Phalanges and Interphalangeal Joints

8/18/2019 Phalanges and Interphalangeal Joints

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Phalanges and Interphalangeal Joints

Epidemiology

■ Phalangeal fractures are the most common injury to the forefoot.

■ The proximal phalanx of the fifth toe is the most often involved.

Anatomy

■ The first and fifth digits are in especially vulnerable positions for injury because they formthe

medial and lateral borders of the distal foot.

Mechanism of Injury

■ A direct blow such as a heavy object dropped onto the foot usually causes a transverse or

comminuted fracture.

■ A stubbing injury is the result of axial loading with secondary varus or valgus force

resulting in a

spiral or oblique fracture pattern.

Clinical Evaluation

■ Patients typically present with pain, swelling, and variable deformity of the affected digit.■ Tenderness can typically be elicited over the site of injury.

Radiographic Evaluation

■ AP, lateral, and oblique views of the foot should be obtained.

■ f possible, isolation of the digit of interest for the lateral radiograph may aid in

visuali!ation of the

injury. Alternatively, the use of small dental radiographs placed between the toes has been

described.

■ "# may aid in the diagnosis of stress fracture when the injury is not apparent on plain

radiographs.

Classification

Descriptive

■ Location: Proximal, middle, distal phalanx

■ Angulation

■ $isplacement

■ %omminution

■ ntra&articular involvement

■ Presence of fracture&dislocation

Treatment

■ 'ondisplaced fractures irrespective of articular involvement can be treated with a stiff&

soled shoe

and protected weight bearing with advancement as tolerated.■ (se of buddy taping between adjacent toes may provide pain relief and help to stabili!e

potentially

unstable fracture patterns.

■ )ractures with clinical deformity require reduction. %losed reduction is usually adequate

and

stable *)ig. +.-.


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■ /perative reduction is reserved for those rare fractures with gross instability or persistent

intraarticular

discontinuity. This problem usually arises with an intra&articular fracture of the proximal phalanx of the great toe or multiple fractures of lesser toes.

■ A grossly unstable fracture of the proximal phalanx of the first toe should be reduced and

stabili!ed

with percutaneous 0irschner wires or mini&fragment screws.

■ (nstable intra&articular fractures of any joint despite adequate reduction should be reduced

and

percutaneously pinned in place to avoid late malalignment.

Complications

■ Nonunion: This is uncommon.

■ Posttraumatic osteoarthritis: This may complicate fractures with intra&articular injury,

with

resultant incongruity. t may be disabling if it involves the great toe.

Dislocation of the Interphalangeal Joint

■ This is usually due to an axial load applied at the terminal end of the digit.

■ "ost such injuries occur in the proximal joint, are dorsal in direction, and occur in

exposed,

unprotected toes.

■ %losed reduction under digital bloc1 and longitudinal traction comprise the treatment of

choice for

these injuries.


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■ /nce reduced, the interphalangeal joint is usually stable and can be adequately treated with

buddy

taping and progressive activity as tolerated.


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Fraktur adalah terputusnya kontinutas struktur tulang. Fraktur bisa tidak lebih darisebuah keretakan, sebuah pengkisutan atau pelepasan korteks tulang; lebih seringterputusnya lengkap dan pecahan tulang terdislokasi. Jika kulit tetap utuh, frakturnyaadalah sebuah fraktur tertutup atau sederhana. Jika kulit atau satu dari rongga tubuhterbuka, frakturnya adalah sebuah fraktur terbuka atau compound, cenderung terhadapkontaminasi dan infeksi.

HOW FRA!"R#$ HA%%#& !ulang relatif rapuh, namun mempunyai kekuatan yang cukup dan ketahanan untukmenahan tekanan yang cukup besar. Fraktur merupakan hasil dari' () cedera *) tekananyang berulang +) pelemahan abnormal pada tulang fraktur patologis)

Fraktur akibat cederaFRA!"R#$ -"# !O &J"R/$ebagian besar fraktur disebabkan oleh kekuatan yang tiba0tiba dan berlebihan, baiksecara langsung maupun tidak langsung.1ebanyakan dengan gaya langsung, tulang patah pada titik benturan, 2aringan lunak 2ugaikut rusak. $ebuah pukulan langsung biasanya membagi tulang melintang atau mungkinmembengkok di atas titik tumpu sehingga menciptakan sebuah patahandengan3butter4y 5fragmen. 1erusakan pada kulit adalah umum, 2ika penghancuranter2adi, pola fraktur akan men2adi ringsek dengan kerusakan 2aringan lunak yang luas.-engan sebuah gaya tidak langsung, tulang pecah pada suatu 2arak di mana gayadiaplikasikan, kerusakan 2aringan lunak pada tempat fraktur tidak dapat dihindari.Walaupun kebanyakan fraktur disebabkan oleh suatu kombinasi gaya pelintiran,pembengkokan, kompresi atau tekanan), pola 60ray menu2ukkan mekanisme yangdominan'7 %elintiran menghasilkan suatu fraktur spiral;7 kompresi menghasilkan suatu fraktur obli8 yang pendek.7pembengkokan menghasilkan fraktur dengan suatu fragmen segitiga 3butter4y5;7 !ekanan cenderung untuk memecahkan tulang secara trans9ersal; dalam beberapa

situasi, tekanan dengan sederhana dapat merenggut menga9ulsi) suatu fragmen keciltulang pada titik insersi ligamen atau tendo.CATATAN: -eskripsi di atas diaplikasikan terutama pada tulang pan2ang. $uatu tulangkanselosa, seperti sebuah 9ertebra atau calcaneus, saat mengalammi se2umlah gayayang cukup, akan terbelah atau men2adi remuk ke bentuk tidak normal.

fraktur stress atau kelelahanFA!:"# OR $!R#$$ FRA!"R#$Fraktur ini ter2adi pada tulang normal yang mengalami beban berat berulang, biasanyapada atlet, penari, atau personil militer yang memiliki program latihan yang melelahkan.eban tinggi ini membuat deformasi beberapa yang memunculkan proses remodellingnormal0 suatu kombinasi resorpsi tulang dan pembentukan tulang baru menurut dengan

hukum WolO:A> FRA!"R#$Fraktur Fractures may occur e9en =ith normal stresses if the bone has been =eakened bya change in its structure e.g. in osteoporosis, osteogenesis imperfecta or %aget5sdisease) or through a lytic lesion e.g. a bone cyst or a metastasis).

!/%#$ OF FRA!"R#

Fractures are 9ariable in appearance but for practical reasons they are di9ided into a fe==ell0defined groups.


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mo9ing inde@nitely; the bone ends must, at some stage, be brought to rest relati9e toone another. ut it is not mandatory for the surgeon to impose this immobility arti@ciallyI nature can do it =ith callus, and callus forms in response to mo9ement, not tosplintage. ?ost fractures are splinted, not to ensure union but to' () alle9iate pain; *)ensure that union takes place in good position and +) permit early mo9ement of the limband a return of function. !he process of fracture repair 9aries according to the type of

bone in9ol9ed and the amount of mo9ement at the fracture site.H#A>&: / A>>"$ !his is the 3natural5 form of healing in tubular bones; in the absence of rigid @6ation, itproceeds in @9e stages'(. Tissue destruction and haematoma formation I Lessels are torn and a haematomaforms around and =ithin the fracture. one at the fracture surfaces, depri9ed of a bloodsupply, dies back for a millimetre or t=o.*. Inammation and cellular proliferation I Within M hours of the fracture there is anacute in4ammatory reaction =ith migration of in4ammatory cells and the initiation of proliferation and di


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fracture is solid enough to allo= penetration andbridging of the area by bone remodelling units, i.e.osteoclastic 3cutting cones5 follo=ed by osteoblasts.Where the e6posed fracture surfaces are in intimatecontact and held rigidly from the outset, internalbridging may occasionally occur =ithout any intermediate

stages contact healing).Healing by callus, though less direct the term3indirect5 could be used) has distinct ad9antages' itensures mechanical strength =hile the bone ends heal,and =ith increasing stress the callus gro=s strongerand stronger an e6ample of Wol


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splintage.7 #on$union I $ometimes the normal process of fracturerepair is th=arted and the bone fails to unite.auses of non0union are' () distraction and separationof the fragments, sometimes the result of interposition of soft tissues bet=een the fragments;

*) e6cessi9e mo9ement at the fracture line; +) ase9ere in2ury that renders the local tissues non9iableor nearly so; ) a poor local blood supplyand C) infection. Of course surgical inter9ention, if ill02udged, is another cause&on0unions are septic or aseptic. n the latter group,they can be either sti< or mobile as 2udged by clinicale6amination. !he mobile ones can be as free and painlessas to gi9e the impression of a false 2oint pseudoarthrosis). On 60ray, non0unions are typi@ed bya lucent line still present bet=een the bone fragments;sometimes there is e6uberant callus trying I but failingI to bridge the gap h%pertrophic non$union) or at

times none at all atrophic non$union) =ith a sorry,=ithered appearance to the fracture ends.

>&A> F#A!"R#$

H$!OR/ !here is usually a history of in2ury, follo=ed by inabilityto use the in2ured limb I but be=are !he fractureis not al=ays at the site of the in2ury' a blo= to theknee may fracture the patella, femoral condyles, shaftof the femur or e9en acetabulum. !he patient5s ageand mechanism of in2ury are important. f a fractureoccurs =ith tri9ial trauma, suspect a pathologicallesion. %ain, bruising and s=elling are common symptoms

but they do not distinguish a fracture from asoft0tissue in2ury. &eformit% is much more suggesti9e.Al=ays en8uire about symptoms of associatedin2uries' pain and s=elling else=here it is a commonmistake to get distracted by the main in2ury, particularlyif it is se9ere), numbness or loss of mo9ement,skin pallor or cyanosis, blood in the urine, abdominalpain, diculty =ith breathing or transient loss of consciousness.Once the acute emergency has been dealt =ith, askabout pre9ious in2uries, or any other musculoskeletalabnormality that might cause confusion =hen the60ray is seen. Finally, a general medical history is im 0portant, in preparation for anaesthesia or operation.

:#RA> $:&$"nless it is ob9ious from the history that the patient hassustained a localiKed and fairly modest in2ury, prioritymust be gi9en to dealing =ith the general e


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or abnormal mo9ement is unnecessarily painful; 60raydiagnosis is more reliable. &e9ertheless the familiar headingsof clinical e6amination should al=ays be considered,or damage to arteries, ner9es and ligaments may beo9erlooked. A systematic approach is al=ays helpful'7 #6amine the most ob9iously in2ured part.

7 !est for artery and ner9e damage.7 >ook for associated in2uries in the region.7 >ook for associated in2uries in distant parts.

>ook$=elling, bruising and deformity may be ob9ious, butthe important point is =hether the skin is intact; if theskin is broken and the =ound communicates =ith thefracture, the in2ury is 3open5 3compound5). &ote alsothe posture of the distal e6tremity and the colour of the skin for tell0tale signs of ner9e or 9essel damage).

Feel !he in2ured part is gently palpated for localiKed tenderness.

$ome fractures =ould be missed if not speci@callylooked for, e.g. the classical sign indeed the onlyclinical sign) of a fractured scaphoid is tenderness onpressure precisely in the anatomical snu


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of the distal end of the cla9icle, scaphoid, femoralneck and lateral malleolus, and also stress fracturesand physeal in2uries =here9er they occur.

$%#A> ?A:&:$ometimes the fracture I or the full e6tent of the fractureI is not apparent on the plain 60ray. omputedtomography may be helpful in lesions of the spine orfor comple6 2oint fractures; indeed, these crosssectionalimages are essential for accurate 9isualiKationof fractures in 3dicult5 sites such as the calcaneum oracetabulum. ?agnetic resonance imaging may be theonly =ay of sho=ing =hether a fractured 9ertebra isthreatening to compress the spinal cord. Radioisotopescanning is helpful in diagnosing a suspected stressfracture or other undisplaced fractures.

-#$R%!O&-iagnosing a fracture is not enough; the surgeonshould picture it and describe it) =ith its properties'

() s it open or closedP *) Which bone is broken,and =hereP +) Has it in9ol9ed a 2oint surfaceP )What is the shape of the breakP C) s it stable orunstableP B) s it a high0energy or a lo=0energyin2uryP And last but not least ) =ho isthe person=ith the in2uryP n short, the e6aminer must learn torecogniKe =hat has been aptly described as the 3personality5of the fracture.

$hape of the fractureA transverse fracture is slo= to 2oin because the areaof contact is small; if the broken surfaces are accuratelyapposed, ho=e9er, the fracture is stable on compression.

A spiral fracture 2oins more rapidly becausethe contact area is large) but is not stable on compression.!omminuted fractures are often slo= to 2oinbecause' () they are associated =ith more se9ere softtissuedamage and *) they are likely to be unstable.

-isplacementFor e9ery fracture, three components must beassessed'(. hift or translation I back=ards, for=ards,side=ays, or longitudinally =ith impaction oro9erlap.*. Tilt or angulation I side=ays, back=ards orfor=ards.

+. Twist or rotation I in any direction.A problem often arises in the description of angulation.3Anterior angulation5 could mean that the ape6of the angle points anteriorly or that the distal fragmentis tilted anteriorly' in this te6t it is al=ays the lattermeaning that is intended 3anterior tilt of the distalfragment5 is probably clearer).

$#O&-AR/ &J"R#$ertain fractures are apt to cause secondary in2uriesand these should al=ays be assumed to ha9e occurreduntil pro9ed other=ise'

7 Thoracic in'uries I Fractured ribs or sternum maybe associated =ith in2ury to the lungs or heart. t isessential to check cardiorespiratory function.


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7 pinal cord in'ur% I With any fracture of the spine,neurological e6amination is essential to' () establish=hether the spinal cord or ner9e roots ha9ebeen damaged and *) obtain a baseline for latercomparison if neurological signs should change.7 elvic and abdominal in'uries I Fractures of the pel9is

may be associated =ith 9isceral in2ury. t is especiallyimportant to en8uire about urinary function; if aurethral or bladder in2ury is suspected, diagnosticurethrograms or cystograms may be necessary.7 ectoral girdle in'uries I Fractures and dislocationsaround the pectoral girdle may damage the brachialple6us or the large 9essels at the base of the neck.&eurological and 9ascular e6amination is essential.

TREATMENT OF CLOSED

FRACTURES:eneral treatment is the @rst consideration' treat the patient, not onl% the fracture. !he principles are discussed

in hapter **. !reatment of the fracture consists of manipulationto impro9e the position of the fragments, follo=ed bysplintage to hold them together until they unite;mean=hile 2oint movement and function must be preser9ed.Fracture healing is promoted by physiologicalloading of the bone, so muscle acti9ity and earlyweightbearing are encouraged. !hese ob2ecti9es areco9ered by three simple in2unctions'7 Reduce.7 Hold.7 #6ercise. !=o e6istential problems ha9e to be o9ercome. !he@rst is ho= to hold a fracture ade8uately and yet permitthe patient to use the limb suciently; this is acon4ict *old 9ersus +ove) that the surgeon seeks toresol9e as rapidly as possible e.g. by internal @6ation).Ho=e9er the surgeon also =ants to a9oid unnecessaryrisks I here is a second con4ict peed 9ersus afet% ). !his dual con4ict epitomiKes the four factors thatdominate fracture management the term 3fracture8uartet5 seems appropriate). !he fact that the fracture is closed and not open)is no cause for complacency. !he most importantfactor in determining the natural tendency to heal is

the state of the surrounding soft tissues and the localblood supply. >o=0energy or lo=09elocity) fracturescause only moderate soft0tissue damage; high0energy9elocity) fractures cause se9ere soft0tissue damage,no matter =hether the fracture is open or closed. !scherne Oestern and !scherne, (DM) hasde9ised a helpful classi@cation of closed in2uries'7 rade - I a simple fracture =ith little or no softtissuein2ury.7 rade . I a fracture =ith super@cial abrasion orbruising of the skin and subcutaneous tissue.7 rade / I a more se9ere fracture =ith deep softtissuecontusion and s=elling.

7 rade 0 I a se9ere in2ury =ith marked soft0tissuedamage and a threatened compartment syndrome.


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!he more se9ere grades of in2ury are more likely tore8uire some form of mechanical @6ation; good skeletalstability aids soft0tissue reco9ery.

R#-"!O&Although general treatment and resuscitation mustal=ays take precedence, there should not be undue

delay in attending to the fracture; s=elling of the softparts during the @rst (* hours makes reductionincreasingly dicult. Ho=e9er, there are some situationsin =hich reduction is unnecessary' () =henthere is little or no displacement; *) =hen displacementdoes not matter initially e.g. in fractures of thecla9icle) and +) =hen reduction is unlikely to succeede.g. =ith compression fractures of the 9ertebrae).Reduction should aim for adequate apposition andnormal alignment of the bone fragments. !he greaterthe contact surface area bet=een fragments the morelikely healing is to occur. A gap bet=een the fragmentends is a common cause of delayed union or nonunion.On the other hand, so long as there is contactand the fragments are properly aligned, some o9erlapat the fracture surfaces is permissible. !he e6ception isa fracture in9ol9ing an articular surface; this should bereduced as near to perfection as possible because anyirregularity =ill cause abnormal load distributionbet=een the surfaces and predispose to degenerati9echanges in the articular cartilage. !here are t=o methods of reduction' closed andopen.

>O$#- R#-"!O&"nder appropriate anaesthesia and muscle rela6ation,

the fracture is reduced by a three0fold manoeu9re' ()the distal part of the limb is pulled in the line of thebone; *) as the fragments disengage, they are repositionedby re9ersing the original direction of force if this can be deduced) and +) alignment is ad2usted ineach plane. !his is most e


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=hen the aim is some form of internal or e6ternal @6ation. !raction, =hich reduces fracture fragmentsthrough ligamentota1is ligament pull), can usually beapplied by using a fracture table or bone distractor.

O%#& R#-"!O&Operati9e reduction of the fracture under direct 9isionis indicated' () =hen closed reduction fails, eitherbecause of diculty in controlling the fragments orbecause soft tissues are interposed bet=een them; *)=hen there is a large articular fragment that needsaccurate positioning or +) for traction a9ulsion) fracturesin =hich the fragments are held apart. As a rule,ho=e9er, open reduction is merely the @rst step tointernal @6ation.

HO>- R#-"!O& !he =ord 3immobiliKation5 has been deliberatelya9oided because the ob2ecti9e is seldom completeimmobility; usually it is the pre9ention of displacement.

&e9ertheless, some restriction of mo9ement isneeded to promote soft0tissue healing and to allo=free mo9ement of the una


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!raction is safe enough, pro9ided it is not e6cessi9eand care is taken =hen inserting the traction pin. !heproblem is speed' not because the fracture unitesslo=ly it does not) but because lo=er limb tractionkeeps the patient in hospital. onse8uently, as soon asthe fracture is 3sticky5 deformable but not displaceable),

traction should be replaced by bracing, if thismethod is feasible. !raction includes'7 Traction b% gravit% I !his applies only to upperlimb in2uries. !hus, =ith a =rist sling the =eight of the arm pro9ides continuous traction to thehumerus. For comfort and stability, especially =itha trans9erse fracture, a "0slab of plaster may bebandaged on or, better, a remo9able plastic slee9efrom the a6illa to 2ust abo9e the elbo= is held on=ith Lelcro.7 kin traction I $kin traction =ill sustain a pull of nomore than or C kg. Holland strapping or one=ay0stretch #lastoplast is stuck to the sha9ed skin

and held on =ith a bandage. !he malleoli are protectedby :amgee tissue, and cords or tapes areused for traction.7 keletal traction I A sti< =ire or pin is inserted Iusually behind the tibial tubercle for hip, thigh andknee in2uries, or through the calcaneum for tibialfractures I and cords tied to them for applying traction.Whether by skin or skeletal traction, the fractureis reduced and held in one of three =ays' @6edtraction, balanced traction or a combination of thet=o.

Fi6ed traction

!he pull is e6erted against a @6ed point. !he usualmethod is to tie the traction cords to the distal end of a !homas5 splint and pull the leg do=n until the pro6imal,padded ring of the splint abuts @rmly against thepel9is.

alanced tractionHere the traction cords are guided o9er pulleys at thefoot of the bed and loaded =ith =eights; counter0tractionis pro9ided by the =eight of the body =hen thefoot of the bed is raised.

ombined tractionf a !homas5 splint is used, the tapes are tied to theend of the splint and the entire splint is then suspended,

as in balanced traction.

omplications of traction!irculator% embarrassment n children especially,traction tapes and circular bandages may constrict thecirculation; for this reason 3gallo=s traction5, in =hichthe baby5s legs are suspended from an o9erhead beam,should ne9er be used for children o9er (* kg in =eight.#erve in'ur% n older people, leg traction maypredispose to peroneal ner9e in2ury and cause a dropfoot;the limb should be checked repeatedly to see thatit does not roll into e6ternal rotation during traction.

in site infection %in sites must be kept clean andshould be checked daily.


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A$! $%>&!A:#%laster of %aris is still =idely used as a splint, especiallyfor distal limb fractures and for most children5s fractures.t is safe enough, so long as the practitioner isalert to the danger of a tight cast and pro9ided pressuresores are pre9ented. !he speed of union is neithergreater nor less than =ith traction, but the patient cango home sooner. Holding reduction is usually noproblem and patients =ith tibial fractures can bear=eight on the cast. Ho=e9er, 2oints encased in plastercannot mo9e and are liable to sti


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the signs of 9ascular compression appear. !he limbshould be ele9ated, but if the pain persists, the only safecourse is to split the cast and ease it open' ()throughout its length and *) through all the paddingdo=n to skin. Whene9er s=elling is anticipated the castshould be applied o9er thick padding and the plastershould be split before it sets, so as

to pro9ide a @rmbut not absolutely rigid splint.ressure sores #9en a =ell0@tting cast may press uponthe skin o9er a bony prominence the patella, heel,elbo= or head of the ulna). !he patient complains of localiKed pain precisely o9er the pressure spot. $uchlocaliKed pain demands immediate inspection througha =indo= in the cast.kin abrasion or laceration !his is really a complicationof remo9ing plasters, especially if an electric sa= isused. omplaints of nipping or pinching during plasterremo9al should ne9er be ignored; a ripped forearmis a good reason for litigation.

Loose cast Once the s=elling has subsided, the castmay no longer hold the fracture securely. f it is loose,the cast should be replaced.

F"&!O&A> RA&:Functional bracing, using either plaster of %aris or oneof the lighter thermoplastic materials, is one =ay of pre9enting 2oint stiatta $armientoand >atta (DDD, *EEB).


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&!#R&A> FA!O&one fragments may be @6ed =ith scre=s, a metalplate held by scre=s, a long intramedullary rod or nail=ith or =ithout locking scre=s), circumferentialbands or a combination of these methods.%roperly applied, internal @6ation holds a fracturesecurely so that mo9ement can begin at once; =ithearly mo9ement the 3fracture disease5 sti


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children or for distal radius fractures), and some formof e6ternal splintage usually a cast) is applied assupplementary support.erclage and tension0band =ires are essentiallyloops of =ire passed around t=o bone fragments andthen tightened to compress the fragments together.

When using cerclage =ires, make sure that the =ireshug the bone and do not embrace any of the closelyingner9es or 9essels.oth techni8ues are used for patellar fractures' thetension0band =ire is placed such that the ma6imumcompressi9e force is o9er the tensile surface, =hich isusually the con9e6 side of the bone.lates and screws !his form of @6ation is useful fortreating metaphyseal fractures of long bones anddiaphyseal fractures of the radius and ulna. %lates ha9e@9e di


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conditions'Infection atrogenic infection is no= the most commoncause of chronic osteomyelitis; the metal doesnot predispose to infection but the operation and8uality of the patient5s tissues do.#on$union f the bones ha9e been @6ed rigidly =ith a

gap bet=een the ends, the fracture may fail to unite. !his is more likely in the leg or the forearm if onebone is fractured and the other remains intact. Othercauses of non0union are stripping of the soft tissuesand damage to the blood supply in the course of [email protected] failure ?etal is sub2ect to fatigue and can failunless some union of the fracture has occurred. $tressmust therefore be a9oided and a patient =ith a brokentibia internally @6ed should =alk =ith crutches and staya=ay from partial =eightbearing for B =eeks or longer,until callus or other radiological sign of fracture healingis seen on 60ray. %ain at the fracture site is a danger signal

and must be in9estigated.Refracture t is important not to remo9e metalimplants too soon, or the bone may refracture. A yearis the minimum and (M or * months safer; for se9eral=eeks after remo9al the bone is =eak, and care or protectionis needed.

#!#R&A> FA!O&A fracture may be held by trans@6ing scre=s or tensioned=ires that pass through the bone abo9e and belo= thefracture and are attached to an e6ternal frame. !his isespecially applicable to the tibia and pel9is, but themethod is also used for fractures of the femur, humerus,

lo=er radius and e9en bones of the hand.ndications#6ternal @6ation is particularly useful for'(. Fractures associated =ith se9ere soft0tissue damageincluding open fractures) or those that arecontaminated, =here internal @6ation is risky andrepeated access is needed for =ound inspection,dressing or plastic surgery.*. Fractures around 2oints that are potentially suitablefor internal @6ation but the soft tissues are toos=ollen to allo= safe surgery; here, a spanninge6ternal @6ator pro9ides stability until soft0tissueconditions impro9e.+. %atients =ith se9ere multiple in2uries, especially if there are bilateral femoral fractures, pel9icfractures =ith se9ere bleeding, and those =ith limband associated chest or head in2uries.

. "nunited fractures, =hich can be e6cised andcompressed; sometimes this is combined =ithbone lengthening to replace the e6cised segment.C. nfected fractures, for =hich internal @6ationmight not be suitable.

!echni8ue !he principle of e6ternal @6ation is simple' the bone is

trans@6ed abo9e and belo= the fracture =ith scre=s ortensioned =ires and these are then connected to eachother by rigid bars. !here are numerous types of


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e6ternal @6ation de9ices; they 9ary in the techni8ue of application and each type can be constructed to pro9ide9arying degrees of rigidity and stability. ?ost of them permit ad2ustment of length and alignment afterapplication on the limb. !he fractured bone can be thought of as broken into

segments I a simple fracture has t=o segments =hereasa t=o0le9el segmental) fracture has three and so on. #achsegment should be held securely, ideally =ith the half0pinsor tensioned =ires straddling the length of that segment. !he =ires and half0pins must be inserted =ith care.1no=ledge of 3safe corridors5 is essential so as to a9oidin2uring ner9es or 9essels; in addition, the entry sitesshould be irrigated to pre9ent burning of the bone atemperature of only CEo can cause bone death). !he fracture is then reduced by connecting the 9ariousgroups of pins and =ires by rods.-epending on the stability of @6ation and theunderlying fracture pattern, =eightbearing is started

as early as possible to 3stimulate5 fracture healing.$ome @6ators incorporate a telescopic unit that allo=s3dynamiKation5; this =ill con9ert the forces of =eightbearinginto a6ial micromo9ement at the fracture site,thus promoting callus formation and acceleratingbone union 1en=right et al., (DD().

omplications&amage to soft$tissue structures !rans@6ing pins or=ires may in2ure ner9es or 9essels, or may tetherligaments and inhibit 2oint mo9ement. !he surgeonmust be thoroughly familiar =ith the cross0sectionalanatomy before operating.

7verdistraction f there is no contact bet=een thefragments, union is unlikely.in$track infection !his is less likely =ith goodoperati9e techni8ue. &e9ertheless, meticulous pin0sitecare is essential, and antibiotics should be administeredimmediately if infection occurs.

##R$#?ore correctly, restore function I not only to thein2ured parts but also to the patient as a =hole. !heob2ecti9es are to reduce oedema, preser9e 2oint mo9ement,restore muscle po=er and guide the patientback to normal acti9ity' revention of oedema $=elling is almost ine9itable aftera fracture and may cause skin stretching and blisters.

%ersistent oedema is an important cause of 2ointsti


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8levation An in2ured limb usually needs to be ele9ated;after reduction of a leg fracture the foot of the bed israised and e6ercises are begun. f the leg is in plasterthe limb must, at @rst, be dependent for only shortperiods; bet=een these periods, the leg is ele9ated ona chair. !he patient is allo=ed, and encouraged, to

e6ercise the limb acti9ely, but not to let it dangle.When the plaster is @nally remo9ed, a similar routine of acti9ity punctuated by ele9ation is practised untilcirculatory control is fully restored.n2uries of the upper limb also need ele9ation. Asling must not be a permanent passi9e arm0holder; thelimb must be ele9ated intermittently or, if need be,continuously.

Active e1ercise Acti9e mo9ement helps to pump a=ayoedema 4uid, stimulates the circulation, pre9ents softtissueadhesion and promotes fracture healing. A limbencased in plaster is still capable of static muscle

contraction and the patient should be taught ho= todo this. When splintage is remo9ed the 2oints aremobiliKed and muscle0building e6ercises are steadilyincreased. Remember that the una


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=ound is @rst carefully inspected; any gross contaminationis remo9ed, the =ound is photographed =ith a%olaroid or digital camera to record the in2ury and thearea then co9ered =ith a saline0soaked dressing underan imper9ious seal to pre9ent desiccation. !his is leftundisturbed until the patient is in the operating theatre.

!he patient is gi9en antibiotics, usually co0amo6icla9or cefuro6ime, but clindamycin if the patient isallergic to penicillin. !etanus prophyla6is is administered'to6oid for those pre9iously immuniKed, humanantiserum if not. !he limb is then splinted until surgeryis undertaken. !he limb circulation and distal neurological status=ill need checking repeatedly, particularly after anyfracture reduction manoeu9res. ompartment syndromeis not pre9ented by there being an open fracture;9igilance for this complication is =ise.

>A$$F/&: !H# &J"R/

!reatment is determined by the type of fracture, thenature of the soft0tissue in2ury including the =oundsiKe) and the degree of contamination. :ustilo5s classi@cationof open fractures is =idely used :ustilo etal., (DM)'T%pe . I !he =ound is usually a small, clean puncturethrough =hich a bone spike has protruded. !here islittle soft0tissue damage =ith no crushing and thefracture is not comminuted i.e. a lo=0energyfracture).T%pe II I !he =ound is more than ( cm long, butthere is no skin 4ap. !here is not much soft0tissuedamage and no more than moderate crushing or

comminution of the fracture also a lo=0 tomoderate0energy fracture).T%pe III I !here is a large laceration, e6tensi9edamage to skin and underlying soft tissue and, in themost se9ere e6amples, 9ascular compromise. !hein2ury is caused by high0energy transfer to the boneand soft tissues. ontamination can be signi@cant. !here are three grades of se9erity. n t%pe III A thefractured bone can be ade8uately co9ered by soft tissuedespite the laceration. n t%pe III 6 there is e6tensi9eperiosteal stripping and fracture co9er is notpossible =ithout use of local or distant 4aps. !he fractureis classi@ed as t%pe III ! if there is an arterial

in2ury that needs to be repaired, regardless of theamount of other soft0tissue damage. !he incidence of =ound infection correlatesdirectly =ith the e6tent of soft0tissue damage, risingfrom less than * per cent in type to more than (E percent in type fractures.

%R&%>#$ OF !R#A!?#&!All open fractures, no matter ho= tri9ial they mayseem, must be assumed to be contaminated; it isimportant to try to pre9ent them from becominginfected. !he four essentials are'

7 Antibiotic prophyla6is.7 "rgent =ound and fracture debridement.7 $tabiliKation of the fracture.


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7 #arly de@niti9e =ound co9er.

$terility and antibiotic co9er !he =ound should be kept co9ered until the patientreaches the operating theatre. n most cases co0amo6icla9or cefuro6ime or clindamycin if penicillin allergyis an issue) is gi9en as soon as possible, often in the

Accident and #mergency department. At the time of debridement, gentamicin is added to a second dose of the @rst antibiotic. oth antibiotics pro9ide prophyla6isagainst the ma2ority of :ram0positi9e and :ramnegati9ebacteria that may ha9e entered the =ound atthe time of in2ury. Only co0amo6icla9 or cefuro6imeor clindamycin) is continued thereafter; as =ounds of :ustilo grade fractures can be closed at the time of debridement, antibiotic prophyla6is need not be formore than * hours. With :ustilo grade and Afractures, some surgeons prefer to delay closure aftera 3second look5 procedure. -elayed co9er is also usuallypractised in most cases of :rade and in2uries. As the =ounds ha9e no= been present in ahospital en9ironment for some time, and there aredata to indicate infections after such open fracturesare caused mostly by hospital0ac8uired bacteria andnot seeded at the time of in2ury, gentamicin and 9ancomycinor teicoplanin) are gi9en at the time of de@niti9e =ound co9er. !hese antibiotics are e


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only enough to lea9e healthy skin edges.3ound e1tension !horough cleansing necessitatesade8uate e6posure; poking around in a small =oundto remo9e debris can be dangerous. f e6tensions areneeded they should not 2eopardiKe the creation of skin4aps for =ound co9er if this should be needed. !he

safest e6tensions are to follo= the line of fasciotomyincisions; these a9oid damaging important perforator9essels that can be used to raise skin 4aps for e9entualfracture co9er.&eliver% of the fracture #6amination of the fracture surfacescannot be ade8uately performed =ithout e6tractingthe bone from =ithin the =ound. !he simplest andgentlest) method is to bend the limb in the manner in=hich it =as forced at the moment of in2ury; the fracturesurfaces =ill be e6posed through the =ound =ithoutany additional damage to the soft tissues. >argebone le9ers and retractors should not be used.Removal of devitali5ed tissue -e9italiKed tissue pro9ides

a nutrient medium for bacteria. -ead muscle can berecogniKed by its purplish colour, its mushyconsistency, its failure to contract =hen stimulated andits failure to bleed =hen cut. All doubtfully 9iabletissue, =hether soft or bony, should be remo9ed. !hefracture ends can be nibbled a=ay until seen to bleed.3ound cleansing All foreign material and tissue debrisis remo9ed by e6cision or through a =ash =ith copious8uantities of saline. A common mistake is to in2ectsyringefuls of 4uid through a small aperture I this onlyser9es to push contaminants further in; BI(* > of saline may be needed to irrigate and clean an openfracture of a long bone. Adding antibiotics orantiseptics to the solution has no added bene@t.#erves and tendons As a general rule it is best to lea9ecut ner9es and tendons alone, though if the =ound isabsolutely clean and no dissection is re8uired I and pro9idedthe necessary e6pertise is a9ailable I they can besutured.

Wound closureA small, uncontaminated =ound in a :rade or fracture may after debridement) be sutured, pro9idedthis can be done =ithout tension. n the more se9eregrades of in2ury, immediate fracture stabiliKation and=ound co9er using split0skin grafts, local or distant

4aps is ideal, pro9ided both orthopaedic and plasticsurgeons are satis@ed that a clean, 9iable =ound hasbeen achie9ed after debridement. n the absence of this combined approach at the time of debridement,the fracture is stabiliKed and the =ound left open anddressed =ith an imper9ious dressing. Adding gentamicinbeads under the dressing has been sho=n to help,as has the use of 9acuum dressings. Return to surgeryfor a 3second look5 should ha9e de@niti9e fractureco9er as an ob2ecti9e. t should be done by MI* hours, and not later than C days. Open fractures donot fare =ell if left e6posed for long and multiple

debridement can be self0defeating.$tabiliKing the fracture


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$tabiliKing the fracture is important in reducing thelikelihood of infection and assisting reco9ery of the soft tissues. !he method of @6ation dependson the degree of contamination, length of time fromin2ury to operation and amount of soft0tissue damage.f there is no ob9ious contamination and de@niti9e

=ound co9er can be achie9ed at the time of debridement,open fractures of all grades can be treated as fora closed in2ury; internal or e6ternal @6ation may beappropriate depending on the indi9idual characteristicsof the fracture and =ound. !his ideal scenario of 2udicious soft0tissue and bone debridement, =oundcleansing, immediate stabiliKation and co9er is onlypossible if orthopaedic and plastic surgeons are presentat the time of initial surgery.f =ound co9er is delayed, then e6ternal @6ation issafer; ho=e9er, the surgeon must take care to insertthe @6ator pins a=ay from potential 4aps needed bythe plastic surgeon

!he e6ternal @6ator may be e6changed for internal@6ation at the time of de@niti9e =oundco9er as longas () the delay to =ound co9er is less than days; *)=ound contamination is not 9isible and +) internal@6ation can control the fracture as =ell as the e6ternal@6ator. !his approach is less risky than introducinginternal @6ation at the time of initial surgery and lea9ingboth metal=ork and bone e6posed until de@niti9eco9er se9eral days later.

Aftercaren the =ard, the limb is ele9ated and its circulationcarefully =atched. Antibiotic co9er is continued but

only for a ma6imum of * hours in the more se9eregrades of in2ury. Wound cultures are seldom helpful asosteomyelitis, if it =ere to ensue, is often caused byhospital0deri9ed organisms; this emphasiKes the needfor good debridement and early fracture co9er.

$#S"#>$ !O O%#& FRA!"R#$$kinf split0thickness skin grafts are used inappropriately,particularly =here 4ap co9er is more suited, there canbe areas of contracture or friable skin that breaksdo=n intermittently. Reparati9e or reconstructi9e surgeryby a plastic surgeon is desirable.

onenfection in9ol9es the bone and any implants that mayha9e been used. #arly infection may present as =oundin4ammation =ithout discharge. dentifying thecausal organism =ithout tissue samples is dicult but,at best guess, it is likely to be 2 aureus includingmethicillin0resistant 9arieties) or seudomonas. $uppressionby appropriate antibiotics, as long as the @6ationremains stable, may allo= the fracture toproceed to union, but further surgery is likely later,=hen the antibiotics are stopped.>ate presentation may be =ith a sinus and 60ray e9idenceof se8uestra. !he implants and all a9ascular

pieces of bone should be remo9ed; robust soft tissueco9er ideally a 4ap) is needed. An e6ternal @6ator canbe used to bridge the fracture. f the resulting defect is


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too large for bone grafting at a later stage, the patientshould be referred to a centre =ith the necessarye6perience and facilities for limb reconstruction.

JointsWhen an infected fracture communicates =ith a 2oint,the principles of treatment are the same as =ith bone

infection, namely debridement and drainage, drugs andsplintage. On resolution of the infection, attentioncan be gi9en to stabiliKing the fracture so that 2ointmo9ement can recommence. %ermanent stiocal complications can be di9ided into earl% thosethat arise during the @rst fe= =eeks follo=ing in2ury)and late2

#AR>/ O?%>A!O&$#arly complications may present as part of the primaryin2ury or may appear only after a fe= days or =eeks.

L$#RA> &J"R/Fractures around the trunk are often complicated byin2uries to underlying 9iscera, the most importantbeing penetration of the lung =ith life0threateningpneumothora6 follo=ing rib fractures and rupture of the bladder or urethra in pel9ic fractures. !hesein2uries re8uire emergency treatment.

LA$">AR &J"R/ !he fractures most often associated =ith damage to ama2or artery are those around the knee and elbo=,and those of the humeral and femoral shafts. !heartery may be cut, torn, compressed or contused,either by the initial in2ury or subse8uently by 2aggedbone fragments. #9en if its out=ard appearance isnormal, the intima may be detached and the 9esselblocked by thrombus, or a segment of artery may be

in spasm. !he e


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that the artery is being compressed or kinked,prompt reduction is necessary. !he circulation is then reassessedrepeatedly o9er the ne6t half hour. f there is noimpro9ement, the 9essels must be e6plored by operationI preferably =ith the bene@t of preoperati9e or peroperati9eangiography. A cut 9essel can be sutured, or a segment

may be replaced by a 9ein graft; if it is thrombosed,endarterectomy may restore the blood 4o=. f 9essel repairis undertaken, stable @6ation is a must and =here itis practicable, the fracture should be @6ed internally.

RL# &J"R/&er9e in2ury is particularly common =ith fractures of the humerus or in2uries around the elbo= or the kneesee also hapter ((). !he telltalesigns should belooked for and documented) during the initial e6aminationand again after reduction of the fracture.

losed ner9e in2uriesn closed in2uries the ner9e is seldom se9ered, and

spontaneous reco9ery should be a=aited I it occurs inDE per cent =ithin months. f reco9ery has notoccurred by the e6pected time, and if ner9e conductionstudies and #?: fail to sho= e9idence of reco9ery,the ner9e should be e6plored.

Open ner9e in2uriesWith open fractures the ner9e in2ury is more likely tobe complete. n these cases the ner9e should bee6plored at the time of debridement and repaired atthe time or at =ound closure.

Acute ner9e compression&er9e compression, as distinct from a direct in2ury,

sometimes occurs =ith fractures or dislocationsaround the =rist. omplaints of numbness or paraesthesiain the distribution of the median or ulnarner9es should be taken seriously and the patient monitoredclosely; if there is no impro9ement =ithin Mhours of fracture reduction or splitting of bandagesaround the splint, the ner9e should be e6plored anddecompressed.

O?%AR!?#&! $/&-RO?#Fractures of the arm or leg can gi9e rise to se9ereischaemia, e9en if there is no damage to a ma2or 9essel.leeding, oedema or in4ammation infection)may increase the pressure =ithin one of the osseofascial

compartments; there is reduced capillary 4o=,=hich results in muscle ischaemia, further oedema,still greater pressure and yet more profound ischaemiaI a 9icious circle that ends, after (* hours or less, innecrosis of ner9e and muscle =ithin the compartment.&er9e is capable of regeneration but muscle, onceinfarcted, can ne9er reco9er and is replaced by inelastic@brous tissue :olkmann;s ischaemic contracture).A similar cascade of e9ents may be caused by s=ellingof a limb inside a tight plaster cast.

linical featuresHigh0risk in2uries are fractures of the elbo=, forearm

bones, pro6imal third of the tibia, and also multiple fractures of the hand or foot, crushin2uries and circumferentialburns. Other precipitating factors are


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Fractures in9ol9ing a 2oint may cause acutehaemarthrosis. !he 2oint is s=ollen and tense and thepatient resists any attempt at mo9ing it. !he bloodshould be aspirated before dealing =ith the fracture.

&F#!O&Open fractures may become infected; closed fractureshardly e9er do unless they are opened by operation.%ost0traumatic =ound infection is no= the mostcommon cause of chronic osteitis. !he managementof early and late infection is summariKed under thesection equels to open fractures (page


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local infection) and surgical incisions through blisters,=hilst generally safe, should be undertaken only =henlimb s=elling has decreased.

%>A$!#R A&- %R#$$"R# $OR#$%laster sores occur =here skin presses directly ontobone. !hey should be pre9ented by padding the bonypoints and by moulding the =et plaster so thatpressure is distributed to the soft tissues around thebony points. While a plaster sore is de9eloping thepatient feels localiKed burning pain. A =indo= must

Phalanges and Interphalangeal Joints

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