Fractures and dislocations
A fracture is a loss in the normal continuity of bone following the application of a direct or indirect force to that bone. A fracture may involve a part or the entire
circumference of the cortex.
All fractures are painful. There is normally a history of trauma except in pathological fractures where minimal trauma or no trauma is the rule. Fractures are tender, swollen, occasionally deformed, mobile at the fracture site, and associated with loss of limb function.
All suspected fractures should be X-rayed in two planes perpendicular or oblique to the fracture line to detect the fracture. CT is good for demonstrating periosteal
new bone formation and may be valuable for diagnosing subtle stress fractures such as minimally displaced femoral neck fractures, pelvic ring fractures, and rib
Magnetic resonance imaging (MRI) Limited MRI scans in the coronal or surgical plane
excellent for demonstrating fractures which are suspected but not readily apparent on plain X-rays. T1 weighted MRI’s are able to detect the fracture immediately
after injury and T2 weighted images can differentiate soft tissue inflammation from intraosseous oedema. MRI scans are excellent for early detection of
undisplaced scaphoid and femoral neck fractures.
The principles of management of a closed fracture
Correction of the deformity (reduction)
Immobilization of the fracture
Protection until the fracture has consolidated
Rehabilitation of the muscles and joints of the affected
Under appropriate anaesthesia (local, regional, general) the fracture fragments should be manipulated and reduced into normal alignment. In reducing the fracture, combinations of distraction, increasing and then reducing the deformity of the fracture, and holding reduction with 3 point fixation are employed. This technique of reduction is also used with open fractures.
Open reduction is indicated when closed manipulation of bone fragments has failed to reduce the fracture into a satisfactory position, if reduction is impossible or if
reduction is lost after initial closed reduction. Open reduction may be indicated to stabilize fractures securely to allow safe and effective management of the patients
with multiple other bone or soft tissue injuries, or if movement of the adjacent joint is paramount.
Dislocation is a complete loss of contact between the articular surfaces of the bones forming a joint. Subluxation is displacement of the joint with the loss
of normal congruity but the articular surfaces remain in partial contact with each other
Subluxations and dislocations normally follow direct or indirect trauma. This condition may also occur voluntarily in patients with ligamentous laxity. Dislocations
may also follow an epileptic seizure or electrocution, and the classic injury is a posterior shoulder dislocation. Patients complain of pain, deformity and loss of function. Examination demonstrates a loss of normal contour of the joint, marked restriction of movement and pain on attempted passive motion of the joint.
Plain radiographs are sufficient to demonstrate dislocations and subluxations. Radiographs in two planes (anteroposterior and lateral) are essential for confirming
the diagnosis. Occasionally associated fractures may be seen and care should be taken not to displace these fractures in an attempt to reduce the dislocation.
The principles of treatment are to reduce the dislocation, immobilize the joint and to rehabilitate the joint. Closed reduction of the joint under adequate anaesthesia
and analgesia is undertaken with the combination of traction, rotation and angulations. At all times forceful manipulation of the joint should be avoided in order to prevent fracture of adjacent bones or neuro vascular trauma.
Open reduction is undertaken when closed reduction has failed. This may occur because of the interposition of tissue or the entrapment of the dislocated bone by capsular or ligamentous attachments. Open reduction may also be undertaken if the dislocation is associated with a complex fracture or neurovascular injury that
requires exploration and repair. Chronic dislocations, that is, joints that have been
dislocated for more than 1 week, are usually treated by open reduction because soft tissue scarring and fi-brosis within the joint would normally prevent normal