AN Outline To Bones and Tissue Injuries Management - 4 PDF

AN Outline to Bones and Tissue
Injuries Management
Vignesh Narayan R | Ravi Verma T | Ravi Kumar Chittoria
OMICS eBooks
International
AN Outline to Bones and Tissue
Injuries Management
Authors
Vignesh Narayan R
JIPMER, Pondicherry-605006, India.
Email: scienceisbest@gmail.com
Ravi Verma T.
Vascular Society of India (VSI)
Email: ravivarmavas@gmail.com
Ravi Kumar Chittoria

Professor of Plastic Surgery, Registrar (Academic), Head of IT
Wing, Jawaharlal Institute of Postgraduate Medical Education
& Research (JIPMER), (An Institution of National Importance,
Ministry of Health & Family Welfare (MOHFW), Govt of India)
Pondicherry-605006, India.
Email: drchittoria@yahoo.com
ISBN: 978-1-63278-081-2
DOI: 10.4172/978-1-63278-081-2
Published: November 2019

Printed: November 2019
Published by OMICS International

Heathrow Stockley Park, Lakeside House,1 Furzeground Way,
Heathrow UB11 1BD, UK
OMICS eBooks
International
III
Copyright © 2019 OMICS International
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Additional hard copies can be obtained from orders @ www.esciencecentral.org/ebooks
IV
CONTENTS
PREFACE VI
ACKNOWLEDGEMENTS VII
Chapter 1
1
Types of bones
Chapter 2
3
Terminologies
Chapter 3
5
Stages and Factors Affecting Fracture Healing
Chapter 4
5
Classification and General Description of fractures
Chapter 5
25
Approach to a patient with limb injury
Chapter 6
28
Special Investigations and General Techniques
Chapter 7
30
General Principles for the Fracture Treatment
Chapter 8
31
Methods of immobilisation
Chapter 9
33
Splints
Chapter 10
35
Traction
Chapter 11
36
Methods of fracture fixation
Chapter 12
38
Approaches to treat Open Fractures
Chapter 13
39
Rehabilitation
Chapter 14
40
Complications Related to Fractures
Chapter 15
44
Fractures in Children
Chapter 16
46
Amputation
Chapter 17
48
Recent Advancements in the Fracture Treatmen
V
Section B -Outline of Dislocations and Subluxations 51
Chapter 18
51
Approches to Dislocations and Subluxation
Section C- Outline of Nerve Injuries 53
Chapter 19
53
Approches to peripheral nerve injuries
References 59
VI
PREFACE
Trauma is the third leading cause of death world-wide, hence giving it a very
important place on the podium of any health care professionals knowledge. There
are volumes written on trauma, ranging from soft tissue to bones. Practicing
professionals have hardly any time to revise such gargantuan amount of material.
Even if they did read, they always find themselves muddled in the barrage
of information overload. Teachers find it difficult deciding what to teach about
trauma given its vast multitude, and often find themselves unable to express as
required. On the receiving end students find trauma very confusing and tiring to
read. Revising a text on trauma though very important becomes an imaginary task
given its arduous content. Thus, this book was created by an amalgamation of a
student, a teacher and a practicing surgeon. The student giving his doubts and
difficulties in understanding and retaining. The teacher making the material as
easy to understand and grasp in a fast and effective manner. The surgeon giving
insights into the importance of the topics and skimming down and abstracting
information to easily digest. This book is thus not meant for people who may be
getting into the pool of trauma for the first time. It requires some prior knowledge
about the field. It intends to target students who are preparing for exams, in want
of a quick revision. For busy practitioners to quickly glance through in order to
be on top of their game. And to help teachers to summarize their modules in
their most effective way. The numerous tables and line diagrams are produced by
amassing and refining notes on soft tissue and bone injuries.
This book provides a collection of outlines on such trauma and their management.
Readers who wish to cover much distance in little time, will find this to be their
cup of tea.
Vignesh Narayan R
T Ravivarma
Ravikumar Chittoria
VII
ACKNOWLEDGEMENTS
I dedicate this book to my parents without whose support this book would not
have been possible. My sister for understanding whenever I said I was busy. My
for guiding me ever patiently in producing this masterpiece. My institution for
inculcating a research attitude in me. My friends for giving me time to work. And
most of all my dear readers and students, who I always keep in mind.
VIII
Section- A
Outline of Fractures
1
Chapter 1
Types of Bones
This chapter outlines types of bones

Cancellous bone This chapter outlines the commonly used terminologies, stages, types and factors affecting
healing of fractures.
Eponym (trabecular) bone

Distribution one-quarter of the total skeletal mass, two-thirds of the total bone surface.
Appearance honeycomb;
Location ends of the tubular bones and the vertebral bodies.
thickest and strongest along trajectories of compressive stress
Thickness
thinnest in the planes of tensile stress.
spaces between marrow and fine sinusoidal vessels
trabeculae metabolic disorders first in trabecular bone.
Cortical bone
Forms Majority of the skeletal mass.
Location Diaphyseal
thickest and strongest along trajectories of compressive stress
Thickness
thinnest in the planes of tensile stress.
Author: Narayan RV, Ravivarma T, Chittoria RK (2019) AN Outline to Bones and Tissue Injuries
Management. Copyrights © 2018 OMICS International. All rights reserved.
2
Chapter 2
Terminologies
This chapter outlines the commonly used terminologies, stages, types and factors affecting healing
of fractures.
Terminologies
epiphyseal plate separating epiphysis from metaphysis.
articular cartilage Cover articular end s of the epiphyses
Periosteum rest of the bone
random arrangement of bone cells (osteocytes) and collagen
Woven bone or immature bone
fibres initial: fracture healing
Lamellar bone or mature bone both cortical and cancellous
Haversian canals run longitudinally
Clavicle Only long bone to ossify from cartilage
secondary centres of ossification, not contributing to the
Apophysis
length of a bone (greater trochanter)
Wolff's law remodelling: bone hypertrophy occurs in the plane of stress.
Nutrient artery Metaphyseal vessels Epiphyseal vessels
blood supply of typical long bone.
Periosteal vessels (outer-third)
Bone mineralised mesenchymal tissue
3
Chapter 3
Stages and Factors Affecting

Fracture Healing
Stages of Fracture Healing

Stage Time Fracture Features Radiologically
Fracture end necrosis
haematoma <1w
Sensitisation of precursor
Mobile sensitised precursor cells (daughter Not visible
1-3
granulation cells) differentiate → soft tissue
weeks
anchorage
1-3
Callus Mineralisation Visible
months
no more
Outline of callus
4 months mobile
remodelling Lamellar bone formation becomes dense and
-2 years clinically
sharply defined
united
Many Modelling of endosteal and periosteal Fracture site
modelling
years surfaces stimulus: local bone strains indistinguishable
Types of Fracture Healing

Types of Fracture Healing Haematoma Callus X ray
Primary Disturbed No Difficult to evaluate union
Secondary Opposite of primary
Factors Affecting Fracture Healing

Fractures unite faster if Fractures unite Slower if
(i) Younger patient (i) Soft tissue interposition;
(ii) Flat and cancellous bones (ii) Ischaemic fracture ends.
(iii) Spiral fractures (iii) Fracture of the neck of the femur (poor immobilisation)
(iv) Good apposition (iv) Open fractures
(v) Compression at fracture site
4
Chapter 4
Classification and General

Description of Fractures
This chapter gives outline of classification of fractures, description of pathological, stress fractures
And some commonly seen fractures
Schematic Classification Of Fractures
Fractures may be classified on following basis:
On The Basis of Aetiology

1. Traumatic fracture
2. Pathological fracture: bone made weak by underlying disease
3. Stress Fracture: chronic repetitive injury (may not be visible on X-rays.)
Basis of Displacements
1. Undisplaced fracture:
2. Displaced fracture:
a. factors responsible
fracturing force; (ii) muscle pull (iii) gravity.
5
Relationship With External Environment
• Closed fracture: not communicating with the external environment,
• Open fracture
o Internally open (from within):
o Externally open (open from outside)
Complexity Of Treatment
Simple fracture: A fracture in two pieces
Complex fracture
Quantum Of Force Causing Fracture

High-velocity injury
1. Soft tissue injury
2. Unstable
3. Slow to heal
Low-velocity injury
Based in the force and the fracture line we can classify pattern of fractures as:
Transverse fracture fracture line perpendicular to long axis of the bone.

Oblique fracture bending force which+ component along long axis of the bone.
Spiral fracture more than one plane. twisting force
Comminuted fracture: multiple fragments crushing / compression force along long axis
Segmental two fractures in one bone different levels
The following table gives a list of fractures with eponyms
Fracture Dislocation
Monteggia fracture-
Fracture of proximal third of ulna head of the radius
dislocation
Galeazzi fracture Fracture of distal third radius Distal radio-ulnar joint
Night-stick fracture Fracture of shaft of ulna
Colles’ fracture: At cortico-cancellous junction of dorsal tilt
Smith's fracture: distal radius ventral tilt
Barton's fracture Intra-articular fracture of carpals, displaced
(Marginal fracture) radius distal articular surface anteriorly or posteriorly
Chauffeur fractur oblique fracture of styloid process of the radius.
intraarticular oblique fracture of (subluxation) trapezio-
Bennett's
base of the first metacarpal metacarpal joint
Boxers' Fracture of neck of the 5th metacarpal Ventrally
Side-swipe fracture/ -Fracture of distal end of the humerus
baby car fracture -proximal ends of radius and/or ulna
comminuted, depressed fracture of
Bumper
lateral condyle of tibia.
Pott's Bimalleolar fracture of ankle
6
Cotton's Trimalleolar fracture of ankle
Massonaise's Fracture of neck fibula and ankle
Pilon Comminuted intra-articular fracture of distal tibia.
Aviator's Fracture neck of talus
Chopart Fracture of inter-tarsal joints
Jone's Avulsion fracture of base of the 5th metatarsal.
extra-articular fracture of
Rolando
base of the first metacarpal
Jefferson’s Fracture of first cervical vertebra.
Whiplash Fracture of cervical spine
Chance fracture
Horizontal fracture through body of vertebra
(seat belt fracture)
March Fatigue fracture of shaft of 2nd or 3rd metatarsal.
Burst comminuted fracture of vertebral body
avulsion fracture of
Clay-Shoveller spinous process of one or more of the lower
cervical or upper thoracic vertebrae
Hangman's Fracture of the pedicle and lamina of C2 vertebra C2 over C3
posterior dislocation of
Dashboard Fracture of the posterior lip acetabulum
the hip.
Bilateral fracture of superior and inferior pubic
Straddle
rami
same side fracture of pubic rami anteriorly and
Malgaigne's
sacro-iliac joint / ilium posteriorly
Pathological Fractures
Following are details of pathological fractures:
Definition Fracture with normal stresses if the bone has been weakened by a
change in its structure
Causes
Points to be noted in history trivial injury, weight, pain, a lump,

Local signs
-infected sinus
-an old scar
-swelling or deformity
Signs to be checked on
At the site
examination
-involutional osteoporosis
General examination
-Fibrous dysplasia
-Cushingoid habitus
7
Additional investigations radionuclide imaging
required ESR, protein electrophoresis
Biopsy Atypical lesions
Generalized bone Immobilized in internal fixation

disease(pagets) Treatment of systemic disease
-biopsy lesion
-immobilize the fracture
Local benign conditions
-curettage/ excision
Primary malignant tumour Splinting
Treatment Modalities long-bone shaft

internal fixation (load-sharing)
Metastatic tumours near a bone end

excision and prosthetic replacement
local irradiation
Spine operative stabilization
Pathological fractures have different capacity to unite as mentioned in table below:
generalised disorder (Paget's disease,

unite (conventional methods of treatment)
osteogenesis imperfecta, osteoporosis)
bone cyst or a benign tumour Delayed

osteo myelitic long time
metastatic bone lesions do not unite
Stress Fracture (Fatigue Fracture)

These types of fractures develop due to repetitive and persistent forces and may be discussed as
follows:
-In a normal bone

Features - In a healthy patient,
-Due to small repetitive stresses
Bending stress
-bone responds to deformation changing the pattern of remodelling.
-osteoclastic resorption exceeds osteoblastic formation
-there is formation of a zone of relative weakness
Stress types
Compressive stress
-Causes osteochondritis in soft cancellous bone
-Due to compression and shearing stresses
-It causes spontaneous fractures/insufficiency fractures
-shaft of humerus (adolescent cricketers)
-pars interarticularis of fifth lumbar vertebra (causing spondylolysis);
Sites affected
-distal shaft of the fibula (the ‘runner’s fracture’);
-metatarsals (especially the second).
8
-unaccustomed and repetitive activity causes initial pain after exercise
Clinical features
-which develops into pain during exercise and finally into pain without exercise
X-RAY
-increased activity
Imaging
-transverse defect
-localized periosteal new-bone formation.
Best diagnostic test For unilateral fractures it is MRI

For Bilateral fracture it is bone scan
Differential diagnosis osteosarcoma
-elastic bandage
-avoidance of the painful activity until the lesion heals;
Treatment
-stress fracture of the femoral neck is internally fixed with screws as
prophylactic measure
Outline Of Features Of Some Of The Commonly Seen Frac-

tures
A) Fracture humerus
Sub
location classification Basis of subclassification
system
Based on number of displaced fragments
Proximal Neer
classification
Mid shaft
Classification Type A – an extra-articular supracondylar fracture
Type B – an intra-articular unicondylar fracture
Distal
AO-ASIF Group (one condyle sheared off
Type C – bicondylar fractures with varying
degrees of comminution
Type I Complete fracture
Bryan and
Capitulum Type II Cartilaginous shell
Morrey
Type III Comminuted fracture
Etiology and
mechanism
-In proximal fractures are often Impacted, pain is not severe
Clinical
-In shaft fracture arm is painful, bruised and swollen
features
-In capitular fractures, there is fullness in front of elbow
-X rays
-Axillary and scapular views must to obtained to rule out displacements in proximal
Diagnosis
fractures
-CT scan is preferred in distal fractures
9
Proximal fractures
Minimally displaced fractures
-Sling for 2 weeks
-Active exercises after 6 weeks
Two-segment fractures
-Surgical neck fracture is manipulated, sling for 4 weeks

-Anatomical neck fractures are fixed with screws
Three-segment fractures
Open reduction and internal fixation
Four-segment fracture
-In young patient, reconstruction is attempted
Treatment -In old patients we perform prosthetic replacement
Shaft fractures
-Hanging cast from shoulder to wrist, elbow flexed at 90 degrees for 2 weeks
-Shoulder to elbow cast for 6 weeks
Distal fractures
-for undisplaced fractures posterior slab is applied
-Displaced fractures are opened reduced and fixed internally
-Skeletal traction
Undisplaced
Splintage 2 weeks
Capitulum
Displaced
Reduced and held
Capitulum fractures
Proximal fractures
Vascular injury
Avascular necrosis
Shoulder joint stiffness
Shaft fractures
Complications Radial nerve injury
Delayed union
Distal
Stiffness
Heterotopic ossification
10
B) Fracture humerus
Etiology and mech- cause by
anism • Falling on outstretched hand
• distal fragment collapses into extension
The following diagram shows the normal position of radius and ulna
Seen in
• older people
Clinical features • postmenopausal osteoporosis
dinner-fork’ deformity: prominence on back of wrist and depression in front.
local tenderness and pain on wrist movements.
Findings of X-ray:
1. transverse fracture of the radius at the corticocancellous junction,
Diagnosis
2. dorsal displacement, radial tilt, shortening
3. ulnar styloid process is broken
Treatment Undisplaced fractures
-dorsal splint is applied for a day or two
-cast is completed.
-x-ray: at 10–14 days
-cast removed after four weeks
Displaced fractures
In elderly patients with low functional demands, modest degrees of displace-

ment are accepted because
(a) outcome not so dependent upon anatomical perfection, and
(b) fixation of fragile bone difficult.
fracture unites in 6 weeks Impacted or comminuted Colles’ fractures

-reduced and held with percutaneous wires
-external fixator (neutralizing device) +bone graft or bone
-fixation removed after 5–6 weeks
-volar locking plate
11
In:
Poor outcome - shortening of more than 2mm at the distal radio-ulnar joint
-dorsal tilt of more than 10 degrees
-dorsal translation of more than 30 per cent
Early complications
-Circulatory problems
-Nerve injury
-Reflex sympathetic dystrophy .
Complications
-swelling and tenderness of finger joints
Late complications
-Malunion
Stiffness
C) Fracture humerus
Etiology:
• fall on the back of the hand
Etiology and mechanism
Mechanism:
• distal fragment is displaced anteriorly (called a ‘reversed Colles’).
wrist injury
Clinical features
‘garden spade’ deformity.
X-ray features:
1. fracture through distal radial metaphysis;
Diagnosis
2. lateral view shows distal fragment is displaced and tilted anteriorly
3. X-rays should be taken at 7–10 days
reduced by traction
1. supination
Treatment
2. extension of the wrist, forearm is immobilized in a cast for 6 weeks
Unstable fractures should be fixed with percutaneous wires or a plate.
D) Avulsion Fractures
Etiology:
• most commonly occurs in adolescents, most often athletes
Mechanism
• tendon or ligament pull off the bone, making a fracture in the bone
Clinical features severe pain and there will be visible swelling in the area of the fracture
-X ray appearance
Diagnosis
-MRI
Treatment -Cold packs
-Aerobic capacity/endurance conditioning
-ADL training
Complication Osteoarthritis
E) Fracture of Clavicle
Group I fracture of middle third of clavicle

Group II: fracture of lateral third of clavicle
Group III: fracture of medial third of clavicle
.Fractures of lateral third are further classified as:
Classification
A: coracoclavicular ligaments intact
B: coracoclavicular ligaments are torn or detached from the medial
segment but the trapezoid ligament remains intact
C: intra-articular fractures
12
Etiology: fall on the shoulder or the outstretched hand
Etiology and Mechanism
arm is clasped to chest to prevent movement.

Clinical features
feel pulse and gently to palpate the root of the neck.
X ray required:
• anteroposterior view
Diagnosis • 30-degree cephalic tilt.
• medial third fractures: x-rays of the sterno-clavicular joint.
‘clinical’ union usually precedes ‘radiological’ union by several weeks.
Middle third fractures
-undisplaced: treated non- operatively
-simple sling for comfort
-discarded (between 1–3 weeks)
-encouraged to mobilize the limb as pain allows.
-figure-of-eight bandage has disadvantages because of pressures sores,
harm to neurological structures, non-union.
displaced middle third fractures.
Treatment -With less than 2cm displacement is treated by simple splintage
-Those with more than 2cm displacement is fixed by internal fixation
Lateral third fractures
-sling for 2–3 weeks until the pain subsides
-mobilization within the limits of pain-
-Displaced lateral third fractures which are symptomatic are treated with
coracoclavicular screw, plate.
Medial third fractures
-are treated non-operatively
Early:
pneumothorax, damage to the subclavian vessels (rare)
Complications Late:
-Non- union/ malunion
-Stiffness
F) Fracture of Patella of Knee

Transverse
Longitudinal
Classification
polar
comminuted (stellate).
Injury type Direct Indirect

Force types Impact force traction: pulls
Etiology and mechanism Extensor expansion usually intact often tears
fall onto the knee or catches the foot against
Mechanism a blow against the object + contracts the
dashboard quadriceps
- Knee becomes swollen and painful.

Clinical feature
- Abrasion or bruising
X-ray
• Separation of the fragments is considered significant:
When it creates a step on the articular surface of the patella or a gap of
Diagnosis more than 3mm width.
• It should be differentiated from bipartite patella which is often bilateral.
Knee joint aspiration: may reveal the presence of blood and fat
droplets.
13
Undisplaced or minimally displaced fractures
-Any hemarthrosis is aspirated.
If extensor mechanism is intact, then a plaster cylinder holding the knee
straight is applied (3–4 weeks)
Treatment
Comminuted (stellate) fracture
-Patellectomy (by tension-band principle.
-Extensor expansions are repaired.
-Plaster backslab or hinged brace
Complication patellofemoral osteoarthritis
G) Fracture of Shaft of Both Forearm Bones (Radius And Ulna)

A fall on the hand causes a spiral fracture
An angulating force causes a transverse fracture
Clinical features
In fractures of proximal-third
-Proximal forearm supinated
-Distal forearm is pronated.
In fractures of middle-third
-Pronation
Greenstick fractures are minimally displaced
Diagnosis X rays
Treatment
-Moulding plaster - maintain interosseous space
-above-elbow plaster cast
-Weekly X-rays taken for 3 weeks
Open reduction and internal fixation:

-The radius and ulna should be approached through separate incisions
- Compression plating is the preferred method.
- Additional bone grafting: fractures older than three weeks.
- limb mobilised depending upon rigidity of the fixation.
- External fixation: compound fracture ease of dressing.
Complications - Infection
-. Volkmann's ischaemia
-. Delayed union and non-union
-. Malunion
-. Cross union
H) Fracture of Head of Radius

Etiology and mechanism Seen in adults with valgus force
-swelling over the lateral aspect of the elbow.

Clinical features
-semi-flexed elbow, and painful forearm rotation
Diagnosis X ray
a) A crack only: above-elbow plaster slab for 2 weeks with the elbow at
90°+ forearm in mid pronation.
Treatment b) fragment is less than 1/3: as above.
more than 1/3 - lying loose: excision.
c) Comminuted fracture: excision of head
- Joint stiffness
Complications
-Osteoarthritis
14
I) Fracture of Ulna (Olecranon)
I: Crack
classification
II: Separation of fragments
III: Comminuted
Etiology and mech- -comminuted fracture are caused by a fall onto point of the elbow.
anism -transverse break is caused by falls onto hand with triceps muscle contracted
comminuted fracture:
graze or bruise over the elbow
Clinical features Transverse fracture:
-gap at fracture site.
-Active extension elbows not possible
Diagnosis Lateral view X ray of elbow
Type I:
immobilising above-elbow plaster slab in 30 degree* of flexion.
Type II:
Treatment
open reduction + internal fixation: tension-band wiring
Type III
plaster slab+ tension-band wiring
1. Non-union
complications 2. Elbow stiffness
3. Osteoarthritis
J) Fracture of Neck of Femur

I: incomplete impacted fracture
Garden Classifica-
II: complete but undisplaced fracture
tion system
III: complete fracture with moderate displacement.
IV: severely displaced fracture
Commonly seen in:

• Elderly
Etiology • Women
And mechanism • Steroid therapy
• Osteomalacia
Mechanism
• Fall
Limb in:
Clinical features Flexion
Abduction
External Rotation
X ray:
Diagnosis Based on degree of mismatch of trabecular lines in femoral head and neck
and the supra-acetabular pelvis
Bone scan and MRI can help differentiate it from stress fracture
children Elderly
Treatment Undisplaced Internal fixation with cannulated screws
Displaced Open Reduction with internal fixation muscle
Hip replacement
pedicle graft
Non union
Complications Avascular necrosis
Osteoarthritis
15
K) Fracture of Intertrochanteric Region of Femur
1. elderly: sideway fall or / blow over the greater trochanter.

2. young: violent trauma, / road traffic accident.
Features neck-shaft angle is reduced (coxa vara)
X ray features indicating a bad prognosis:

Diagnosis
1. comminution of medial cortex of neck
2. avulsion of the lesser trochanter
3. extension of the fracture to the subtrochanteric region
1. Conservative methods: Russell’s traction / Thomas splint

2. Operative method:
Treatment (unite readily) (i) Dynamic Hip Screw (DHS)
ii) Ender’s nails
(iii) gamma nail, Proximal femoral nail (PFN).
-Malunion:
Treated in elderly: suitable shoe raise
Treated in young people: inter-trochanteric osteotomy

Complications
-Osteoarthritis
Treated in young: osteotomy
Treated in elderly: total hip replacement
L) Fracture of Condyle of Femur
(i) supracondylar fractures;
Classification
(ii) intercondylar fractures – T or Y types; (direct force)
(iii) unicondylar fractures – medial or lateral
Mechanism Indirect force on the knee

(i) valgus; (ii) varus; (iii) hyperextension; or (iv) twisting
inability to actively extend the knee, called extensor lag.

Clinical feature
pain, swelling and bruising around the knee.
Diagnosis X ray
CT scan: depression, displacement can be picked up
1. Unicondylar fractures
undisplaced: long leg cast
Displaced: ORIF
Treatment
2. Intercondylar fractures:
ORIF + Condylar blade-plate, DCS and LCP implant
3. Supracondylar fractures: internal fixation.
1. Knee stiffness:
Complications 2. Osteoarthritis
3. Malunion
16
M) Fracture of Proximal Tibia (Tibial Plateau)
1: vertical split of the lateral condyle

2: vertical split of the lateral condyle combined with depression of an
adjacent loadbearing part of the condyle
Classification 3: depression of the articular surface with an intact condylar rim
4: fracture of the medial tibial condyle
5: fracture of both condyles
6: combined condylar and sub condylar fracture
Etiology and vehicular accidents when one lands on the knee.

mechanism Mechanism: varus or valgus force combined with axial loading
Doughy feel of knee

Clinical features
Foot examined for signs of vascular and neurological injury
CT is preferred
Diagnosis
posterior condylar component should be looked for
Treatment Traction followed by conservative methods
N) Fracture of Both Bones of Leg (Tibia And Fibula)

Characteristics of leg bones
a) A subcutaneous bone
b) Massive loss of skin
c) Precarious blood supply: of lower 1/3 tibia
Etiology and d) Hinge joints proximally and distally:
Mechanism small degree of rotational mal-alignment - noticeable.
Mechanism
Direct forces cause same level fracture in both bones
Indirect forces cause oblique or spiral fracture
soft-tissue damage
Clinical features
signs of impending compartment syndrome
X ray
Diagnosis
entire length of the tibia and fibula, + knee and ankle joints.
Closed fractures:
closed reduction under anaesthesia + above-knee plaster cast
Open fractures:
• Grade I: Wound dressing through a window in an above-knee plaster
Treatment cast, and antibiotics.
• Grade II: Wound debridement and primary closure (less than 6 hours
old), and above-knee plaster cast.
• Grade III: Wound debridement, dressing and external fixator application.
wound is left open
-supine + knees flexed over the end of table.

Technique of closed -under general anaesthesia traction is given
reduction -below-knee cast applied over evenly applied cotton padding
-extended to above the knee.
1. Delayed union and non-union:
2. Malunion:
Complications 3. Infection
4. Compartment syndrome
5. Injury to major vessels and nerves:
17
O) Fracture of Metatarsal of Foot
Etiology and Clinical

Site diagnosis Treatment modality Complication
Mechanism Features
Fracture of
the base
Forced point tenderness below-knee walking
of 5th
inversion of over base of the X ray plaster cast for 3 non-union
metatarsal
foot fifth metatarsal. weeks.
(Jones'
fracture)
Fracture radioisotope
It is a ‘fatigue’
of shaft of scan will show
Stress Tender lump fracture of third
metatarsal an area of non union
fracture distal to midshaft metatarsal,
(March intense activity
heals spontaneously
fracture) in the bone
Outline of Injuries Occuring at Joints

There are two types of injuries that can occur at joints
Dislocation Subluxation
Articular surfaces have no contact Articular surfaces retain some contact
Injuries to Ligaments
Following gives an account of the degree of sprains
Sprain
Functional disability
Joint movements/ Stress X ray

Tenderness, on stress
TREATMENT
First-degree (<1/3)
Minimal
Classification Normal
Yes
RICE
Second-degree
Unable
brace / cast (1-2 weeks)
third-degree.
Abnormal
No
Surgery
rest, ice therapy, compression bandage, elevation (RICE)
The most common feature is:
localised swelling, tenderness, and ecchymosis
Clinical
Features Where is it absent?
Answer: ligament covered by synovium (e.g., intra-synovial tear of anterior cruciate
ligament).
Injury to ligament is called as sprain
18
1. X-ray: avulsions
2. stress X-ray: abnormal opening (3rd degree)
Diagnosis
3. MRI
4. Arthroscopy
Other connective tissue structures that can undergo rupture are:
Ruptured Age commonly seen in

Muscles (strain) Young
Tendons Elderly
Common Ligamentous Injuries

1) Anterior cruciate ligament injury at the knee joint
Structural anatomy of cruciate ligaments

-They provide both anteroposterior and rotary stability
-double bundle structure - some fibres of each bundle are taught in all positions of
the knee
example: anterior cruciate has anteromedial and posterolateral bundles
How this stabilizes

-anteromedial bundle resists anterior tibial displacement
Etiology and
-posterolateral part tightens as the knee extends
Mechanism
How injuries are produced
multidirectional forces
Mechanism of injury and pathological anatomy

-Flexing knee relaxes capsule and ligaments allowing femur to rotate on the tibia.
-This in addition to a valgus force damages the ACL.
-When MCL, ACL and medial meniscal is injured together it is called O’Donoghue
triad
History
-knee swelling appears almost immediately.
-Paradoxically in a complete tear the patient may have little or no pain, permitting
abnormal movement
Examination
Clinical features
-should be under anaesthesia
-Sideways tilting in fill extension indicates rupture of the capsule in addition to

cruciate ligaments
-positive drawer sign - diagnostic of a tear,
-negative Lachman test - RULES OUT a tear
Imaging
-Plain x-rays
-Stress films
Diagnosis
-Magnetic resonance imaging (MRI)
Arthroscopy
19
Sprains and partial tears
-active exercise
-aspirating
-applying ice-packs
-angulatory strain or rotational strain prevention (heavily padded bandage or a
Treatment
-functional brace.
Complete tears
- early operative reconstruction.
-muscle strengthening exercises
-Adhesions
Complications
-Ossification (Pellegrini–Stieda’s disease)
2) Ligament injuries at the ankle joint (Ankle sprain)
Etiology and Clinical Diagnosis Treatment

complication
mechanism features
Lateral ankle inverted able to walk Ottawa Ankle Rules rest, ice,
ligaments and plantarflexed faint bruising compression and
injury X-ray examination is elevation (RICE),
Tenderness: called for if there is: which is continued
distal and for 1–3 weeks
slightly anterior
to the lateral (1) pain around protection
malleolus. malleolus (crutches, splint
or brace)
passive (2) inability to take rehabilitation
inversion of weight on the ankle (supported
the ankle is
extremely (3) inability to take four non-steroidal anti-
painful. steps inflammatory drugs
(NSAIDs)
(4) bone tenderness
ate medial or lateral Functional
malleolus or the base treatment,
fifth metatarsal bone. i.e. ‘protected
mobilization’,
anteroposterior, lateral stiffness
and ‘mortise’ (30-degree OPERATIVE
oblique) views TREATMENT
exclude at 12 weeks after

undisplaced fibular injury, despite
fracture physiotherapy,
Persistent inability to Arthroscopic

weight bear over 1 week repair or ligament
or longer should call for substitution
re-examination
6 weeks or longer,
despite appropriate early
treatment, magnetic
resonance imaging
(MRI) or computed
tomography (CT)
20
(a) Anterior
drawer test:
modifying shoe-
When the
wear, raising the
heel is drawn
outer side of the
forwards under
heel and extending
the tibia, the
it laterally.
abnormally
lax ligaments
excessive talar strengthen the
Recurrent allow the talus
tilting in sagittal peroneal muscles
lateral to displace
plane or anterior
ligament injury anteriorly.
displacement in
(instability)
coronal plane operations for
(b) Talar tilt
e Broström–
test: Forcibly
Karlsson or Gould
inverting the
operation
ankle causes
‘double-breasting’
the talus to tilt
– technique
abnormally in
,
the mortise.
joint space
completely
look for a
reduced,
fracture or stiffness
fracture of distal
dislocation of
Deltoid end of fibula widening of the medial free any soft tissue
the proximal
ligament or tearing of the joint space in the mortise trapped in the joint.
fibula – the
injuries (tears) distal tibiofibular view;
highly unstable
ligaments below-knee cast
Maisonneuve
injury.
foot plantigrade
and is retained for
8 weeks.
Partial tears can

be treated by
strapping the
ankle firmly for 2–3
weeks
twisting injury, tenderness
Inferior
directly over
tibiofibular ankle mortise is Complete tears
abduction strain the inferior
Ligament widened; are best managed
tibiofibular joint.
injury at the by internal fixation
external rotation ‘squeeze test’
ankle with a transverse
force.
screw
plaster for 8
weeks,
21
3) Dislocation Elbow
Classification postero- medial, postero-lateral, and divergent:
Etiology and mechanism fall on the outstretched hand with the elbow in extension.
triceps tendon stands prominent (bowstringing of triceps).

Clinical features
three bony points relationship: reversed
X-ray examination:
Diagnosis
(a) to confirm dislocation
(b) to identify any associated fractures.
reduction under anaesthesia

Treatment
immobilisation: above-elbow cast
Early
brachial artery injury
Median / ulnar nerve damage
Complications Late
Stiffness
Myositis ossificans
Unreduced dislocation
Recurrent dislocation
Osteoarthritis
4) Patellar Dislocation
(i) acute dislocation;

Types (ii) recurrent dislocation;
(iii) habitual dislocation.
Etiology/ mechanism
sudden contraction of quadriceps while knee is flexed or semi-
flexed (stretched in valgus and external rotation.)
Clinical features
-unable to straighten knee
-medial condyle of femur appears more prominent.
Acute dislocation Diagnosis

of the patella: -Anteroposterior, lateral and tangential (‘skyline’) x-ray views
-MRI: disruption of medial patellofemoral ligament
Treatment
-reduction + immobilisation in cylinder cast
-osteochondral fragment: removed
Complications
-Recurrent dislocation
22
a. excessive joint laxity;
b. small patella;
c. patella alta
d. genu valgum.
e. girls
Clinical features
-acute pain
-knee is stuck in flexion
-apprehension test is positive:
Diagnosis
Recurrent dislocation
-X-rays: loose bodies in the knee,
-lateral view with the knee in slight flexion
MRI: patello-femoral soft-tissue disruption.
Treatment
a. patellar tendon insertion shifted
medially (Hauser's operation)
b. pes anserinus transferred to lower pole of the patella (‘check
rein’ effect.)
c. correcting underlying cause.
Complications
Incongruency of patella
shortened (vastus lateralis component) + causes of recurrent
dislocation
clinical features
patella dislocates laterally every time knee is flexed.
Habitual dislocation
Diagnosis
of the patella:
Normal whenever knee is extended
Rx
release: tight structures on lateral side
repair of lax structures on medial side.
Complication
permanent patellar dislocation
Tendon Rupture
Common sites of tendon rupture
1. Supraspinatus tendon
Etiology and 2. Biceps long head tendon
mechanism 3. Extensor pollicis longus tendon
4. Quadriceps tendon
5. Achilles tendon
Tendon ruptured Movement affected
Supraspinatus Abduction of arm
Biceps long head Elbow flexion Supination of forearm in elbow flexion
Clinical features
Extensor pollicis longus Extension of thumb
Quadriceps Knee extension
Achilles tendon Plantar flexion of ankle
23
Ultrasonography
Diagnosis
MRI
-Fresh ruptures are repaired end-to-end repair
Treatment
-If there is a gap: graft/ tendon transfer is preformed
Complications Joint stiffness
24
Chapter 5
Approach to a Patient with Limb Injury
This chapter outlines features of injuries, approach to polytrauma patients and cervical spine injuries
Approach to A Polytrauma Patient

An algorithm such as this one can ensure speedy yet effective treatment, while wasting no time
FIELD TRIAGE
A: Airway
Primary survey B: Breathing
Resuscitation C: Circulation
D: Disability
E: Exposure
i) neurologic assessment
ii) thoraco-abdominal assessment
Secondary survey
iii) genito-urinary assessment
iv) musculo-skeletal assessment
Definitive treatment Already discussed
Clinical Features
A patient often presents as
-Pain
-Swelling
Presenting complaints
-Deformity
-Loss of function
Tenderness
i) Direct Pressure
ii) Indirect Pressure:
• Springing test (forearm bones)
• Axial pressure (scaphoid fracture)
Examination
-Swelling
-Deformity
-Bony irregularity:
-Abnormal mobility
-Absence of transmitted movements
i) trivial trauma
ii) pain / swelling in affected bone prior to fracture
Pathological fracture
iii) frequent fractures in past
iv) debilitating systemic illness (rheumatoid arthritis).
25
Features of Injuries
There are a few common clinical presentations, which if we keep in our mind will help in swift
diagnosis.
Mechanism of
Age group Fracture/ dislocation Deformity Special X rays
injury
Birth Clavicle
Fall on
outstretched Children Supracondylar fracture gunstock
hand
Elderly Colles fracture Dinner fork deformity
Flexion abduction
Fall in bathroom Elderly Fracture neck of femur
external rotation
Dash board Flexion adduction
Any age Posterior dislocation hip
injury internal rotation
Don Juan/ lovers/calcaneal
Fall onto heal Young age Broadening of heel Skyline view
fracture
Children Spiral fracture tibia shaft
Reading An X-Ray
Here is a check list for reading an X ray for a patient with a limb injury
i) Which bone
ii) Which part
iii) Pattern
iv) displaced?
v) nearby joint
vi) bone appears pathological.
vii) fresh or an old fracture
viii) correlated with clinical findings,
Other Special Views

Few injuries require special radiological views in order to detect them
Oblique view wrist Scaphoid

Merchant view Patello femoral joint
Judet view Acetabular fracture
Outline of Treatment of Cervival Spine Injuries

One of the most dreaded injuries. But can be managed with proper guidelines as follows.
First aid for cervical spine injury
26
manual, in-line immobilization
cervical collar, head supports and strapping.
-In-line immobilization: head and neck are supported in neutral position.
-Quadruple immobilization: backboard, sandbags, a forehead tape and a semirigid collar
-Thoracolumbar spine: scoop stretcher and spinal board
-head and face are thoroughly inspected for bruises or grazes
-bones and soft tissues of the neck are gently palpated for tenderness and areas of ‘bogginess’,
-cervical spine must not be moved
Definitive Management of Cervical Spine Trauma

Collars
-Collars Soft collars for minor sprain
-Semirigid collars for acute setting.
-Four-poster braces for unstable injury patterns
Tongs
-pin is inserted into the outer table on each side of the skull
-reduce the fracture or dislocation and to maintain
Fixation
- odontoid fractures with lag screws,
-burst fractures with anterior decompression plates
-facet fractures with posterior decompression wires
-Movement best postponed until the neck has been x-rayed.

Imaging Plain x-rays
anteroposterior view:
-spinous processes and tracheal shadow in the midline
-An open-mouth view C1 and C2
Lateral view
-smooth lordotic curve
-include all seven cervical vertebrae and the upper half of T1,
- should be repeated while the patient’s shoulders are pulled down.
-distance between the odontoid peg and the back of the anterior arch of the atlas should be no more
than 3mm in adults and 4.5mm in children
-retropharyngeal space
soft-tissue shadow should be less than 5mm in thickness above the level of the trachea and less than
one vertebral body’s width in thickness below.
27
Chapter 6
Special Investigations and General

Techniques
This chapter outlines the various procedures and techniques used in the management of soft tissue
and bony injuries. arthroscopy, arthroplasty, synovial fluid analysis and bone grafting.
Arthroscopy
Definition Keyhole access into a joint cavity either for therapeutic or diagnostic purposes
- Arthroscopic meniscectomy
-Arthroscopic acromioplasty
Indications
-Subacromial decompression
-Acromioclavicular joint excisions
-Biopsy
Tube diameter: 2 mm (for small joints) to 4–5 mm (for the knee). It

under general anaesthesia;
Technique
joint is distended with fluid
At end of procedure the joint is washed out
differentiation between
-inflammatory and noninflammatory
-destructive and non-destructive lesions.
-Meniscal tears
Diagnosis
-synovial ‘tumours’
-Rotator cuff lesions
-torn triangular fibrocartilage
-interosseous ligament ruptures.
-Labral tears, synovial lesions, loose bodies
-Haemarthosis
-Thrombophlebitis
Complications -Infection
-Joint stiffness.
-Algodystrophy
Arthroplasty
surgical refashioning of a joint, aims to relieve pain and to retain or restore
Definition
movement.
Restore movement at the joint
Indications
Relieves pain
28
Excision arthroplasty
-create a gap at which movement can occur
(e.g. Girdlestone’s hip arthroplasty).
-movement is limited and occurs through intervening fibrous tissue,
-shaped ‘spacer’ can be inserted; this is often tendon harvested from nearby.
Partial replacement arthroplasty

-One articulating part only is replaced (e.g. a femoral prosthesis for a fractured
Techniques
femoral neck, without an acetabular component)
-one compartment of a joint is replaced (e.g. the medial or lateral half of the
tibiofemoral joint).
-kept in position either by acrylic cement or by a press-fit between implant and
bone.
Replacement
Both the articulating parts are replaced by prosthetic implants;
-Osteoarthritis
Complications
-Stiffness
Bone Grafting
Definition Transfer of bone from one donor site to recipient
Indication Loss of bone
Mechanism
- stimulus for bone growth (osteoinduction),
- scaffold for new bone growth (osteoconduction).
Technique
Basic requirements for osteogenesis
osteoprogenitor cells, a bone matrix and growth factors
Complication Operative complications such as haemorrhage, infection
29
Chapter 7
General Principles for the Fracture

Treatment
This chapter outlines the general principles of approach to fracture treatment; in immediate, early
and late phase
RICE
-Rest
Immediate -Ice
I Treatment -Compression
(First Aid) -Elevation
Emergency Medical Services
- Basic Life Support
Fundamental Principles
(i) reduction; (ii) immobilisation; (iii) preservation of functions
REDUCTION
1. imperfect angulatory alignment or rotational mal-alignment NOT
accepted
2. prefect reduction: intraarticular fractures
Methods:
-Closed manipulation
-Continuous traction
-Open reduction
IMMOBILISATION
-prevent displacement or angulation
Early Treatment -prevent movement that might interfere with the union e.g. scaphoid
II
(Definitive) fracture
-relieve pain
Methods
NON-OPERATIVE METHODS
Mostly
1. Strapping
2. Sling
3. Cast immobilisation
4. Functional bracing
5. Splints and traction
OPERATIVE METHODS
Wherever open reduction performed
1. Internal fixation
2. External fixator
1. Joint mobilisation
Late Treatment
III 2. Muscle re-education exercises
(Rehabilitation)
3. Functional use of the limb
30
Chapter 8
Methods of Immobilisation
This chapter outlines the details about the methods of immobilisation.
NON-OPERATIVE METHODS OF IMMOBILISATION

strapped to adjacent part
Strapping
example: phalanx fracture
strict immobilisation not necessary
.
Sling upper extremity
example: triangular sling: clavicle
Definition: Slab covers only a part of the circumference of limb whereas
cast covers whole of the circumference
Material: Plaster-of-Paris, fibreglass
Principles:
a. Immobilise the joints above and below fracture.
b. Immobilise joints in functional position
c. Pad the limb (bony prominences)
Complications:
1.Impairment: circulation (tight cast)
Characterised by:
-stretch pain
-inability to move fingers
2. Plaster sores
Characterised by:
Cast / Slab Patch of blood/soakage over the cast
Types of Cast according to the site/indication:
31
- Usually Joints are not included
Functional
- Axial pressure on limb (weight bearing / muscle contraction) -provides hydraulic
Brace
pressure within brace maintaining fracture alignment
Indicated for stable fractures of the tibia and humerus.
Splints Refer to the chapter on Splints
Traction Refer to the chapter on Traction.
OPERATIVE METHODS OF IMMOBILISATION
Internal Material: implants made of high-quality stainless steel(inert)
fixation Indications:
fracture: unstable
early mobility
associated neurovascular injury
Methods:
Material: steel frame outside the limb
Indication:
External useful in the treatment of open fractures
fixation
type:
1. Pin fixation
2. Ring fixation
32
Chapter 9
Splints
This chapter outlines splints and their applications.
A splint is any device used to immobilize and provide support to a limb and fracture
Definition
fragments
-prevent muscle contracture

Purpose -maintain joint position
-improve movement and function.
Corrective
aim to hold a passively correctable deformity
Types
Adoptive
splint adopts the shape of the foot and simply aims to prevent further loss of
position
Care of a patient in a splint
a) properly applied, well-padded at bony prominences and at the fracture site.
b) not be too tight; nor too loose
Technique/
c) actively exercise as much as permitted
mechanism
d) compression of nerve or vessel, detected early and managed.
e) daily checking and adjustments,
regular portable x-rays
Badly fit splint leads to
Complications
pain and spasm and increasing deformity.
Examples of Commonly Used Splints According to

The Site/ Condition
33
Application of Splints in Nerve Injuries
Nerve injured Condition Type of Splint applied
Radial Wrist drop Cock up
Ulnar Ulnar Claw hand Knuckle bender splint
Common Peroneal Foot drop Toe raising splint
Brachial plexus Aeroplane splint
Application of Splints in Trauma

Trauma to various body parts Crammer wire
Trauma to neck Four post collars
34
Chapter 10
Traction
This chapter outlines traction and its application
Traction is the force applied on a limb in order to realign the forces

Definition
acting on it in a desired manner
To prevent muscle contracture and
Purpose
maintain joint position
Counter traction by part of the body

Fixed traction
Example: Thomas splint
Sliding traction Counter traction by weight of body
Skin traction Traction is given on skin
-Traction is given on the skeleton,
-It provides more force,
Skeletal traction -Can be used for longer duration
- More weight can be used
- Suitable for adults
Examples of commonly used traction according to the site
Types
1. It should be comfortable
General precautions for a
2. Traction weights should not touch ground
patient in traction
3. Feet should not touch the pulley
4. Terminals should be warm and of normal colour
-Damaged skin
Contraindications of skin
-Deep vein thrombosis
traction
-Significant vascular or Neurological deficit
-Pin tract infection
Complications
-Stiffness
35
Chapter 11
Methods of Fixation of Fractures
This chapter outlines the various methods of fixation of fractures.
Internal Fixation of Fractures

Fractures
1. cannot be reduced except by operation
2. unstable and prone to re-displace after reduction
Indications 3. unite poorly and slowly, (femoral neck.)
4. Pathological fractures
5. Multiple fractures: reduces risk of general complications
6. nursing difficulties
Interfragmentary screws
-only partially threaded (over drilling ‘near’ cortex of bone)
-exert a compression or ‘lag’ effect
-reducing single fragments onto the main shaft or fitting together fragments of
a metaphyseal fracture.
Wires (transfixing, cerclage and tension-band)

-Hold major fracture fragments: healing predictably quick (e.g.
-Cerclage and tension-band wires: patellar fractures:
- Tension-band wire: maximum compressive force over tensile surface,
(usually the convex side)
Plates and screws

metaphyseal fractures
diaphyseal fractures of the radius and ulna.
Technique
diaphyseal fractures of the radius and ulna.
bridge a fracture
Neutralization supplement effect of interfragmentary lag screws;
resist torque and shortening.
Compression healing across gap occur directly, without periosteal callus.
less appropriate for diaphyseal fractures
props up ‘overhang’ of the expanded metaphysis
Buttressing
(e.g. treating fractures of proximal tibial plateau).
on tensile surface of bone
Tension-band allows compression to be applied biomechanically more
advantageous
over the tip of a spiral or oblique fracture line
Anti-glide minimal stripping of soft tissues.
prevent shortening and recurrent displacement.
36
Intramedullary nails
- long bones.
- into medullary canal
- rotational forces are resisted by introducing transverse interlocking
screws that transfix the bone cortices
- expense of temporary loss of intramedullary blood supply.
-holds fracture securely

Advantages
-early movement
A method of fixation is based on a quartlet of

1.its safety
2.the strength of hold
Disadvantages/ 3. the speed of recovery
limitations 4. the range of movement permitted
-Greatest danger in internal fixation is sepsis, so safety is the weakest

member of quartlet.
-Infection
Complications of -Non-union
internal fixation -Implant failure
-Refracture
External Fixation of Fractures

1. severe soft-tissue damage / internal fixation is risky
2. soft tissues are too swollen
Indications 3. severe multiple injuries,
4. Ununited fractures, / bone lengthening
5. Infected fractures,
Principle
-bone: transfixed above and below fracture
-permit adjustment of length and alignment
Technique
Telescopic Unit:
convert the forces of weightbearing into axial micromovement - promoting callus
formation and accelerating bone union
-Damage to soft-tissue structures
Complications -Over distraction
-Pin-track infection
37
Chapter 12
Approach to Open Fractures
This chapter outlines the approach to open fractures
OPEN FRACTURES
In general Have a greater tendency to get infected
Airway Breathing Circulation+ Rest Immobilisation Compression

Treatment at the site of
Elevation+ bleeding from wound: stopped
accident
Antibiotics+ Tetanus prophylaxis
Wound debridement:
-Skin preserve as much as possible
-Indicator of muscle viability: contractility
Definitive treatment
wound management
-Clean wounds are closed primarily
-Others: secondary closure
Step1
Reduce
Step2
Immobilisation
Fracture
management: (i) Pins and plaster(unstable)
(ii) Plaster immobilisation with window
(iii) Skeletal traction (circumferential skin loss)
(iv) External skeletal fixation
-Infection of bone
Complications
-Inability to use traditional methods
-Problems related to union
Rehabilitation As mentioned in chapter of rehabilitation protocol
38
Chapter 13
Rehabilitation Prtotocol
This chapter outlines the details about the rehabilitation protocol.
REHABILITATION OF A FRACTURED LIMB
Indication
It prevents Joint stiffness due to:
(i) immobilisation
(ii) pain
(iii) injury
In Bed mobilisation
Method
-passive mobilisation
-active assisted
-active mobilisation
-continuous passive motion (CPM) machines
Muscle
Indication
Re-Education/
Prevent muscles wasting
Exercises
Out of Bed gradual weight bearing is → partial → full

mobilisation
39
Chapter 14
Complications Related to Fractures
This chapter outlines complications related to fractures.
Outline of Complications Related to Fractures
Brief Description of Common Complications Related to

Fractures
Types of Etiology and
Clinical features Treatment
complication mechanism
Due to blood loss in
-Two large bore intravenous
fractures:
-Palpitations cannulas (No. 16 or No. 14) for
1) Hypovolaemic pelvis
-Hypotension fluid and blood transfusions
shock (1500–2000 ml),
-Headache -Avoiding moving patient
femur
(1000–1500 ml).
2) Adult
-tachypnoea
respiratory Non cardiogenic 100 percent oxygen and
-laboured breathing.
distress syndrome pulmonary oedema. assisted ventilation
-arterial PO2 falls
(ARDS)
1. Respiratory support
-petechial rash 2. Heparinisation
-respiratory distress 3. intravenous low
1. free fatty acids
3) Fat embolism - coma molecular weight
2. vasculitis
syndrome -Sputum and urine: fat dextran (Lomodex-20) +
3. fat globules
globules corticosteroids
-Chest x ray: snowstorm 4. intravenous 5 percent
appearance dextrose solution with 5
percent alcohol
40
4) Deep vein
1. elevation of limb
thrombosis (DVT) Leg swelling and calf
Stasis of blood 2. elastic bandage
and pulmonary tenderness
3. anticoagulant therapy
embolism
Myohaemoglobinuria
5) Crush apply tourniquet, → gradually
→ acute renal Palpitations
syndrome released
tubular necrosis.
-Exercise ischaemia
-Ischaemic contracture
-Gangrene
Diagnosis:
1) at the fracture site
-Rapidly increasing
Penetration by
swelling
bone fragment/
-Massive external -Establish homeostasis
compression
6) Injury to major bleeding -Maintains circulation
blood vessels -A wound in anatomical -Explore vessel
path
2)limb distal to the

fracture--Pain – cramp
like
-Pulse – absent
-Pallor
-Paraesthesia
-Paralysis
7) Injury to nerves radial nerve is most frequently damaged nerve.
rise in pressure
within compartment -Excessive pain, not
1. limb elevation, active finger
enclosed by relieved with usual doses
movements
bones, fascia of analgesics
2. Fasciotomy
and interosseous -Stretch test
3. Fibulectomy (middle third)
membrane due to: -Hypo-aesthesia
oedema of muscles. -compartment pressure
Haematoma
Mechanism of compartment syndrome
8) Compartment
syndrome
41
-3 months after fracture
1. Open reduction, internal
(i) Excessive of neck of femur,
fixation and bone grafting
movements at supracondylar fractures
2. Excision of fragments +
fracture site of humerus and 6 months
9) Non-union arthroplasty (replacement of
(ii) Tissue after fracture of other
head of femur in elderly)
interposition bones
3. No treatment for scaphoid
(iii) Poor blood
fracture
supply -mobility at the fracture
4. Ilizarov’s method
site
1. Improper
-Osteoclasis
treatment
(refracturing the bone) to correct
10) Malunion 2. unchecked deformity, shortening,
mild to moderate angular
muscle pull limitation of movements
deformities
3. excessive
-Corrective osteotomy
comminution
1. Malunion Shortening less than 2-5 cm Is

11) Shortening 2. Crushing Discrepancy in length of not much noticeable
3. Injury to the bone & can be managed by shoe heel
growth plate
Common fractures
associated with 1. Sclerosis of necrotic -Delay weight bearing
12) Avascular
avascular necrosis: area -Revascularisation procedure
necrosis
-Neck of femur 2. Deformity of the bone -Excision+ replacement
-Waist scaphoid
-Neck of talus
-Intra-articular
and peri-articular
adhesions
-Excise muscle
13) Stiffness of -Contracture of the
Limitation of movement -Lengthen muscle
joints muscles
-Tethering of muscle
-Myositis ossificans
14) Reflex In early stage, the skin is

sympathetic red, shiny and warm 1. Physiotherapy
Autonomic
dystrophy 2. beta blockers
dysfunction
(Sudeck’s Later there is progressive 3. sympathetic blocks
dystrophy) atrophy of the skin,
muscles and nails
-Immediately there is pain -For active myositis, limb is

-capsule and the followed by local swelling rested, and Non-Steroidal Anti-
15) Myositis periosteum stripped inflammatory drug is given
ossificans from bones -In next 2–3 weeks, joint
(post-traumatic -ossification of movement is limited -surgical excision of bone mass
ossification) haematoma around in cases of mature myositis
a joint -In 8 weeks, ossification
is easily palpable -physiotherapy
42
-Osteomyelitis
-Septic arthritis - For Early stage
-Hemoglobinopathy (1) bisphosphonates
-Sickle cell disease (2) reduce loading of weight-
-Storage disorder bearing joint by ‘unloading’
-Gaucher’s osteotomy
(3) medullary decompression
-In the subarticular and bone grafting
regions the entire
system is encased in -For Intermediate stage:
unyielding bone. -Deformity realignment osteotomy +
-there is no -Limb length discrepancy curettage and bone grafting
adventitial layer and
patency of sinusoids -In Late stage
is determined by (1) non-operative management
volume and pressure including pain control,
of surrounding (2) arthrodesis
marrow tissue, (3) partial or total joint
-one element can replacement,
expand only at the
expense of the
others
16)Avascular
Necrosis
43
Chapter 15
Fractures in Children
This chapter outlines how fractures differ in children from that of adults, including classification &
management of physeal injuries.
Salter Harris classification
Type
Description of fracture
Eponym
I Separation
II Triangular fragment metaphysis Thurston Holland
III L shaped epiphysis
IV Through epiphysis and metaphysic

Classification
V Impaction
Etiology and
falls or traction injuries.
mechanism of
injury
Clinical features More commonly seen in boys
Common age of presentation is around 10 years of age
X-rays:
-widening of the physeal ‘gap’
Diagnosis
-incongruity of the joint
-tilting of the epiphyseal axis.
- For undisplaced fractures close-fitting plaster slab is applied
Treatment
-For displaced fractures after reduction a cast or k wire is applied
-Damage to proliferative zone
-Missed malunion or non-union
Complication
-Premature fusion
-Deformity
44
Differences in the Fractures : Children VS. Adults
Epiphyseal plate Is a potentially weak point

Springy bones So are more prone to greenstick fractures
Loose periosteum Because of which develops lot of callus
Fractures Generally, unite quickly
remodelling potential Is usually greater
45
Chapter 16
Amputation
This chapter outlines indications, technique, complications, care of the amputated part, reimplantation,
and pain problems related to amputees.
Limb or part of it is commonly amputated if it is:
Indications 1. painful
2. non-viable
provisional amputation
- is done when primary healing is unlikely as seen in case of Infected tissue
definitive end-bearing amputation
Techniques
-usually performed in lower limb amputations: Syme’s amputations
definitive non-end-bearing amputation
-usually performed in upper limb amputations
Early:
-Breakdown of skin flaps
-Gas gangrene
Complications
Late:
-Skin Eczema
-Poor blood supply
Care of Amputated Limb

Once amputated the part needs to be treated as follows:
Replantation of Amputated Parts

There are a few relative contraindications for reimplantation, along with post-operative management
-Single digits
-Exception is an amputation beyond the insertion of flexor digitorum
Relative superficialis, when a cosmetic,
contraindications -Crushed, mangled or avulsed parts
-long ischaemic time
-General medical disorders: anaesthesia
46
-Single digits
-Exception is an amputation beyond the insertion of flexor digitorum
Relative superficialis, when a cosmetic,
contraindications -Crushed, mangled or avulsed parts
-long ischaemic time
-General medical disorders: anaesthesia
IMMEDIATE AFTERCARE
-Hand is kept elevated in a roller towel or high sling.
-Antibiotics are continued as necessary.
Postoperative LATER STAGE:
management -Movements commenced within a few days
-Splintage
-Dynamic splintage
-Passive, active or elastic-band assisted flexion.
Pain Related to Amputees

Phantom pain Pain that feels like it's coming from a body part that's no longer there
Residual limb pain Pain in the area of the stump.
47
Chapter 17
Recent Advancements in the Fracture

Treatment
This chapter outlines the recent advances in the treatment of fractures like stable fixation, Ilizarov’s
technique and distraction osteogenesis.
Stable Fixation
1. To provide stability
Indications
2. To preserve blood supply
There are two ways for providing a stable fixation:

a. Inter-fragmentary compression
b. Splinting
Lag screw fixation

-screw passed across fracture site
-fracture surfaces are compressed
against each other (proximal cortex is
Static 'over drilled'.)
Compression
Compression plating
Inter- -Muller's compression clamp
fragmentary -self-compression plates.
Technique
compression
External fixators
tension-band principle.
Dynamic
methods:
Compression
a) Tension-band wire
b) Tension-band plate
-Intra-medullary splinting by use of 'nail'

Splinting -Extra-medullary splinting by the use of a Plate
-Outside the body with external fixators
Complication Increased operative morbidity
48
Ilizarov’s Technique (Ring Fixator)
Limb lengthening
Fractures
Indication Non-union
Osteomyelitis
Arthrodesis
Callotasis
-careful fracture of bone followed by a short wait before the young callus is
gradually distracted via a circular or unilateral external fixator. (distraction
histogenesis)
-desired length is reached,
-second wait - Weightbearing is permitted and assists consolidation process.
Chondrodiatasis
-distracting the growth plate (chondrodiatasis)
- no osteotomy is needed
Technique & -distraction rate is slower, usually 0.25 mm twice daily.
Components -physis closes after the process.
Bone transport
-creating a ‘floating’ segment of bone through a corticotomy
-moved slowly across defect
-bifocal compression-distraction brings the bone ends together;
Correcting bone deformities and joint contractures

-carefully planned osteotomies
-followed by application of external fixator;
-By correcting soft-tissue contractures.
i) Inconvenience
ii) Long duration
Complications iii) Pin tract infection
iv) Nerve palsy
v) Joint stiffness
49
Section- B
Outline of Dislocations
and Subluxations
50
Chapter 18
Approach to Dislocations and

Subluxation
This chapter outlines types, clinical features, complications related to dislocations and subluxations
Traumatic
-Acute traumatic dislocation
-Old unreduced dislocation
Types
-Recurrent dislocation
-Fracture-dislocation
Pathological
infective / neoplastic process
a) Pain
b) Deformity
Clinical Features c) Swelling

d) Loss of movement
e) Shortening
f) Telescopy
Diagnosis X ray
Treatment Reduction under general anaesthetic / muscle relaxants / rest / immobilized for
2 weeks.
Early
(i) Recurrence
(ii) myositis ossificans
(iii) persistent instability
Complications
(iv) joint stiffness
Late
(i) recurrence
(ii) osteoarthritis
(iii) avascular necrosis
51
Section- C
Outline of Nerve Injuries
52
Chapter 19
Approches to peripheral nerve injuries
This chapter deals with outline of anatomy, pathology, classification, predisposing factors, deformities,
palsies, clinical & laboratory testing, treatment and prognostic factors related peripheral nerve injuries.
Anatomy
Layers of a peripheral nerve
Individual nerve fibre is covered by Endoneurium

Fasciculus is covered by Perineurium
Number of fasciculi is covered by Epineurium
Pathology
A nerve can undergo regeneration and degeneration.
Nerve degeneration -distal to injury the nerve undergoes Wallerian degeneration

-proximal part undergoes retrograde degeneration up to single node.
-If both endoneural tube and Schwann cells are intact, the nerves
reinnervate proximal to distal (motor march) at rate of 1 mm per day
Nerve regeneration -If the endoneural tube interrupted, it forms a partial /end-neuroma /
neuroma in continuity
-Partial interruption of nerve forms a side neuroma
Type A
Type B Endo Peri Epi
Lundborg Intraneural Myelin Axonal
Intraneural Neureum Neureum Neureum
circulatory damage damage
oedema Damage Damage Damage
arrest
Sunderland
I II III IV V
Axonotmesis
(motor march
Seddon Neurotmesis
Neuropraxia present,
(end/side neuroma)
Neuroma in
continuity)
53
Predisposing Factors
A few nerves predispose themselves to injury because of the following reasons:
Superficially placed Median nerve at wrist

proximity to bone / joint Radial nerve injury due to fracture of shaft of humerus.
close relation to a major vessel While ligating the vessel or pressure by aneurysm
confined space Median nerve entrapped in carpal tunnel
Anatomical location Common peroneal nerve injury at neck of fibula
Deformities
This table gives named pathological conditions along with the nerve injured and muscle paralysed
Deformities Nerve involved Muscles affected

Wrist drop
radial nerve palsy Dorsiflexors of wrist
Deformity
common peroneal nerve
Foot drop deformity Dorsiflexors of foot
palsy
Winging scapula long thoracic nerve palsy/
serratus anterior / trapezius
deformity cn 11
Claw hand deformity
Median/ ulnar Lumbricals
(Main-en-griffe)
Ape thumb deformity median nerve palsy opponens pollicis
Pointing index median nerve palsy at a flexors (digitorum superficialis and lateral half
Deformity level proximal to the elbow. of the digitorum profundus) of the index finger
Policeman tip Upper trunks of brachial abductor and external rotators of the shoulder
deformity plexus + flexors and supinators of elbow
Palsies
Radial Nerve Palsy
Site of Etiology and Sensory
Motor loss Treatment
injury mechanism loss
brachioradialis, -Open injuries: exploration and nerve
extensor carpi radialis repair
Low Injury at elbow longus and brevis) are
spared is limited -Closed injuries: wait for 12 weeks for
to a small signs of recovery
patch on
the dorsum -small joints of the hand must be
- fractures of around the put through a full range of passive
Extensors of wrist are anatomical
the humerus movements (physiotherapy)
High paralysed snuffbox
-prolonged tour-
(wrist drop).
niquet pressure. -wrist is splinted in extension
tendon transfers:
triceps is paralysed -pronator teres to short radial
chronic com- and triceps reflex is extensor
Very -flexor carpi radialis to long finger
pression in the absent (‘Saturday
high extensors
axilla night palsy’)
(‘crutch palsy’) -palmaris longus to thumb abductor
54
Median Nerve Palsy
Site Etiology and mechanism Motor loss Sensory loss Treatment
Injury to distal third of finger -Open injuries: exploration and

Low nerve repair
forearm flexors
- Closed injuries: wait for 12

weeks for signs of recovery
All flexor
muscles In the territory of -small joints of the hand
Injury to proximal two third of forearm median nerve in must be put through a full
of forearm and above other than hand range of passive movements
High
elbow those (physiotherapy)
supplied by
ulnar nerve -wrist is splinted in extension
is paralysed
-tendon transfer
Ulnar Nerve Palsy

Sensory
Site Etiology and mechanism Motor loss Treatment
loss
-Exploration and repair
-anterior transposition at elbow
Injury to distal-third of Hypothenar and -skin protected from burns
Low forearm interosseous -Hand physiotherapy
muscle of hand -Splintage
In the terri-
Tendon transfer:
tory of ulnar
- extensor carpi radialis longus
nerve
to intrinsic tendons (Brand),
ulnar half of
Injury proximal two third of flexor digitorum -looping a slip of flexor
High
forearm profundus is digitorum superficialis around
And above elbow paralysed (high the opening of the flexor
ulnar paradox) sheath (Zancolli procedure).
Clinical Testing of Nerve Regeneration

On tapping over nerve along its course, from distal to proximal, pins and
needle sensation felt in area of skin supplied by nerve
Tinel's sign
-In neurapraxia, the Tinel’s sign is negative
-In axonotmesis, it is positive at the site of injury
motor march (proximal to distal muscle recovery)
Motor examination This phenomenon is absent in neuropraxia where all muscles recover
together.
Electrodiagnostic test
55
Laboratory Testing
EMG is a graphic recording of electrical activity of muscle at rest and during

activity. Following are the findings:
In normal muscle
-a weak contraction produces single motor unit potentials
-a strong contraction produces interference pattern
In denervated muscle
denervation potentials, which appear around 15-20 days after denervation.
EMG can be represented in Strength duration curve as follows:
Strength-Duration Curve
Following are the parameters represented in a strength duration curve
a. Rheobase (milliamperes)
It is the minimal current strength, required to elicit muscle contraction
b. Chronaxie(milliseconds)
It is the duration of current required to excite a muscle with a current-strength
of double the rheobase
1. Electromyogra-
phy (EMG)
-In a normal muscle, as the duration of current is decreased, a progressive

increase in the strength of current is required in order to produce a contraction.
-In a denervated muscle a current either of more strength or for a longer

duration is required to produce a contraction.
-The curve becomes flatter and shifts to the left on recovery.
-Normal nerve conduction velocity of a motor nerve is 70 metres/second.

Nerve Conduction -In a compressive lesion conduction velocity is delayed.
Study (NCS) -In complete nerve injury, there is absence of transmitted impulse.
-The following diagram simplifies the interpretation of conduction studies
56
Treatment
The following algorithm may be followed in case of nerve injuries:
We can treat a nerve injury conservatively or surgically by following methods
57
Conservative Treatment
1. Splintage of the paralysed limb
2. Preserve mobility of the joints
3. Care of the skin and nails
4. Physiotherapy
5. Relief of pain
Operative Treatment
1. Primary repair
2. Delayed repair
Techniques of Nerve Repair

1. Nerve suturing
2. Nerve grafting
3. Neurolysis
PROGNOSTIC FACTORS
Following are the poor prognostic factors
1. Old age
2. Tension at suture line
3. Proximal injury
4. Mixed nerve
5. Crush Injury
6. Infection
58
References
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J. P. Medical Lt, India.
2. Solomon, L., Warwick, D., Nayagam, S et al (2010). Apley’s system of orthopaedics and fractures
(9th ed.). Hodder Arnold, London.
3. Kaushik Banerjee (2018) Handbook for Orthopaedics Examination : Theory & Practical, 7th edition,
Academic Publishers. India
4. Standing S and Livingsston C (ed) (2004) Musculoskeletal system. In: Gray’s Anatomy, 39th Ed.,
Elsevier, New York,.
5. Den Boer, FC, Patka, P, Bakker et al (2002) Current concepts of fracture healing, delayed unions,
and nonunions. Osteo Trauma Care. 10:1–7.
6. Weber, BG, Ĉech, O (1976). Pseudarthrosis, Pathology Biomechanics, Therapy, Results. Hans
Huber, Bern
7. Foucher JT (1863) De la divulsion des epiphyses. Cong Med France.; 1:63–72.
8. Dale GG, Harris WR (1958) Prognosis of epiphyseal separation: an experimental study. Journal of
Joint & Bone Surgery, British Volume, 40-B(1):116-22..
9. Ogden JA (1981) Injury to the growth mechanisms of the immature skeleton. Skeletal Radiol.,
6:237–253. doe: 10.1007/BF00347197.
10. Rang M (1968) The Growth Plate and Its Disorders. Edinburgh: E. & S. Livingstone Ltd.
11. Clarke B (2008) Normal bone anatomy and physiology. Clinical Journal of American Society of
Nephrology. 131-9.
12. P Villa, E Mahieu (1991) Breakage patterns of human long bones Journal of human evolution, –
Elsevier.
13. Baber YF, Robinson AHN, Villar RN (1999) Is diagnostic arthroscopy of the hip worthwhile? Journal
of Bone Joint Surgery; 81B: 600–3.
14. Boileau P, Sinnerton RJ, Chuinard C et al(2006). Arthroplasty of the shoulder. Journal of Bone
Joint Surgery; 88B: 562– 75.
15. Robinson CM (1998). Fractures of the clavicle in the adult: Epidemiology and classification. Journal
of Bone Joint Surgery; 80B: 476–84.
16. Neer CS (1970) Displaced proximal humeral fractures. Classification and evaluation. Journal of
Bone Joint Surgery; 52A: 1077–89.
17. Morrey BF (1995) Current concepts in the treatment of fractures of the radial head, the olecranon
and coronoid. Journal of Bone Joint Surgery; 77A: 316–27.
18. Charnley J (1961.). The Closed Treatment of Common Fractures. Churchill Livingstone, Edinburgh,
19. Salter RB and Harris WR (1963). Injuries involving the epiphyseal plate. Journal of Bone Joint
Surgery; 45A: 587– 622.
20. Woo SL, Vogrin TM, Abramowitch SD (2000). Healing and repair of ligament injuries in the knee.
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21. Müller M., Nazarian S, Koch P et al (1990), The Comprehensive Classification of Fractures of Long
Bones. Springer Verlag, Berlin, Heidelberg, New York.
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Trauma; 29: 981–1000.
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24. Ajis A, Younger AS, Maffulli N (2006) Anatomic repair for chronic lateral ankle instability. Foot Ankle
Clin; 11: 539–45.60
25. Broström L. Sprained ankles. Surgical treatment of ‘chronic’ ligament ruptures. Acta Chir Scand
1966; 132: 551–65.
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ligament injuries. Foot Ankle; 12: 69–73.
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28. Seddon HJ (1942). A classification of nerve injuries,. British Medical Journal,; 2: 237–239.
29. Birch R, Bonney G, Wyn Parry CB (1998) Surgical Disorders of the Peripheral Nerves. Churchill
Livingstone.
30. Sunderland S (1978). Nerves and Nerve Injuries, 2nd ed. Edinburgh, Churchill, Livingstone.
31. Saleh M. (1988) Commission on the Provision of Surgical Services. The Management of Patients
with Major Injuries., The Royal College of Surgeons of England.
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60
Vignesh Narayan R
Vignesh Narayan R is a gold medalist, graduate from JIPMER
Puducherry. he has Published two scientific papers and has received
the best paper award from the Indian Journal of Rheumatology for
paper “Neuropathic pain in patients of knee osteoarthritis a cross
sectional study”. He has also received twice the GJSTRAUS award
for his research. He is an ardent student ever trying to make
learning easier yet effective.
T. Ravi Varma
T. Ravi Varma is a vascular surgeon with over 30 years of experience
as surgeon. experience, with vast expertise on endovascular repair,
cases involving orthopaedic trauma, neuronal injury. He has a
flourishing carrer in vascular surgery in Bangalore, karnataka, and
was one of the pioneers of Vascular surgery in Bangalore. He has
a bright academic record and has completed his graduation from
Hubli karnataka and has done his vascular surgery from cologne
Germany.
Prof Dr. Ravi Kumar Chittoria is born, Brought up & completed his
schooling in Delhi, Did his MBBS from Maulana Azad Medical College
Delhi, MS (Surgery) from PGIMER chandigarh, MCh (Plastic Surgery)
from Grant Medical College Mumbai & PhD (Plastic Surgery) from
SVIMS University Andhra Pradesh. He has additional qualifications
including DNB (Diplomate Natinal Board), MNAMS (Member of
National Academy of Medical Sciences), PGCHM (Postgraduate
Course in Hospital Management), PGCHA Postgraduate Couse in
Hospital Administration). MBA (Hospital Administration). PGDMLS
(Postgraduate Diploma in Medico Legal System), PDCR (Postgraduate
Diploma in clinical Research) and PGDTM (Postgraduate Diploma
in Telemedicine). He received Higher Trainings in Laser aesthetic
Surgery from Boston University USA. Endoscopic Aesthetic Surgery from Emory University
USA, Aesthetic Surgery from PACES Plastic Surgery Centre Atlanta Georgia USA, Course
on Fundamentals of Clinical Trials, Epidemiology & Biostatistics from Harvard University,
USA.He is is Fellow of Academy of General Education (FAGE), Fellow of Society fir Advanced
Studies in medical Science (FSASMS) and Fellow of Rural Health Society (FRHS). His area
of intersts includes Burns, wound Healing, Laser Surgery, Telemedicine, Anti Ageing,
Regenerative Medicine, Clinical Research, medicolegal issues, Medical Education and Hospital
Administration. He has work & He has 27 years of professional and teaching experience of
more than 27 years. He has more than 170 publications in peer reviewed indexed national
& international Journals. He has been Editor-in-Chief of 6 issues of journal and acted as an
Associate/assistant editor 7 Journals. He is Author of 4 Text Books, 5 Chapters, 7 Manuals
and 1 Abstract Book. He has completed 15 Research Projects. He has received 30 Awards &
Honours including BMJ Award WMC Award, VIMA Award and skoch Award. He is Visiting
Professor to AIIMS New Delhi. He has developed more than 20 innovations including one
patent. He is Member of Editorial Board of more than of 71 National & International Journals.
He has received more than two crores of research grants. He has been an expert, examiner,
question paper setter and thesis guide for Medical Council of India (MCI) and National Board
of Examinations (NBE) recognized courses for more than 12 years. He is an Advisor to Union
Public Service commission (UPSC), World Yoga Foundation (WYF) and Board of Medical
Studies (BOS) for Pondicherry University. At Present he is a Professor of Plastic Surgery,
Head of IT Wing, Nodal Officer and Registar (Academic) in JIPMER Pondicherry.
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AN Outline to Bones and Tissue

Ravi Kumar Chittoria

Published: November 2019

Published by OMICS International

Additional hard copies can be obtained from orders @ www.esciencecentral.org/ebooks

This chapter outlines types of bones

Eponym (trabecular) bone

Stages and Factors Affecting

Stages of Fracture Healing

Types of Fracture Healing

Factors Affecting Fracture Healing

Classification and General

Schematic Classification Of Fractures

Fractures may be classified on following basis:

On The Basis of Aetiology

Quantum Of Force Causing Fracture

Transverse fracture fracture line perpendicular to long axis of the bone.

The following table gives a list of fractures with eponyms

Points to be noted in history trivial injury, weight, pain, a lump,

Generalized bone Immobilized in internal fixation

Primary malignant tumour Splinting

Treatment Modalities long-bone shaft

Metastatic tumours near a bone end

Pathological fractures have different capacity to unite as mentioned in table below:

generalised disorder (Paget's disease,

bone cyst or a benign tumour Delayed

Stress Fracture (Fatigue Fracture)

-In a normal bone

Best diagnostic test For unilateral fractures it is MRI

Differential diagnosis osteosarcoma

Outline Of Features Of Some Of The Commonly Seen Frac-

-Surgical neck fracture is manipulated, sling for 4 weeks

Reduced and held

In elderly patients with low functional demands, modest degrees of displace-

fracture unites in 6 weeks Impacted or comminuted Colles’ fractures

Group I fracture of middle third of clavicle

arm is clasped to chest to prevent movement.

F) Fracture of Patella of Knee

Injury type Direct Indirect

- Knee becomes swollen and painful.

G) Fracture of Shaft of Both Forearm Bones (Radius And Ulna)

Open reduction and internal fixation:

H) Fracture of Head of Radius

-swelling over the lateral aspect of the elbow.

J) Fracture of Neck of Femur

Commonly seen in:

1. elderly: sideway fall or / blow over the greater trochanter.

Features neck-shaft angle is reduced (coxa vara)

X ray features indicating a bad prognosis:

1. Conservative methods: Russell’s traction / Thomas splint

Treated in elderly: suitable shoe raise

Treated in young people: inter-trochanteric osteotomy

Treated in young: osteotomy

Treated in elderly: total hip replacement

L) Fracture of Condyle of Femur

Mechanism Indirect force on the knee

inability to actively extend the knee, called extensor lag.

1: vertical split of the lateral condyle

Etiology and vehicular accidents when one lands on the knee.

Doughy feel of knee

Treatment Traction followed by conservative methods

N) Fracture of Both Bones of Leg (Tibia And Fibula)

-supine + knees flexed over the end of table.