
otherwise. Older patients should always be asked
about previous illnesses or operations. A malignant
tumour, no matter how long ago it occurred, may be
the source of a late metastatic lesion; a history of gas-
trectomy, intestinal malabsorption, chronic alco-
holism or prolonged drug therapy should suggest a
metabolic bone disorder.
Symptoms such as loss of weight, pain, a lump,
cough or haematuria suggest that the fracture may be
through a secondary deposit.
In younger patients, a history of several previous
fractures may suggest a diagnosis of osteogenesis
imperfecta, even if the patient does not show the clas-
sic features of the disorder. 725
23
FRACTURES AND JOINT INJURIES
(a) (b) (c)
23.48 Pathological fractures Six examples of pathological fractures, due to: (a) primary chondrosarcoma;
(b) postoperative bone infection at a screw-hole following plating of an intertrochanteric fracture; (c) Paget’s disease;
(d) vertebral metastases; (e) metastasis from carcinoma of the breast and (f) myelomatosis.
EXAMINATION
Local signs of bone disease (an infected sinus, an old
scar, swelling or deformity) should not be missed. The
site of the fracture may suggest the diagnosis: patients
with involutional osteoporosis develop fractures of the
vertebral bodies and corticocancellous junctions of
long bones; a fracture through the shaft of the bone
in an elderly patient, especially in the subtrochanteric
region, should be regarded as a pathological fracture
until proved otherwise.
General examination may be informative. Congen-
ital dysplasias, fibrous dysplasia, Cushing’ syndrome
and Paget’ disease all produce characteristic appear-
ances. The patient may be wasted (possibly due to
malignant disease). The lymph nodes or liver may be
enlarged. It should be noted whether there is a mass
in the abdomen or pelvis. Old scars should not be
overlooked and rectal and vaginal examinations are
mandatory.
Under the age of 20 the common causes of patho-
logical fracture are benign bone tumours and cysts.
Over the age of 40 the common causes are multiple
myeloma, secondary carcinoma and Paget’s disease.
X-ray
Understandably, the fracture itself attracts most atten-
tion but the surrounding bone must also be exam-
ined, and features such as cyst formation, cortical
erosion, abnormal trabeculation and periosteal thick-
ening should be sought. The type of fracture, too, is
important: vertebral compression fractures may be
due to severe osteoporosis or osteomalacia, but they
can also be caused by skeletal metastases or myeloma.
Middle-aged men, unlike women, do not normally
726 become osteoporotic: x-ray signs of bone loss and ver-
(d) (e) (f)
tebral compression in a male younger than 75 years
should be regarded as ‘pathological’ until proven
otherwise.
Additional investigations
Local radionuclide imaging may help elucidate the
diagnosis, and whole-body scanning is important in
revealing or excluding other deposits.
X-ray of other bones, the lungs and the urogenital
tract may be necessary to exclude malignant disease.
Investigations should always include a full blood
count, ESR, protein electrophoresis, and tests for
syphilis and metabolic bone disorders.
Urine examination may reveal blood from a
tumour, or Bence–Jones protein in myelomatosis.
Biopsy
Some lesions are so typical that a biopsy is unnecessary
(solitary cyst, fibrous cortical defect, Paget’s disease).
Others are more obscure and a biopsy is essential for
diagnosis. If open reduction of the fracture is indicated,
the biopsy can be carried out at the same time; other-
wise a definitive procedure should be arranged.
Treatment
The principles of fracture treatment remain the same:
reduce, hold, exercise. However the choice of method
is influenced by the condition of the bone; and the
underlying pathological disorder may need treatment
in its own right (see Chapter 9).
Generalized bone disease In most of these conditions
(including Paget’s disease) the bones fracture more
easily, but they heal quite well provided the fracture is

(a) (b)
23.49 Pathological fractures – treatment (a,b) Paget’s disease of the femur increases the brittleness of bone, making
it more likely to fracture. Intramedullary fixation allows the entire femur to be supported. (c,d) A fracture through a solitary
metastasis from a previously excised renal cell carcinoma can be resected in order to achieve cure. In this case replacement
of the proximal femur with an endoprosthesis is needed.
properly immobilized. Internal fixation is therefore
advisable (and for Paget’s disease almost essential).
Patients with osteomalacia, hyperparathyroidism, renal
osteodystrophy and Paget’s disease will need systemic
treatment as well.
Local benign conditions Fractures through benign cyst-
like lesions usually heal quite well and they should be
allowed to do so before tackling the local lesion.
Treatment is therefore the same as for simple fractures
in the same area, although in some cases it will be
necessary to take a biopsy before immobilizing the
fracture. When the bone has healed, the tumour can
be dealt with by curettage or local excision.
Primary malignant tumour The fracture may need
splinting but this is merely a prelude to definitive
treatment of the tumour, which by now will have
spread to the surrounding soft tissues. The prognosis
is almost always very poor.
Metastatic tumours Metastasis is a frequent cause of
pathological fracture in older people. Breast cancer is
the commonest source and the femur the commonest
site. Nowadays cancer patients (even those with metas-
tases) often live for several years and effective treatment
of the fracture will vastly improve their quality of life.
Fracture of a long-bone shaft should be treated by
internal fixation; if necessary the site is also packed
with acrylic cement. Bear in mind that the implant
will function as a load-bearing and not a load-sharing
device; intramedullary nails are more suitable than
plates and screws.
Fracture near a bone end can often be treated by
excision and prosthetic replacement; this is especially
true of femoral neck fractures.
23
Principles of fractures
(c) (d)
Preoperatively, imaging studies should be per-
formed to detect other bone lesions; these may be
amenable to prophylactic fixation. Once the wound
has healed, local irradiation should be applied to
reduce the risk of progressive osteolysis.
Pathological compression fractures of the spine cause
severe pain. This is due largely to spinal instability and
treatment should include operative stabilization. If
there are either clinical or imaging features of actual
or threatened spinal cord or cauda equina compres-
sion, the segment should also be decompressed. Post-
operative irradiation is given as usual.
With all types of metastatic lesion, the primary
tumour should be investigated and treated as well.
INJURIES OF THE PHYSIS
In children over 10 per cent of fractures involve
injury to the growth plate (or physis). Because the
physis is a relatively weak part of the bone, joint
strains that might cause ligament injuries in adults
are liable to result in separation of the physis in chil-
dren. The fracture usually runs transversely through
the hypertrophic or the calcified layer of the growth
plate, often veering off into the metaphysis at one of
the edges to include a triangular lip of bone. This has
little effect on longitudinal growth, which takes
place in the germinal and proliferating layers of the
physis. However, if the fracture traverses the cellular
‘reproductive’ layers of the physis, it may result in
premature ossification of the injured part and serious
disturbances of bone growth. 727
23 23.50 Battered baby
syndrome (a–c) The
fractures are not
pathological but the
family is. The
metaphyseal lesions in
each humerus are
FRACTURES AND JOINT INJURIES

characteristic.

(a) (b) (c)

Classification fractures are liable to displacement and a conse-

The most widely used classification of physeal injuries
is that of Salter and Harris (Salter and Harris, 1963),
which distinguishes five basic types of injury:
• Type 1 – A transverse fracture through the hyper-
trophic or calcified zone of the plate. Even if the
fracture is quite alarmingly displaced, the growing
zone of the physis is usually not injured and growth
disturbance is uncommon.
• Type 2 – This is essentially similar to type 1, but
towards the edge the fracture deviates away from
the physis and splits off a triangular metaphyseal
fragment of bone (sometimes referred to as the
Thurston– Holland fragment).
• Type 3 – A fracture that splits the epiphysis and then
veers off transversely to one or the other side,
through the hypertrophic layer of the physis.
Inevitably it damages the ‘reproductive’ layers of
the physis (as these layers are closer to the epiphysis
than the metaphysis) and may result in growth dis-
turbance.
• Type 4 – As with type 3, the fracture splits the epi-
physis, but it extends into the metaphysis. These
quent misfit between the separated parts of the
physis, resulting in asymmetrical growth.
• Type 5 – A longitudinal compression injury of the ph-
ysis. There is no visible fracture but the growth plate
is crushed and this may result in growth arrest.
Rang (Rang, 1969) has added a Type 6, an injury to
the perichondrial ring (the peripheral zone of Ran-
vier), which carries a significant risk of growth distur-
bance. The diagnosis is made usually in retrospect
after development of deformity.
Mechanism of injury
Physeal fractures usually result from falls or traction
injuries. They occur mostly in road accidents and dur-
ing sporting activities or playground tumbles.
Clinical features
These fractures are more common in boys than in
girls and are usually seen either in infancy or between
the ages of 10 and 12. Deformity is usually minimal,

1 2 3 4 5
23.51 Physeal injuries Type 1 – separation of the epiphysis – which usually occurs in infants but is also seen at puberty as
a slipped femoral epiphysis. Type 2 – fracture through the physis and metaphysis – is the commonest; it occurs in older
children and seldom results in abnormal growth. Type 3 – an intra-articular fracture of the epiphysis – needs accurate
reduction to restore the joint surface. Type 4 – splitting of the physis and epiphysis – damages the articular surface and may
also cause abnormal growth; if it is displaced it needs open reduction. Type 5 – crushing of the physis – may look benign
728 but ends in arrested growth.
but any injury in a child followed by pain and tender- 23
ness near the joint should arouse suspicion, and x-ray
examination is essential.

X-rays

Principles of fractures
The physis itself is radiolucent and the epiphysis may
be incompletely ossified; this makes it hard to tell
whether the bone end is damaged or deformed.
The younger the child, the smaller the ‘visible’ part of (a) (b)
the epiphysis and thus the more difficult it is to make
the diagnosis; comparison with the normal side is a
great help. Telltale features are widening of the phy-
seal ‘gap’, incongruity of the joint or tilting of the epi-
physeal axis. If there is marked displacement the
diagnosis is obvious, but even a type 4 fracture may at
first be so little displaced that the fracture line is hard
to see; if there is the faintest suspicion of a physeal
fracture, a repeat x-ray after 4 or 5 days is essential.
Types 5 and 6 injuries are usually diagnosed only in
retrospect.
(c) (d)

Treatment
Undisplaced fractures may be treated by splinting the
part in a cast or a close-fitting plaster slab for 2–4
weeks (depending on the site of injury and the age of
the child). However, with undisplaced types 3 and 4
fractures, a check x-ray after 4 days and again at about
10 days is mandatory in order not to miss late dis-
placement.
Displaced fractures should be reduced as soon as
possible. With types 1 and 2 this can usually be done
closed; the part is then splinted securely for 3–6
weeks. Types 3 and 4 fractures demand perfect
anatomical reduction. An attempt can be made to
achieve this by gentle manipulation under general
anaesthesia; if this is successful, the limb is held in a
cast for 4–8 weeks (the longer periods for type 4
injuries). If a type 3 or 4 fracture cannot be reduced
accurately by closed manipulation, immediate open
reduction and internal fixation with smooth K-wires is
essential. The limb is then splinted for 4–6 weeks, but
it takes that long again before the child is ready to
resume unrestricted activities.
Complications
Types 1 and 2 injuries, if properly reduced, have an
excellent prognosis and bone growth is not adversely
affected. Exceptions to this rule are injuries around
the knee involving the distal femoral or proximal tib-
ial physis; both growth plates are undulating in shape,
so a transverse fracture plane may actually pass
through more than just the hypertrophic zone but
also damage the proliferative zone. Complications
such as malunion or non-union may also occur if the
(e) (f)
23.52 Physeal injuries (a) Type 2 injury. The fracture
does not traverse the width of the physis; after reduction
(b) bone growth is not distorted. (c,d) This type 4 fracture
of the tibial physis was treated immediately by open
reduction and internal fixation and a good result was
obtained. (e,f) In this case accurate reduction was not
achieved and the physeal fragment remained displaced;
the end result was partial fusion of the physis and severe
deformity of the ankle.
diagnosis is missed and the fracture remains unre-
duced (e.g. fracture separation of the medial humeral
epicondyle).
Types 3 and 4 injuries may result in premature
fusion of part of the growth plate or asymmetrical
growth of the bone end. Types 5 and 6 fractures cause
premature fusion and retardation of growth. The size
and position of the bony bridge across the physis can
be assessed by tomography or magnetic resonance
imaging (MRI). If the bridge is relatively small (less
than one-third the width of the physis) it can be
excised and replaced by a fat graft, with some prospect
of preventing or diminishing the growth disturbance
(Langenskiold, 1975; 1981). However, if the bone 729
23
FRACTURES AND JOINT INJURIES
(a) (b) (c)
23.53 Langenskiold procedure for physeal arrest Small tethers across the physis can be mapped out by MRI (a,b),
then surgically removed by drilling out and curettage (c) and filling the defect with fat graft (d,e).
bridge is more extensive the operation is contraindi-
cated as it can end up doing more harm than good.
Established deformity, whether from asymmetrical
growth or from malunion of a displaced fracture (e.g.
a valgus elbow due to proximal displacement of a lat-
eral humeral condylar fracture) should be treated by
corrective osteotomy. If further growth is abnormal,
the osteotomy may have to be repeated.
INJURIES TO JOINTS
Joints are usually injured by twisting or tilting forces
that stretch the ligaments and capsule. If the force is
great enough the ligaments may tear, or the bone to
which they are attached may be pulled apart. The
articular cartilage, too, may be damaged if the joint
surfaces are compressed or if there is a fracture into
the joint.
As a general principle, forceful angulation will tear
the ligaments rather than crush the bone, but in older
people with porotic bone the ligaments may hold and
the bone on the opposite side of the joint is crushed
instead, while in children there may be a fracture-
separation of the physis.
Sprains, strains and ruptures
There is much confusion about the use of the terms
‘sprain’, ‘strain’ and ‘rupture’. Strictly speaking, a
sprain is any painful wrenching (twisting or pulling)
movement of a joint, but the term is generally
reserved for joint injuries less severe than actual tear-
ing of the capsule or ligaments. Strain is a physical
effect of stress, in this case tensile stress associated
with some stretching of the ligaments; in colloquial
usage, ‘strained ligament’ is often meant to denote
an injury somewhat more severe than a ‘sprain’,
which possibly involves tearing of some fibres. If the
730 stretching or twisting force is severe enough, the
(d) (e)
ligament may be strained to the point of complete
rupture.
STRAINED LIGAMENT
Only some of the fibres in the ligament are torn and
the joint remains stable. The injury is one in which
the joint is momentarily twisted or bent into an
abnormal position. The joint is painful and swollen
and the tissues may be bruised. Tenderness is localized
to the injured ligament and tensing the tissues on that
side causes a sharp increase in pain.
Treatment
The joint should be firmly strapped and rested until
the acute pain subsides. Thereafter, active movements
are encouraged, and exercises practised to strengthen
the muscles.
RUPTURED LIGAMENT
The ligament is completely torn and the joint is unsta-
ble. Sometimes the ligament holds and the bone to
which it is attached is avulsed; this is effectively the
same lesion but easier to deal with because the bone
fragment can be securely reattached.
As with a strain, the joint is suddenly forced into an
abnormal position; sometimes the patient actually
hears a snap. The joints most likely to be affected are
the ones that are insecure by virtue of their shape or
least well protected by surrounding muscles: the knee,
ankle and finger joints.
Pain is severe and there may be considerable bleed-
ing under the skin; if the joint is swollen, this is prob-
ably due to a haemarthrosis. The patient is unlikely to
permit a searching examination, but under general
anaesthesia the instability can be demonstrated; it is
this that distinguishes the lesion from a strain. X-ray

(a) (b) (c) (d)
23.54 Joint injuries Severe stress may cause various types of injury. (a) A ligament may rupture,
leaving the bone intact. If the soft tissues hold, the bone on the opposite side may be crushed (b), or
a fragment may be pulled off by the taut ligament (c). Subluxation (d) means the articular surfaces
are partially displaced; dislocation (e) refers to complete displacement of the joint.
may show a detached flake of bone where the liga-
ment is inserted.
Treatment
Torn ligaments heal by fibrous scarring. Previously
this was thought inevitable and the surgeon’s task was
to ensure that the torn ends were securely sutured so
as to restore the ligament to its normal length. In
some injuries, e.g. rupture of the ulnar collateral liga-
ment of the metacarpophalangeal joint of the thumb,
this approach is still valid. In others, however, it has
changed; thus, solitary medial collateral ligament rup-
tures of the knee, even complete ruptures, are often
treated non-operatively in the first instance. The joint
is splinted and local measures are taken to reduce
swelling. After 1–2 weeks, the splint is exchanged for
a functional brace that allows joint movement but at
the same time prevents repeat injury to the ligament,
especially if some instability is also present. Physio-
therapy is applied to maintain muscle strength and
later proprioceptive exercises are added. This non-
operative approach has shown better results not only
in the strength of the healed ligament but also in the
nature of healing – there is less fibrosis (Woo et al.,
2000). An exception to this non-operative approach is
when the ligament is avulsed with an attached frag-
ment of bone; reattachment of the fragment is indi-
cated if the piece is large enough. Occasionally
non-operative treatment may result in some residual
instability that is clinically detectable; often this is not
symptomatic, but if it is then surgical reconstruction
should be considered.
DISLOCATION AND SUBLUXATION
‘Dislocation’ means that the joint surfaces are com-
pletely displaced and are no longer in contact; ‘sub-
luxation’ implies a lesser degree of displacement, such
that the articular surfaces are still partly apposed.
23
Principles of fractures
(e)
Clinical features
Following an injury the joint is painful and the patient
tries at all costs to avoid moving it. The shape of the
joint is abnormal and the bony landmarks may be dis-
placed. The limb is often held in a characteristic
position; movement is painful and restricted. X-rays
will usually clinch the diagnosis; they will also show
whether there is an associated bony injury affecting
joint stability – i.e. a fracture-dislocation.
Apprehension test If the dislocation is reduced by the
time the patient is seen, the joint can be tested by
stressing it as if almost to reproduce the suspected
dislocation: the patient develops a sense of impending
disaster and violently resists further manipulation.
Recurrent dislocation If the ligaments and joint margins
are damaged, repeated dislocation may occur. This is
seen especially in the shoulder and patellofemoral joint.
Some patients acquire
Habitual (voluntary) dislocation
the knack of dislocating (or subluxating) the joint by
voluntary muscle contraction. Ligamentous laxity may
make this easier, but the habit often betrays a
manipulative and neurotic personality. It is important
to recognize this because such patients are seldom
helped by operation.
Treatment
The dislocation must be reduced as soon as possible;
usually a general anaesthetic is required, and some-
times a muscle relaxant as well. The joint is then
rested or immobilized until soft-tissue swelling
reduces – usually after 2 weeks. Controlled move-
ments then begin in a functional brace; progress with
physiotherapy is monitored. Occasionally surgical
reconstruction for residual instability is called for.
Complications
Many of the complications of fractures are seen also after
dislocations: vascular injury, nerve injury, avascular 731
23 necrosis of bone, heterotopic ossification, joint stiffness
and secondary osteoarthritis. The principles of diagno-
sis and management of these conditions have been dis-
cussed earlier.
FRACTURES AND JOINT INJURIES
REFERENCES AND FURTHER READING
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shot wounds to the extremities. Bull NYU Hosp Jt Dis
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Giordano CP, Koval KJ, Zuckerman JD, Desai P. Fracture
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Gustilo RB, Mendoza RM, Williams DN. Problems in the
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Müller M., Nazarian S, Koch P, Schatzker J. The Compre-
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of soft tissue injuries associated with fractures. In: H.
Tscherne and L. Gotzen (eds) Fractures with Soft Tissue
Injuries. Springer Verlag, Berlin, 1984.
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 Injuries of the
shoulder, upper arm
and elbow
Andrew Cole, Paul Pavlou, David Warwick
The great bugbear of upper limb injuries is stiffness –
particularly of the shoulder but sometimes of the
elbow and hand as well. Two points should be con-
stantly borne in mind:
• Whatever the injury, and however it is treated, all
the joints that are not actually immobilized – and
especially the finger joints – should be exercised
from the start.
• In elderly patients it is sometimes best to disregard the
fracture and concentrate on regaining movement.
FRACTURES OF THE CLAVICLE
In children the clavicle fractures easily, but it almost
invariably unites rapidly and without complications.
In adults this can be a much more troublesome injury.
In adults clavicle fractures are common, accounting
for 2.6–4 per cent of fractures and approximately 35 per
cent of all shoulder girdle injuries. Fractures of the mid-
shaft account for 69–82 per cent, lateral fractures for
21–28 per cent and medial fractures for 2–3 per cent.
Mechanism of injury
A fall on the shoulder or the outstretched hand may
break the clavicle. In the common mid-shaft fracture,
the outer fragment is pulled down by the weight of
the arm and the inner half is held up by the sterno-
mastoid muscle. In fractures of the outer end, if the
ligaments are intact there is little displacement; but if
the coracoclavicular ligaments are torn, or if the frac-
ture is just medial to these ligaments, displacement
may be severe and closed reduction impossible.
Clinical features
The arm is clasped to the chest to prevent movement.
A subcutaneous lump may be obvious and occasion-
ally a sharp fragment threatens the skin. Though vas-
cular complications are rare, it is prudent to feel the
24
pulse and gently to palpate the root of the neck.
Outer third fractures are easily missed or mistaken for
acromioclavicular joint injuries.
Imaging
Radiographic analysis requires at least an anteroposte-
rior view and another taken with a 30 degree cephalic
tilt. The fracture is usually in the middle third of the
bone, and the outer fragment usually lies below the
inner. Fractures of the outer third may be missed, or
the degree of displacement underestimated, unless
additional views of the shoulder are obtained. With
medial third fractures it is also wise to obtain x-rays of
the sterno-clavicular joint. In assessing clinical
progress, remember that ‘clinical’ union usually pre-
cedes ‘radiological’ union by several weeks.
CT scanning with three-dimensional reconstruc-
tions may be needed to determine accurately the
degree of shortening or for diagnosing a sterno-
clavicular fracture-dislocation, and also to establish
whether a fracture has united.
Classification
Clavicle fractures are usually classified on the basis of
their location: Group I (middle third fractures),
Group II (lateral third fractures) and Group III
(medial third fractures). Lateral third fractures can be
further sub-classified into (a) those with the coraco-
clavicular ligaments intact, (b) those where the cora-
coclavicular ligaments are torn or detached from the
medial segment but the trapezoid ligament remains
intact to the distal segment, and (c) factures which are
intra-articular. An even more detailed classification
proposed by Robinson (1998) is useful for managing
data and comparing clinical outcomes.
Treatment
MIDDLE THIRD FRACTURES
There is general agreement that undisplaced fractures
should be treated non- operatively. Most will go on to
24
FRACTURES AND JOINT INJURIES
(a)
(b)
24.1 Fracture of the clavicle (a) Displaced fracture of
the middle third of the clavicle – the most common injury.
(b) The fracture usually unites in this position, leaving a
barely noticable ‘bump’.
unite uneventfully with a non-union rate below 5 per
cent and a return to normal function.
Non-operative management consists of applying a
simple sling for comfort. It is discarded once the pain
subsides (between 1–3 weeks) and the patient is then
encouraged to mobilize the limb as pain allows. There
(a)
(b)
24.2 Severely displaced fracture (a) A comminuted
fracture which united in this position (b) leaving an
unsightly deformity (c). This fracture would have been bet-
734 ter managed by (d) open reduction and internal fixation.
is no evidence that the traditional figure-of-eight
bandage confers any advantage and it carries the risk
of increasing the incidence of pressures sores over the
fracture site and causing harm to neurological struc-
tures; it may even increase the risk of non-union.
There is less agreement about the management of
displaced middle third fractures. Treating those with
shortening of more than 2 cm by simple splintage is
now believed to incur a considerable risk of sympto-
matic mal-union – mainly pain and lack of power dur-
ing shoulder movements (McKee et al., 2006) – and
an increased incidence of non-union. There is, there-
fore, a growing trend towards internal fixation of
acute clavicular fractures associated with severe dis-
placement. Methods include plating (specifically con-
toured locking plates are available) and intramedullary
fixation.
LATERAL THIRD FRACTURES
Most lateral clavicle fractures are minimally displaced
and extra-articular. The fact that the coracoclavicular
ligaments are intact prevents further displacement and
non-operative management is usually appropriate.
Treatment consists of a sling for 2–3 weeks until the
pain subsides, followed by mobilization within the
limits of pain.
Displaced lateral third fractures are associated with
disruption of the coracoclavicular ligaments and are
therefore unstable injuries. A number of studies have
shown that these particular fractures have a higher
than usual rate of non-union if treated non-opera-
tively. Surgery to stabilize the fracture is often recom-
(c)
(d)

(a)
(b)
24.3 Fracture of the outer (lateral) third (a) The shaft
of the clavicle is elevated, suggesting that the medial part
of the coracoclavicular ligament is ruptured. (b) This was
treated by open reduction and internal fixation, using a
long screw to fix the clavicle to the coracoid process tem-
porarily while the soft tissues healed.
mended. However the converse argument is that
many of the fractures that develop non-union do not
cause any symptoms and surgery can therefore be
reserved for patients with symptomatic non-union.
Operations for these fractures have a high complica-
tion rate and no single procedure has been shown to
be better than the others. Techniques include the use
of a coracoclavicular screw, plate and hook plate fixa-
tion and suture and sling techniques with Dacron
graft ligaments.
MEDIAL THIRD FRACTURES
Most of these rare fractures are extra-articular. They
are mainly managed non-operatively unless the frac-
ture displacement threatens the mediastinal struc-
tures. Initial fixation is associated with significant
complications, including migration of the implants
into the mediastinum, particularly when K-wires are
used. Other methods of stabilization include suture
and graft techniques and the newer locking plates.
Complications
EARLY
Despite the close proximity of the clavicle to vital
structures, a pneumothorax, damage to the subclavian
vessels and brachial plexus injuries are all very rare.
LATE 24
Non-union In displaced fractures of the shaft non-
union occurs in 1–15 per cent. Risk factors include in-
creasing age, displacement, comminution and female
sex. However accurate prediction of those fractures
most likely to go on to non-union remains difficult.
Injuries of the shoulder, upper arm and elbow
Symptomatic non-unions are generally treated with
plate fixation and bone grafting if necessary. This
procedure usually produces a high rate of union and
satisfaction.
Lateral clavicle fractures have a higher rate of non-
union (11.5–40 per cent). Treatment options for symp-
tomatic non-unions are excision of the lateral part of
the clavicle (if the fragment is small and the coraco-
clavicular ligaments are intact) or open reduction, in-
ternal fixation and bone grafting if the fragment is
large. Locking plates and hooked plates are used.
Malunion All displaced fractures heal in a non-
anatomical position with some shortening and
angulation, however most do not produce symptoms.
Some may go on to develop periscapular pain and this
is more likely with shortening of more than 1.5cm. In
these circumstances the difficult operation of corrective
osteotomy and plating can be considered.
Stiffness of the shoulder This is common but
temporary; it results from fear of moving the fracture.
Unless the fingers are exercised, they also may become
stiff and take months to regain movement.
FRACTURES OF THE SCAPULA
Mechanisms of injury
The body of the scapula is fractured by a crushing
force, which usually also fractures ribs and may dislo-
cate the sternoclavicular joint. The neck of the scapula
may be fractured by a blow or by a fall on the shoul-
der; the attached long head of triceps may drag the
glenoid downwards and laterally. The coracoid
process may fracture across its base or be avulsed at
the tip. Fracture of the acromion is due to direct
force. Fracture of the glenoid fossa usually suggests a
medially directed force (impaction of the joint) but
may occur with dislocation of the shoulder.
Clinical features
The arm is held immobile and there may be severe
bruising over the scapula or the chest wall. Because of
the energy required to damage the scapula, fractures
of the body of the scapula are often associated with
severe injuries to the chest, brachial plexus, spine,
abdomen and head. Careful neurological and vascular
examinations are essential. 735
24 X-Ray
Scapular fractures can be difficult to define on plain x-
rays because of the surrounding soft tissues. The films
may reveal a comminuted fracture of the body of the
scapula, or a fractured scapular neck with the outer
FRACTURES AND JOINT INJURIES

fragment pulled downwards by the weight of the arm.

Occasionally a crack is seen in the acromion or the
coracoid process. CT is useful for demonstrating
glenoid fractures or body fractures.
Type I Type II

Classification
Fractures of the scapula are divided anatomically into
scapular body, glenoid neck, glenoid fossa, acromion
and coracoid processes. Scapular neck fractures are the
most common. Further subdivisions are shown in
Table 24.1.

Table 24.1

Fractures of the scapular body Type III Type IV

Fractures of the glenoid neck

Intra-articular glenoid fossa fractures (Ideberg modified

by Goss)
Type I Fractures of the glenoid rim
Type II Fractures through the glenoid fossa, inferior fragment
displaced with subluxed humeral head
Type III Oblique fracture through glenoid exiting superiorly (may
be associated with acromioclavicular dislocation or fracture)
Type IV Horizontal fracture exiting through the medial border of
Type V Type VI
the scapula
24.4 Fractures of the glenoid – classification Dia-
Type V Combination of Type IV and a fracture separating the
grams showing the main types of glenoid fracture.
inferior half of the glenoid
Type VI Severe comminution of the glenoid surface

Fractures of acromion process Intra-articular fractures Type I glenoid fractures, if

Type I Minimally displaced
Type II Displaced but not reducing subacromial space
Type III Inferior displacement and reduced subacromial space
Fractures of coracoid process
Type I Proximal to attachment of the coracoclavicular ligaments
and usually associated with acromioclavicular separation
Type II Distal to the coraco-acromial ligaments
Treatment
Body fractures Surgery is not necessary. The patient
wears a sling for comfort, and from the start practises
active exercises to the shoulder, elbow and fingers.
The fracture is usually
Isolated glenoid neck fractures
impacted and the glenoid surface is intact. A sling is
736 worn for comfort and early exercises are begun.
displaced, may result in instability of the shoulder. If
the fragment involves more than a third of the glenoid
surface and is displaced by more than 5 mm surgical
fixation should be considered. Anterior rim fractures
are approached through a delto-pectoral incision and
posterior rim fractures through the posterior approach.
Type II fractures are associated with inferior
subluxation of the head of the humerus and require
open reduction and internal fixation. Types III, IV, V
and VI fractures have poorly defined indications for
surgery. Generally speaking, if the head is centred on
the major portion of the glenoid and the shoulder is
stable a non-operative approach is adopted.
Comminuted fractures of the glenoid fossa are likely
to lead to osteoarthritis in the longer term.
Fractures of the acromion Undisplaced fractures are
treated non-operatively. Only Type III acromial
fractures, in which the subacromial space is reduced,
require operative intervention to restore the anatomy.

(a) (b)
Fractures of the coracoid process Fractures distal to the
coracoacromial ligaments do not result in serious
anatomical displacement; those proximal to the
ligaments are usually associated with acromioclavicular
separations and may need operative treatment.
Combined fractures Whereas an isolated fracture of
the glenoid neck is stable, if there is an associated
fracture of the clavicle or disruption of the acromio-
clavicular ligament the glenoid mass may become
markedly displaced giving rise to a ‘floating shoulder’
(Williams et al, 2001). Diagnosis can be difficult and
may require advanced imaging and three-dimensional
reconstructions. At least one of the injuries (and
sometimes both) will need operative fixation before
the fragments are stabilized.
SCAPULOTHORACIC DISSOCIATION
This is a high energy injury. The scapula and arm are
wrenched away from the chest, rupturing the subcla-
vian vessels and brachial plexus. Many patients die.
Clinical features
The limb is flail and ischaemic. The diagnosis is usu-
ally made on the chest x-ray. There is swelling above
the clavicle from an expanding haematoma. A distrac-
tion of more than 1 cm of a fractured clavicle should
give rise to suspicion of this injury.
(a) (b)
24.6 Acromioclavicular joint injuries (a) Normal joint. (b) Sprained acromioclavicular joint; no displacement. (c) Torn
capsule and subluxation but coracoclavicular ligaments intact. (d) Dislocation with torn coracoclavicular ligaments.
24.5 Glenoid fracture – 24
imaging (a) Three-dimen-
tional CT of a Type II glenoid
fracture.
(b) X-ray after open reduction
and internal fixation.
Injuries of the shoulder, upper arm and elbow
Treatment
The patient is resuscitated. The outcome for the
upper limb is very poor. Neither vascular reconstruc-
tion nor brachial plexus exploration and repair are
likely to give a functional limb.
ACROMIOCLAVICULAR JOINT
INJURIES
Acute injury of the acromioclavicular joint is common
and usually follows direct trauma. Chronic sprains,
often associated with degenerative changes, are seen
in people engaged in athletic activities like weightlift-
ing or occupations such as working with jack-ham-
mers and other heavy vibrating tools.
Mechanism of injury
A fall on the shoulder with the arm adducted may strain
or tear the acromioclavicular ligaments and upward
subluxation of the clavicle may occur; if the force is
severe enough, the coracoclavicular ligaments will also
be torn, resulting in complete dislocation of the joint.
Pathological anatomy and classification
The injury is graded according to the type of ligament
injury and the amount of displacement of the joint.
(c) (d)
737
24
FRACTURES AND JOINT INJURIES
(a) (b)
24.7 Acromioclavicular dislocation (a) Clinically one
sees a definite ‘step’ in the contour at the lateral end of
the clavicle. (b) The x-ray shows complete separation of
the acromioclavicular joint.
Type I is an acute sprain of the acromioclavicular liga-
ments; the joint is undisplaced. In Type II the acromio-
clavicular ligaments are torn and the joint is subluxated
with slight elevation of the clavicle. In Type III the
acromioclavicular and coracoclavicular ligaments are
torn and the joint is dislocated; the clavicle is elevated
(or the acromion depressed) creating a visible and
palpable ‘step’. Other types of displacement are less
common, but occasionally the clavicle is displaced pos-
teriorly (Type IV), very markedly upwards (Type V) or
inferiorly beneath the coracoid process (Type VI).
Clinical features
The patient can usually point to the site of injury and
the area may be bruised. If there is tenderness but no
deformity, the injury is probably a sprain or a sublux-
ation. With dislocation the patient is in severe pain
and a prominent ‘step’ can be seen and felt. Shoulder
movements are limited.
X-ray
The acromioclavicular joint is not always easily visual-
ized; anteroposterior, cephalic tilt and axillary views
are advisable. In addition, a stress view is sometimes
helpful in distinguishing between a Type II and Type
III injury: this is an anteroposterior x-ray including
both shoulders with the patient standing upright,
arms by the side and holding a 5 kg weight in each
hand. The distance between the coracoid process and
the inferior border of the clavicle is measured on each
side; a difference of more than 50 per cent is diagnos-
tic of acromioclavicular dislocation.
Treatment
Sprains and subluxations do not affect function and
do not require any special treatment; the arm is rested
in a sling until pain subsides (usually no more than a
week) and shoulder exercises are then begun.
Dislocations are poorly controlled by padding and
bandaging, yet the role of surgery is controversial.
738 The large number of operations suggests that none is
ideal. There is no convincing evidence that surgery
provides a better functional result than conservative
treatment for a straightforward Type III injury. Oper-
ative repair should be considered only for patients
with extreme prominence of the clavicle, those with
posterior or inferior dislocation of the clavicle and
those who aim to resume strenuous overarm or over-
head activities.
Whilst there is no consensus regarding the best sur-
gical solution, there are a number of underlying prin-
ciples to consider if surgery is contemplated. Accurate
reduction should be the goal. The ligamentous stabil-
ity can be recreated either by transferring existing lig-
aments (the coracoacromial or conjoined tendons), or
by using a free graft (e.g., autogenous semitendinosis
or a synthetic ligament). This reconstruction must
have sufficient stability to prevent re-dislocation dur-
ing recovery. Any rigid implants which cross the joint
will need to be removed at a later date to prevent
loosening or fracture.
In the modified Weaver–Dunn procedure the lateral
end of the clavicle is excised and the coracoacromial
ligament is transferred to the outer end of the clavicle
and attached by trans-osseous sutures. Tension on the
repair can be reduced either by anchoring the clavicle
to the coracoid with a Bosworth coracoclavicular screw
(which has to be removed after 8 weeks) or by em-
ploying a Dacron sling – looped round the coracoid
and the clavicle – for the same purpose. Great care is
needed to avoid entrapment or damage to a nerve or
vessel. Elbow and forearm exercises are begun on the
day after operation and active-assisted shoulder move-
ments 2 weeks later, increasing gradually to active
movements at 4–6 weeks. Strenuous lifting movements
are avoided for 4–6 months.
Recent advances in instrumentation have made it
24.8 Modified Weaver Dunn operation The lateral
end of the clavicle is excised; the acromial end of the
coracoacromial ligament is detached and fastened to the
lateral end of the clavicle. Tension on the ligament is
lessened by placing a ‘sling’ around the clavicle and the
coracoid process. (Dotted lines show former position of
coracoacromial ligament).
feasible to perform this type of reconstructive surgery
arthroscopically (Snow and Funk, 2006).
Complications
Rotator cuff syndrome An acute strain of the acromio-
clavicular joint is sometimes followed by supraspinatus
tendinitis. Whether this is directly due to the primary
injury or whether it results from post-traumatic
oedema or inflammation of the overlying acromio-
clavicular joint is unclear. Treatment with
anti-inflammatory preparations may help.
Unreduced dislocation An unreduced dislocation is ugly
and sometimes affects function. Simple excision of the
distal clavicle will only make matters worse. An attempt
should be made to reconstruct the coracoclavicular
ligament. The Weaver–Dunn procedure may be
suitable (See Figure 24.8).
Ossification of the ligamentsThe more severe injuries
are quite often followed by ossification of the coraco-
clavicular ligaments. Bony spurs may predispose to
later rotator cuff dysfunction, which may require
operative treatment.
Secondary osteoarthritis A late complication of Type I
and II injuries is osteoarthritis of the acromioclavicular
joint. This can usually be managed conservatively, but
if pain is marked the outer 2 cm of the clavicle can be
excised. The patient will be aware of some weakness
during strenuous over-arm activities and pain is often
not completely abolished.
STERNOCLAVICULAR DISLOCATIONS
Mechanism of injury
This uncommon injury is usually caused by lateral
compression of the shoulders; for example, when
someone is pinned to the ground following a road
accident or an underground rock-fall. Rarely, it fol-
(a) (b)
24.9 Sternoclavicular dislocation (a) The bump over
the sternoclavicular joint may be obvious, though this is
difficult to demonstrate on plain x-ray. (b) Tomography (or,
better still, CT) will show the lesion.
lows a direct blow to the front of the joint. Anterior 24
dislocation is much more common than posterior.
The joint can be sprained, subluxed or dislocated.
Clinical features
Injuries of the shoulder, upper arm and elbow
Anterior dislocation is easily diagnosed; the dislocated
medial end of the clavicle forms a prominent bump
over the sternoclavicular joint. The condition is
painful but there are usually no cardiothoracic com-
plications.
Posterior dislocation, though rare, is much more
serious. Discomfort is marked; there may be pressure
on the trachea or large vessels, causing venous con-
gestion of the neck and arm and circulation to the arm
may be decreased.
X-Ray
Because of overlapping shadows, plain x-rays are diffi-
cult to interpret. Special oblique views are helpful and
CT is the ideal method.
Treatment
Sprains and subluxations do not require specific treat-
ment.
Anterior dislocation can usually be reduced by
exerting pressure over the clavicle and pulling on the
arm with the shoulder abducted. However, the joint
usually redislocates. Not that this matters much; full
function will be regained, though this may take sev-
eral months.
Internal fixation is unnecessary and very dangerous
(because of the large vessels behind the sternum).
Posterior dislocation should be reduced as soon as
possible. This can usually be done closed (if necessary
under general anaesthesia) by lying the patient supine
with a sandbag between the scapulae and then pulling
on the arm with the shoulder abducted and extended.
The joint reduces with a snap and stays reduced. If
this manoeuvre fails, the medial end of the clavicle is
grasped with bone forceps and pulled forwards. If this
too, fails (a very rare occurrence) open reduction is
justified, but great care must be taken not to damage
the mediastinal structures. After reduction, the shoul-
ders are braced back with a figure-of-eight bandage,
which is worn for 3 weeks.
DISLOCATION OF THE SHOULDER
Of the large joints, the shoulder is the one that most
commonly dislocates. This is due to a number of
factors: the shallowness of the glenoid socket; the
extraordinary range of movement; underlying condi- 739
24 tions such as ligamentous laxity or glenoid dysplasia;
and the sheer vulnerability of the joint during stress-
ful activities of the upper limb.
In this chapter, acute anterior and posterior dislo-
cations are described. Chronic instability is described
in Chapter 13.
FRACTURES AND JOINT INJURIES
ANTERIOR DISLOCATION
Mechanism of injury
Dislocation is usually caused by a fall on the hand.
The head of the humerus is driven forward, tearing
the capsule and producing avulsion of the glenoid
labrum (the Bankart lesion). Occasionally the pos-
terolateral part of the head is crushed. Rarely, the
acromion process levers the head downwards and the
joint dislocates with the arm pointing upwards (luxa-
tio erecta); nearly always the arm then drops, bringing
the head to its subcoracoid position.
Clinical features
Pain is severe. The patient supports the arm with the
opposite hand and is loathe to permit any kind of
examination. The lateral outline of the shoulder may
be flattened and, if the patient is not too muscular, a
bulge may be felt just below the clavicle. The arm
must always be examined for nerve and vessel injury
before reduction is attempted.
X-Ray
The anteroposterior x-ray will show the overlapping
shadows of the humeral head and glenoid fossa, with
the head usually lying below and medial to the socket.
(a) (b)
24.10 Anterior dislocation of the shoulder (a) The prominent acromion process and flattening of the contour over
740 the deltoid are typical signs. (b) X-ray confirms the diagnosis of anterior dislocation. (c,d) Two methods of reduction.
A lateral view aimed along the blade of the scapula
will show the humeral head out of line with the
socket.
If the joint has dislocated before, special views may
show flattening or an excavation of the posterolateral
contour of the humeral head, where it has been
indented by the anterior edge of the glenoid socket,
the Hill–Sachs lesion.
Treatment
Various methods of reduction have been described,
some of them now of no more than historical interest.
In a patient who has had previous dislocations, simple
traction on the arm may be successful. Usually,
sedation and occasionally general anaesthesia is
required.
With Stimson’s technique, the patient is left prone
with the arm hanging over the side of the bed. After
15 or 20 minutes the shoulder may reduce.
In the Hippocratic method, gently increasing trac-
tion is applied to the arm with the shoulder in slight
abduction, while an assistant applies firm counter-
traction to the body (a towel slung around the
patient’s chest, under the axilla, is helpful).
With Kocher’s method, the elbow is bent to 90°
and held close to the body; no traction should be
applied. The arm is slowly rotated 75 degrees laterally,
then the point of the elbow is lifted forwards, and
finally the arm is rotated medially. This technique car-
ries the risk of nerve, vessel and bone injury and is not
recommended.
Another technique has the patient sitting on a
reduction chair and with gentle traction of the arm
over the back of the padded chair the dislocation is
reduced.
An x-ray is taken to confirm reduction and exclude
(c)
(d)
a fracture. When the patient is fully awake, active
abduction is gently tested to exclude an axillary nerve
injury and rotator cuff tear. The median, radial, ulnar
and musculocutaneous nerves are also tested and the
pulse is felt.
The arm is rested in a sling for about three weeks in
those under 30 years of age (who are most prone to
recurrence) and for only a week in those over 30 (who
are most prone to stiffness). Then movements are
begun, but combined abduction and lateral rotation
must be avoided for at least 3 weeks. Throughout this
period, elbow and finger movements are practised
every day.
There has been some interest in the use of external
rotation splints, based on the theory that this would
reduce the Bankart lesion into a better position for
healing. However a recent Cochrane review has con-
cluded that there is insufficient evidence to inform on
the choices for conservative treatment and that fur-
ther trials are needed to compare different types and
duration of immobilization.
Young athletes who dislocate their shoulder trau-
matically and who continue to pursue their sports
(particularly contact sports) are at a much higher risk
of re-dislocation in the future. With increasing
advances and techniques of arthroscopy and arthro-
scopic anterior stabilization surgery, some are now
advocating early surgery in this group of patients to
repair the Bankart lesion of the anterior labrum.
However a consensus on early surgery has still not
been reached.
Complications
EARLY
Rotator cuff tear This commonly accompanies anterior
dislocation, particularly in older people. The patient
may have difficulty abducting the arm after reduction;
palpable contraction of the deltoid muscle excludes an
axillary nerve palsy. Most do not require surgical
attention, but young active individuals with large tears
will benefit from early repair.
Nerve injury The axillary nerve is most commonly
injured; the patient is unable to contract the deltoid
muscle and there may be a small patch of anaesthesia
over the muscle. The inability to abduct must be
distinguished from a rotator cuff tear. The nerve lesion
is usually a neuropraxia which recovers spontaneously
after a few weeks; if it does not, then surgery should be
considered as the results of repair are less satisfactory if
the delay is more than a few months.
Occasionally the radial nerve, musculocutaneous
nerve, median nerve or ulnar nerve can be injured.
Rarely there is a complete infra-clavicular brachial
plexus palsy. This is somewhat alarming, but fortu-
nately it usually recovers with time.
24
Injuries of the shoulder, upper arm and elbow
(a) (b)
24.11 Anterior fracture-discloation Anterior disloca-
tion of the shoulder may be complicated by fracture of (a)
the greater tuberosity or (b) the neck of the humerus –
this often needs open reduction and internal fixation.
Vascular injury The axillary artery may be damaged,
particularly in old patients with fragile vessels. This can
occur either at the time of injury or during overzealous
reduction. The limb should always be examined for
signs of ischaemia both before and after reduction.
Fracture-dislocation If there is an associated fracture of
the proximal humerus, open reduction and internal
fixation may be necessary. The greater tuberosity may
be sheared off during dislocation. It usually falls into
place during reduction, and no special treatment is
then required. If it remains displaced, surgical
reattachment is recommended to avoid later
subacromial impingement.
LATE
Shoulder stiffness Prolonged immobilization may lead
to stiffness of the shoulder, especially in patients over
the age of 40. There is loss of lateral rotation, which
automatically limits abduction. Active exercises will
usually loosen the joint. They are practised vigorously,
bearing in mind that full abduction is not possible until
lateral rotation has been regained. Manipulation under
anaesthesia or arthroscopic capsular release is advised
only if progress has halted and at least 6 months have
elapsed since injury.
Unreduced dislocation Surprisingly, a dislocation of the
shoulder sometimes remains undiagnosed. This is
more likely if the patient is either unconscious or very
old. Closed reduction is worth attempting up to 6
weeks after injury; manipulation later may fracture the
bone or tear vessels or nerves. Operative reduction is
indicated after 6 weeks only in the young, because it is
difficult, dangerous and followed by prolonged
stiffness. An anterior approach is used, and the vessels
and nerves are carefully identified before the
dislocation is reduced. ‘Active neglect’ summarizes the
treatment of unreduced dislocation in the elderly. The
dislocation is disregarded and gentle active movements
are encouraged. Moderately good function is often
regained. 741
24 24.12 Recurrent dislocation
of the shoulder (a) The
classic x-ray sign is a depres-
sion in the posterosuperior part
of the humeral head (the Hill-
Sachs lesion). (b,c) MRI scans
showing both the Hill–Sachs
FRACTURES AND JOINT INJURIES

lesion and a Bankart lesion of

the glenoid rim (arrows).

(a) (b) (c)

Recurrent dislocation If an anterior dislocation tears a direct blow to the front of the shoulder or a fall on
the shoulder capsule, repair occurs spontaneously fol- the outstretched hand.
lowing reduction and the dislocation may not recur;
but if the glenoid labrum is detached, or the capsule
Clinical features
is stripped off the front of the neck of the glenoid,
repair is less likely and recurrence is more common. The diagnosis is frequently missed – partly because
Detachment of the labrum occurs particularly in reliance is placed on a single anteroposterior x-ray
young patients, and, if at injury a bony defect has (which may look almost normal) and partly because
been gouged out of the posterolateral aspect of the those attending to the patient fail to think of it. There
humeral head, recurrence is even more likely. In older are, in fact, several well-marked clinical features. The
patients, especially if there is a rotator cuff tear or arm is held in internal rotation and is locked in that
greater tuberosity fracture, recurrent dislocation is position. The front of the shoulder looks flat with a
unlikely. The period of post-operative immobilization prominent coracoid, but swelling may obscure this
makes no difference. deformity; seen from above, however, the posterior
The history is diagnostic. The patient complains displacement is usually apparent.
that the shoulder dislocates with relatively trivial
everyday actions. Often he can reduce the dislocation
himself. Any doubt as to diagnosis is quickly resolved
X-Ray
by the apprehension test: if the patient’s arm is pas- In the anteroposterior film the humeral head, because
sively placed behind the coronal plane in a position of it is medially rotated, looks abnormal in shape (like an
abduction and lateral rotation, his immediate resist-
ance and apprehension are pathognomonic. An
anteroposterior x-ray with the shoulder medially
rotated may show an indentation in the back of the
humeral head (the Hill–Sachs lesion).
Even more common, but less readily diagnosed, is
recurrent subluxation. The management of both types
of instability is dealt with in Chapter 13.

POSTERIOR DISLOCATION OF THE

SHOULDER

Posterior dislocation is rare, accounting for less than 2

per cent of all dislocations around the shoulder.

Mechanism of injury
Indirect force producing marked internal rotation and
adduction needs be very severe to cause a dislocation.
This happens most commonly during a fit or convul-
sion, or with an electric shock. Posterior dislocation
742 can also follow a fall on to the flexed, adducted arm,
24.13 Posterior dislocation of the shoulder The
characteristic x-ray image. Because the head of the
humerus is internally rotated, the anteroposterior x-ray
shows a head-on projection giving the classic ‘electric
light-bulb’ appearance.
electric light bulb) and it stands away somewhat from
the glenoid fossa (the ‘empty glenoid’ sign). A lateral
film and axillary view is essential; it shows posterior
subluxation or dislocation and sometimes a deep
indentation on the anterior aspect of the humeral
head. Posterior dislocation is sometimes complicated
by fractures of the humeral neck, posterior glenoid
rim or lesser tuberosity. Sometimes the patient is too
uncomfortable to permit adequate imaging and in
these difficult cases CT is essential to rule out poste-
rior dislocation of the shoulder.
Treatment
The acute dislocation is reduced (usually under gen-
eral anaesthesia) by pulling on the arm with the shoul-
der in adduction; a few minutes are allowed for the
head of the humerus to disengage and the arm is then
gently rotated laterally while the humeral head is
pushed forwards. If reduction feels stable the arm is
immobilized in a sling; otherwise the shoulder is held
widely abducted and laterally rotated in an airplane
type splint for 3–6 weeks to allow the posterior
capsule to heal in the shortest position. Shoulder
movement is regained by active exercises.
Complications
Unreduced dislocation At least half the patients with
posterior dislocation have ‘unreduced’ lesions when
first seen. Sometimes weeks or months elapse before
the diagnosis is made and up to two thirds of poste-
rior dislocations are not recognised initially. Typically
the patient holds the arm internally rotated; he cannot
abduct the arm more than 70–80 degrees, and if he
lifts the extended arm forwards he cannot then turn
the palm upwards. If the patient is young, or is
uncomfortable and the dislocation fairly recent, open
reduction is indicated. This is a difficult procedure. It
is generally done through a delto-pectoral approach;
the shoulder is reduced and the defect in the humeral
head can then be treated by transferring the sub-
scapularis tendon into the defect (McLaughlin proce-
dure). Alternatively, the defect on the humeral head
can be bone grafted. A useful technique for treating a
defect smaller than 40 per cent of the humeral head is
to transfer of the lesser tuberosity together with the
subscapularis into the defect. For defects larger than
this a hemiarthroplasty may be considered.
Late dislocations, especially in the elderly, are best
left, but movement is encouraged.
Recurrent dislocation or subluxation Chronic posterior
instability of the shoulder is discussed in Chapter
13.
24
INFERIOR DISLOCATION OF THE
SHOULDER (LUXATIO ERECTA)
Inferior dislocation is rare but it demands early recog-
nition because the consequences are potentially very
Injuries of the shoulder, upper arm and elbow
serious. Dislocation occurs with the arm in nearly full
abduction/elevation. The humeral head is levered out
of its socket and pokes into the axilla; the arm remains
fixed in abduction.
Mechanism of injury and pathology
The injury is caused by a severe hyper-abduction
force. With the humerus as the lever and the
acromion as the fulcrum, the humeral head is lifted
across the inferior rim of the glenoid socket; it
remains in the subglenoid position, with the humeral
shaft pointing upwards. Soft-tissue injury may be
severe and includes avulsion of the capsule and sur-
rounding tendons, rupture of muscles, fractures of the
glenoid or proximal humerus and damage to the
brachial plexus and axillary artery.
Clinical features
The startling picture of a patient with his arm locked
in almost full abduction should make diagnosis quite
easy. The head of the humerus may be felt in or below
the axilla. Always examine for neurovascular damage.
X-ray
The humeral shaft is shown in the abducted position
with the head sitting below the glenoid. It is impor-
tant to search for associated fractures of the glenoid or
proximal humerus.
NOTE: True inferior dislocation must not be con-
fused with postural downward displacement of the
humerus, which results quite commonly from weak-
ness and laxity of the muscles around the shoulder,
especially after trauma and shoulder splintage; here
24.14 Inferior dislocation
of the shoulder You can
see why the condition is
called luxatio erecta. The
shaft of the humerus points
upwards and the humeral
head is displaced down-
wards.
743
24 the shaft of the humerus lies in the normal anatomical
position at the side of the chest. The condition is
harmless and resolves as muscle tone is regained.
Treatment
FRACTURES AND JOINT INJURIES
Inferior dislocation can usually be reduced by pulling
upwards in the line of the abducted arm, with
counter-traction downwards over the top of the
shoulder. If the humeral head is stuck in the soft tis-
sues, open reduction is needed. It is important to
examine again, after reduction, for evidence of neu-
rovascular injury.
The arm is rested in a sling until pain subsides and
movement is then allowed, but avoiding abduction
for 3 weeks to allow the soft tissues to heal.
SHOULDER DISLOCATIONS IN
CHILDREN
Traumatic dislocation of the shoulder is exceedingly
rare in children. Children who give a history of the
shoulder ‘slipping out’ almost invariably have either
voluntary or involuntary (atraumatic) dislocation or
subluxation. With voluntary dislocation, the child can
demonstrate the instability at will. With involuntary
dislocation, the shoulder slips out unexpectedly dur-
ing everyday activities. Most of these children have
generalized joint laxity and some have glenoid dyspla-
sia or muscle patterning disorders (Chapter 13).
Examination may show that the shoulder subluxates
in almost any direction; x-rays may confirm the diag-
nosis.
Treatment
Atraumatic dislocation should be viewed with great
caution. Some of these children have behavioural or
muscle patterning problems and this is where treat-
2 2
3 3
4 proximal humerus, showing the
4 four main fragments, two or
1 there is a sizeable medial calcar
1
744 (a) (b)
ment should be directed. A prolonged exercise pro-
gramme may also help. Only if the child is genuinely
distressed by the disorder, and provided psychological
factors have been excluded, should one consider
reconstructive surgery.
FRACTURES OF THE PROXIMAL
HUMERUS
Fractures of the proximal humerus usually occur after
middle age and most of the patients are osteoporotic,
postmenopausal women. Fracture displacement is
usually not marked and treatment presents few prob-
lems. However, in about 20 per cent of cases there is
considerable displacement of one or more fragments
and a significant risk of complications due to bone
fragility, damage to the rotator cuff and the prevailing
co-morbidities. Deciding between operative and non-
operative treatment can be very difficult.
Mechanism of injury
Fracture usually follows a fall on the out-stretched
arm – the type of injury which, in younger people,
might cause dislocation of the shoulder. Sometimes,
indeed, there is both a fracture and a dislocation.
Classification and pathological anatomy
The most widely accepted classification is that of Neer
(1970) who drew attention to the four major seg-
ments involved in these injuries: the head of the
humerus, the lesser tuberosity, the greater tuberosity
and the shaft. Neer’s classification distinguishes
between the number of displaced fragments, with dis-
placement defined as greater than 45 degrees of angu-
lation or 1 cm of separation. Thus, however many frac-
ture lines there are, if the fragments are undisplaced it
is regarded as a one-part fracture; if one segment is sep-
24.15 Fractures of the
proximal humerus Diagram of
(a) the normal and (b) a fractured
more of which are seen in almost
all proximal humeral fractures.
1=shaft of humerus; 2=head of
5 humerus; 3=greater tuberosity;
4=lesser tuberosity. In this figure
spike; 5=suggesting a low risk of
avascular necrosis.

(a) (b) (c)
24.16 X-rays of proximal humeral fractures Classification is all very well, but x-rays are more difficult to interpret than
line drawings. (a) Two-part fracture. (b) Three-part fracture involving the neck and the greater tuberosity. (c) Four-part
fracture. (1=shaft of humerus; 2=head of humerus; 3=greater tuberosity; 4=lesser tuberosity). (d) X-ray showing fracture-
dislocation of the shoulder.
arated from the others, it is a two-part fracture; if two
fragments are displaced, that is a three-part fracture; if
all the major parts are displaced, it is a four-part frac-
ture. Furthermore, a fracture-dislocation exists when
the head is dislocated and there are two, three or four
parts. This grading is based on x-ray appearances, al-
though observers do not always agree with each other
on which class a particular fracture falls into.
Clinical features
Because the fracture is often firmly impacted, pain
may not be severe. However, the appearance of a large
bruise on the upper part of the arm is suspicious.
Signs of axillary nerve or brachial plexus injury should
be sought.
24.17 CT with three-dimensional reconstruction
Advanced imaging provides a much clearer picture of the
injury, allowing better pre-operative planning.
24
Injuries of the shoulder, upper arm and elbow
(d)
X-ray
In elderly patients there often appears to be a single,
impacted fracture extending across the surgical neck.
However, with good x-rays, several undisplaced frag-
ments may be seen. In younger patients, the frag-
ments are usually more clearly separated. Axillary and
scapular-lateral views should always be obtained, to
exclude dislocation of the shoulder.
It has always been difficult to apply Neer’s classifi-
cation when based on plain x-rays and not surprisingly
there is a relatively high level of both inter- and intra-
observer disagreement. Neer himself later noted that
when this classification was developed the criteria for
displacement (distance >1 cm, angulation >45
degrees) were set arbitrarily. The classification was not
intended to dictate treatment, but simply to help clar-
ify the pathoanatomy of the different fracture pat-
terns.
The advent of three-dimensional CT reconstruc-
tion has helped to reduce the degree of inter- and
intra-observer error, enabling better planning of treat-
ment than in the past.
As the fracture heals, the humeral head is some-
times seen to be subluxated downwards (inferiorly);
this is due to muscle atony and it usually recovers once
exercises are begun.
Treatment
MINIMALLY DISPLACED FRACTURES
These comprise the vast majority. They need no treat-
ment apart from a week or two period of rest with the
arm in a sling until the pain subsides, and then gentle
passive movements of the shoulder. Once the fracture
has united (usually after 6 weeks), active exercises are
encouraged; the hand is, of course, actively exercised
from the start. 745
24 TWO-PART FRACTURES
Surgical neck fractures The fragments are gently
manipulated into alignment and the arm is immobi-
lized in a sling for about four weeks or until the frac-
ture feels stable and the x-ray shows some signs of
healing. Elbow and hand exercises are encouraged
FRACTURES AND JOINT INJURIES
throughout this period; shoulder exercises are com-
menced at about four weeks. The results of conserva-
tive treatment are generally satisfactory, considering
that most of these patients are over 65 and do not
demand perfect function. However, if the fracture
cannot be reduced closed or if the fracture is very
unstable after closed reduction, then fixation is
required. Options include percutaneous pins, bone
sutures, intramedullary pins with tension band wiring
or a locked intramedullary nail. Plate fixation requires
a wider exposure and the newer locking plates offer a
stable fixation without the need for extensive
periosteal stripping.
Greater tuberosity fractures Fracture of the greater
tuberosity is often associated with anterior dislocation
and it reduces to a good position when the shoulder is
relocated. If it does not reduce, the fragment can be
re-attached through a small incision with interosseous
sutures or, in young hard bone, cancellous screws.
Anatomical neck fractures These are very rare. In young
patients the fracture should be fixed with a screw. In
older patients prosthetic replacement (hemi-
arthroplasty) is preferable because of the high risk of
avascular necrosis of the humeral head.
THREE-PART FRACTURES
These usually involve displacement of the surgical
neck and the greater tuberosity; they are extremely
difficult to reduce closed. In active individuals this
injury is best managed by open reduction and internal
fixation. There is little evidence that one technique is
better than another although the newer implants with
(a) (b)
24.18 Proximal humerus fractures – treatment (a) Three-part fracture, treated by (b) locked nail fixation. (c) Four-part
746 fracture fixed with a locked plate; the intra-operative picture (d) shows how the plate was positioned.
locked plating and nailing are biomechanically supe-
rior in osteoporotic bone.
FOUR-PART FRACTURES
The surgical neck and both tuberosities are displaced.
These are severe injuries with a high risk of complica-
tions such as vascular injury, brachial plexus damage, in-
juries of the chest wall and (later) avascular necrosis of
the humeral head. The x-ray diagnosis is difficult (how
many fragments are there, and are they displaced?). Of-
ten the most one can say is that there are ‘multiple dis-
placed fragments’, sometimes together with gleno-
humeral dislocation. In young patients an attempt
should be made at reconstruction. In older patients,
closed treatment and attempts at open reduction and
fixation can result in continuing pain and stiffness and
additional surgical treatment can compromise the
blood supply still further. If the fracture pattern is such
that the blood-supply is likely to be compromised, or
that reconstruction and internal fixation will be ex-
tremely difficult, then the treatment of choice is pros-
thetic replacement of the proximal humerus.
The results of hemiarthroplasty are somewhat
unpredictable. Anatomical reduction, fixation and
healing of the tuberosities are prerequisites for a satis-
factory outcome; even then, secondary displacement
of the tuberosities may result in a poor functional out-
come. In addition the prosthetic implant should be
perfectly positioned. Be warned – these are operations
for the expert; the subject is well covered by Boileau
et al. (2006).
FRACTURE-DISLOCATION
Two-part fracture-dislocations (greater tuberosity
with anterior dislocation and lesser tuberosity with
posterior) can usually be reduced by closed means.
(c) (d)
 Three-part fracture-dislocations, when the surgical Malunion Malunion usually causes little disability, but 24
neck is also broken, usually require open reduction loss of rotation may make it difficult for the patient to
and fixation; the brachial plexus is at particular risk reach behind the neck or up the back.
during this operation.
Four-part fracture-dislocations have a poor progno-
sis; prosthetic replacement is recommended in all but

Injuries of the shoulder, upper arm and elbow

young and very active patients.
FRACTURES OF THE PROXIMAL
HUMERUS IN CHILDREN
Complications
Vascular injuries and nerve injuries The patient should At birth, the shoulder is sometimes dislocated or the
always be carefully assessed for signs of vascular and proximal humerus fractured. Diagnosis is difficult and
nerve injuries, both at the initial examination and again a clavicular fracture or brachial plexus injury should
after any operation. The axillary nerve is at particular also be considered.
risk, both from the injury and from surgery. In infancy, the physis can separate (Salter–Harris I);
Avascular necrosis The reported incidence of avascular reduction does not have to be perfect and a good out-
necrosis (AVN) of the humeral head ranges from 10– come is usual.
30 per cent in three-part fractures and 10 to over In older children, metaphyseal fractures or Type II
50 per cent in four-part fractures. The ability to predict physeal fractures occur. Considerable displacement
the likelihood of this outcome is important in making and angulation can be accepted; because of the
the choice between internal fixation and hemi- marked growth and remodelling potential of the
arthroplasty for complex fractures. proximal humerus, malunion is readily compensated
The blood-supply of the humeral head is provided for during the remaining growth period.
mainly by the anterior circumflex artery and its Pathological fractures are not unusual, as the prox-
ascending branch (the arcuate artery) which pene- imal humerus is a common site of bone cysts and
trates into the humeral head and arches across sub- tumours in children. Fracture through a simple cyst
chondrally. Additional blood-supply is provided by usually unites and the cyst often heals spontaneously;
vessels entering the posteromedial aspect of the all that is needed is to rest the arm in a sling for 4–6
proximal humerus, metaphyseal vessels and vessels of weeks. Other lesions require treatment in their own
the greater and lesser tuberosities that anastomose right (See Chapter 9).
with the intraosseous arcuate artery. Thus, in three-
and four-part fractures with the only supply coming
from the posteromedial vessels, there may still be suf-
ficient perfusion of the humeral head if the head frag-
ment includes a sizeable part of the calcar on the
medial side of the anatomical neck. Hertel et al.
(2004) have made the point that fractures at the
anatomical neck with a medial metaphyseal (calcar)
spike shorter than 8 mm carry a high risk of develop-
ing humeral head avascular necrosis (see Fig. 24.15).
Disruption of the medial periosteal hinge is another
predictor of avascular necrosis and the presence of
these two factors combined has a positive predictive
value of 98 per cent for avascular necrosis of the
humeral head. Contrariwise, fractures with an intact
medial hinge and/or a large posteromedial metaphy-
seal spike carry a much better prognosis. The mere
number of fracture parts, their degree of displacement
and split-head fractures are rated as poor predictors of
avascular necrosis, as is the presence of dislocation.
Stiffness of the shoulder This is a common (a) (b)
complication, particularly in elderly patients. Unlike a
24.19 Fractures of the proximal humerus in children
frozen shoulder, the stiffness is maximal at the outset. (a) The typical metaphyseal fracture. Reduction need not
It can be prevented, or at least minimized, by starting be perfect as remodelling will compensate for malunion.
exercises early. (b) Fracture through a benign cyst. 747
24 FRACTURED SHAFT OF HUMERUS
Mechanism of injury
A fall on the hand may twist the humerus, causing a
spiral fracture. A fall on the elbow with the arm
FRACTURES AND JOINT INJURIES
abducted exerts a bending force, resulting in an
oblique or transverse fracture. A direct blow to the
arm causes a fracture which is either transverse or
comminuted. Fracture of the shaft in an elderly
patient may be due to a metastasis.
Pathological anatomy
With fractures above the deltoid insertion, the proxi-
mal fragment is adducted by pectoralis major. With
fractures lower down, the proximal fragment is
abducted by the deltoid. Injury to the radial nerve is
common, though fortunately recovery is usual.
Clinical features
The arm is painful, bruised and swollen. It is impor-
tant to test for radial nerve function before and after
treatment. This is best done by assessing active exten-
sion of the metacarpophalangeal joints; active exten-
sion of the wrist can be misleading because extensor
carpi radialis longus is sometimes supplied by a branch
arising proximal to the injury.
X-ray
The site of the fracture, its line (transverse, spiral or
comminuted) and any displacement are readily seen.
The possibility that the fracture may be pathological
should be remembered.
(a) (b) (c) (d)
24.20 Fractured shaft of humerus (a) Bruising is always extensive. (b,c) Closed transverse fracture with moderate
displacement. (d) Applying a U-slab of plaster (after a few days in a shoulder-to-wrist hanging cast) is usually adequate.
(e) Ready-made braces are simpler and more comfortable, though not suitable for all cases. These conservative methods
748 demand careful supervision if excessive angulation and malunion are to be prevented.
Treatment
Fractures of the humerus heal readily. They require
neither perfect reduction nor immobilization; the
weight of the arm with an external cast is usually
enough to pull the fragments into alignment. A
‘hanging cast’ is applied from shoulder to wrist with
the elbow flexed 90 degrees, and the forearm section
is suspended by a sling around the patient’s neck. This
cast may be replaced after 2–3 weeks by a short
(shoulder to elbow) cast or a functional polypropylene
brace which is worn for a further 6 weeks.
The wrist and fingers are exercised from the start.
Pendulum exercises of the shoulder are begun within
a week, but active abduction is postponed until the
fracture has united (about 6 weeks for spiral fractures
but often twice as long for other types); once united,
only a sling is needed until the fracture is consoli-
dated.
OPERATIVE TREATMENT
Patients often find the hanging cast uncomfortable,
tedious and frustrating; they can feel the fragments
moving and that is sometimes quite distressing. The
temptation is to ‘do something’, and the ‘something’
usually means an operation. It is well to remember
(a) that the complication rate after internal fixation of
the humerus is high and (b) that the great majority of
humeral fractures unite with non-operative treatment.
(c) There is no good evidence that the union rate is
higher with fixation (and the rate may be lower if
there is distraction with nailing or periosteal stripping
with plating). There are, nevertheless, some well
defined indications for surgery:
• severe multiple injuries
• an open fracture
(e)

(a) (b) (c)
• segmental fractures
• displaced intra-articular extension of the fracture
• a pathological fracture
• a ‘floating elbow’ (simultaneous unstable humeral
and forearm fractures)
• radial nerve palsy after manipulation
• non-union
• problems with nursing care in a dependent person.
Fixation can be achieved with either (1) a compression
plate and screws, (2) an interlocking intramedullary nail
or semi-flexible pins, or (3) an external fixator.
Plating permits excellent reduction and fixation,
and has the added advantage that it does not interfere
with shoulder or elbow function. However, it requires
wide dissection and the radial nerve must be pro-
tected. Too much periosteal stripping or inadequate
fixation will probably increase the risk of non-union.
Antegrade nailing is performed with a rigid inter-
locking nail inserted through the rotator cuff under
fluoroscopic control. It requires minimal dissection
but has the disadvantage that it causes rotator cuff
problems in a significant proportion of cases (the
reported incidence ranges from 5–40 per cent). The
nail can also distract the fracture which will inhibit
(a) (b) (c) (d)
24.21 Fractured shaft of humerus 24
– treatment (a,b) Most shaft frac-
tures can be treated in a hanging
cast or functional brace, but beware
the upper third fracture which tends
to angulate at the proximal border of
a short cast. This fracture would
Injuries of the shoulder, upper arm and elbow
have been better managed by
(c) intramedullary nailing (and better
still with a locking nail).
union; if this happens, exchange nailing and bone
grafting of the fracture may be needed.
Retrograde nailing with multiple flexible rods is not
entirely stable. Retrograde nailing with an interlock-
ing nail is suitable for some fractures of the middle
third.
External fixation may be the best option for high-
energy segmental fractures and open fractures. How-
ever, great care must be taken in placing the pins as
the radial nerve is vulnerable.
Complications
EARLY
Vascular injury If there are signs of vascular
insufficiency in the limb, brachial artery damage must
be excluded. Angiography will show the level of the
injury. This is an emergency, requiring exploration and
either direct repair or grafting of the vessel. In these
circumstances, internal fixation is advisable.
Nerve injury Radial nerve palsy (wrist drop and
paralysis of the metacarpophalangeal extensors) may
occur with shaft fractures, particularly oblique fractures
24.22 Fractured humerus –
other methods of fixation
(a,b) Compression plating,
and (c,d,e) external fixation.
(e) 749
24 at the junction of the middle and distal thirds of the
bone (Holstein–Lewis fracture). If nerve function was
intact before manipulation but is defective afterwards,
it must be assumed that the nerve has been snagged
and surgical exploration is necessary. Otherwise, in
closed injuries the nerve is very seldom divided, so
FRACTURES AND JOINT INJURIES
there is no hurry to operate as it will usually recover.
The wrist and hand must be regularly moved through
a full passive range of movement to preserve joint
motion until the nerve recovers. If there is no sign of
recovery by 12 weeks, the nerve should be explored. It
may just need a neurolysis, but if there is loss of
continuity of normal-looking nerve then a graft is
needed. The results are often satisfactory but, if
necessary, function can be largely restored by tendon
transfers (see Chapter 11).
LATE
Delayed union and non-union Transverse fractures
sometimes take months to unite, especially if excessive
traction has been used (a hanging cast must not be too
heavy). Simple adjustments in technique may solve the
problem; as long as there are signs of callus formation
it is worth persevering with non-operative treatment,
but remember to keep the shoulder moving. The rate
of non-union in conservatively treated low-energy
fractures is less than 3 per cent. Segmental high energy
fractures and open fractures are more prone to both
delayed union and non-union.
Intramedullary nailing may contribute to delayed
union, but if rigid fixation can be maintained (if nec-
essary by exchange nailing) the rate of non-union can
probably be kept below 10 per cent.
A particularly vicious combination is incomplete
union and a stiff joint. If elbow or shoulder move-
ments are forced before consolidation of the fracture,
or if an intramedullary nail is removed too soon (e.g.,
because of shoulder problems), the humerus may re-
fracture and non-union is then more likely.
The treatment of established non-union is
operative. The bone ends are freshened, cancellous
bone graft is packed around them and the reduction
is held with an intramedullary nail or a compression
plate.
Joint stiffness is common. It can be
Joint stiffness
minimized by early activity, but transverse fractures (in
which shoulder abduction is ill-advised) may limit
shoulder movement for several weeks.
SPECIAL FEATURES IN CHILDREN
Fractures of the humerus are uncommon; in children
under 3 years of age the possibility of child abuse
should be considered and tactful examination for
750 other injuries performed.
Taking advantage of the robust periosteum and the
power of rapid healing in children, the humeral frac-
ture can usually be treated by applying a collar and
cuff bandage for 3 or 4 weeks. If there is gross short-
ening, manipulation may be needed. Older children
may require a short plaster splint.
FRACTURES OF THE DISTAL
HUMERUS IN ADULTS
Fractures around the elbow in adults – especially
those of the distal humerus – are often high-energy
injuries which are associated with vascular and nerve
damage. Some can be reduced and stabilized only by
complex surgical techniques; and the tendency to
stiffness of the elbow means that with all severe
injuries the striving for anatomical perfection has to
be weighed up against the realities of imperfect post-
operative function.
The AO-ASIF Group have defined three types of
distal humeral fracture:
Type A – an extra-articular supracondylar fracture;
Type B – an intra-articular unicondylar fracture (one
condyle sheared off);
Type C – bicondylar fractures with varying degrees of
comminution.
TYPE A – SUPRACONDYLAR FRACTURES
These extra-articular fractures are rare in adults. When
they do occur, they are usually displaced and unstable
– probably because there is no tough periosteum to
tether the fragments. In high-energy injuries there
may be comminution of the distal humerus.
Treatment
Closed reduction is unlikely to be stable and K-wire
fixation is not strong enough to permit early mobi-
lization. Open reduction and internal fixation is there-
fore the treatment of choice. The distal humerus is
approached through a posterior exposure. It is some-
times possible to fix the fracture without recourse to
an olecranon osteotomy or triceps reflection. A simple
transverse or oblique fracture can usually be reduced
and fixed with a pair of contoured plates and screws.
TYPES B AND C – INTRA-ARTICULAR
FRACTURES
Except in osteoporotic individuals, intra-articular
condylar fractures should be regarded as high-energy
injuries with soft-tissue damage. A severe blow on the
point of the elbow drives the olecranon process
upwards, splitting the condyles apart. Swelling is con-
siderable, but if the bony landmarks can be felt the
elbow is found to be distorted. The patient should be
carefully examined for evidence of vascular or nerve
injury; if there are signs of vascular insufficiency, this
must be addressed as a matter of urgency.
X-Ray
The fracture extends from the lower humerus into the
elbow joint; it may be difficult to tell whether one or
both condyles are involved, especially with an undis-
placed condylar fracture. There is often also com-
minution of the bone between the condyles, the
extent of which is usually underestimated. Sometimes
the fracture extends into the metaphysis as a T- or Y-
shaped break, or else there may be multiple fragments
(comminution). The lesson is: ‘Prepare for the worst
before operating’. CT scans can be helpful in planning
the surgical approach.
Treatment
These are severe injuries associated with joint damage;
prolonged immobilization will certainly result in a stiff
elbow. Early movement is therefore a prime objective.
Undisplaced fractures These can be treated by applying
a posterior slab with the elbow flexed almost 90
degrees; movements are commenced after 2 weeks.
However, great care should be taken to avoid the dual
pitfalls of underdiagnosis (displacement and
comminution are not always obvious on the initial x-
ray) and late displacement (always obtain check x-rays
a week after injury).
Displaced Type B and C fractures If the appropriate
expertise and facilities are available, open reduction and
internal fixation is the treatment of choice for displaced
(a) (b) (c)
fractures (some would say for all Type B and C 24
fractures – minor displacement is easily overlooked in
the early post-injury x-rays). The danger with
conservative treatment is the strong tendency to
stiffening of the elbow and persistent pain.
Good exposure of the joint is needed, if necessary
Injuries of the shoulder, upper arm and elbow
by performing an intra-articular olecranon osteotomy.
The ulnar nerve should be identified and protected
throughout. The fragments are reduced and held
temporarily with K-wires. A unicondylar fracture
without comminution can then be fixed with screws;
if the fragment is large, a contoured plate is added to
prevent re-displacement. First the articular block is
reconstructed with a transverse screw; bone graft is
sometimes needed. The distal block is then fixed to
the humeral shaft with medial and lateral plates. Pre-
contoured plates with locking screws are now avail-
able. These hold the distal fragments more effectively.
Postoperatively the elbow is held at 90 degrees with
the arm supported in a sling. Movement is encour-
aged but should never be forced. Fracture healing
usually occurs by 12 weeks. Despite the best efforts,
the patient often does not regain full extension and in
the most severe cases movement may be severely
restricted.
A description of this sort fails to convey the real dif-
ficulty of these operations. Unless the surgeon is more
than usually skilful, the elbow may end up stiffer than
if treated by activity (see below).
ALTERNATIVE METHODS OF TREATMENT
If it is anticipated that the outcome of operative treat-
ment will be poor (either because of the degree of
comminution and soft-tissue damage or because of
lack of expertise and facilities) other options can be
considered.
Elbow replacement The elderly patient with a
comminuted fracture, a low transverse fracture or
osteopaenic bone, may be best served by replacement
of the elbow.
24.23 Bicondylar
fractures X-rays taken
(a,b) before and
(c,d) after open
reduction and internal
fixation. An excellent
reduction was obtained
in this case; however,
the elbow sometimes
ends up with
considerable loss of
movement even though
the general anatomy
has been restored.
(d) 751
24 The ‘bag of bones’ technique The arm is held in a collar
and cuff or, better, a hinged brace, with the elbow
flexed above a right angle; active movements are
encouraged as soon as the patient is willing. The
fracture usually unites within 6–8 weeks, but exercises
are continued far longer. A useful range of movement
FRACTURES AND JOINT INJURIES

(45–90 degrees) is often obtained.

Skeletal traction An alternative method of treating
either moderately displaced or severely comminuted
fractures is by skeletal traction through the olecranon
(beware the ulnar nerve!); the patient remains in bed
with the humerus held vertical, and elbow movements
are encouraged. Again, meticulous internal fixation or
elbow replacement are usually preferable. (a) (b)

24.24 Fractured capitulum Anteroposterior and lateral

Complications
EARLY
Vascular injury Always check the circulation (repeat-
edly!). Vigilance is required to make the diagnosis and
institute treatment as early as possible.
Nerve injury There may be damage to either the
median or the ulnar nerve. It is important to examine
the hand and record the findings before treatment is
commenced. The ulnar nerve is particularly vulnerable
during surgery.
LATE
Stiffness Comminuted fractures of the elbow always
result in some degree of stiffness. However, the
disability may be reduced by encouraging an energetic
exercise programme. Late operations to improve elbow
movement are difficult but can be rewarding.
Heterotopic ossification Severe soft-tissue damage may
lead to heterotopic ossification. Forced movement
should be avoided.
FRACTURED CAPITULUM
This is a rare articular fracture which occurs only in
adults. The patient falls on the hand, usually with the
elbow straight. The anterior part of the capitulum is
sheared off and displaced proximally.
Clinical features
Fullness in front of the elbow is the most notable fea-
ture. The lateral side of the elbow is tender and flex-
ion is grossly restricted.
x-rays showing proximal displacement and tilting of the
capitular fragment.
longer points directly towards it. Bryan and Morrey
classify these as:
Type I Complete fracture
Type II Cartilaginous shell
Type III Comminuted fracture.
CT scans can be helpful in clarifying the diagnosis.
Treatment
Undisplaced fractures can be treated by simple splin-
tage for 2 weeks.
Displaced fractures should be reduced and held.
Closed reduction is feasible, but prolonged immobi-
lization may result in a stiff elbow. Operative treat-
ment is therefore preferred. The fragment is always
larger than expected. If it can be securely replaced, it
is fixed in position with a small screw. Headless bone
screws are ideally passed from front to back; alterna-
tively, if the fragment is large enough, lag screws can
be passed from back to front. If this proves too diffi-
cult, the fragment is best excised. Movements are
commenced as soon as discomfort permits. The
longer term outcome is not always good because of
stiffness and sometimes instability.
FRACTURED HEAD OF RADIUS

Radial head fractures are common in adults but are

X-Ray
hardly ever seen in children (probably because the
In the lateral view the capitulum (or part of it) is seen proximal radius is mainly cartilaginous) whereas radial
752 in front of the lower humerus, and the radial head no neck fractures occur in children more frequently.