FRACTURES AND JOINTS

DISLOCATIONS MANAGEMENT
Dr. BAYISENGA Justin, MD, MMed, SURGERY
Senior Consultant General Surgeon
July 2023
 INTRODUCTION
• Fractures and dislocations are mostlty caused
by high energy trauma.
• High energy trauma is a major cause of
mortality among young citizens worldwide.
• Injury is the leading cause of death under the
age of 40 (USA)
• The cost is also high to cure extremities
injuries.
 Fracture healing
It can be conveniently divided, based on the
biologic events taking place, into the following
four stages
1. Hematoma formation (inflammation) and
angiogenesis.
2. Cartilage formation with subsequent
calcification
3. Cartilage removal and bone formation
4. Bone remodeling
 Orthopedic Assessment & Management of
Polytrauma Patients
Life-Threatening Conditions: The ABCs of Trauma Care
• A systematic approach is required in all cases.
• The patient is assessed and treatment priorities are
established according to the type of injury, stability
of vital signs, and mechanism of injury.
• In a severely injured patient, treatment priorities are
dictated by the patient's overall condition, with the
first goal being to save life and preserve the major
functions of the body.
 Assessment consists of four
overlapping phases:
1. Primary survey (ABCDE)
2. Resuscitation
3. Secondary survey (head-to-toe evaluation and
history taking)
4. Definitive care
 Primary survey
• Airway maintenance (with cervical spine
protection);
• Breathing and ventilation;
• Circulation (with hemorrhage control);
Disability (neurologic status);
• Exposure and environmental control (undress
the patient but prevent hypothermia).
 A: Airway + C-spine protection
• The airway should be rapidly assessed for signs of
obstruction, foreign bodies and facial, mandibular, or
tracheal/laryngeal fractures.
• A chin lift or jaw thrust maneuver should be used to
establish an airway.
• A Glasgow Coma Scale of 8 or less is an indication
for the placement of a definitive airway (Intubation)
• Any patient with a blunt injury above the clavicle
should be considered at risk for cervical spine injury).
 B: Breathing + Oxygenotherapy
• The surgeon should evaluate the patient's chest.
• Adequate ventilation requires not only airway patency
but also adequate oxygenation and carbon dioxide
elimination.
• If any breathing problem on trauma patient think
about:
1. Tension pneumothorax
2. Flail chest with pulmonary contusion
3. Open pneumothorax and
4. Massive hemothorax.
 C: Circulation
• Hemorrhage is the principal cause of post injury
deaths that are preventable.
• Level of consciousness, skin color and pulses are
simple to assess the hemodynamic status of the
patient, especially if recorded serially.
Pay attention on fractures because they can cause
major blood loss and severely compromise the
ultimate survival of the patient:
• Fractures of the femur (blood loss of 1.5 to 2l)
• Pelvic fracture (blood loss of 2to 3l).
 D: Disability (Neurologic Status)
• Glasgow Coma Scale should be used to assess
neurologic status.
• A simpler way to monitor central neurologic
status is to remember the mnemonic AVPU
and check if the patient is:
• Alert
• Verbal response
• Pain response
• Unresponsive
 E: Exposure and Environmental
Control
• Recognition of lacerations, contusions,
abrasions, swelling and deformity can only be
accomplished in the completely disrobed
patient.
• Hypothermia must be avoided.
• Sterile dressings should be applied to any
wounds and wound exploration in the
emergency department should be avoided to
prevent further contamination.
 Care of Patient before
Hospitalization
• Recognition and appropriate splinting of
major fractures, adequate immobilization of
the cervical spine, and proper handling of the
injured patient are essential to prevent
further damage to the neurovascular
elements and limit hemorrhage.
• Proper care at this stage will prevent or limit
shock as well as avoid catastrophic damage to
the spinal cord.
 General rule:
The following measures should be taken
managing fractures or joints dislocations:
1. The joints above and below the fracture should be immobilized.
2. Splints can be improvised with pillows, blankets, or clothing.
3. Immobilization does not need to be absolutely rigid.
4. Apply gentle in-line traction to realign the extremity in severe
angulation.
5. Overt bleeding should be tamponaded with available dressings
and firm pressure.
6. Tourniquets should be avoided, unless it is obvious that the
patient's life is in danger.
GENERAL PRINCIPLES OF
FRACTURES MANAGEMENT
 Introduction and Definitions
 Fracture is disruption of bone continuity
 Most of fractures occur as a result of a single
episode by a force powerful enough to
fracture a normal bone
 Pathological fracture: is one in which a bone
is broken through an area weakened by pre-
existing disease , & by a degree of force that
would have left normal bone intact like
osteoporosis , Osteomyelitis, bone tumors.
 Introduction and Definitions
 Stress fracture: Bone , like other materials ,
reacts to repeated loading .
 On occasion , it becomes fatigued & a crack
develops e.g. military installations , ballet
dancers & athletes.
 Introduction and Definitions
 Other types of fractures
Introduction and Definitions
 Introduction and Definitions
 Greenstick fracture-occurs in children.
 Stress fracture- common in athletes.
 Fatigue fracture- in occupation like police
 Pathological fractures-usually seen in elderly.
 Introduction and Definitions
 Description of a fracture
Which bone is injured
The region of the bone injured
Is the fracture simple or multifragmentary?
The direction of the fracture line: transverse,
oblique or spiral
 Introduction and Definitions
Displaced or undisplaced?
Angulation?
Rotation?
Shortening
Alignment, length and rotation
Any evidence of pre-existing pathology?
 Introduction and Definitions
Seven sign of fracture
Tenderness
Swelling and Ecchymosis
Deformity
Crepitus
Exposed fragment
False Motion
Inability to Use the Limb
 Introduction and Definitions
• Fractures may be classified into open and
closed
 For open Fractures, Gustilo & Anderson
Classification is used
For closed fractures there are multiple
classifications especially according to the
location of fractures.
 Management of fracture
Goals
 Restore the patient to optimal functional
state;
 Prevent fracture and soft-tissue
complications;
 Get the fracture to heal, and in a position
which will produce optimal functional
recovery;
 Rehabilitate the patient as early as possible.
 Management of fracture
Uncomplicated closed fracture
 Three fundamental principles of fracture
treatment
Reduction
Immobilization
Preservation of function
 1. Reduction
• Can be done by:
 Closed manipulation
 Mechanical traction with or without
manipulation
 Open reduction and internal fixation (ORIF)
 Reduction
 Manipulative reduction
the standard initial method of reducing most
common fractures.
The technique is simply to grasp the
fragments through the soft tissues, to
disimpact them if necessary, then to adjust
them as nearly as possible to their correct
position
 Reduction
 Reduction by mechanical traction
When the contraction of large muscles exerts a
strong displacing force, some mechanical aid may
be necessary to draw the fragments out to the
normal length of the bone,
Traction may be applied either by weights or by a
screw device,
This particularly applies to fractures of the shaft
of the femur, and to certain types of fracture or
displacement of the cervical spine.
 Reduction
 Operative reduction
When an acceptable reduction cannot be
obtained, or maintained,
Open reduction may be required for some
fractures involving articular surfaces, or when
the fracture is complicated by damage to a
nerve or artery.
Success by open reduction depends on :

 Proper indication
 Proper timing
 Proper Surgical approach
 Proper technique
 Proper selection of implant
 Proper Surgeon
 2. Immobilization
Indications
 To prevent displacement or angulation of the
fragments
 To prevent movement that might interfere with
union
 To relieve pain.
 Can be achieved by
 plaster of Paris cast or other external splint
 continuous traction
 external fixation
 internal fixation
 A. Immobilization by plaster, splint or
brace
 For most fractures the  but except in a few
standard method of developing countries, most
immobilization is by a hospitals now use ready-
plaster of Paris cast made proprietary
 Plaster technique bandages.
 Plaster of Paris is  These are best used with
hemihydrated calcium cold water because setting
sulphate. It reacts with is too rapid with warm
water to form hydrated water
calcium sulphate
 Plaster bandages may be
prepared by impregnating
rolls of book muslin with
the dry powdered plaster
The plaster bandages are applied in two forms:
round-and-round bandages and longitudinal
strips or ‘slabs’ to reinforce a particular area
Round-and round bandages must be applied
smoothly without tension, the material being
drawn out to its full width at each turn.
Slabs are prepared by unrolling a bandage to and
fro upon a table: an average slab consists of
about 12 thicknesses.
The slabs are placed at points of weakness or
stress and are held in place by further turns of
plaster bandage.
A plaster is best dried simply by exposure to
the air: artificial heating is unnecessary. A
plaster will not dry satisfactorily if it is kept
covered by clothing or bed-linen.
B. Continuous skeletal traction
 C. External fixation
Indications
Acute trauma - open and unstable fractures
Non union of fractures
Arthrodesis
Correction of joint contracture
Filling of segmental limb defects
Limb lengthening
 Contraindications

 Active infection (local or systemic) or

osteomyelitis
 poor soft-tissue quality due to soft-tissue injury
or burns, excessive swelling, previous surgical
scars, or active infection
 Medical conditions that contraindicate surgery or
anesthesia (eg, recent myocardial infarction)
 Cases in which amputation, rather than attempt
at fracture fixation, would better serve the limb
and the patient
 D. Internal fixation Indications

Absolute : Relative :
Polytrauma Loss of position with closed
method,
Displaced intra-
 Poor functional result with
articular fractures non-anatomical reduction,
Open #’s Displaced fractures with
#’s with vascular poor blood supply,
injury or  Economic and medical
compartment syn, indications
Pathological #’s
Non-unions
 Methods
 Metal plate held by screws or locking plate (with
screws fixed to the plate by threaded holes)
 Intramedullary nail, with or without cross-screw
fixation for locking
 Dynamic compression screw-plate
 Condylar screw-plate
 Tension band wiring
 Transfixion screws
 How do fracture heal in nature?
1) Reactivephase
– Fracture and inflammatory phase
– Granulation tissue formation
2) Reparative phase
– Callus formation
– Lamellar bone deposition
3) Remodelling phase
– Remodelling to original bone contour
 Fracture healing in nature
1. Reactive phase  Cell division begins
Bone ends bleeds within 8 hours following
Haematoma formation release of vasoactive
mediators, growth
Periosteum is stripped factors and other
for variable length cytokines eg. BMP, TGF-
Surrounding soft tissue B, PDGF, FGF, IGF-II, IL-
may be damaged 1, IL-6
Acute inflammation  Cell proliferation seen
within periosteum
 Fracture healing in nature
2. Reparative phase  Amount of callus formed
Vasoactive substances directly proportional to
(NO and ESAF) causes amount of movement at
neovascularisation & local fracture site
vasodilatation  Dead bone resorbed and
Mesenchymal cells immature woven bone
migrate and form laid down
chondrogenic,osteogenic
and fibrous tissue  Consolidation – Woven
Fracture haematoma bone and hyaline
organized and Type II cartilage is replaced by
collagen laid down lamellar bone
 Fracture becomes united
 Fracture healing in nature
3. Remodelling
Phase of remodelling
Medullary cavity is
restored
Bone returns to normal
shape
 How do fractures heal when
operated?
1) Reduction and compression
 Primary bone healing
 Slow process, rehabilitation rapid, high risk

2) Nailing or external fixation

 Healing by callus
 Rapid process, rehabilitation rapid, lesser risk
Healing by callus formation – rapid process
 Factors affecting fracture healing
 Energy transfer of the injury
 The tissue response
– Two bone ends in apposition or compressed
– Micro-movement or no movement
– Blood supply (scaphoid, talus, femoral & humeral head)
– Type of bone
– No infection
 The patient
 The method of treatment
 Rehabilitation
 Restore the patient as close to
pre-injury functional level as
possible
 May not be possible with
severe fractures or other
injuries and in frail elderly
patients
 Approach needs to be:
 Pragmatic with realistic
targets
 Multidisciplinary
 Rest, Elevation, Mobilisation
(active/passive)
 Physiotherapy, OT, District
nurse, GP
 Drugs – analgesia
 Social worker – housing,
disability grants
 Work assessment and re-
employment
 Why had injury? – epilepsy?
alcohol?
 Complications of fracture
• General
 Shock
 ARDS
 Fat embolism
 Head, chest, abdomen and pelvic injuries
 Crush syndrome
 Tetanus
 Gas gangrene
 Infections – UTI, Chest
 DVT/PE
 Bed sores
 Depression/PTSD
 Specific Complications of fracture
Early Late
Visceral injury Delayed union
Vascular injury Non-union
Compartment Mal-union
syndrome (later Tendon rupture
Volkmann Myositis ossificans
conctracture) Osteonecrosis
Nerve injury Algodystrophy
Haemarthrosis Osteoarthritis and
Infection joint stiffness
DISLOCATIONS
 Introduction
• The most dislocated joint is shoulder
• Each joint may dislocate (Shoulders, elbows,
Hips, Knees, ankle joints, etc.)
• Dislocation may be solitary or associated with
fractures or any other injuries depending on
the energy causing the injury.
 SHOULDER
• GENERAL PRINCIPLES
Shoulder is a complex 4 part joint:
• Glenohumeral joint
• Acromioclavicular (AC) joint
• Scapulothoracic joint
• Sternoclavicular joint
• The joint is highly mobile therefore decreased
stability,
• dislocations and subluxations following trauma are
common
• Active ROM
• • forward flexion and abduction
• • external rotation (elbows at side and flexed 90
degrees, move arms away from midline)
• • internal rotation (hand behind the back, measure
wrt. level of the spine)
• Passive ROM
• abduction – 180 degrees
• adduction – 45 degrees
• flexion – 180 degrees
• extension – 45 degrees
• external rotation – 40 - 45 degrees
 ANTERIOR SHOULDER DISLOCATION

• over 90% of all shoulder dislocations, usually

traumatic
• two general types:
• involuntary: traumatic, unidirectional,
Bankart lesion, responds to surgery
• voluntary: atraumatic, multidirectional,
bilateral, rehab, surgery is last resort
•
• occurs when abducted arm is externally
rotated or hyperextended
• recurrence rate depends on age of first
dislocation
• at age 20: 80%; at age 21-40: 60-70%; at age
40-60: 40-60%; at age > 60: < 10%
• Physical Examination
• “squared off” shoulder
• humeral head can be palpated anteriorly
• arm held in slight abduction and external rotation
• loss of internal rotation with anterioinferior humeral
head
NB: Axillary nerve may be damaged, therefore check
sensation and contraction over lateral deltoid;
X-Rays ere enough to make diagnosis
• Humeral head anterior (to Mercedes Benz
sign) in trans-scapular view
• Axillary view is diagnostic
• AP view may show Hill-Sachs lesion if
recurrent
• Rule out associated humeral neck fracture
MERCEDES BENZ SIGN
 Treatment

• intravenous sedation and muscle relaxation

• gentle longitudinal traction and countertraction
• +/– alternating internal and external rotation
• Hippocratic Method - foot used in axilla for
countertraction (not recommended - risk of nerve
damage)
• Stimsons’s method - patient prone with arm hanging
over edge of table, weight hung on wrist
• (typically 5 lbs for 15-20 mins)
• X-Ray to verify reduction and check neurologic
status
• Arm sling x 3 weeks with movement of elbow,
wrist, fingers
Rehabilitation aimed at strengthening dynamic
stabilizers and avoiding the unstable position
• (i.e. external rotation and abduction)
• recurrent instability and dislocations may
require surgery
 POSTERIOR SHOULDER DISLOCATION

• 5% of all shoulder dislocations

• caused by force applied along the axis of the arm
• shoulder is adducted, internally rotated and flexed
The four Es which cause posterior dislocation
• Epileptic seizure (Bilateral shoulder dislocations)
• Ethanol intoxication
• Electricity (ECT, Electrocution)
• Encephalitis
Physical Examination
• anterior shoulder flattening, prominent
coracoid
• blocked external rotation, limited abduction
X-Rays
• humeral head posterior in trans-scapular view
 Treatment

• inferior traction on flexed elbow + pressure on

back of humeral head
• It may require reduction under general
anesthetic
• Splint for 3 weeks following reduction
 ELBOW DISLOCATION
• usually young people in sporting events or
high speed MVA
• > 90% are posterior or posterior-lateral fall
on outstretched hand
• rule out concurrent radial head or coracoid
process fractures
Treatment of Posterior Dislocation

• closed reduction: traction then flexion

• above elbow backslab with elbow 90 degrees
and wrist pronated
• open reduction if unstable
 Complications
• stiffness
• intra-articular loose body
• occasionally medial epicondyle is pulled into
joint, especially in children
• heterotopic ossification (bone formation)
• prevented by indomethacin immediately
following surgery
• recurrent dislocation is extremely rare
 HIP DISLOCATIONS
• Most hip Dislocations occur in the geriatric
population,
• Young patients : High-energy injuries (MVA)
about the hip
• Rapid increase in the US (with an estimated
458,000 to 1,037,000 hip fractures per year by
2050 in patients 45 years old or older)

Campbell’s Operative Orthopedics (12th Ed).

 1. Anterior (rare)

• Blow to knee with hip widely abducted

Clinical findings:
• Limb fixed, externally rotated and abducted
• Femoral head tends to migrate superiorly
Treatment:
• Attempt closed reduction under GA then CT of
hip to assess joint congruity.
 2. Posterior (>90%)

• severe forces to knee with hip flexed and

adducted (e.g. knee into dashboard in MVA)
Clinical finding:
• limb shortened, internally rotated and adducted
• femoral head tends to migrate
inferiorly/medially
• +/– fracture of posterior lip of acetabulum or
intra-articular fracture
•
• sciatic nerve injury common especially with
associated acetabular fracture
• assess knee, femoral shaft for other
injuries/fractures
• +/– fracture of posterior lip of acetabulum or intra-
articular fracture
• attempt closed reduction under GA
• then CT to assess congruity and acetabular integrity
• traction for 6 weeks, then ROM
• ORIF if unstable, intra-articular fragments, or
posterior wall fractures
 Classic appearance
Posterior hip dislocation Anterior Hip dislocation

Campbell’s Operative Orthopedics (12th Ed).

 3. Central hip dislocation

• It is associated with acetabular fracture.

• The reduction and traction may give good
prognosis
• It may need the total hip replacement when
the femoral head gets necrosis.
 Radiographs: AP Pelvis X-Ray

• Should allow diagnosis and show direction of dislocation.

– Femoral head not centered in acetabulum.
– Femoral head appears larger (anterior) or smaller
(posterior).
• Usually provides enough information to proceed with closed
reduction.
 Complications of hip dislocations

• Post-traumatic arthritis due to cartilage injury or

intra-articular loose body
• Femoral head injury including osteonecrosis +
fracture; 100% if nothing12 hours before reduction
• Sciatic nerve palsy in 25%
• Heterotopic ossification;
• Fracture of femoral shaft or neck
• Knee injury (posterior cruciate ligament (PCL) tear
with dashboard injury)
 DISLOCATED KNEE
• It is due to bad high energy injury
Associated injuries:
• Popliteal artery intimal tear or disruption 35-50%
• Capsular, ligamentous and common peroneal nerve
injury
Investigations:
• X-ray is enough to make diagnosis
• Angiogram to rule out the popliteal vessels injury
 DISLOCATED KEE Cont’d
Treatment
• Closed reduction,
• Above knee cylinder cast for 4 weeks
• Alternately, external fixation especially if
vascular repair
• Surgical repair of all ligaments if high demand
patient (sport, profession)
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