INJURIES OF THE UPPER AND LOWER LIMBS

Some regional fractures and dislocation

INJURIES OF SHOULDER GIRDLE (A) Fractures : Clavicle Scapula Proximal humerus , the most commonly fractures are

those of greater tuberosity and surgical neck. (B) Dislocations (1) shoulder :common and mostly affects young adult

male than female classified according to position of humeral head as:

Anterior (commonest) Posterior (uncommon) Inferior (rare) (2) Acromio-clavicular joint :common injury mainly

in young athletic (3) Sterno-clavicular joint : rare dislocation

Acromio-clavicular dislocation

Scapula fracture

Fracture of the mid-shaft of clavicle

AP anterior dislocation glenohumeral joint

relationship of radial nerve to fractures in the spiral groove

THE ELBOW AND FOREARM Injuries of elbow A .Fractures 1- fractures f the distal end of the humerus such as fractures

of .a - superacondylar b -condylar c-infercodylar 2- Fractures of proximal end of the ulna 3- Fractures of proximal end of the radius 4- avulsion fracture of the epiphysis of the humeral (medial

and lateral condyle)

SUPRACONDYLAR fractures

Are most often seen in children and the distal fragment may be  displaced posteriorly or anteriorly.

B. Dislocations 1-acromio-cavicular joint dislocation : it is common injury

mainly in young athletic 2- sterno-clavicular joint dislocation : it is rare  

Partial avulsion of the medial epicondyle

Undisplaced supracondylarfracture

OPEN REDUCTION AND FIXATION OF MONTEGGIA FRACTURE-DISLOCATION

MONTEGGIA FRACTURE DISLOCATION  This is a fracture of the proximal third of the ulna with dislocation of the proximal

 (superior) radio-ulnar joint. It usually arises due to fall on to the hand with body  twisting at the point of impact

leading to a pronation of the forearm leading to  dislocation of the radial head. Open reduction and fixation of Monteggia fracture dislocation Radiographs of the forearm with the superior radio-ulnar joint is essential.  dislocation. In adults this usually requires surgery, with post operative   immobilisation of the arm in above elbow cast for six weeks to prevent redislocation  of

the radial head. 

FRACTURES OF THE FOREARM

SINGLE FOREARM BONE FRACTURES Fractures of the shaft of the radius or the ulna alone are uncommon and

are usually caused by a direct blow. Ulnar fractures are rarely displaced were as in radial  

fractures of both bones (radius and ulnar) is relatively common in children.

GALEAZZI FRACTURE DISLOCATION OF THE FOREARM

This fracture is caused by a fall on to the hand with a rotational force super-imposed.  

The radius fracture is in the lower third with dislocation of the inferior radio-ulna  Joint .

The treatment In adults is carried out by open reduction and plating of the radius.

open reduction and fixation of Galeazzi fracture -dislocation

COLLES’ FRACTURE Abraham Colles’ first described this injury in 1814 as a transverse

fracture of the  distal radius with dorsal displacement of the distal fragment associated with fracture of ulnar styloid process.

It is one of the  commonest fractures of the elderly. The fracture occurs due to the application of a  longitudinal force in the length of the radius with the wrist in extension.

Radiographs show dorsal displacement, radial displacement (dinner fork) deformity . 

SMITHS’ FRACTURE In this fracture the distal fragment is displaced towards

the volar aspect of the wrist as  a result the fracture is often called a reversed Colles’.

It is often caused by a fall on  the back of the hand. The forearm is placed in a cast with the wrist in

extension. 

fracture through waist of scaphoid

INJURIES TO THE SCAPHOID

Scaphoid injuries account for almost 70% of the carpus injuries. The mechanism of  injury is a fall on the dorsi-flexed hand. There is

tenderness in s. Radiographs taken include lateral, two oblique and a A.P view of the  

carpus. The fracture line is usually transverse and frequently through the waist of

the   scaphoid. It is important to look for angulation of the distal fragment since this is

 often a cause of non-union. fracture through waist of scaphoid.  Sometimes early diagnosis is not possible however if there is an index of

suspicion   the forearm is placed in a scaphoid plaster with check radiographs at two

weeks. The scaphoid glass holding position.   Displaced fractures are treated by open reduction and compression

screws.  

METACARPAL FRACTURES

Fractures of the fifth metacarpal are common The fracture usually is at the neck or the shaft of

the metacarpal and is usually spiral  in pattern.   Bennett's fracture-subluxation This is fracture of the base of the first metacarpal

with oblique fracture line Complete separation of fragemeublant allows

posterior subluxation or dislocation of the remainder of the bone

LOWER LIMB FRACTURES INTRODUCTION Fractures of the lower limb are common especially in the elderly. They are often associated  with considerable morbidity

Pelvic fractures

Usually secondary to massive force, such as a road traffic accident or fallfrom a height.

FRACTURES OF THE FEMORAL NECK (INTRA-CAPSULAR)

This is one of the commonest fractures of the elderly, with vast number of the patients being  women in the ages between 60-80 years.

The fracture usually arises due to a fall on the  greater trochanter.

The classification commonly used to describe the displacement of the  femoral head is referred to as the Gardens classification which is composed of the following  stages: 

grade1: incomplete impacted fracture of the femoral neck.  grade 2: complete undisplaced fracture.  grade 3: complete fracture with moderate displacement.  grade 4: severely displaced fracture.  Clinically the patient complains of pain in the hip and the limb

may be shortened and  externally rotated. 

Subcapital fracture

Pelvic fracture following a road traffic accident

FEMORAL SHAFT FRACTURE This is usually a fracture of young adults and the fracture

pattern may vary considerably  depending on the cause. A spiral fracture is usually produced by a fall in which

the foot has  been anchored whilst a twisting force is transmitted to the femur.

Transverse and oblique  fractures are often due to direct violence.

It has to be remembered that up to two units of blood may be lost from a femoral  shaft fracture and that shock may be present therefore it is important to ensure that blood is  available. Management.

 Primary survey. In young patients these injuries are usually high energy injuries which may be associated with additional trauma.   

A.P and lateral radiographs of the entire femur. There may well be an associatedsubcapital fracture with a fracture of the shaft of the femur

fixation of femoral shaft fracture

INTERTROCHANTERIC FRACTURES OF THE FEMUR

The fracture is caused by a fall on to the greater trochanter and the fracture runs  between the lesser and greater trochanter

Management. This is similar to subcapital fractures but the consent is for a Dynamic Hip screw.  The classification used for these fractures is referred to as the Jensons classification.

Types of intertrochanteric fractures

SUPRACONDYLAR FRACTURES These are produced as a result of direct violence or

due to a fall in elderly patients. Clinically   the knee is swollen and painful and movement should

not be tested, however a record of the   neurovascular status should be documented.

Radiologically the fracture is seen just above the  femoral condyles and the fracture pattern may be

transverse or comminuted Primary survey in young patients these injuries are

usually high energy injuries which may be associated with additional trauma. 

FRACTURES OF THE PATELLA Fractures of the patella may be caused by direct or indirect trauma. The direct injury may be   due to a fall on the knee and fracture is usually easily visible in A.P radiographs.  patello-femoral osteoarthritis is a common complication.

Transverse patella fracture

FRACTURES OF THE TIBIA AND FIBULA These are relatively common fractures and in  addition open fractures of the tibia are more common than in any other long bone.

The  method of fracture is usually blunt trauma and the risk of complications is directly related to  

the degree and nature of soft tissue damage.  The fracture pattern is also variable depending upon the

nature of the injury and subsequently   Fractures of the shaft of the tibia are usually cased by

rotational forces and lead to spiral  fractures . Fractures of the fibula may be due to direct violence or

may occur in association with external rotation and abduction injuries of the ankle.

It is  important to exclude ankle injuries in the presence of fibular fractures. 

Fractures of both bones usually occur as a result of direct trauma with road traffic being the  commonest cause.

Fracture mid shaft of tibia, note the associated fracture of the fibula

Comminuted mid-femoral shaft fracture

FRACTURES OF THE ANKLE The ankle is usually injured by indirect forces,   The important factor in  ankle fractures is the stability

of the ankle mortice.   An important point to remember is that ankle injuries

may present as fracture-dislocations.  In these injuries the skin may be tented and neurovascular structures may be compromised by  the displaced bone.

Bimalleolar fracture of the ankle

Weber C ankle fracture

Lateral view of a calcaneal fracture

Posterior dislocation of the right hip.Note the acetabular posterior column fracture.

Base of 5th metatarsal fracture