SPECIAL FRACTURES AND

DISLOCATIONS
Casting, Surgical Overview, and Prevalence
CLAVICULAR FRACTURES
The Clavicle
• An S-shaped bone
• acts as a strut which provides the only bony
connection between upper limb and the
thorax
• It protects major underlying vessels, lung,
and brachial plexus.
• Displaced clavicle fractures can injure these
structures because of their proximity and
sharp edges.
Clavicular Fractures
• Most common fx in both adults and children
• The fx usually occurs in the junction between the
middle third & the outer third of the shaft
• Can present in the newborn period, especially
following a difficult delivery
• Nearly half of all clavicle fractures occur in children
younger than 7 years.
Mechanisms of Injury
• Fall onto shoulder or outstretched upper
extremity
• Direct blow to clavicle
• Forceful muscle contraction during seizures
 Classification of Clavicular
Fractures
• Medial Third (Group III) – 5%
• Middle Third (Group I) – 85%
• Lateral Third (Group II) – 10%
Signs & Symptoms
• Tenderness
• Crepitus
• Deformity & tenting of skin
• Ecchymosis
- especially when severe displacement
• Bleeding from open fracture (rare)
• Refusal to use the arm on the affected
side in neonates
Closed Treatment
• It is difficult to reduce and maintain the
reduction of clavicle fractures
• Despite deformity, healing usually
proceeds rapidly
• Union usually occurs rapidly & produces
prominent callus
Figure-8 Bandage
Open Treatment
• INDICATIONS FOR SURGERY:
• Open fractures
• Gross displacement of fracture w/ tenting
of skin
• Presence of neurovascular injuries
• Cosmesis (relative indication)
INTRAMEDULLARY PINNING PLATE & SCREWS
COMPLICATIONS
• Brachial plexus compression
• resulting from hypertrophic callus formation
• Delayed union or nonunion
• especially with distal third fractures
• Poor cosmetic appearance
• Posttraumatic arthritis
• Intrathoracic injury/Pneumothorax
• Vascular injury
• Subclavian artery and vein injury
• Internal jugular vein injury
• Axillary artery injury
Anterior Shoulder Dislocation

SUBCORACOID SUBGLENOID SUBCLAVICULAR

Anterior Shoulder Dislocation
• the most frequent type of shoulder dislocation
• (85-90% of shoulder dislocations)
• are usually the result of direct or indirect trauma,
with the arm forced into abduction and external
rotation
• 40% become recurrent as a result of associated
damage of the surrounding ligamentous and
capsular structures that stabilize the joint
• Damaged Axillary Nerve resulting to decreased in
Deltoid strength
ANTERIOR
DISLOCATION
  STIMSON TECHNIQUE

MILCH MANEUVER 
HIPPOCRATIC
MANEUVER 

TRACTION-COUNTER
TRACTION TECHNIQUE
COMPLICATIONS:
 High recurrence rate (re-
dislocations, joint instability)
 High incidence of rotator cuff
tear in ages >40 years old
 Axillary nerve / artery damage
 Glenoid fossa fx’s, labrum tears
 FRACTURES
OF THE
PROXIMAL HUMERUS
• 2-3% of all upper extremity fractures occur in the
proximal humerus
• 75% of proximal humerus fractures occur in the
elderly (60 years up), mostly women
• Most fractures occur through osteoporotic bone in
elderly, although high-energy trauma may also be a
cause
 BASIC
ANATOMY

FOUR PARTS:
articulating surface
greater tuberosity
lesser tuberosity
humeral shaft
Displacing Forces
ROTATOR CUFF

SUBSCAPULARIS
DELTOID

PECTORALIS
Neer Classification
of Proximal Humeral Fractures

1-PART
3-PART

2-PART 4-PART
Mechanisms of Injury
• Fall on the arm
• Strong muscular contractions
(electric shock, seizures)
• Direct blow to the shoulder
DIAGNOSIS: Imaging Studies
• X-RAY
• Anteroposterior and
lateral views of the
humerus
Signs & Symptoms
• Pain, swelling, tenderness
• Ecchymosis & edema
• Decreased range of
motion (ROM)
Closed Treatment of Proximal
Humeral Fractures
• Most fractures are
displaced minimally
and treated
conservatively
Open Treatment of Proximal Humeral
Fractures
• Operative treatment decisions are based primarily
on the number of segments involved and degree of
displacement.
• Three- and 4-part fractures often need operative
repair
 FIXATION USING
PERCUTANEOUS PINNING
ORIF using
PLATES & SCREWS
Complications
• Axillary nerve injury
• Avascular necrosis of the humeral head
• Stiff shoulder/Frozen shoulder
 FRACTURES OF
THE HUMERAL SHAFT
• Fractures of the humeral shaft account for
approximately 3% of all fractures
• the humerus is also a common site for metastases
and pathologic fractures
B
A
S
I
C

A
N
A
T
O
M
Y
DIAGNOSIS: Imaging Studies
• AP & lateral x-ray views of
the arm
• CT & MRI are rarely
indicated
Mechanism of Injury
• Bending force produces transverse fx of the
shaft;
• Torsion force will result in a spiral fracture;
• Combination of bending and torsion
produce oblique fx w/ or w/o a butterfly
fragment;
• Compression forces will fracture either
proximal or distal ends of humerus
Signs & Symptoms
• Arm pain,
tenderness, swelling
• Deformity,
shortening of arm
• Motion and crepitus
present on
manipulation
Closed Treatment of Humeral Shaft
Fractures
• Although most
fractures of the
humeral shaft are
inherently unstable,
non-operative
treatment remains the
standard
 Open Treatment of Humeral Shaft
Fractures

ORIF PLATE & SCREWS ORIF IM NAILING

COMPLICATIONS
• Radial nerve injury occurs in up to 16-18% of
humeral shaft fractures
• Brachial artery injury (Volkmann’s Ischemia
Injury)
• Nonunion, Malunion, Delayed union
NONUNION
VASCULAR / NERVE INJURY
FRACTURE-DISLOCATIONS OF THE
ELBOW
ANTERIOR
DISLOCATION WITH
FRACTURE OF THE
CORONOID PROCESS
FRACTURE-DISLOCATIONS OF THE
ELBOW

POSTERIOR
DISLOCATION
WITH FRACTURES
OF THE CORONOID
& RADIAL HEAD
 FRACTURE-DISLOCATIONS OF THE
ELBOW

ANTERIOR DISLOCATION WITH FRACTURE OF

THE OLECRANON
FRACTURES OF THE
FOREARM
Mechanism of Injury
• Fractures of the wrist and elbow usually involve a fall onto
the outstretched arm, while forearm shaft fractures more
commonly are the result of a direct blow
• Sports, particularly in-line skating, skateboarding, mountain
biking, and contact sports
• Trauma, commonly from vehicle collisions, blows with a
blunt object, or child abuse
Signs & Symptoms

• Swelling about the elbow

• Deformity
• Crepitus
• Pain on movement
FRACTURES OF THE FOREARM

• Fracture of both shafts of the radius & ulna

• Isolated ulna fracture (Nightstick)
• Monteggia’s Fracture
• Galleazzi’s fracture
• Wrist & distal forearm fractures
• Colle’s fracture
• Smith’s fracture
• Barton’s fracture
FRACTURES OF THE
SHAFTS OF BOTH
RADIUS & ULNA
Mechanism of Injury

• High speed vehicular trauma are common causes

• Direct blows to the forearm
• Fall (usually from a height) on an outstretched hand
Signs & Symptoms

• Pain & tenderness over the forearm

• Deformity, usually obvious in displaced
fractures
• Loss of function
• Crepitus
DIAGNOSIS: Imaging Studies

• AP & Lateral x-ray views are usually sufficient

• X-ray films must include the elbow & wrist
Classification

Fractures of both the radius & ulna are classified

according to:
Level of fracture
Pattern of the fracture
Degree of displacement
Presence or absence of comminution or segmental
bone loss
Whether they are open or closed
Closed Treatment
INDICATIONS FOR CLOSED
TREATMENT:
Nondisplaced fractures
Open Treatment
INDICATIONS FOR OPEN TREATMENT:
• All displaced fractures of radius and ulna in adults
• All isolated displaced fractures of the radius
• Isolated fractures of the ulna with angulation greater than
10°
• Open fractures
• Fractures associated with
compartment syndrome
ORIF – IM PINNING ORIF – PLATE & SCREWS
 MALUNION

RADIO-ULNAR SYNOSTOSIS
OSTEOMYELITIS
DELAYED UNION
NIGHTSTICK FRACTURE

• Defined as an isolated midshaft ulnar

fracture
• Nightstick fractures have no associated radial
head instability
• Usually due to direct blows (with the patient
using the forearm as a shield)
 With undisplaced
Closed Treatment or
slightly displaced
fractures, a plaster cast
or fracture brace is
adequate
MONTEGGIA FRACTURE

• A fracture of the ulna with associated dislocation of

the radial head (proximal radioulnar joint)
COMPLICATIONS

 PIN (posterior interosseous nerve) or radial nerve

palsy from anterior displacement of radial head
Nonunion of frx of ulnar shaft
Radiohumeral ankylosis
Radioulnar synostosis
Recurrent radial head dislocation
GALEAZZI FRACTURE
• Defined as a fracture of the distal one third of
the radius with dislocation of the distal
radioulnar joint (DRUJ). “Reverse Monteggia
fracture”.
• Galeazzi fracture is 3 times more common than
Monteggia lesion.
• Disruption of DRUJ when overlooked results in a
higher rate of morbidity
Mechanism of Injury

• Direct blows on the

dorsolateral side of the wrist
• Fall on the outstretched
hand combined with marked
pronation of the forearm
DISTAL FOREARM FRACTURES

• Colle’s Fracture
• Smith’s Fracture
• Barton’s Fracture
COLLE’S FRACTURE

• Defined as an extra-articular fracture of the distal

metaphysis of the radius, with dorsal displacement
& angulation of the distal fragment

• “dinnerfork deformity”
Mechanism of Injury
• Fall on the outstretched arm with
the wrist extended
Imaging Studies
DORSAL ANGULATION

RADIAL SHORTENING
SMITH’S FRACTURE

• Defines as a volarly angulated fracture of the distal

radius with the hand and wrist displaced volarly
with respect to the forearm.
• The fracture may be extra-articular, intra-articular,
or part of a fracture–dislocation of the wrist
“garden spade deformity”
Mechanism of Injury

• Fall on an outstretched
hand with the wrist flexed
& pronated
BARTON’S FRACTURE

• Defined as a fracture–
dislocation or subluxation
in which the rim of the
distal radius, dorsally or
volarly, is displaced with
the hand and carpus
VOLAR BARTON’S FRACTURE

DORSAL BARTON’S FRACTURE

(CHAUFFER’S FRACTURE)
Imaging Studies

INTRA ARTICULAR
FRACTURE
Closed Treatment

Closed
reduction and
application of
a long arm cast
Closed reduction with percutaneous pinning
EXTERNAL FIXATION
OF DISTAL RADIUS FX
Open Treatment
• The primary indication is articular fragment
displacement, which, if left unreduced, leads to
radiocarpal or radioulnar arthritis.

ORIF – MULTIPLE SCREWS ORIF – PLATE & SCREWS

Complications

• Median or ulnar nerve stretch, contusion, or

compression
• Post-reduction swelling; compartment syndrome
• Tendon damage
• Delayed union, Nonunion, Malunion
• Posttraumatic arthritis
• DRUJ pathology
• Reflex sympathetic dystrophy
Pelvic Ring Fractures
• Low-energy fractures
• Muscular contractions in young athletes
• Domestic falls
• High-energy fractures
• Vehicular accidents
• Motor vehicular accidents 57%
• Pedestrian 18%
• Motorcycle accidents 9%
• Fall from heights 9%
• Crush mechanisms 4%
Goals of Treatment
• Restore the bony anatomy
• Prevent deformity
• Minimize discomfort
• Facilitate return of mobility and function
 Treatment Guidelines
• Minimally displaced injuries

• Partial disruption of the bony and ligamentous stability

of the pevic ring

• Generally, pubic rami fractures do not require surgical

treatment, for anterior diastasis of less than 2.5 cm;

• Protected weight bearing and symptomatic treatment

• Repeat radiographs 2-5 days after injury
• Traction
• Temporizing measure
• Reserved for patients unable to undergo surgery
• Pneumatic Anti-shock Garments
 Hip Dislocation

• caused by high-energy trauma, usually from

motor-vehicle accidents
• they occur most frequently in young patients
 Posterior Hip Dislocation
• More common
• Outnumber anterior dislocations by 9:1
• Typical mechanism of injury
• Deceleration accident
• Limb is shortened internally rotated and adducted
 Anterior Hip Dislocation
• 10-15% of traumatic dislocations
• occur when knee strikes dashboard with thigh
abducted, falls from height, or from a blow to the
back of patient while in squatted position
• neck of femur or greater trochanter impinges on
rim of acetabulum & thereby levers head of femur
out of acetabulum thru tear in anterior hip capsule
• degree of hip flexion determines whether superior
or inferior type of anterior dislocation results
 Proximal Femoral Fracture
Two types of proximal femur fractures :
• intracapsular: femoral neck fractures
• extracapsular: intertrochanteric fractures
 MECHANISMS OF INJURY
• Direct impact on lateral aspect of greater
trochanter
• Lateral rotation with sudden increase in load
• Sudden but spontaneous completion of fatigue
fracture that precedes the fall
 Intertrochanteric and Subtrochanteric Femoral
Fractures
• fracture is incomplete and results in spontaneous
healing in over 80% of patients

• Complications of prolonged bed rest in skeletal

traction
• Decubitus ulcers
• Joint contractures
• Pneumonia
• Thromboembolic complications
 Nonoperative treatment
• Skin traction
• Skeletal Traction
• Balanced skeletal traction
• Thomas splint with Pearson attachment
• Neufeld traction technique
• 90-90 traction
• Cast Brace
• Spica Cast
 Tibial fractures
• Fractures of the proximal tibia, particularly those that
extend into the knee joint, are serious injuries that
frequently result in functional impairment

• Comprise 1% of all fractures and 8% of fractures in

the elderly
 Mechanism of Injury
• blunt trauma such as motor vehicle accidents
• fall from a height on an extended knee
• valgus injuries such as bumper injuries to the knee,
football or soccer accidents, or falls from a height
NON-OPERATIVE TREATMENT

• Consisted of attempts at closed reduction with or

without skeletal traction and prolonged cast
immobilization
• Knee stiffness and malalignment were common
• Controlled motion hinged knee casts or braces make for
shorter hospital stays, earlier ambulation, and better
knee motion
Fractures of the ankle
• The stability of the ankle is primarily dependent on
four groups of bony and ligamentous structures
• medial malleolus and medial collateral ligaments
• lateral malleolus and lateral collateral ligaments
• anterior syndesmotic ligaments and their bony attachment
sites on the tibia and fibula
• posterior syndesmotic ligament and posterior malleolus
Mechanism of Injury
• The common deforming forces acting on the ankle
are adduction, abduction, external rotation, and
vertical loading
References
• Zaleske, D. J. (2005). Netter's Orthopedics. Chicago:
Elsevier.