Clinical program on

basic principles of
management of
common fractures
and dislocation

Fracture
Definition:
A fracture is a breach of the
structural continuity of bone, this
structural breach hence fracture, may also
occur through cartilage, epiphysis &
physis. It may be no more than a crack, a
crumpling or a splintering of the cortex;
more often the break is complete & the
bone fragments are displaced.

Dislocation
Definition:
Dislocation means the joint
surfaces are completely displaced &
the articular surfaces are no longer
in contact with each other.
Subluxation means partial
separation of the articular surfaces.

Common fractures & dislocations:

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.

Supracondylar fracture
Colles fracture
Fracture radius & ulna
Fracture humerus
Fracture tibia & fibula
Fracture femur
Fracture foot(tarsal, metatarsal & phalanges)
Fracture hand(carpal, metacarpal & phalanges)
Shoulder dislocation
Elbow dislocation
Hip dislocation

How fracture happen?

Bone is relatively brittle, yet it has sufficient strength &
resilience to withstand considerable stress.

1.
2.
3.

Fracture results from:

A single traumatic incidence
Repetitive stress
Abnormal weakening of the bone(a pathological bone)
In all fractures there is an element of soft tissue
damage, either contusion or laceration, & in some cases,
the soft tissue damage may be more important than the
bone or joint injury.

Basic principles of management of

fracture
A.

Diagnosis:
History
Physical examination
Investigation

Contd.
B. Assesment:

General condition of the patient

Nature of fracture
Affection of neurovascular bundle
Other soft tissue inlury

Contd.
C. Treatment:
a)General1. Treatment of shock
2. Control of haemorrhage, if significant.
3.Relieve of pain, if severe.
4. Treatment of associated injury.
5. Prevention of infection if fracture is compound* Cleaning & debridement of wound
* Tetanus prophylaxis
* Antibiotic
* Treatment of skin wound
6. Prevention & treatment of complication.

Contd.
b) Specific- 3R
1. Reduction:
Gravity-

Collar & cuff

Hanging cast

ClosedManipulation-reduction by hand tractionSurface

Skeletal
Fixed
Balanced
Open2. Rest.
3. Rehabilitation.

General scheme of fracture

management

Define fracture
Detect complication
Does the fracture need reduction?
Is the fracture unstable or stable?
How can the fracture be stabilized?
Does the fracture need immobilization &
for how long?
How can the patient be best rehabilitated?

Possible method of fracture

treatment

Protection alone
Immobilize with external splint
without reduction
Closed reduction
Manipulation & traction
followed by immobilization with
external splint or traction.
Open reduction & internal fixation
Excision of fracture fragment.

Indications for operative treatment

of fracture
1.
2.
3.
4.
5.
6.

Compound fracture
Reduction of fracture
Stabilization of fracture
Time factor-metastasis disease
Soft tissue management
Management of complicationVascular injury
Head injury

History
Importance:the history gives important
clues to the type of trauma likely. The
energy of trauma is related to the mass &
square of the velocity. The direction of the
trauma will also affect the injury that
should be seeking. The important thing to
remember is that if the trauma was severe
enough to fracture or dislocate the
skeleton, then it is highly likely that there
was enough energy to cause a second or
even third dislocation or fracture.

Contd
The following points should be noted during taking history
from a patient:

Age- # may occur at any age but there are some

fractures which are common in specefic age group.
*Greenstick # in children
*Colles # in postmenopausal womaen
*# neck of femur in old age

History of trauma

Amount & nature of violance

Local pain

Loss of function

Loss of sensation

Examination
During examination the key features are to
make sure that the patients overall condition
is stable by checking their airways, breathing
& circulation before concentrating on the
musculoskeletal injuries. The examination
then should be systemic from top to bottom
of the body, with complete exposure & care
taken to check the patients back as well as
their front. For each limb, be sure to check
the distal circulation & neurology. Finally, it is
important to record these findings.

Contd
Musculoskeletal examination works on a simple system originally
designed by Apley. It consists of four letter words dividedinto threes,
The first stem is
*look;
*feel;
*move.
The second stem branching off from each of these stem is
*skin
*soft tissue
*bone
Finally move is divided into
*active
*passive
*stability

Look

Skin:Look once at the skin for:

*bruising & wounds- evidence of recent injury;
*redness- signs of inflammation;
*scars- the archaeology of injury;
*sweating- loss of sweating may indicate nerve damage;
Soft tissue: Look a second time at the soft tissue. Should
look for*swelling- a cardinal sign of injury & inflammation;
*wasting- signs of disuse & nerve damage, the
archaeology of injury.
Bones:Look a third time at the bones(shape of the
skeleton). Should look for*deformity- unusual angles or joints held in unusual
position.

Feel

Skin:
* temperature
*sensation
Soft tissue:
*tenderness
*lumps
*circulation
Bone:
*bone outlines
*joint margins

Move

Active:
The patient should move their own joints within the
limit of pain. Better to use simple language to explain what
we want them to do & if necessary should demonstrate the
movement.
Passive:
Should not take the range of movement without
watching the patients face.
Stability:
There are two type of stability; dynamic & static.
Dynamic stability is provided by muscle power; static
stability by ligaments & intact joint surfaces.

Pathological anatomy

With fracture above the deltoid insertion,

the proximal fragment is adducted by
pectoralis major, with fracture lower down
the proximal fragment is abducted by
deltoid. Injury to the radial nerve is
common though fortunately recovery is
usual.
3% in adults mostly- 70 years- 80%
female.
At age 20 years&&: 80%
&&&&&&&&&&male mainly due to RTA.

Contd.

C/F:
Painful, swollen & bruised. May be open fracture.
Rx:
The weight of the arm with an external cast is usually
enough to pull the fragments into alignments. A hanging
cast is applied from shoulder to wrist with the elbow flexed
suspended by a sling around the patients neck. The cast
may be replaced 2-3 weeks later by a short cast (shoulder
to elbow) or a functional polypropylene brace which is worn
for a further 6 weeks.
If alignment is not acceptable- open reduction &
internal fixation DCP & screw.

Fracture tibia & ulna

Mechanism of injury: A twisting force causes a spiral

fracture of both leg bones at different levels, an angulatory
force causes transverse or short oblique fracture.
Indirect injury- low energy
Direct injury- high energy

Clinical features: deformity is usual. Carefully examined for

signs of soft tissue damage, severe swelling, bruising,
crushing or tenting of the skin, circulatory changes or
absent pulse. Always alert for signs of impending
compartment syndrome. Specially in upper third of femur.
RX: Closed stable- long leg plaster.
open unstable- external fixator.

Management of tibial fracture

Type

Treatment

Undisplaced, stable
closed reduction
possible
Displaced

Long leg plaster then

patellar tendon
bearing brace
Intermedulary nail

Unstable, reduction
Plate & screw
only achievable, open
Severe soft tissue
External fixator
injury or loss

Compartment syndrome

Common in fracture tibia.

Dx is by high index suspicion, when pain is
excessive specially on passively extending
the toes.
Treatment must be undertaken quickly.
Plaster must be split or removed (even if
fracture position is lost) & if symptoms fail
to improve, a fasciotomy must be
performed.

Fracture femur

C/F: Swelling & deformity, painful on

movement, vascular or other injury.
Emergency Rx: If shock, should be
treated. And use splint before move.
Definitive Rx:
In children- surface traction
Adult- Locked intermedullary
nail/skeletal traction.

Fracture foot, ankle & hand

Ankle: Simple undisplaced fracture can be

treated with a moulded cast for 6 weeks.
Unstable injury: Internal fixation
mandatory.
Four guiding principles are:
*Dont delay
*Treat the entire injury
*Reduce accurately
*Check & maintain reduction
*Think of compartment syndrome in
foot fracture.

Contd.

Foot:
Simple closed undisplaced fracture
can be treated by moulded cast in
dorsiflexion 4-6 weeks.
Think of compartment syndrome.
Hand:
simple closed undisplaced fracture
can be treated by full plaster from below
elbow to knuckle in the position safe
immobilization (POSI) & a collar & calf
sling apply.

Shoulder dislocation
(Anterior)

Mechanism of injury: Dislocation is usually caused

by a fall on the hand. The humerus is driven
forwards, tearing the capsules or avulsing the
glenoid labrum.
external rotation & abduction.
C/F: Pain is severe, the patient supports the arm
with opposite hand & is loath to permit any kind
of examination. The lateral outline of the shoulder
may be flattened.
The arm always be examined for nerves &
vessels before reduction is attempted.

Contd.

Rx of anterior dislocation:
Under G/A, the elbow is bent to 90 &
held closed to body; no traction should be
applied , the arm is slowly rotated laterally
75, then the point of elbow is lifted
forwards & finally the arm is rotated
medially, if fingers can touch opposite
shoulder- Reduction compatible.
The entire limb is fixed to the body
by adhesive strapping for 3 weeks to
prevent recurrent dislocstion.

Shoulder dislocation
(Posterior)

Mechanism of injury: Indirect force producing

marked internal rotation & adduction causes
dislocation. Fit or convulsion, electric shock, fall
on the flexed abducted arm.
C/F: The arm is held in medial rotation & is
locked in that position. The front of the shoulder
looks flat with that of prominent coracoid
Rx under G/A: The acute dislocation is reduced
by pulling on the arm with the shoulder in
adduction, a few mins allowed for the head
humerus to disengage & then the arm is gently
rotated laterally while the humeral head is
pushed forwards.
Fixed over the body as before for 3 weeks.

Dislocation of hip(posterior)

Mechanism of injury: This occurs usually in a RTA, when

someone seated in a truck or car thrown forwards, striking
the knee against the dashboard, the femur thrust upwards
& the femoral head is forced out of its socket.
C/F: The leg is short & lies adducted, internally rotated &
slightly flexed, like beauty contest position.
Rx under G/A: An assistant steadies the pelvis & the
surgeon starts by applying a traction in the line of the
femur as it lies, & then gradually flexes the patients hip &
knee to 90, maintaining traction, at 90of hip flexion,
traction is increased & sometimes a little rotation is
required to accomplish reduction.
Immobilization- surface/skeletal traction bar-3 weeks.

Dislocation of hip (anterior)

C/F:
The leg lies externally rotated,
abducted & slightly flexed.
Rx:
Like posterior dislocation- While
the hip is gently flexed upwards, it
should be kept adducted an assistant
then helps by applying lateral
traction to the thigh.

Elbow dislocation

Usually posterior.
Should be reduced as early as possible.
Fall on outstretched hand with the elbow
in extension.
C/F: The patient supports forearm with
the elbow in flexion. The deformity is
obvious. The bony landmark may be
palpable & abnormally placed.

Contd.

Rx under G/A:
Pull on the forearm while the elbow is
slightly flexed with one hand sideway
displacement is corrected. Then the elbow
is further flexed while the olecrenon
process is pushed forwards with the thumb
unless almost fall flexion can be obtained,
the olecrenon is not in the trochlear
groove.
LABS for 3 weeks.

D/D of pain in the upper limb

1.
2.
3.
4.
5.
6.
7.
8.

Cervical spondylosis (common)

Carpal tunnel syndrome
Supraspinatus tedinitis
Tennis elbow
Secondary malignant disease of bone
De Quervains disease
Pancoasts syndrome
Thoracic outlet syndrome

Fall on outstretched hand

1.
2.
3.
4.
5.
6.

Dislocation of shoulder joint

Fracture of clavicle
Supracondylar fracture of humerus
Dislocation of elbow joint
Colles fracture
Greenstick fracture of radius & ulna
in children

Supracondylar fracture (types)

Type-1:
#undisplaced but radiograph carefully
confirm this.
Type-2:
Posteriorly angulated but posterior
periosteum remaining intact.
Type-3:
Completely displaced, with shortening &
overlap the fragments.

Supracondylar fracture (in children)

1.
2.
3.

4.

5.

6.

Common after fall on outstretched hand

Radiograph interpretation is difficult
Varus or valgus malunion will not
remodel
Traction is safe early management while
the swelling is settle
Brachial artery occlusion requires
immediate reduction & close observation.
Compartment syndrome must be
identified & treated only.

Forearm fracture

Most are two bone fracture

Single bone fracture are either from a
direct blow or combined with ajoint
dislocation.
Two bone fracture usually requires internal
fixation as they are unstable.
Single bone fracture need careful review of
the joints at the both ends, as there may
be an associated dislocation.

Forearm fracture

Monteggia#: consists of a fracture of the ulna &

dislocation of the superior radioulnar joint.
Galeazzi#: Consists of a fracture radius &
dislocation of inferior radioulnar joint.
Rx: Both under G/A. Open reduction &
compression plate-ulna & radius respectively. In
children- Closed reduction.
Smiths fracture: Just reverse to colles fracture.
a) ventral displacement b)ventral angulation
c) medial angulation d) pronation.