Generality about fractures Clinical Signs, complications and treatment

Probable Signs: 1. Pain 2. Swelling 3. Hematoma

Sure Signs: 1. Loss of motility distal to fracture 2. abnormal motility 3. Bone
crepitation (heard/felt)
4. Discontinuity of bone 5. X-ray “antero – posterior” “lateral” “Special eg oblique”

Complications
1. General immediate: hemorragical shock
2. General late: due to immobility of patients in bed => bronchopneumonia, UTI
3. Local immediate: most dangerous open fracture, we have a big risk of bacterial
contamination
4. Local late: malunion of the bone, osteoarthritis of bone

Treatment
For simple non opened and non-displaced fracture
• Simple cast to immobilize the limb is enough
(6 weeks on epiphyseal part & 3 months diaphysis part)
Surgery when we have
• Open fracture; clean with water & fix bone
• Displaced fracture; which can´t be reduced or immobilized in a cast
• Pathologic bone
• Complicated fractures
A- Techniques
1. Closed operation
2. Closed reduction & fixation: The skin on fracture is not opened because
hematoma helps to heal the fracture + to reduce risk of infection at the
fracture site. Patient can stand on his limb from the next day
3. Open reduction and fixation: Cut skin over the fracture  go through muscle
 find fracture  put plate on bone fixed by screws.
 Fractures of the Clavicle. Clinical signs, Complications, Treatment
Signs
1. Pain ( On movement of upper extremity or in the front part of the upper chest)
2. Swelling
3. After swelling fracture can be felt through skin
4. Discontinuity of bone
5. Friction of the two heads
6. Sharp pain at any movement made
7. Possible nausea, dizziness, spotty vision

Complications
1. Open fracture
2. Injury to nerve and vessels
3. Malunion (incomplete union or union in a faulty position after a fracture or wound)

Treatment
Immobilization for simple fracture with no larger displacement (6-8 weeks) in an arm sling
or sling around the neck.
 Acromioclavicular dislocations; Classification. Treatment
Classification: (Six types of injuries)
Type 1  Injuries involve the acromioclavicular ligament sprain; the joint itself is not
disrupted.
Type 2  Acromioclavicular ligaments are completely torn and the coracoclavicular
ligaments are sprained,  this results in slight vertical subluxation of the clavicle
Type 1 + Type 2 Injuries are incomplete. The AC joint isn´t displaced.
Type 3
• Injuries are complete
• involve disruption of the acromio and coracoclavicular ligaments resulting in
acromioclavicular joint dislocation.
• Clavicle displaced superior by 25%-100%
Type 4 
• Injuries are complete.
• Clavicle displaced posteriorly into or through trapezius muscle.
Type 5 
• Injuries are severe Type 3.
• Detachment (extensive) of deltoid & trapezius muscle.
• Extreme superior displacement of clavicle 100-300%
Type 6 
• Injuries are extremely rare
• Involve inferior dislocation of the acromioclavicular joint in which the clavicle is
displaced into a subacromial or subcoracoid position

Treatment
Type 1 & Type 2  Sling + early motion (Closed treatment)
Type 3  Surgical treatment. Surgical realignment and fixation.
Fixation by Kirschner wires or Steinman pin.
Fixation of clavicle to the coracoid process by screw or wire.
Type 4 – Type 6  Surgical treatment or closed treatment and rehabilitation. If pain
remains after 3-6 months of Closed treatment  Surgery is required

Surgical techniques
1. Fixatin of the AC joint by K wires + tension band.
2. Indirect purchase on the AC joint & fixation with screw, wire loop.
3. Plication of the torn deltotrapezius at the distal clavicle.
 Shoulder dislocation; Clinical signs, Complications, Treatment
Signs
1. Flattening of the deltoid region
2. Pain  Restriction of motion
3. Anterior fullness
4. Humeral head is palpable anteriorly
5. Berger´s symptom – Elastic abduction of the arm

Complications
1. Injury to the axillary nerve
2. Vascular injury
3. Fracture of the humeral head, neck or greater tuberosity
4. Compression or avulsion of the anterior glenoid
5. Tears of the capsulotendinous rotator cuff

Treatment
A. Hippocrate´s manipulation : Surgeon applies traction on the patient´s arm while
placing an unshod heel in axilla
B. Kocher´s method:
• General anaesthesia
• Elbow is fixed to a right angle
• Surgeon applies traction and gentle external rotation to the forearm in the
axis of the humerous. (External rotation, forearm flexed, traction)
 Fracture of the Proximal Humerous, Clinical signs, Complication, Treatment
Clinical signs
1. Pain at palpation
2. Swelling of the shoulder region
3. Ecchymosis and edema
4. Palpable deformity
5. Restriction of motion due to pain

Complications
1. Axillary nerve or axillary artery injury
2. Brachial plexus injury
3. Brachial artery injury
4. Non-union or malunion
5. Posterior dislocation

Treatment
1. Urgent consultation
• Open fracture
• Neurovascular compromise
• Fracture dislocation
2. Open reduction and internal fixation
• 1-part fracture greater tuberosity (>1cm displaced)
• Displaced 2 - part fracture of humeral head
• Displaced 3 - part fractures
• Anatomic neck fractures
3. Prosthesis (Hemianthroplasty)
• Displaced 4 - part fractures
 Fractures of the Shaft (Body) of the Humerus. Clinical signs,
Complications, Treatment
Signs
1. Swelling of the arm region
2. Visible or palpable deformity
3. Restriction of motion due to pain
4. Abnormal motion and bone friction in arm region

Complication
 Injury to the radial nerve
 Injury to the brachial vessels
 The open fracture

Treatment
1. Skeletal traction with a wire through the olecranon
2. Application of a U-shaped coaptationplaster splint with shoulder immobilization
3. Caldwell´s hanging cast which consists of a plaster dressing from axilla to the
wrist with elbow in 90*C flexion.
 Fracture of the olecranon and Radial Head Clinical Signs, Complication,
Treatment
Fracture of the Proximal Ulna

Signs
1. Swelling of the elbow
2. Deformity
3. Discoloration
4. Difficulty moving
5. Numbness
6. Severe pain after elbow injury
7. Tight sensation

Complication
1. Open fractures occur in 2-31% of cases
2. Neurologic injuries to median, radial & ulnar nerves – Neuropaxia
3. Injury of blood vessels or compression due to trauma/ swelling

Treatment
A. Closed Reduction  if minimal displacement. A closed manipulation with elbow in
full extension and immobilization in plaster cast from axilla to wrist for 6 weeks.
B. Open reduction + Internal fixation  if former not successful or early mobilisation
desired by patient. Screws, plate figure of 8 wires. Mobilization in 5-7 days.
C. Excension of proximal fragments: as much as 80% of the olecranon can be removed
without producing instability to the elbow joint.

Fracture of the Shaft of the forearm. Clinical signs, Complications,

Treatment
Signs
Deformity, pain, swelling, loss of forearm and hand function
Complications
Synostosis, infection, Compartment Syndrome (Increased risk with vascular injuries
and coagulopathies and high energy crush injury)
Non-union (result from technical error), malunion, Neurovascular injury, Refracture.
Treatment
A- Without displacement: immobilization in a tubular plaster cast from axilla to the
metacarpophalangeal joints with elbow at a right angle and the forearm in
supination. Immobilization for 16-20 weeks.
B- With displacement: Open reduction and internal fixation if former not possible
(plate, screws, intramedullary rods)
 Fracture of the Distal Radius
• A distal radius fracture is a common bone fracture of the radius in the
forearm.
• Specific types of distal radius fractures are
1. Colle´s fracture
2. Smith´s fracture
3. Barton´s fracture
4. Chauffeur´s fracture

Signs
 Numbness of the hand can occur due to compression of the median nerve
across the wrist.
 Limited digital motion secondary to wrist deformity
Treatment
Non – operative treatment  if the fracture is undisplaced and stable, non-operative
treatment involves immobilization. Initially the wrist is splinted to allow swelling then
subsequently a cast is applied.
In displaced fractures the fracture may be manipulated by Anasthaesia and splinted in a
position to minimize the risk of re-displacement.
Manual Reduction + Maintain position in a well formed splint or cast.

Fractures of the Scaphoid bone; Diagnosis, Treatment

Diagnosis Clinically patients present with snuff box tenderness
• AP X-ray
• CT scan
• Blood flows from top/distal end of the bone in Retrograde fashion down to the
proximal pole; if this blood flow is disrupted by the fracture, bone may not heal 
Surgery is necessary.

Treatment
People with tenderness over the scaphoid are often casted for 7-10 days at which point a
second set of x-ray is taken. (6-12 weeks of casting to heal)
 Hip fractures. Clinical signs, Complications
Clinical sign
• Inability to move immediately after a fall
• Severe pain in your hip or groin
• Inability to put weight on your legs on the side of the injured hip area
• Shorter leg on the side of your injured hip
• Turning outward your leg on the side of the injured hip (external rotation &
abduction)

Other Signs
Bitrochanteric line  passes under pubal bone
 Aliss signe – softness of fascia lata
 Nelaton – Roser line
 Delbet´s sign
 Viscitus attitude of the lower limb- the foot is shorter in the external
rotation & abduction

Complications
• Bedsores complications
• Pseudarthrosis
• Necrosis of the femoral head
• Hip arthrosis

Classification of the Femoral neck fractures (Garden´s classification)

Type 1 – Incomplete fracture with no displacement or displacement in Coxa Vara
Type 2 – Complete fracture with no displacement
Type 3 – Complete fracture with partial displacement
Type 4 – Complete fracture with big displacement, abduction and external rotation
 Classification of Trochantrial fractures
Evan´s classification:
Type 1 – Undisplaced 2 – fragment fracture
Type 2 – Displaced 2 – fragment fracture
Type 3 – 3 fragment fracture without posterolateral support, owing to displacement of
greater trochanter fragment

Type 4 – 3 fragment fracture without medial support, owing to displaced lesser trochanter
or femoral arch fragment

Type 5 – 4 fragment fracture without posterolateral and medial support

(combination of Type 3 & Type 4)

R : Reserved obliquity fracture

Treatment of hip fractures

1. Internal fixation: Stabilizing broken bones with surgical screws, rods or plates.
The bones need to be realigned
2. Hip replacement therapy: also known as (arthroplasty) involves replacing part
or all of the joint with artificial (usual metal) parts. Sometimes a total hip
replacement can be done if the hop joint area was already damaged before fracture
by arthritis or an injury & joint wasn´t working properly
3. Open reduction + Internal fixation: often done on younger and more active
people
 Femur fractures; Clinical signs, Complications, Treatment
Signs
• A broken thigh bone
• Severe pain
• Inability to move the leg
• deformity
• Swelling
• Injured thigh may be shorter than uninjured

Complications
• Traumatic and hemorrhagic shock
• Open fracture – less often
• Wrong or late healing – up to pseudo arthrosis

Treatment
• Simple, non displaced fractures  orthopaedic treatment for 6 – 12 weeks. In all
other cases, if not a general problem, surgical treatment is required.
• Closed reduction with internal fixation
• Open reduction with internal fixation
Internal or external fixation

Patella fractures; Clinical signs, Treatment

Clinical signs: Pain in the affected knee  accompanying intra articular effusion may be
present, which, if aspirated will reveal fat globules. If the fracture is displaced, a defect is
palpable at the fracture site.
As a result of pain, patient won´t be able to raise his/her leg
Disruption of the extensor mechanism result in inability to extend the knee against gravity
(usually implies that a tear is present in medial and lateral quadriceps expansion)

Treatment:
A- Medical treatment: If the fracture is not displaced and extensor mechanism is
intact, the fracture may be treated with immobilization. This usually involves placing the
affected extremity in a cylindrical cast for 4-6 weeks.
B- Surgical therapy:
 Operative treatment to restore extensor function, align articular
incongruities, & allow early motion.
 Operative treatment is emergent if the fracture is open or if an associated
traumatic arthrotomy is present
Fractures of Tibia and Fibula; Clinical signs, Complications, treatment
Signs
Unstable: pain/deformity/ Restriction of movement/ swelling

Complication
Immediate local: Open fracture, thromboembolism, infection
Late: Pseudo arthritis, malunion, osteitis

Treatment: Treatment is directed towards reduction & stabilization of the tibial fracture
until healing takes place.
If displacement has reccured:

• Cast wedging
• Skeletal traction after surgery
• Open reduction + interval fixation

Ankle fractures; Clinical signs, Complications, Treatment

Signs
Pain, Swelling, tenderness and bruising at your ankle joint
 Inability to move your ankle through it´s normal range of motion
 Inability to bear weight on your injured ankle
 In some cases, a “crack” or a “snap” in the ankle at the time of injury
 In open fractures, severe ankle deformity

Complications
• Nerve or vessel damage resulting in a permanent loss of sensation, movement or
blood flow to the foot.
• Bone Infection  a bone infection can spread to the entire body and can cause
amputation of the leg or foot.
• Compartment syndrome  Neurovascular condition that causes pain, swelling and
disability around the lower leg.
• Osteoarthritis  Can result in pain, swelling and inflammation of the ankle.

Treatment
Medial malleoleus if undisplaced – immobilisation 6-8 weeks in a plaster boot (from knee
to toes with ankle flexed in a right angle and foot slightly inverted)
If displaced: Closed manipulation (anatomic realignment) under general Anasthasia, then
immobilisation in a plaster boot. If no good results  then open reduction + Internal
fixation (bone screws)
 Calcaneous fracture; Clinical signs, Complication, Treatment
Signs
1. Pain
2. Bruising
3. Swelling
4. Heel deformity
5. Inability to put weight on the heel or walk

Complications
• Skin blisters might get infected  leads to necrotizing fascitis or osteomyelitis,
causing irreparable bone / muscle damage
• Achilles tendon injury with posterior (Type C) fractures.
• Vertebral compression fractures occur in approximately 10% of these patients.

Treatment
1. Non-surgical treatment  treatment is indicated for extrarticular fracture & sanders
Type 1 intrarticular fracture
• Closed reduction with or without fixation (casting)
• Fixation alone (without reduction)
2. Surgical treatment 
• Displaced intrarticular fracture
•  surgery consists: 1) “close reduction with percutaneous fixation”
“open reduction with internal fixation”
Closed reduction:

• Less wound complications

• Better soft tissue healing
• Decreased intraoperative time
• Increased risk of inadequate calcaneal bone fixation.