FRACTURE and

Dislocation
Dr.Zerihun Tamrat
(orthopaedic surgeon}

1
 2

CONTENT
 DEFINITION
 PRINCIPLE
MANAGEMENT
 COMPLICATIONS
 3

DEFINITION

A fracture is a break
in the structural
continuity of bone.
 4

CAUSES
 trauma
 direct(fracture of the ulna caused by blow on the arm)
 indirect(spiral fractures of the tibia and fibula due to
torsion of the leg, vertebral compression fractures, avulsion
fractures)
 Stress or fatigue-repetitive stress(athletes, dancers, army
recruits)
 Pathological(osteoporosis,rickets,infections, Paget’s
disease, bone tumor)
 5

TYPES OF FRACTURES
CLOSED/ OPEN/
SIMPLE COMPOUND
• no opening in • bone
the skin. fragments
have broken
through the
skin.
6
 7

COMPLETE INCOMPLETE
• bone is completely • bone is incompletely
broken into 2 or more divided and the
fragments. periosteum remains in
• -eg: continuity.
• transverse fracture • -eg:
• oblique fracture • greenstick fracture
• spiral fracture • torus fracture
• impacted fracture • stress fracture
• comminuted fracture • compression fracture.
• segmental fracture
 8

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.
 9

COMPLETE FRACTURES
 10

OBLIQUE FRACTURE

SEGMENTAL FRACTURE
 11

TRANSVERSE FRACTURE

SPIRAL FRACTURE
 12

COMMINUTED FRACTURE

IMPACTED
FRACTURE
 13

INCOMPLETE FRACTURE
 14

GREENSTICK

TORUS
 15

FRACTURES DISPLACEMENT
 After a complete fracture the fragments usually
displaced:
 partly by the force of injury
 partly by gravity
 partly by the pull of muscles attached to them.

4 types:
 Translation/Shift
 Alignment/Angulation
 Rotation/Twist
 Altered length
 SHIFT ANGULATION TWIST/
/TILT ROTATION

SIDEWAYS

OVERLAP
IMPACTION

16
 17

HOW FRACTURES HEAL?

 Healing by callus
 Healing without callus
 18

Healing by callus
 Callus is the response to movement at the fracture site to
stabilize the fragments as rapidly as possible.
 Steps:

Tissue destruction and haematoma formation.

Inflammation and cellular proliferation.

Callus formation: dead bone is mopped up & woven bone(immature)

appears in fracture callus.
Consolidation: woven bone(immature) is replaced by lamellar
bone(mature).
Remodelling:Newly formed bone is remodelled to resemble the
normal structure.
19
 20

RATE OF REPAIR DEPENDS UPON:

Patient’s
Type of State of
Type of bone general Patient’s age
fracture blood flow
constitution

spiral
cancello
fracture poor healing
us bone
heals circulati healthy is faster
heals
faster on will bone in
faster
than slow the heals children
than
transver healing faster. than
cortical
se process. adults.
bone.
fracture.
 21

CAUSES OF DELAYED UNION OR

NON-UNION OF THE FRACTURES
Interposition of
Distraction & Excessive
soft tissues
separation of the movement at the
between the
fragments fracture site
fragments.

Severe damage to
Poor local blood soft tissues which
Infection
supply makes them
nearly/non-viable.

Abnormal bone.
 22

Clinical Features
Symptoms:
Pain, Swelling, deformity, inability to use the affected part.
P/E
Look – Deformity, swelling, Shortening
Feel: Tenderness,
Move : Abnormal mobility, Crepitus
 23

Remember
 Clinical manifestation in a fracture is due to :
Fracture per se ,Its complications or both
Impendening vascular damage is detected by five ‘P’
Pain, Pallor,
Paraesthesia,
Pulselessness, Paralysis
24
 25

X-RAY INVESTIGATION
 X-ray examination is mandatory.
 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 limbs – In children, the appearance of

immature epiphyses may confuse the diagnosis of a
fracture; x-rays of the uninjured limb are needed for
comparison.
26

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.
 27

Two limbs:
Sometimes the
abnormality can be
appreciated only by
comparison with the
normal side; in this
case
there is a fracture of
the lateral condyle
on the left side

R L
 28

 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 injuries – Severe force often causes injuries at more than

one level. Eg: In fractures of the calcaneum or femur it is
important to also x-ray the pelvis and spine.
 Two occasions – Some fractures are notoriously difficult to
detect soon after injury, but another x-ray examination a week or
two later may show the lesion. Eg: Undisplaced fractures of the
distal end of the clavicle, scaphoid, femoral neck and lateral
malleolus, and also stress fractures and physeal injuries.
29

Two joints: The

first x-ray (1) did
not include the
elbow.
This was, in fact,
a Monteggia
fracture – the
head of the radius
is dislocated; (2)
shows the
dislocated
radiohumeral
joint.
 30

SPECIAL IMAGING
 Computed tomography (CT) may be helpful in lesions
of the spine or for complex joint fractures; help in
accurate visualization of fractures in ‘difficult’ sites such
as the calcaneum or acetabulum.
 Magnetic resonance imaging (MRI) 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.
 FRACTURES-
PRINCIPLE OF
TREATMENT

31
32

Management of
Closed Fracture
 33

First aid management

 Airway, Breathing and Circulation
 Splint the fracture
 Look for other associated injuries
 Check distal circulation – is distal circulation
satisfactory?
 Check neurology – are the nerve intact?
 Radiographs – 2 views, 2sides, 2 joints, 2 times.
 34

Reduce Hold

Exercise

Principle Of Treatment
 35

Outline
Closed Fracture

Reduce

Closed Reduction

Mechanical Traction

Open Reduction

Hold

Sustained Traction

Cast Splintage

Functional Bracing

Internal Fixation

External Fixation

Exercise
 36

Reduce
 Aim for adequate apposition and normal alignment of
the bone fragments
 The greater contact surface area between fragments, the
more likely is healing to occur
 37

Reduction
Non-Operative

operative
Closed reduction

Mechanical Traction
Open
reduction
 38

Closed Reduction
 Suitable for
 Minimally displaced fractures
 Most fractures in children
 Fractures that are likely to be stable after reduction
39
 40

Mechanical Traction
 Some fractures (example fracture of femoral shaft) are
difficult to reduce by manipulation because of powerful
muscle pull
 However, they can be reduced by sustained muscle
mechanical traction; also serves to hold the fracture until
it starts to unite
 41

Open Reduction
 Operative reduction under direct vision
 Indications:
 When closed reduction fails
 When there is a large articular fragment that needs accurate
positioning
 For avulsion fractures in which the fragments are held
apart by muscle pull
 When an operation is needed for associated injuries
 When a fracture needs an internal fixation
 Poly trauma
 Segmental fracture
42
 43

Hold
N
on
OO •Sustained
traction
pepe
•Cast Splintage
•Functional
•Internal
rara
Bracing
Fixation
•External
tiv
tiv Fixation

ee
 44

To alleviate pain by
To prevent
some restriction of
displacement
movement

To allow free
To promote soft-tissue
movement of the
healing
unaffected parts

HOLD
 45

Sustained Traction
• Traction is applied to limb distal to the fracture
• To exert continuous pull along the long axis of the bone
 46

 Disadvantage and complications

 Patient kept on bed for long time
 Pressure ulcer
 General weakness
 Pulmonary infection
 Contracture
 Pin tract infection
 Thromboembolic event

 Methods
 Traction by gravity
 Balanced traction
 Fixed traction
47

Traction By Gravity
Example:
Fracture of humerus
-Weight of arm to
supply traction
-Forearm is
supported in a wrist
sling
 48

Balanced Traction
Traction is applied to the limb either by
way of adhesive strapping, kept in
place by bandages  skin traction

• Sustain a pull no more than 4-5 kg

Contraindications:

• Abrasion, dermatitis, wound

• Vascular insufficiencies
• When greater traction force in
needed
49

Thomas’s Splint
 50

Traction applied via Complications:

stiff wire or pin • Pin tract infection
inserted through the • Damage to
bone distal to the epiphyseal
fracture  skeletal growth plate
traction • Vertical fracture
• Can apply several of the bone
times as much • Injury to the
force vessels or nerves
 51

Fixed Traction
 Principle= balanced traction
 Useful for when patient has to be transported
 Thomas’s splint
 52

Cast Splintage
 Methods:
 Plaster of Paris
 Fibreglass
 Especially for distal limb # and for most children #
 Disadvantage: joint encased in plaster cannot move and
liable to stiffen
 Can be minimized:
 Delayed splintage (traction initially)
 Replace cast by functional brace after few weeks
53
 54 Complications
Tight cast
 put on
too
tightly/lim
b swells
Hold Safety
Pressure sores 
even a well-
fitting cast may
press upon the
Speed Move skin over a bony
prominence (the
patella, the heel)

Skin
abrasion or
laceration 
during
removal of
the plaster
 INTERNAL
FIXATION
55
 56

Principle

Bony fragment may be fixed with:

• screws,
• transfixing pins or nails,
• a metal plate held by screws,
• a long intramedullary nails,
• circumferential band,
• or a combination with these method
 57

Indication
2. Fracture that are
1. Fracture that cannot be
inherently unstable and
reduced except by
prone to displacement after
operation
reduction

3.Fracture that unite

poorly and slowly
• Principally fracture of
the femoral neck
4.Pathological fracture
• Bone disease may
prevent healing

5.Multiple fracture
6.Fracture in patient who
58
 59

advantages

Precise Immediate Early

reduction stability movement
•ORIF-open •‘fracture
reduction •Hold the disease ‘ like
and fracture oedema,s
internal tifness,etc
securely may abolish
fixation
 60

Infection

Refracture
Complica Non-union
tions

Implant failure
 EXTERNAL
FIXATION

61
 62

Principle

The bone is transfixed above and below the fracture

with screw or pins or tension wire and these are then
clamped to a frame or connected to each other by rigid
bars outside the skin
Indication
63

Fracture associated with soft Severely comminuted and

tissue injury unstable fracture
• Where the wound can be left • Which can be held out to
open for inspection, dressing and length until healing
definitive coverage commence

Fracture of the pelvis

• Which often cannot be Fracture associated with nerve
controlled quickly by any and vessel damage
other method

United fracture
Infected fracture • Where dead or sclerotic fragment
 64

(a)The patient was fixed with a plate and screw but did not unite (b)
external fixation was applied
 65

Advantages
no soft tissue
technically quick and
stripping;
easy to perform

risk of infection at the

ease of removing
site of the fracture is
hardware;
minimal
 66

Complication

Damage to soft tissue

Over distraction Pin track infection
structure
 67

Exercise
 Prevention of edema
 active exercise and elevation
 Active exercise also stimulates the circulation. Prevents
soft-tissue adhesion and promotes fracture healing.
 Preservethe joint movement
 Restore muscle power
 Functional activity
68

Management of

Open Fractures
A break in skin and
underlying soft tissues
leading directly to
communicating with
the fracture
 69

Open Fracture
First Aid & Management of the Whole
Patient
Prompt wound debridement

Antibiotic prophylaxis

Stabilization of the fracture

Definitive wound cover

 70

First Aid & Management of the Whole Patient

B
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 71

1. Emergency Management of
Open Fracture
 A,B,C
 Splint the limb
 Sterile cover - prevent contamination
 Look for other associate injury
 Check distal circulation – is distal circulation satisfactory?
 Check neurology – are the nerve intact?
 AMPLE history- Allergies, Medications, Past medical history, Last meal, Events
 Radiographs – 2 view, 2sides, 2 joints, 2 times.
 Relieve pain
 Tetanus prophylaxis
 Antibiotics
 Washout / Irrigation
 Wound debridement
 fracture stabilisation
Open Fractures
Classification

72
 73

Treatment- Outline

Irrigation

Debridement: Skin, Fat, Muscle, Bone

Wound closure

Analgesic + Antibiotic + Antitetanus

(AAA): IV, IM

Fracture stabilization
 74

Aftercare

The limb is
elevated & it's
Antibiotic
circulation
cover
carefully
monitored

If the wound
has been left
open, it is Physiotherapy
inspected and
after 2-3 days rehabilitation
& covered
appropriately
 COMPLICATIO
N OF
FRACTURE

75
 76

complication
77
78
 Early Late
79

General Shock Crush Syndrome

Diffuse Coagulopathy Chest Infection

GENERAL
Tetanus Urinary Tract Infection
Respiratory Dysfunction Gas Gangrene
DVT & Pulmonary Emb.
Fat Emboli Syndrome
Bone Infection Non-union / Mal-union / Delayed union
Avascular Necrosis

BONE
Length discrepancy
Disuse Osteoporosis
Joint Haemarthrosis Instability / Mal-alignment
Ligament injury Osteoarthritis
Stiffness

JOINT
Overuse injuries
Soft Tissue Plaster Sore Nerve compression
Tendon Rupture Volkmann’s contracture
Neurovascular Injury Bedsores
Compartment Syndrome Myositis Ossificans

SOFT TISSUE
Visceral injury Tendinitis & Tendon rupture
 80

General 1: Shock
Altered physiologic status with generalized inadequate tissue
perfusion relative to metabolic requirements.  irreversible
damage to vital organs

Cardiogenic • direct injury to heart  effect the pump functions

• injury to brain stem (vasomotor center) spinal cord  loss of

Neurogenic sympathetic tone  increase venous capacitance  low venous
return àlow cardiac output (but bradycardia)

Hypovolemic • reduction of blood volume

 81

1500-3000ml 500-1000ml

1500-3000ml
100-300ml

1000-2000ml

500-1000ml

VOLUME DISTRIBUTION

General 1: Shock
Why we need to treat shock?
• Blood redistribution
• Renal shutdown
• Intestinal ischemia
• Tissue hypoxia
• function test and decreased
Metabolic acidosis
• Reduced hepatic blood flow
• Acute Respiratory Distress
Sydrome
• Altered consciousness
82
How to manage shock?
• Identify: Thirst, rapid shallow
breathing, the lips and skin
are pale and the extremities
feel cold, impaired renal
urinary output.
• ABC
• IV lines: fluids and blood
• Oxygenation/Ventilation
• Urinary Catheter
• Central Venous Pressure
• Ionotropic drugs
 83

General 2: DIFFUSE COAGULOPATHY

Consumptive
Management
Coagulopathy
• activation by tissue • Stop the bleeding
thromboplastin • Fresh Frozen Plasma
• endothelial injury (FFP)
activating platelets • Cryoprecipitate
• massive blood • Platelet transfusion
transfusion • Heparin
General 3: RESPIRATORY 84

DYSFUNCTION
Pathophysiology Management
• Alveolar edema • Oxygenation
• endothelial injury • Ventilation
• capillary • positive end
permeability expiratory pressure
• Poor lung compliance (PEEP)
• inactivated
surfactant
• Arterial hypoxemia
 85

General 4: Crush Syndrome

[traumatic rhabdomyolitis]

Serious medical condition characterized by

major shock & renal failure following a
crushing injury to skeletal muscles or tourniquet
left too long

Bywaters’ Syndrome

Oliguria,
When Myohaematin
Nephrotoxic uremia,
compression release from Block tubules
effects metabolic
released cells
acidosis
 86

General 4: Crush Syndrome

Clinically Management
• Shock • PREVENTION
• Pulseless limb  redness  • Strict tourniquet timing
swelling • Amputation
• Loss of muscle sensation and • limb crushed severely
power • tourniquet left on > 6 hrs
• Decrease renal secretion • above site of compression &
• Uremia, acidosis before compression released
• Prognosis • Monitor intake & output
• If renal secretion return within 1 • Dialysis
week the patient survive • Correct electrolytes & acidosis
• But most of them die within 14 • Antibiotics
days
 87

General 5: Deep vein thrombosis and

pulmonary embolism.
 Virchow’s triad factor  Clot formation in large
vein  thrombus breaks off  Emboli
 Site: leg, thigh and pelvic vein.
 Risk factors:

Knee and hip

Elderly Immobility Malignancy
replacement

Cardiovascular Hypercoagulabl
Trauma
disease e status
 88

General 5: Management Deep vein

thrombosis and pulmonary embolism.

 PREVENTION  Anticoagulation
 Correct hypovolemia  Ambulate patient

 Calf muscle exercise  Established

 Proper positioning thrombosis/embolism

 Limb elevation
 Well fitting bandages & cast
 Heparinization
 Limb elevation
 Thrombolysis
 Graduated compression
 Oxygenation or
stockings ventilation
 Calf muscle stimulation
 89

General 6: Fat Embolism

Fat globules from marrow pushed into circulation by
the force of trauma that causing embolic phenomena

Fractures that Fat in bone Formation of fat

most often Closed/open
marrow globules in
cause FES Fracture vessels
escape
• Long bones
• Ribs
• Tibia
• Pelvis
Triad of Stick in target
Fat embolus
symptoms organ
 90
General 6: Fat Embolism
Triad of Symptoms
• Brain: mental confusion
• Lung: breathlessness,
ARDS
• Skin: Petechia
Management
• Prevent hypoxemia
• oxygenation or
ventilation
• Rule out head injury
• CT Scan of brain
• Monitor fluid &
electrolyte balance
• CVP, urinary catheter
 91

General 6: Fat Embolism

SKIN: Fat droplets 

obstruct alveolar capillaries 
thromboplastin release 
consumption of coagulation fx
& platelets  DIVC/Skin
necrosis  Petechia

LUNG: Fat droplets 

obstruct alveolar capillaries
 thromboplastin release 
alter membrane
permeability / lung surfactant
 oedema  respiratiory BRAIN: Fat droplets  obstruct
failure [V/Q Mismatch] capillaries  confusion  coma/fits
 death
 92

General 7: Gas Gangrene

Rapid and extensive necrosis of the muscle accompanied by
gas formation and systemic toxicity due to clostridium
perfringens infection

Clinical Features Management

• sudden onset of pain localized to the • early diagnosis .
infected area. • surgical intervention and
• swelling , edema debridement are the mainstay of
• +/- pyrexia treatment.
• profuse serous discharge with • IV antibiotics
sweetish and mousy odor . • fluid replacement.
• Gas production • hyperbaric Oxygen
 93

General 7: Gas Gangrene

Prevention: ALL DEAD TISSUE [4C]

SHOULD BE COMPLETELY
EXCISED,
 94

General 8: Tetanus
A condition after clostridium tetani infection that passes to
anterior horn cells where it fixed and cant be neutralized
later produces hyper-excitability and reflex muscle spasm

Clinical
Management
Features
•Tonic and clonic contractions of esp. •Prophylaxis
jaw, face, around the wound •Treatment
itself ,neck ,trunk, finally spasm of •Antitoxin & antibiotic
the diaphragm and intercostal •Muscle relaxant
muscles leads to asphyxia and •Tracheal intubation
death. •Respiration control
 Early
Complications

1. Visceral Injury
2. Vascular Injury
3. Compartment
Syndromes
4. Nerve injury
5. Haemarthrosis
6. Infection

95
 96

Early 1: Visceral injury

 Fracturesaround the trunk are often
complicated by visceral injury.
 E.g. Rib fractures  pneumothorax /
spleen trauma / liver injuries.
 E.g. Pelvic injuries  bladder or
urethral rupture / severe hematoma in
the retro-peritoneum .
 Rx: Surgery of visceral injuries
 97

Early 2: Vascular injury

 Commonly associated with high-energy open
fractures. They are rare but well-recognized.
 Mechanism of injuries:
 The artery may be cut or torn.
 Compressed by the fragment of bone.
 normal appearance, with intimal detachment that
lead to thrombus formation.
 segment of artery may be in spasm.
 It may cause
 Transient diminution of blood flow
 Profound ischaemia
 Tissue death and gangrene
 98

Early 2: Vascular injury

5P’s of ischemia

Pain

Pallor

Pulseless

Paralysis

Paraesthesia

X-ray: suggest high-risk fracture.

Angiogram should be performed to confirm diagnosis.
 99

Early 2: Vascular injury

Vessel Injury
 muscle ischaemic is subclavian 1st rib fracture
irrevesible after 6 hours. Axillary Shoulder dislocation
 Remove all bandages and Brachial Humeral supracondylar
fracture
splint & assess circulation
Brachial Elbow dislocation
 Skeletal stabilization – Presacral Pelvic fracture
temporary external fixation. and
internal
 Definitive vascular repair. iliac
 Vessel sutured Femoral Femoral supracondylar
 endarterectomy fracture
Popliteal Knee dislocation
Popliteal or Proximal tibial fracture
its branches
 100

Early 3: Compartment Syndrome

A condition in which increase in pressure within a closed
fascial compartment leads to decreased tissue perfusion.
Untreated, progresses to tissue ischaemia and eventual
necrosis

Leg Forearm
•3 compartments: dorsal,
•4 compartments: anterior,
superficial and deep volar
lateral, superficial and •interconnected, hence
deep posterior fasciotomy of 1 compartment
•NOT interconnected may decompress the other 2
 101

Early 3: Compartment Syndrome

 Most common sites (in ↓ freq): leg (after tibial fracture)
→ forearm → thigh → upper arm. Other sites: hand,
foot, abdomen, gluteal and cervical regions.

 High risk injuries:

 # of elbow, forearm bones, and proximal 3rd of tibia (30-
70% after tibial #)
 multiple fracture of the foot or hand
 crush injuries
 circumferential burns
 102

Early 3: Compartment Syndrome

[aetiology]
↑ Compartmental ↓ Compartment
volume (↑ fluid volume (constriction
content) of the compartment)
•Trauma – fractures /osteotomies, •Constrictive
crush injury
•Vascular – haemorrhage, post- dressings/plaster casts
ischaemic swelling •Thermal injuries with eschar
•Soft tissue injury – burns, formation
prolonged limb compression •Pneumatic antishock
•Iatrogenic – intraosseous fluid
resuscitation in children, intraarterial garments (MAST)
drug injection •Surgical closure of fascial
•Extreme muscular exertion defects
 Early 3: Compartment
103 Syndrome

Vicious cycle
↑ fluid content Constriction of compartment

↑ INTRACOMPARTMENTAL PRESSURE

Obstruct venous return Capillary basement

membranes become leaky
→ oedema
Vascular congestion
Muscle and nerve ischaemia

Further ↑ intracompartmental ↓ capillary perfusion

pressure
Compromise arterial circulation
→ PROGRESSIVE NECROSIS OF MUSCLES AND NERVES !!
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 105

A vicious circle that ends after 12 hours or less

Necrosis of the nerve and muscle within the compartment

Nerve Muscle
-capable to regenerate -infarcted

Never recover

Replaced by inelastic fibrous tissue

( Volkmann’s ischaemic contracture)
 106

Investigations of compartment
sydromes

 Intra-compartment Pressure Measurement (ICP)

 Use of slit catheter; quick and easy
 Indications:
 Unconscious patient
 Those who are difficult to assess
 Concomitant neurovascular injury
 Equivocal symptoms
 Especially long bone # in lower limb
 Perform as soon as dx considered
 > 40mmHg – urgent Rx! (normal 0 – 10 mmHg)
 107

Investigations of compartment syndromes

 Other Ix – limited value; +ve only when CS is advanced

 Plasma creatinine and CPK
 Urinanalysis – myoglobinuria
 Nerve conduction studies
 Ix to establish underlying cause or exclude differentials
 X-ray of affected extremity
 Doppler US/arteriograms – determine presence of pulses;
exclude vascular injuries and DVT
 PT/APTT – exclude bleeding disorder
 108

Management
 Prompt DECOMPRESSION of affected compartment
 Remove all bandages, casts and dressings
 Examination of whole limb
 Limb should be maintained at heart level
 Elevation may ↓ arterio-venous pressure gradient on which
perfusion depends
 Ensure patient is normotensive.
 Hypotension ↓ tissue perfusion, aggravate the tissue injury.
 109

Management
 Measure intra-compartment pressure
 If > 40mmHg
 Immediate open fasciotomy
 If < 40mmHg
 Close observation and re-examine over next hour
 If condition improve, repeated clinical evaluation until danger
has passed

Don’t wait for the obvious sings of ischemia to appear. If you suspect
An impending compartment syndrome, start treatment straightaway
 110

Fasciotomy

 Opening all 4 compartments

 Divide skin and deep fascia for the whole length of
compartment
 Wound left open
 Inspect 5 days later
 If muscle necrosis, do debridement
 If healthy tissue, for delayed closure or skin
grafting
111
 112

Complications
 Volkmann’s ischaemic contracture
 Motor/sensory deficits
 Kidney failure from rhabdomyolysis (if very severe)
 Infection – fasciotomy converts closed # to open #
 Loss of limb
 Delay in bone union

Prognosis
excellent to poor, depending on how quickly CS is treated
and whether complications develop
 113

Early 4: Nerve Injury

 nerve Injury
It’s more common than Axillary 1. Shoulder dislocation
arterial injuries. Radial 2. Humeral shaft fracture

 The most commonly injured

Median 3. Lower end of radius

nerve is the radial nerve [in Radial or 4. Humeral

its groove or in the lower third of median(ant.interosseous) supracondylar (esp.
children)
the upper arm especially in oblique Ulnar 5. Medial condyle
fracture of the humerus] Ulnar 6. Elbow dislocation
 Common with humerus, Sciatic 7. Hip dislocation
Peroneal 8. Knee dislocation
elbow and knee fractures Peroneal 9. Fracture of fibular
neck
 Most nerve injuries are due
to tension neuropraxia.
 114

Early 4: Nerve Injury

 Damaged by laceration, traction, pressure or prolonged
ischaemia

Neurapraxia Axonotmesis Neurotmesis

•axon remains intact •axonal separation •nerve
but conduction with degeneration
ceases due to completely
of distal portions.
segmental
Sheath remains
divided.
demyelination. Spontaneous
Spontaneous intact, thus
recovery in a few recovery likely recovery
days or weeks but delayed unlikely.
 115

Early 4: Nerve Injury

Investigations
Clinical features  Electromyography
 Numbness and
 Nerve conduction study
weakness
 May help to establish
 Skin smooth and shiny
level and severity of
but feels dry
lesion
 Muscle wasting and
weakness
 Sensation blunted
 Tinel’s sign +ve

Early 4: Nerve Injury
Open injuries
•Exploration
•Cleanly divided – repair
immediately
•Torn/crushed – left alone or
ends lightly tacked together,
re-explore 2 – 3 weeks later
for scar tissue removal and
suturing
116
Closed
injuries
•Usually nerve sheath intact
•Rate of axonal regeneration =
1mm/day
•If no sign of recovery – re-
exploration with excision of scar
tissue and suturing of clean-cut
ends, nerve grafting if gap too
large
•Splinting 3-6 weeks then
physiotherapy
 117

Early 5: Haemarthrosis
 Bleeding into a joint spaces.
 Occurs if a joint is involved in the
fracture.
 Presentation:
 swollen tense joint; the patient
resists any attempt to moving it
 treatment:
 blood aspiration before dealing
with the fracture; to prevent the
development of synovial adhesions.
 118

Early 6: INFECTION
 Closed fractures – hardly ever
 Open fractures – may become infected
 Post traumatic wound – may lead to chronic
osteomyelitis

Clinical
features
Treatment
•wound is inflammed •antibiotic
•draining seropurulent •excise the devitalised tissue
•tissues opened & drained the pus
fluid
 Late
Complications

1. Delayed Union
2. Non-union
3. Mal-union
4. Avascular Necrosis
5. Osteoarthritis
6. Joint Stiffness

119
 120

Late 1: DELAYED UNION

Union of the upper limbs - 4-6 weeks
Union of the lower limbs - 8-12
weeks(rough guide)
Any prolong time taken is considered
delayed
121
 122

Late 1: DELAYED UNION

 Factors are either biological or biomechanical

 Biological :
 Poor blood supply
 Tear of periosteum, interruption of intramedullary circulation
 Necrosis of surface# and healing process will take longer
 Severe soft tissue damage
 Most important factor
 Longer time for bone healing due less inflammatory cell supply
 Infection: bone lysis, tissue necrosis and pus
 Periosteal stripping
 Less blood circulation to bone
 123

Late 1: DELAYED UNION

 Mechanical
 Over-rigid fixation-fixation devise

 Imperfect splintage
 Excessive traction creates a gap#(delay ossification in
the callus)
 124

Late1: DELAYED UNION

 Clinical features:
 Tenderness persist
 Acute pain if bone is subjected to stress*

( * ask pt to walk, move affected limb)

X RAYS -visible line# and very little callus

formation/periosteal reaction
- bone ends are not sclerosed/ atrophic
(it will eventually unite)
 125

Late 1: DELAYED UNION

 Tx: conservative and operative

 Eliminate possible causes of delay
 Promote healing
 Immobilization should be sufficient to prevent movement at #
site(cast / internal fixation)
 Not to neglect # loading so, encourage muscle exercise and
weight bearing in the cast/brace
 Operation
 > 6 mths & no signs of callus formation
 Internal fixation and bone graffting

(operation-least possible damage to the soft tissue)

 126

Late 2 : NON-UNION
 In a minority of cases, delayed union--non-union
 Factors contributing to non-union:-
 inadequate treatment of delayed union
 too large gap
 interposition of soft tissues between the fragments
 The growth has stopped and pain diminished- replaced by
fibrous tissue - pseudoarthrosis
 Treatment :-
 conservative / operative
 atrophic non-union – fixation and grafting
 hypertrophic non-union – rigid fixation
 127

Late 2: NON UNION

 boneends are rounded off or exuberant

 Hypertrophic non union
 Bone ends are enlarged, osteogenesis is still active but
not capable of bridging the gap
 ‘elephant feet’ on X ray

 Atrophic non union

 Cessationof osteogenesis
 No suggestion of new bone formation
 128

A B

Non-union
X- ray
A – Atrophic non- union
B – Hypertrophic non-
union
 129

Late 2: Non union

 Tx:
 Mostly symptomless
 Conservative
 Removable splint
 For hypertrophic non-union, functional bracing-induce union
 Pulsed electromagnetic fields and low frequency pulsed u/s can
also be used to stimulate union.
 Operative
 Hypertrophic--Rigid fixation (internal or external)
 Atrophic--Excision of fibrous tissue ,sclerotic tissue at bone end,
bone grafts packed around the fracture
130
131
 132

Late 3: MALUNION

fragments that are joined in an unsatisfactory position

 Factors:-
 failure to reduce the fracture
 failure to hold the reduction while healing proceed
 gradual collapse of comminuted / osteoporotic bone
133 MALUNION
 134

Late 3: Mal-union

 X-ray are essential to check the position of the

fracture while uniting. important- the first 3 weeks
so it can be easily corrected
 Clinical features:
 Deformity usually obvious , but sometimes the true
extent of malunion is apparent only on x-ray
 Rotational deformity can be missed in the femur, tibia,
humerus or forearm unless is compared with it’s
opposite fellow
 135

Treatment
 Decision about the need for re-manipulation and
correction-difficult

In adults Fracture-reduced as near to the

anatomical position
apposition for as possible
healing
alignment and rotation is
important for function
Angulation(>10-15) in long bone
or apparent rotational
deformity may need correction
In children by re-manipulation
angular or bythe bone
deformity near
osteotomy
ends often and
Rotational internal
remodel
deformitywithfixation
willtime
not

In lower limb shortening Shortening less than 2 cm:

compensated by shoe
Shortening more thanraise
2 cm: limb
lengthening should be
Long term effect of mal-consider.
alignment (>15) results in
asymmetrical loading of joint
and results in late development
of 2 osteoarthritis.
 136

Late 4: AVASCULAR NECROSIS

Certain region-known for their propensity to develop
ischaemia and bone necrosis
 Head of femur
 Proximal part of scaphoid
 Lunate
 Body of talus
 (Actually this is an early complication however the clinical
and radiological effects are not seen until weeks or even
months)
 No clinical feature of avascular necrosis but if there is a
failure to unite or bone collapse-pain
 137

A B

The cardinal X-ray feature – increased bone density in the weight-

bearing part of the joint(new bone ingrowth in necrotic segment)
 138

Treatment:-

 Avascular necrosis can be prevented by early

reduction of susceptible fractures and dislocations.
 Arthroplasty - Old people with necrosis of the
femoral head.
 Realignment osteotomy or arthrodesis - for
younger people with necrosis of the femoral head
 Symptomatic treatment for scaphoid or talus
 139

Late 5: OSTEOARTHRITIS

 A fracture-joint may 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 cause localized stress and so
predispose to secondary osteoarthritis years later
140
 141

Late 6: JOINT STIFFNESS

 Commonly occur at the joints close to malunion or bone
loss eg: knee, elbow, shoulder
 Causes of joint stiffness
 haemarthrosis → lead to synovial adhesion
 oedema and fibrosis
 adhesion of the soft tissues
 Worsen by prolong immobilization
 Treatment
 prevented with exercise
 physiotherapy
142
143
 144

Investigations

 Radiograph of the affected part should include

anterior posterior and lateral views and sometimes
special views needed.
 CT Scan
 145

Principles of management

 Acute dislocation should be reduced as soon as

possible.
 Open reduction is rarely necessary for acute
dislocation.
 Close reduction with intravenous analgesia and
sedation or under GA should be attempted first for
most uncomplicated dislocation.
 146

Complication

1. Acute: Injury to peripheral nerve and vessels

2. Chronic: Unreduced dislocation
Recurrent dislocation
Traumatic osteoarthritis
Joint stiffness
Avascular necrosis
Myositis ossificans
 147

Shoulder Dislocation

 Types:
 Anterior dislocation: Varities of dislocations like
Subcoracoid, subglenoid, sub-infraclavicular,
inferior.
 Posterior Dislocation
148
Reduction Techniques

 Stimson’s Gravity Method

149
Reduction Techniques

150
Hip Dislocation

Types:
A. Posterior Dislocation
B. Anterior Dislocation
C. Center Dislocation

151
Hip Dislocation
 Clinical Features:
o H/O Trauma
o The patient has a
flexion, adduction and
medial rotational
deformity of the
affected limb.
o Hip movement grossly
restricted.

152
Mechanism of Dislocation

153
 154

Radiological Images
Hip dislocation
Hip Dislocation
Reduction techniques
 The patient is supine on
the floor under GA.
 The hip is flexed to 90
degree.
 Assistant stabilizing the
pelvis.
 Longitudinal traction is
applied.

155
Hip Dislocation
After Treatment

 The patient is put on surface traction for three

weeks.
 Full weight bearing is permitted after 6 wks.
 157

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