Adams Outline of FracturesTWELFTH E D IT ON
INCLUDING JOINT INJURIES
Fractu res
isiiine of
DAVID L. HAMBLEN A. HAMISH R. W. SIMPSON
in g
In c lu d in g Jo i
O u tlin e o f F ra c tu re s
A d a m s '
s
/[lu s tra tio n M a n a g
e r G illia n M u r r a y
Illu s tra to r O x f o r d I ll u s tr a to r s
S e n io r D e s i g
n e r S a r a h R u s s e ll
P roje c t M a n a g e r : N a n c
y A r n o t t
D e u e lo p
m e n t E d i to r : H e le n L e n g
C o JJz)n is s io n in g E d ito r F io n a C o n n
F o r E ls e tTie r
P r in te d in C h in a fro m s u s ta in a b le lo re s
ts p a p e r m a n u la ctu ra u
'
w w w . s a b re . o r g
w w w e ls e v ie r h e a lt h . c o m
in t h e h e a lt h s c ie n c e s
E L S E V IE R jo u r n a ls o n d m u lt im e d ia
y o u r s o u r c e f o r b o o k s ,
T h e P u b lis h e r
re la te d to a n y u s e o f th e m a te r ia l c o n ta in e d in th is b o o k .
p u b lis h e r n o r th e a u th o r s a s s u m e a n y lia b ilit y fo r a n
y in ju r y a n d l o r d a m a
g e to p e r s o n s o r p r o
p e r t
o u t o r
in d iv id u a l p a tie n t, a n d t o t a k e a l l a
p p r o
p r i a t e s a f e l
y p r e c a u t i o n s . T o th e f u lle s t e x te n t o f th e la w n e ith e r th e
a n d k n o w le d g e o f th e p a tie n t, t o m a k e d i a
g n o s e s , t o d e t e r m i n e d o s a
g e s a n d t h e b e s t t r e a t m e n t f o r e a c h
a d m in is tr a tio n a n d c o n tra in d lc a tio n s . Tt is th e r e s p o n s ib ility n [ th e p r a c titio n e r, r e l
) i n g o n th e ir o w n e x p
e r ie n c e
e a c h p r o d u c t to b e a d m in is te re d , t o v c r i f y
t h e r e c o m m e n d e d d o s e o r f o r m u l a , t h e m e t h o d a n d d u r a t i o n o f
a d v js e d to c h e c k th e m o s t c u r re n t in fo r m a tio n p r o v id e d (I) o n p ro c e d u r e s fe a tu r e d o r ( ii) b y th e m a n u fa c tu r e r o f
k n o w le d g e , c h a n g
e s i n p
r a c t i c e , t r e a t m e n t a n d d r u g
t h e r a p y
m a y
b e c o m e n e c e s s a r y
o r a p p
r o p
r i a t e . R e a d e r s a re
K n o w le d g e a n d b e s E p r a c tic e in th is fie ld a r e c o n s ta n tly c h a n g in
g . A s n e w r e s e a r c h a n d e x
p e r ie n c e b r o a d e n o u r
N o te
A c a ta lo g re c o r d fo r th is b o o k is a v a ila b le f ro m th e L ib r a r y
o f C o n g
r e s s
L ib r a r y o f C o n g
r e s s C a t a l o g in
g i n P u b l i c a t io n D a t a
A c a ta lo g u e r e c o r d fo r th is b o o k is a v a ila b le fr o m th e B r itis h L ib r a r y
B r itis h L ib r a r y C a ta lo w in g in P u b lic a t io n D a t a
R e p r in te d 2 0 0 8 , 2 0 1 1 (tw ic e )
International e d itio n IS B N 9 7 8 0 4 4 3 1 0 2 9 8 1
R e p r in te d 2 0 0 8
IS B N 978044 31 029 74
S ix th e d itio n 1 9 7 2 T w e lf th e d itio n 2 0 0 7
F ifth e d itio n 1 9 6 8 E le v e n th e d itio n 1 9 9 9
F o u r th e d itio n 1 9 6 4 T e n th e d itio n 1 9 9 2
T h ir d e d itio n 1 9 6 0 N in th e d itio n 1 9 8 7
S e c o n d e d itio n 1 9 5 8 E ig h th e d itio n 1 9 8 3
F ir s t e d itio n 1 9 5 7 S e v e n th e d itio n 1 9 7 8
m tp / / w w w . e lsc v je r, c o m l. b y s e le c tin g s u p p
o r t a n d c o n ta c t ·
a n d t h e n c o p y
r i g
h t a n d p e r m i s s i o n .o 4 e -
m a il : h e n tth p e n n is s io n s © e ts a , ie r . c o l l i . Y o u m a y a ls o c o m p le te y
o u r r e q u e s t o n - lin e v ia th e E ls e v ie r h o m e
p a g eK e n n e d y
H o u le v a T d , S u i t e 1 8 0 0 , p h i l a d e l p
h i a , P A 1 9 1 0 3 - 2899 , U 5 A
P h o n e : (+ 1 ) 2
1 5 2 3 9 3 8 0 4 fa x : (+ 1 ) 2 1 5 2 3 9 3 8 0 5p u b lis h e r s . p e r m is s io n s m a y b e s o u g
'
s H e a l t h S c i e n c e s R i g
h t s D e p
a r t m e n t , 1 6 0 0 Jo h n F .m e a n s , e l e c t r o n i c , m e c h a n i c a l , p h o t o c o
p y i n
g , r e c o r d i n
g o r [ r t h e n v i s e , w i t h o u t t h e
p r i o r p e r m is s io n o f th eN o p
a r t o f th is p u b lic a tio n m a y
b e re p r o d u c e d , s t o r e d i n a r e t r i e v a l s
y s t e m , o r t r a n s m i t t e d i n a n
y f o r m o r b
y a n
y
T h e r i g h t o f D a v id L H a m b le n a n d A H a m is h R W S i m p
s o n to D e lu " ' " ' " _ _ " _ _ ' " " _ _ " " " _ _ ' " ' " °
W n
© 2 00 7 , E l s e v i e r L i m i t e d . A ll r i g h ts r e s e r
v
e d .
© C h u r c h ill L iv in g s to n e 1 9 9 8
© L o n g m a n G r o u p
U K L in r ite d 1 9 9 2
A n im p r in t o f E ls e v ie r L im ite d
E L SE V I E R U V lN G s T O N E C H U R C H IL L
s t im u la t io n o f b o n e h e a lin g h a v e b e e n in c l u d e d .
d e v e lo p m e n ts in c e ll b i o lo
g y a n d m o l e c u l a r
g e n e t ic s t h a t a l lo w lo c a l
m e n t is d if fic u l t t o p
r e d ic t, b u t s o m e o f th e n e w e r te c h n iq u e s r e s u ltin g
fr o m
fic a tio n s u s e d b y
t h e s p e c ia lis t s u r g
e o n . T h e fu tu r e d ir e c tio n o f fr a c t u r e t r e a t -
th e g
e n e r a l r e a d e r in p r e fe r e n c e to t h e m o r e c o m
p le x tr e a tm e n t - b a s e d c la s s i-
e n h a n c e d . W e fe e l th a t th is p r o v id e s a m o r e r e a d il
y u n d e r s t a n d a b le b a s is f o r
tr e n d s , b u t th e a n a to m ic a l c la s s if ic a tio n o f in ju r ie s h a s b e e n r e ta in e d a n d
M a n y
o f th e illu s tr a tio n s h a v e b e e n u p
d a t e d to r e f le c t c u r r e n t tr e a t m e n t
fr o m th e in c r e a s e d lo n g e v ity
in a g e in
g p o p u la tio n s .
n o w r e c o g n is e d a s a m a jo r h e a l th p
r o b le m w ith a w o r ld -
w id e im p a c t, r e s u ltin g
o s te o p o r o s is a n d i ts a s s o c ia t io n w it h f r a
g ili t
y f r a c t u r e s in th e e ld e r l
y .
,
T h is is a lte r n a t iv e . W e h a v e a d d e d o n e n e w c h a
p te r t o a d d r e s s th e im p o r ta n t t o
p ic o f
o r th o p a e d ic a n d s c ie n t if ic li te r a tu r e w e b s i te s p
r o v id e s a fa r m o r e s a ti s f a c to r y
Tin e e a s y
a v a ila b ility o f th is in f o r m a tio n o n th e I n te r n e t th r o u g
h lin k s to
s in c e th e s e a r e in e v ita b l y
b e c o m in g
o u t o f d a te b y
th e t im e o f p u b lic a tio n .
d e m a n d it . T h e d e ta ile d r e f e r e n c e s to o th e r lit e r a tu r e h a v e a ls o b e e n r e m o v e d
r e a d e r th e o p p o r t u n i ty t o s t u d
y s e le c te d to p ic s in
g r e a te r d e
p th if th e ir in te r e s t s
h a s b e e n c h a n g
e d to a s t a n d a r d f o n t f o r m a t . It is h o p e d th a t th is w ill a llo w th e
w a s p r e v io u s l y p r e s e n t e d in a s m a lle r s iz e o f p
r in t , b u t in th is e d it io n a ll te x t
n e e d s o f th e s tu d e n t o r b a s ic p r a c tit io n e r . S o m e o f t h is a d d it io n a l in f o m i a tio n
s p
e c ia lis t o r th o p a e d ic s u r g e o n , a lth o u g
h m u c h o f th e c o n te n t g
o e s b e y
o n d t h e
s u r g ic a l tr a in e e s . W e h a v e n o t a t te m
p te d to
p r o d u c e a v o lu m e a im e c i a t th e
s t u d e n t , is n o w u s e d b y
a b r o a d r a n g
e o f h e a lth p
r o f e s s io n a ls , in c lu d in g
b a s ic
r e a d e r s h i p
s in c e t h e b o o k , t h a t w a s o n c e a im e d p r im a r ily
a t th e m e d ic a l
T h e c h a n g
e s to th e c o n te n t a n d f o r m a t a ls o r e f le c t c h a n g e s in th e p o te n tia l
d e s c r ib e b o th r a d ic a l a n d c o n s e r v a t iv e s o lu t io n s , w h e r e a p p r o p r ia t e .
p a tie n t d e m a n d , a s b y im p r o v e d lo n
g - te r m o u t c o m e s , a n d w e c o n tin u e t o
m e th o d s . T h is c h a n g
e h a s b e e n d r iv e n a s m u c h b y
h e a lth e c o n o m ic s a n d
tr e a t m e n t o f s o m e c o m m o n f r a c t u r e s p ]'" v io u s l
y m a n a
g e d b
y c o n s e r v a tiv e
th e r e h a s b e e n a m a jo r s h ift to a m o r e a g g
r e s s iv e s u r g
ic a l a p p
r o a c h f o r th e
d r a m a t ic a lly o v e r th is tim e p
e r io d . E v e n in th e 8 y
e a r s s in c e t h e la s t e d i tio n
o f th e m a n a g e m e n t o f in ju r ie s o f th e m u s c u lo s k e ]e ta ] s y
s te m h a s c h a n g
e d
g u id a n c e 1« a s s till a v a ila b le t o u s in it s p r e p a r a tio n . T h e s c ie n c e a n d te c h n o lo
g y
C r a w f o r d A d a m s p u b lis h e d th e f ir s t e d itio n o f h is b o o k a n d t h a t h is w is e
a c c e p t w e r e th a t t h e n e w 1 2 th e d itio n w o u ld a p p e a r 5 0 y
e a r s a f te r Jo h n
O u tlin e o f F r a c tu r e s p r e s e n t e d a c o n s id e r a b le c h a lle n g
e . T h e a t t r a c tio n s to
T h e in v ita tio n to p r o d u c e a n e w e d i tio n o f s u c h a w e ll -
e s ta b lis h e d te x tb o o k a s
P re fa c e
A H a m i s h R W S i m p s o n
D a v i d L H a m b le n
r e s u lts .
tr a d itio n a l c o n s e r v a tiv e m e th o d s a n el s a fe s u r g
ic a l te c h n i q
u e s w ith p r o v e n
m a n a g e m e n t o f m u s c u lo s k e le ta l in ju r ie s ,
b a s e d o n a n a m a l g a m o f e s ta b lis h e d
It is h o p
e d th a t th e b o o k w ill c o n tin u e to p r o v id e a s o u n d b a s is fo r th e
Jo h n C r a w f o r d A d a m s
in to th e f a s c in a tin g s u b je c t o f o r th o p
a e d ic s u r g
e r y
.
n o w m a t u r e d o c to r s - fo r t h e ir in te r e s t in u s in g th e b o o k s to g
a in a n in s i g
h t
o f F r a c tu re s -
r ig h t u p to d a te . In d o in
g s o , I th a n k a ll t h o s e s tu d e n ts -
m a n y
H a m b le n w ith th e t a s k o f o n c e a g
a in b r in g
in g
th e b o o k s - s ta r tin g
w ith O u tlin e
P r o f e s s o r H a m is h S im p s o n , o f th e U n iv e r s it y
o f E d iLr b u r g
h , t o a s s is t P r o fe s s o r
s t ill e v e n t s m o v e o n , a n d th e t im e h a s c o m e f o r m e to b o w o u t a n d to w e lc o m e
a s s is t a n c e t o h e l p
t r a n s f o r m th e b o o k s f o r t h e n e e d s o f th e m o d e r n w o r ld . B u t
O r th o p a e d ic S u r g e r y
in t h e U n iv e r s it y
o f G la s g
o w , w a s w illin g
to c o m e to m y
a u t h o r a n d I w a s f o r t u n a te t h a t P r o f e s s o r D a v id H a m b le n , t h e n P r o fe s s o r o f
ta s k o f k e e p in
g th e t e x t s u p to d a te w a s p r o v in g d if fic u lt f o r m e , a n a g e in
g
a n d a b r o a d , a n d u p d a te d e d itio n s w e r e c a lle d f o r e v e r y
fe w y
e a r s . B y 1 9 9 0 th e
p r o v e d p o p u la r w it h m e d ic a l s t u d e n t s a n d p h y
s io th e r a p
is ts , b o th in th e U K
w a s f o llo w e d in 1 9 5 7 b y th e c o m
p a n io n v o lu m e , O u tlin e o f F r a c t u r e s . T h e b o o k s
T in e fi r s t o f th e t w o b o o k s , O u tlin e o f O r th o p a e d ic s , w a s p u b lis h e d in 1 9 5 6 , a n d
w it h a p
r e s t i g
io u s b o o k s h o p in T e v io t P la c e , u n d e r to o k to p u b lis h th e b o o k s .
fo r la w y
e r s . M r C h a r le s M a c m illa n o f E d in b u r g
h , a n e n t e r p r is in g p u b lis h e r
m i g
h t a ls o b e u s e f u l f o r g
e n e r a l p
r a c t it io n e r s a n d p
h y
is ts , a n d e v e n
th e b o o k s w o u ld b e p r im a r il y
f o r th e b e n e f it o f u n d e r g
r a d u a te s t u d e n ts , t h e y
e m p
h a s is o n th e p r o v is io n o f n u m e r o u s illu s t r a tio n s o f h i g
h q
h
T h e m a t e r ia l w a s to b e in t w o s lim v o lu m e s , a n d th e r e w o u ld b e a h e a v y
r e a d f o r m , t h e e le m e n ts o f o r th o p
a e d ic s u r g
e r y
a n d o f f r a c t u r e m a n a g e m e n t .
s tu d e n ts s h o w e d in te r e s t in w h a t I ta u g
h t , I r e s o lv e d t o s e t d o w n , in a n e a s il y
H o s p ita l in L o n d o n , I d e v e lo p e d a k e e n in te r e s t in te a c h in g
. F in d in g
th a t
F ifty y e a r s a g
o , a s a y o u n g
o r th o p a e d ic a n d t r a u m a s u r g
'
s
N
=J o h n C ra w fo rd A d a m s
w iv e s a n d fa m ilie s d u r in g th e tim e d e v o te d t o th e w r i tin g o f th e b o o k .
F in a ll y , w e r e c o r d o u r a p p r e c ia tio n o f th e s u p p o r t a n d f o r b e a r a n c e o f o u r
m u c h a p p r e c ia te d .
p la y e d a k e
y r o le in th e ty p in
g o f th e m a n u s c r ip t a n d th e ir e ff o r ts a r e v e r y
O u r r e s p e c t iv e s e c r e ta r ie s C a th e r in e D a v id s o n a n d L in d a D i g
a n c e h a v e
n e w e d itio n .
s t a ff a t E ls e v ie r f o r a ll th e ir h e lp a n d e n c o u r a g
e m e n t in th e p
r o d u c t io n o f th is
T h a n k s a r e a ls o d u e t o H e le n L e n g , S a r a h R u s s e ll, N a n c
y A r n o tt, a n d th e
b o n e t u m o u r s .
th e im a g e s o f
p a th o lo g
ic a l f r a c tu r e s r e s u ltin g
f r o m p
r im a r y
a n d s e c o n d a r y
W e a r e g r a te f u l to D r R a b in R e id , W e s te r n I n f ir m a r y , G la s g
o w , fo r p
r o v id in g
u s e d in th e c h a p te r s o n s p in a l in ju r y
a n d p
a r a p
le g ia .
s t a ff a n d p a tie n t s a r e th a n k e d f o r p r o v id in g
u 5 w i th a d v ic e a n d th e illu s tr a tio n s
M r D a v id A lla n , t h e D ir e c to r o f th e S c o t tis h S p
in a l In ju r y C e n tr e , a n d h is
r a d io g
r a p
h s , C T a n d M R s c a n s in c lu d e d in m a n y o
f th e c h a p
t e r s .
th e W e s t e r n In f ir m a r y , G la s
g o w , fo r p r o v id in
g u s w ith t h e n e w im a
g e s o f
c h a n g e s in th e d ia
g n o s is a n d tr e a tm e n t o f in ju r ie s . W e th a n k D r N i
g e l R a b y o f
A la r g e n u m b e r o f a d d it io n a l illu s tr a tio n s h a v e b e e n a d d e d t o r e f le c t t l e
w e w e r e f o r tu n a t e t o h a v e b e e n a b le t o s e e k h is a d y ic e , w h e n r e q u ir e d .
fu F th e r e d i tio n s , T h e s u c c e s s it h a s e n jo y e d is a tr ib u te to h is w r itin
g s k ills a n d
a n d e n th u s ia s m p r o d u c e d th e o r i
g in a l v o lu m e a n d s te e r e d it th r o u
g h e le v e n
w is h to th a n k th e o r i g
in a l a u th o r , Jo h n C r a w f o r d A d a m s , w h o s e in s p ir a tio n
th e p r e p a r a tio n o f th e n e w e d it io n o f th is w e ll e s ta b lis h e d t e x t . In p a r tic u la r , w e
T h e a u th o r s \n r is h t o a c k n o w l e d g
e t h e a s s i s t a n c e o f a n u m b e r o f c o l l e a g
u e s in
A c k n o w le d g e m e n ts
In d e x 3 1 5
F u rth e r re a d in g 3 1 3
1 7 . T h e fo o t 2 9 8
1 6 . L e g a n d a n k le 2 6 8
1 5 . T h ig h a n d k n e e 2 3 8
2 1 11 4 . P e lv is a n d h ip
1 9 01 3 . W r is t a n d h a n d
1 2 . E lb o w a n d fo re a r m 1 6 2
1 1 . S h o u ld e r a n d u p p e r a r m 1 3 1
1 2 21 0 . p a ra p le g ia f ro m s p in a l in ju r ie s
9 . S p in e a n d t h o ra x 1 0 8
8 . C e rv ic a l s p in e 9 2
8 67 . J o in t in ju rie s
7 96 . 0 s te o p o ro s is a n d f ra g ility fra c t u re s
7 45 . S p e c ia l fe a tu re s o f fra c t u re s in c h ild re n
4 . C o m p lic a t io n s o f f ra c t u re s 5 2
3 . P r in c ip le s o f f ra c t u re t re a tm e n t 2 9
2 . C lin ic a l a n d ra d io lo g ic a l fe a t u re s o f fra c t u re s 2 o
1 . P a th o lo g y o f fra c t u re s a n d f ra c t u re h e a lin g 3
In t ro d u c tio n
c o n te n ts
internal fix a tio n , a s a n a lte r n a tiv e to s p
lin ta g
e o r tr a c tio n , fo r th e m a n a g e m e n t
o f m u s c u lo -
s k e le ta l in ju r y
, T h e s e a llo w e d a s h if t to th e m o r e fr e q
u e n t u s e o f
n o lo g y
a v a ila b le to a s s is t c lin ic ia n s in th e d ia g
n o s is a n d t r e a tm e n t o f a l l ty p e s
T h e s e c o n d h a lf o f th e tw e n tie th c e n tu r y
s a w d r a m a tic c h a n g
e s in th e te c h -
th e s p lin ta g e is r e m o v e d .
im p o s e d b y
n e c e s s a r y
s p
lin ta g e , a n d r e d e v e lo p
e d b y g
r a d u a t e d a c t iv i t y
w h e n
m u s c le s , w h o s e f u n c tio n m u s t b e p r e s e r v e d b
y a c tiv e u s e w ith in th e lim its
m a tte r s . A tte n tio n m u s t b e p a id to th e s o f t tis s u e s , a n d e s
p e c ia ll
y to th e
th e r e a lis a t io n th a t in th e tr e a tm e n t o f a fr a c tu r e it is n o t th e b o n e a lo n e th a t
a r e u n ite d : s o m e fr a c tu r e s d o n o t n e e d im m o b ilis a tio n . B u t a b o v e a ll h a s c o m e
b o n e is f r a c t u r e d it m u s t n e c e s s a r ily b e r i
g id l
y im m o b ilis e d u n til th e f r a g
m e n ts
fr a c t u r e s d o n o t r e q u ir e r e d u c tio n . L ik e w is e it is n o lo n
g e r h e ld t h a t b e c a u s e a
m e n ts a r e n o t in e x a c t a p p o s itio n m a n i p
u la tio n m u s t b e c a r r ie d o u t : s o m e p r e c e p
ts . N o lo n g
e r is i t a c c e p te d a u to m a t ic a ll
y t h a t b e c a u s e th e b o n e f r a
g -
o f s o u n d ju d g e m e n t a n d c o m m o n s e n s e r a th e r th a n a s la v is h a d h e r e n c e to r i g
id
o s t -
w a r y e a r s th e tr e n d in f r a c t u r e tr e a t m e n t h a s b e e n t o w a r d s th e e x e r c is e
P R E S E N T T R E N D S
tis s u e s w ith o u t c o r r o s io n .
w h e n m e ta llu r g
is ts d e v e lo p
e d a llo y
s th a t c o u ld r e m a in in d e f in ite l y
in th e
w a s n o t o v e r c o m e u n til th e p e r io d b e tw e e n t h e fir s t a n d s e c o n d w o r ld w a r s ,
th e tis s u e s , c a u s in g a lo c a l r e a c tio n w h ic h o fte n h in d e r e d u n io n . T h is
p r o b le m
a p p lia n c e s o f ir o n , m ild s te e l o r s ilv e r c o r r o d e d a n d p
a r tly d is s o lv e d a w a y
in
th e la c k o f in e r t m e t a ls w it h w h ic h t o f ix th e b o n e s in a p p o s it io n . Internal
b e c a m e a v a ila b le , o p e r a tiv e f r a c tu r e s u r g
e r y
w a s s t ill s e v e r e ly h a n d ic a p p e d b y
E v e n w h e n th e a d v a n ta g e s o f a n a s e p t ic t e c h n iq u e a n d o f r a d io g
r a p
h y
o p
e r a tio n s u p o n b o n e w e r e v ir t u a ll
y p r o h ib ite d b
y th e r is k o f in f e c tio n .
s u r g
e r y
w e r e r e la tiv e l y
r e c e n t in n o v a t io n s , a n d b e fo r e th e ir jn t r o d u c tio n o p e n
A n tis e p
tic s u r g
e r y (in tr o d u c e d b
y L i s t e r i n 1 8 6 7 ) a n d its o ffs p
r in g
tic
th in k m o r e in te r m s o f o p e n o p e r a tio n s in t h e t r e a tm e n t o f d if f ic u lt f r a c t u r e s .
It w a s a t a b o u t th e b e g
in n in g
o f th e c e n tu r y , t o o , t h a t s u r
g e o n s b e g
a n t o
.
n a t u r e o f th e in ju r y
. It is e v id e n t , t h e r e fo r e , t h a t th e y m u s t h a v e w o r k e d la r g e l
y
e d g e o f d is s e c te d s p e c im e n s a n d u
p o n c lin ic a l e v id e n c e in d e te r m in in g
th e
p r e s e n t c e n t u r y
. B e fo r e th a t tim e s u r g
e o n s h a d to r e ly e n t ire l
y u
p o n a k n o w ] -
m o d e r n fr a c tu r e tr e a tm e n t b e g a n to d e v e lo p
a t a b o u t th e b e g
in n in g o f th e
n e c e s s a r y
a p p a r a t u s w a s d e v e lo p e d f o r c lin ic a l u s e , S o it m a
y b e s a id th a t
a n n o u n c e d h is d is c o v e r y
o f X -
r a y s in 1 8 9 5 , s e v e r a l y e a r s e la p s e d b e f o r e th e
s in c e a d e q u a te r a d io g
r a p
h ic te c h n iq u e s b e c a m e a v a ila b le . A lth o u g h R o e n t
g e n
T h e tr e a t m e n t o f f r a c t u r e s o n a p
r e c is e s c ie n t ific b a s is h a s b e e n p o s s ib le o n l y
H IS T O R IC A L N O T E
In tro d u c tio n
e . -
e
g _
p o s s ib ility o f a n e q u a ll
y s u c c e s s fu l o u tc o m e f o r th e p a tie n t .
o p e r a tiv e m e th o d s f o r th e tr e a tm e n t o f in d iv id u a l in ju r ie s , w h e r e th e
y o ffe r th e
b o o k w e h a v e tr ie d to s tr ik e a f a ir b a la n c e b y in c lu d in
g b o th c o n s e r v a tiv e a n d
a p p r o a c h , w h e r e a s o th e r s w ill tu r n m o r e r e a d i l y t o o
p e r a tiv e m e th o d s . In th is
t
he b e s t m e t ho d . S o m e s u r g e
o n s w i ll a l wa y s t en d t o w a r d s a c o n s e r v a t ive
c e r ta in f r a c t u r e s th e r e m u s t a lw a y s b e a d iv e r
g e n c e o f o p in io n o n w h a t is
t he r e i s o f t en m o r e t ha n o n e w a y o f tr e a t ing
a f ra c t u F e s u c c e s s f ul ly , a n d wi th
, a n d th e e x p e r ie n c e o f th e s u r g
e o n in th e ir u s e . It h a s t o b e a c k n o w le d g e d th a t
c h o jc e o f th e b e s t tr e a t m e n t f o r a n y p a t ie n t w ill d e
p e n d o n t h e ir a v a ila b ili t
y
th o s e w o r k in g o u tw ith m a jo r tr a u m a c e n tr e s in th e d e v e lo
p e d w o r ld . T h e
A ll th e s e n e w te c h n o lo g
ie s a r e e x p e n s i v e a n d m a n y
a r e n o t a v a ila b le to
th e a b ility to r e p a ir jo in t s tr u c tu r e s , in c lu d in g
a r tic u la r c a r tila g
e .
a ls o a llo w e d a r th r o s c o p y to b e
p e r f o r m e d o n a ll b u t t h e s m a lle s t jo in ts , w ith
fo r th e m o r e c o m p le x o r m u l ti
p le in ju r ie s . A d v a n c e s in o p tic a l te c h n o lo
g y h a v e
a n d e v e n in th r e e d im e n s io n s , a llo w s b e tte r d ia g n o s is a n d t r e a tm e n t
p la n n in
g
fr a c t u r e s a n d jo in t in ju r ie s . T h e a b ilit y to v ie w im a
g e s in a n
y o f th r e e
p la n e s ,
m a g n e tic r e s o n a n c e im a g
in g (M R I) h a s r e v o lu t io n is e d tir e w a y w e c a n lo o k a t
in tr o d u c t io n o f c o m p
u t e r is e d t o m o g
r a p
g r a
p h ic s c a m l in g
a n el
p a r a lle l d e v e lo p m e n ts in th e te c h n iq u e s o f b o n e a n d s o f t t is s u e im a
g in
g . T h e
T h e s e a d v a n c e s in tr e a tm e n t m e th o d s c o u ld n o t h a v e o c c u r r e d w ith o u t
s p e e d r e h a b ilita tio n .
lim b s , w ith b o th fr a c t u r e s a n d s o f t tis s u e in ju r ie s , w ill p r o m o te h e a lin g
a n d
c u s to m a r y
in th e p a s t , T h e r e is n o w c le a r e v id e n c e th a t e a riie r m o v e m e n t o f
c a s t b r a c in g , n o w a llo w m u c h e a r lie r m o b iliz a tio n o f th e
p a tie n t th a n w a s
a n d b e tt e r d e s i g
n s o f s p lin t . T h e s e , i n c o m b in a t io n w it h th e u s e o f f u n c ti o n a l
a d v a n c e d w it h th e in tr o d u c tio n o f im p
r o v e d li g
h tw e i g
h t s p
lin t in g m a te r ia ls
D u r in g th e s a m e
p e r io d m e th o d s o f c o n s e r v a t iv e t r e a t m e n t h a v e a ls o
m it tin g r e c o n s t r u c tiv e p
r o c e d u r e s o n th e s o f t tis s u e s .
a d v a n ta g
e s o f a llo w in g
a d ju s h n e n l o f th e f r a c tu r e p
o s itio n , a s w e ll a s p e r -
p in s , w h ic h a r e t h e n a t ta c h e d to a r i g
id e x te r n a l f r a m e . T h e m e th o d h a s th e
p e r m i t s ta b iliz a t io n o f th e b o n e f r a g
m e n ts b y
t h e in s e r tio n o f p e r c u ta n e o u s
tu r e s a n d w a r in ju r ie s , h a s b e e n th e im p
r o v e d d e s i g
n s o f e x t e r n a l fix a t o r . T h e s e
A n o th e r d e v e lo p m e n t , in r e s
p o n s e t o th e in c r e a s in g
n u m b e r o f o p e n fr a c -
te c h n o lo g
ie s .
u n d e r s u p
e r v is io n , s u r g e o n s s h o u ld il o t a t te m p
t t o u s e th e s e c o m p
lic a te d
fr a c tu r e s in s y
n th e tic b o n e s . C e ·
ta in l y w ith o u t th is tr a in i n
g a n d e x
p e r ie n c e
'
o n
'
c o u r s e s , w h e r e s tu d e n ts le a r n to a p p l y
th e te c h n i q u e s to s im u la te d
th e ir s a f e u s e . In t u r n , U r is h a s s tim u la te d m o r e e d u c a tio n a l a c tiv it y , in c lu d in
g
r a n g e o f b o n e f ix a tio n s
y s te m s , m a n y o f w h ic h r e
q u ir e s
p e c ia lis e d tr a in in
g fo r
n a il fix a tio n . T h e r e s u lt is th a t th e s u r g
e o n o f to d a y is f a c e d w ith a n e n o r m o u s
b e e n m o d ifie d a n d r e f in e d b y
o th e r s , p a r tic u la r l y
in th e f ie ld o f in tr a m e d u lla r y
in s te a d o f b y s e c o n d a r
y c a llu s f o r m a tio n . T h e s e i d e a s a n d jn n o v a lio n s h a v e
fix a tio n a ls o e m b r a c e d a n e w b io lo g
ic a l c o n c e p
t o f p
r im a r y b o n e h e a lin
g ,
u s in g
a d v a n c e d e n g
in e e r in g
m e th o d s . T h e ir p h ilo s o p
h y o f c o m
p r e s s io n
d e v e lo p m e n t o f n e w d e s i g
n s o f inplants a n d th e in s tr u m e n t s t o in s e r t th e m ,
w h o fir s t p
u b lis h e d th e ir n e w te c h n i q
u e s in 1 9 6 5 . T h e s e d e p e n d e d o n th e
th e S w is s A O (A r b e its g e m e in s h a f t fo r O s te o s y
n th e s e f r a g
e n ) fix a tio n g ro u
p ,
o f lim b b o n e f r a c tu r e s . T h is m o v e a w a y
f r o m c o n s e r v a tiv e r n e t h o d s w a s le d b y
2 1 0 U T L IN E O F F R A C T U R E S
c a u s e s o f p a th o lo
g ic a l fr a c tu r e s w ill b e c o n s id e r e d la te r (p . 1 6 ).
o fte n th e b o n e g iv e s w a y
f r o m t r iv ia l v io le n c e , o r evenontaneously. T h e
fy a le i e t o f f o r c e th a t w o u ld n o t h a v e r e s u lte d in a f r a c t'
J n h e a lth y
t o n e .
a b o w a lr e a d y w e a k e n e d b y .
D i§e a s e . A e a t h o l o g c a l if it is t
p a th o lo g ic a l fra c tu re s . T h e te r m '
p a th o lo g
ic a l '
is a p p
lie d to a fr a c tu r e th r o u g
h
tn e re m u i .th e fe m u r
t e s a r e th e s h f t M m m g b , t h e sheiiEM , a n d th e f
. T h e g
r e a t m a jo r ity o c c u r s in th e , b u t o th e r w e ll
W ith fe w e x c e p tio n s , fa ti
g u e o r s tr e s s fr a c tu r e s a r e c o n fin e d t o th e b o n e s o f th e
to th e fr a c tu r e s th a t o c c u r in c e r ta in m e ta ls w h e n '
fa ti g
u e d '
b y r e p e a t e d s tr e s s .
a c o m p
le te fr a c tu r e a c r o s s th e f u ll w id th o f th e b o n e s . T h e y h a v e b e e n lik e n e d
r e p a ir . In th e s e c ir c u m s ta n c e s , t h e m ic r o d a m a
g e a c c u m u la te s a n d p
r o g r e s s e s to : T h e y
o c c u r w h e n th e r a te o f m ic r o d a m a g e e x c e e d s th e r a te o f
in ju r y
b u t f r o m d . $tr$§, a e £.
c w m o n ly o g u r . In . A th le t §. u D
F a tig u e fra c tu re s . F a ti g
'
, if u n q
u a lif ie d , is g e n e r a lly ta k e n to s ig n if
y th e s e ty p
e o f in ju r ie s .
S o g r e a t is t h e
p r e p o n d e r a n c e o f th e s e g r o u p s o v e r th e o t h e r t w o , t h e te r m
th e ir han5ement a r e d e s c r ib e d m o r e f u lly in C h a
p te r 6 , p a
g e 7 9 .
o s te o p o r o s is , s e e r F m o s t c o m m o n l y in e ld e r l
y p 5 iie i its . T h e s e fr a c tu r e s a n d
a s s o c ja te d w ith a g e g k n e s s uiting fro r» c o n d itjo n o f
£ '
X X X
F ra c tu re s c a u s e d s o le ly b y s u d d e n in ju ry . T h e s e f r a c tu r e s f o r m b y
fa r th e
4 . p a th o lo g
ic a l f r a c tu r e s
3 . Fa ti g
u e o r s tr e s s fr a c t u r e s
2 . Fr a g
f r a c t u r e s .
1 . Fr a c tu r e s c a u s e d s o le l y
b y
s u d d e n in ju r y
F r a c t u r e s m a y
b e s u b d i v id e d , a c c o r d in g
to th e ir a e tio lo g y , in to f o u r
g r o u
p s
C L A S S I F I C A T IO N
it m a y
le te b r e a k .
A fr a c t u r e m a y
b e a c o m p
le te b r e a k in th e c o n tin u it y
o f a b o n e o o c c a s io n a ll y ,
a n d fra c t u re h e a lin g
P a th o lo g y o f fra c tu re s
m o v e m e n t b e tw e e n th e m .
a r e d r iv e n s o fir m l y
to g
e th e r th a t th e y b e c o m e in te r lo c k e d a n d th e r e is n o
b o n e s o f c h ild r l f ). I m p a e d fr c tu r l s a r e \ h s e i n w h i c h t h e b o n e f r a g
m e n t s
II P A T T E R N S O F F R A C TT U RR EEE _
is e x c e e d in g
l y
r a r e u n le s s it h a s b e e n o p e r a te d u
p o n .
6iit a n d m a y
h e r e f o r e B e c o m e m d , w h e r e a s in f e c tio n o f a c lo s e d f r a c tu r e
tp e T
fr a c tu r e is lia b le to b e c o n ta m in a te d b y.
o r g a n is m s in tr o d u c e d f r o m w ith -
T h e d is tin c tio n b e tw e e n c lo s e d a n d o p
e n fr a c tu r e s is im p o r ta n t, b e c a u s e a n
C L O S E D A N D O P E N F R A C T U R E S
th e w o u n d a n d in fe c t th e b o n e .
> w o u n d le a d in g d o w n to th e s ite o f fra c tu re . O rg a n is m s m a y g a in a c c e s s th ro u g h
E fra c tu re d b o n e a n d th e b o d y s u rfa c e . © o p e n o r c o m p o u n d fra c t u re . T h e re is a
-
-
G
4 0 U T L IN E O F F R A C T U R E S
s p ir a lly if a tw is tin g f o
r c e is u s e d .
= e w n t w ill s h o w th a t th e c h a l k is b r o k e n tr a n s v e r s e l y
if a n a n g u l
a to ry
f o r c e is a p p lie d , w h e r e a s
' In its b e h a v io u r to v io le n c e a n a d u lt lo n g b o n e m a
y b e c o m p a r e d w ith a s tic k o f c h a lk . A s im p
le
le n d its e lf w e ll to a n a to m ic a l r e d u c tio n , b e c a u s e th e s p o n
g y b o n e s u b s ta n c e
s u r f a c e (F ig . 1 . 3 ). A c o m p r e s s io n fr a c tu r e (F ig . 1 . 2 , d ia g r a m E ) d o e s n o t a lw a
y s
r o je c t in g s p
ik e s o f b o n e c a n b e lo c k e d in to n o tc h e s in th e o p p o s in
g
r e d u c tio n , w h e r e a s a n o b lB £lu e o r s p ir a l f r a c tu r e iti p r o n e to r p rl is
p jM m e n t
fr a g
m e n ts . T h u s a tr a n s v e r s e f r a c t u i$ m li!se ly , to h e r o m e r p d is p la c e d a f te r
T h e p a tte r n o f f r a c tu r e a ls o g iv e s a n in d ic a tio n o f th e lik e l
y s ta b ilit
y o f th e
tw i g b r
tw is tin g f o r c e , w h e r e a s a
h a s e q u a ll y
s u re l y
b e e n c a u s e d b y a
T h e p a tte r n o f f r a c tu r e is o f m o r e th a n a c a d e m ic in te r e s t . It m a y
in d ic a te th e
fra c tu re s .
© s p ira l fra c tu re ; c o m m in u te d fra c tu re ; © c o m p re s s io n fra c tu re ; © g re e n s tic k
©
5C H A P T E R 1
o r s p ira l fra c tu re te n d s to b e re d is p la c e d b y th e e la s tic p u ll o f t h e m u s c le s .
F lg . 1 . 3 A tra n s v e rs e fra c tu re is s ta b le a g a in s t re d is p la c e m e n t w h e re a s a n o b liq u e
fo rc e .
w e re c a u s e d b y a lo n g itu d in a l c o m p re s s io n fo rc e a n d th o s e in b y a n a n g u la tio n
F ig . 1 . 4 R a d io g ra p h s o f ty p ic a l g re e n s tic k fra c tu re s in c h ild re n . T h e fra c tu re s in
o f th e g
r e e n s ti c k t y r .
e a r e m o r e c o q q o n , e s p e c ia ll y
in y
w w w e n .
v io le n c e c h ild r e n '
s b o n e s o f te n s u ff e ]' " o m p
le t e f r a c lu r e , le te f r a c tu r e s
fr a c t u r e (b u c k le fr a c t u r e o r t o r u s f r a c tu r e ) (F ig . 1 . 4 B ). A lth o u g h w it h s e v e r e
o n e c o r te x a n d t o b u c k le o r b r e a k it a t th e o t t e r , t h u s p r o d u c in g
a n in c o m p
le te
c o m p r e s s io n f o r c e (F ig . 1 . ¢A ) . A n a n g
u la t io n f o F c e t e n d s t o b e n e t th e b o n e a t
'
c r u l n p le cr lik e a c o n c e r tin a b y
a lo n g
th e a g
e o f 1 0 y
e a r s , a r e s p r in g y
a n d r e s ilie n t lik e th e b r a n c h e s o f a y
o u n g
t r e e .
G r e e n s tic k fr a c t u r e s a r e p e c u lia ·
to c h ild r e n , w h o s e b o n e s , e s p e c ia lly b e fo r e
tr a b e c u la r f o r m .
tn a y
b e c r u s h e d a n d c o m p r e s s e d a n d c a n n o t b e r e s t o r e d f u ll
y t o it s o r i
g in a l
6 0 U T L IN E O F F R A C T U R E S
to w a r d s th e o th e r f r a g m e n t .
T h e y
fo r m a c o lla r o f a c tiv e t is s u e th a t s u r r o u n d s e a c h f r a g m e n t a n d g
r o w s o u t P r e c u r s o r s b t s , w h ic ti w ill la te r W d n w n th e in t e r c e llu la r . s u b s ta n e .
fr o m th e d e e p s u r f a c o f . Th e F _
r io s te u m c lo s e to th e fr a c tu r e . 1 h e s e c e lls a r e th e
T h e m o s t p r o m in e n t fe a tu r e in th e e a r l y
s ta g
e s o f r e p a ir is m $fe r a tio n o f c e lls
S ta g e o f s u b p e rio s te a l a n d e n d o s te a l c e llu la r p ro life ra tio n (F ig . 1 . 5 B )
s u r fa c e s d ie . T h e b lo o d c o n tr ib u te s v a r io u s g r o w th f a c to r s w h ic h h e l
p to a t t r a c t
m illim e t r e s . D e p r iv e d o f t h e ir b lo o d s u p p
l y , th e o s te o c
y te s n e a r th e f r a c t u r e
s id e o f th e f r a c t u r e b e c o m e s is c h a e m ic o v e r a v a r ia b le le n g th , u s u a lly a fe w
n a ll y
in th e c o m p a c t b o n e , a n d th e r in
g o f b o n e im m e d ia te l
y a clja c e n t to e a c h
T h e fr a c tu r e in e v ita b l y
d iv id e s m o s t o f t h e c a p illa r ie s t h a t r u n lo n
g itu d i -
m u s c le s , fa s c ia a n d s k in .
h a e m a t o m a is e x t r a v a s a te d in t o th e s o f t t is s u e s , b e in g
c o n ta in e d u lt im a te l y
b y
to r n f r o m th e b o n e e n d s t o a v a r ia b le e x te n t . W h e r e th e p e n o s te u m is to r n , t h e
1 ta in e d b y
th e s u r r o u n d in g p e r io s te u m , w h ic h m a y b e s t r i p p e d u p o r
.
a
S ta g e o f h a e m a to m a (F ig . 1 . 5 A )
tr a te d in F i g
u r e 1 . 5 .
d iffe r e n t p a r ts o f t h e b o n e . T h e p r o c e s s o f h e a lin
g o f a t u b u la r b o n e is illu s -
c a te d a n d th a t tw o o r m o r e s t a g e s o f h e a lin g
m a y b e s e e n a t th e s a m e ti m e in
It m u s t b e e m p
h a s is e d , h o w e v e r , t h a t th e s e s ta g
e s a r e n o t s h a r p
l y d e m a r -
5 . R e m o d e llin g
.
4 . s ta g
e o f c o n s o lid a tio n
3 . s ta g
e o f c a llu s
2 . s ta g e o f s u b p e r io s te a l a n d e n d o s te a l c e llu la r p
r o lif e r a tio n
1 . s ta g e o f h a e m a to m a
m a y
b e c o n s id e r e d a s o c c u r m r g
in f iv e s ta g
e s
F o r p
u r p o s e s o f s im
p lic it y th e
p r o c e s s o f h e a l in g o f a f r a c t u r e d t u b u la r b o n e
a t
r
H L P A IR O F T U B U L A R B O N E
fix a t io n o f t h e f r a g
m e n t s a n d th e c lo s e n e s s o f th e ir c o a p ta tio n .
h e a l in g
in a g iv e n b o n e is p r o b a b l
y in f lu e n c e d b y s u c h f a c t o r s a s th e r i
g id it
y o f
s tr ik in g d iff e r e n c e s f r o m th e r e p a ir o f a c a n c e llo u s b o n e , a n d th e
p a tt e r n o f
fo r a ll b o n e s a n d in a ll c i r c u m s ta n c e s . T h e r e p a ir o f a tu b u ia r b o n e s h o w s
N e v e r t h e le s s , it m u s t b e a p p r e c ia te d th a t t h e p a t te r n o f h e a lin
g is n o t c o n s ta n t
p r o c e s s is s i m ila r in h u m a n s , a t a n y r a te w h e n t h e c o n d it io n s a r e c o m p a r a b le .
m a in l y to r ib f r a c t u r e s in t h e r a b b it , b u t th e e v id e n c e s u
g g e s ts th a t th e r e p a ir
w e r e w e ll d e s c r ib e d b y H a m a n d H a r r is in 1 9 5 6 . T h e ir d e s c r i
p t io n a
p p lie d
T h e h is to lo g
ic a l f e a tu r e s o f f r a c t u r e r e p a ir a t v a r io u s in te r v a ls a f te r in ju r
y
b o n e is c o n s o lid a te d (F ig . 1 . 5 ) .
c o n d itio n s a r e f a v o u r a b le , h e a lin g p r o c e e d s th r o u
g h s e v e r a l s ta g e s u n t il th e o
A fr a c t u r e b e g
in s to h e a l a s s o o n a s th e b o n e is b r o k e n a n d , p r o v id e d t h e
H E A L IN G O F F R A C T U R E S T
C H A P T E R 1
th u s re s to re d m o re o r le s s to lts o rig in a l fo rm .
B o n e is s tre n g th e n e d in th e lin e s o f s tre s s a n d re s o rb e d e ls e w h e re . T h e b o n e is
la y in g d o w n la m e lla r b o n e a t th e e x p e n s e o f th e w o v e n b o n e . © R e m o d e llin g .
c a llu s . © S ta g e o f c o n s o lid a tio n . O s te o b la s ts c o n tin u e th e p ro c e s s o f re p a irt
la y d o w n in te rc e llu la r s u b s ta n c e ; th is b e c o m e s c a lc ifie d , t o f o r m w o v e n b o n e o r
b lo o d c lo t . © S ta g e o f c a llu s . T h e p ro life ra tin g c e lls g iv e ris e to o s te o b la s ts , w h ic h
c a rtila g e , p u s h e s fo rw a rd fro m e a c h s id e o f th e fra c tu re a t th e e x p e n s e o f th e
e n d o s te a l c e llu la r p ro life ra tio n . T h e c e llu la r tis s u e , w h ic h m a y c o n ta in is la n d s o f
o f b o n e im m e d ia te ly a d ja c e n t to th e fra c tu re . S ta g e o f s u b p e rio s te a l a n d
F ig . 1 . 5 S ta g e s in th e h e a lin g o f a fra c tu re . S ta g e o f h a e m a to m a , w it h n e c r o s is
jj LL aa m ee llaa rr b oo n ee
re fo rm e d
M a rro w c a v ity
re s o rb e d
r D e a d b o n e b e in g
ly B lo o d c lo t
rm
Wo v e n bo n e
p ro life ra tio n
E n d o s te a l c e llu la r
p ro life ra tio n
S u b p e rio s te a l c e llu la r
Bl oo d cl ot
L iv in g b o n e
D e a d b o n e
M a rro w
f ij -
M u s c leg -
-
&
8 0 U T U N E O F F R A C T U R E S
e _
e
e
@
_
_
n e w p e rio s te u m . (H a e m a to x y lin a n d e o s in , x 4 0 . )
O u ts id e th is is a th ic k e r la y e r o f ty p ic a l w o v e n b o n e , a n d o u t s id e t h i s a g
a i n is t h e
s e c tio n , i s y o u n g fib ro u s tis s u e (ft) , b o u n d e d a b o v e b y th e o ld p e rio s te u m (p m ) .
b o tto m le ft) is a th in la y e r o f w o v e n b o n e (w b ) . A b o v e th is , n e a r t h e m id d le o f th e
o c c u rrin g m a in ly a ro u n d th e p e rip h e ry o f th e fra c tu re . N e x t to th e b o n e (n e a r
B e tw e e n th e fra g m e n ts is n o th in g m o re th a n o ld b lo o d c lo t (b c ) : u n io n is
o rig in a l b o n e fra g m e n ts a re d e a d (d b ) , a s i n d ic a t e d b y
t h e e m p
t y
l a c u n a e .
fra c tu re is s e e n in th e lo w e r p a rt o f th e s e c tio n . In th e lim ite d a re a s h o w n , t h e
F ig . 1 . 6 S e c tio n s h o w in g a h e a lin g fra c tu re o f h u m a n rib 3 w e e k s a fte r in ju ry . T h e
n o t a n e s s e n t ia l e le m e n t in th e p r o c e s s o f h e a lin
g .
v a r ia b le in a m o u n t : s o m e tim e s it is p r o f L is e b u t jt m a
y b e a b s e n t . E v id e n t ly
it is
b r id g
e th e fr a c t u r e , t h e r e m a y b e s e e n g a n d s o f c a r ti e . T h e c a r tila
g e is
W ith in th e c e llu la r t is s u e th a t g r o w s f o r w a r d o u ts id e a n d in s id e th e b o n e to
o th e r fr a g
m e n t .
to o , g w w s f o r w a r d to m e e t a n d b le n d w ith s im ila r tis s u e g
r o w in g
f r o m th e
fr o m th e e n d o s te u m a n e l f r 6 m th e m a r r o w tis s u e o f e a c h f r a g
m e n t . T h is t is s u e ,
w ith in th t w u ila r y
c a n tJtBi n e p r o life r a tin
g c e lls a
p p e a r to b e d e r iv e d
S im u lta n e o u s l y w ith t h e «Tb{J%!iosteal p r o life r a t io n th e r e is c e llu la r a c t iv it
y
C H A P T E R 1 9
b e c o m e s c a lc ifie d to f o r m w o v e n b o n e .
o p p o s in g
f r a g m e n t . O s te o b la s ts th e n la
y d o w n th e in t e r c e ll u la r m a t r ix , w h ic h
p e n e tr a te u n til th e y m e e t a n d fu s e w ith s im ila r tis s u e
g r o w in g o u t fr o m th e
b lo o d v e s s e ls a n d p r o lif e r a t in g o s t e o
g e n ic c e lls h . o m th e f r a c tu r e s u r f a c e s
T h e f ir s t s ta g e o f l e a lin
g is th e f o r m a t io n o f a h a e m a t o m a , in t o w h ic h n e w
th e m e t e n , a s in a t u b u la r b o n e .
d ir e m b e tw e e n th e b o n e s u r f a c e s a n d it d o e s n o t h a v e t o t a k e p la c e th r o u g
h
tr a b e c u la e a llo w s e a s ie r p e n e tr a tio n b y b o n e - fo r m in g t is s u e . U n io n c a n o c c u r
fr a g m e n ts th a n in th e c a s e o f a t u b u la r b o n e , a h d th e cib p e n m e s h w o r k b f
R E P A IR O F C A N C E L L O U S B O N E
g G
e r m a n e n t l y
m a r k e d b y a n a r e a o f th ic k e n in
g o r s c le r o s is .
a d u lts , r e m o d e llin g g
e n e r a ll y
f a lls s h o r t o f t h is i d e a l, a n d th e s ite o f a fr a c t u r e
th e s it e o f th e f r a c tu r e b e c o m e s in d is ti n g
u is h a b le o n r a d io g
r a p h s (F ig . 1 . 7 ). In
In c h ild r e n , r e m o d e llin g
a f te i' " f r a c t u r e is u s u a ll y s o p
e r f e c t t h a t e v e n tu a ll y
o b v io u s a f te r a fr a c t u r e .
b u t in c o n s p ic u o u s l
y , in e v e r y
b o n e th r o u g
h o u t li f e , b u t it b e c o m e s e s p e c ia ll y
w h ic h is s lo w l y
1'" m o v e d . T h is p r o c e s s o f r e m o d e llin g
is g
o in g o n c o n s ta n tl
y ,
th e lin e s o f s tr e s s a t t h e e x p e n s e o f th e s u r p lu s b o n e o u t s i d e th e lin e s o f s t r e s s ,
In t h e m o n th s th a t f o llo w u n io n , t h e b o n e is g r a d u a ll
y s t r e n
g th e n e d a lo n
g
& \ h ild r e n , b e c a u s e th e p e r io s t e u m is e a s il y s
tr i p p
e c l f r o m th e b o n e b y
e x tr a v a -
iin H£ A ? la te w it h s c r e w s o r
W @ . ia m e lla r s tr u c t u r e .
c o m b in e d a c tiv it y
o f o s te o c la s ts a n d o s t e o b la s ts in t o m q m a t y .
R e b g ! . With . a
S ta g e o f c o n s o lid a tio n (F ig . 1 . 5D )
g iv e s th e fir s t r a d io lo g
ic a l in d ic a tio n th a t th e fr a c tu r e is u n itin g .
fr a c t u r e . T h e m a s s o f c a llu s o r w o v e n b o n e is a ls o T is ib le 5n r a d io g
r a p h s a n d
b o n e is a s u p e r fic ia l o n e th e c a llil s m a y b e fe lt a s s s u r r o u n d in
g th e
b r id g
e o f w o v e n b o n e im p a r ts r ig id ity .
_
b o n e s .
b e lie v e d to e x is t in th e e n d o s te u m , t h e th in la y e r th a t lin e s th e m e d u lla r
y c a n a l
p r o lif e r a tio n u n d e r t h e a p p r o p
r ia te s tim u lu s . S im ila r '
r e s t in g
'
'
'
o s t e o b la s ts w h ic h a r e c a p a b le o f a c tiv a tio n a n d
w h a t s tim u la te s t h e m to a c t iv it y
. It s e e m s c le a r th a t th e d e e p s u r fa c e o f th e
th e r e h a s b e e n m u c h d is c u s s io n o n w h e r e th e y
c o m e fr o m , a n d p a r tic u la r l y
o n
T h e a c tu a l la y in g
d o w n o f b o n e is c le a r ly a f u n c tio n o f o s te o b la s ts , b u t
m a n y o
f th e d e t a ils a r e s t ill n o t f u ll y
u n d e r s to o d .
p r o c e s s e s b y
w h ic h r e p a ir is in it ia te d a n d c a r r ie d th r o u g
h to its c o m p le tio n , b u t
r e p a ir o f a f r a c t u r e . T h e r e h a s b e e n m u c h r e s e a r c h in to th e c o m
p le x b io lo
g ic a l
o in g
is n o m o r e t h a n a b a s ic s k e tc h o f th e p r o c e s s e s c o n c e r n e d in th e
O rig in a n d a c tiv a t io n o f b o n e - fo rm in g c e lls
f m , ·
Q [ c t o r
Fr a = T FTIHJ-H' '" ' ' " w h ' ' "
i5 4 W . - 3 d
'
e a r in p h n n e s. o f th e lo w e F lim b s .
fe m u r . In g e n e r a !, u T °W d s to W
r a th e r m o r e r a p id l y
in th e s le n d e r b o n e s
e x te n d s t o 4 o r e v e n 5 m o n t h s , e s p e c ia ll y in th e c a s e o f a la r
g e b o n e s u c h a s th e
b o n e , in f a v o u r a b le c o n d it io n s , is a b o u t 3 m o n th s , t h o u
g h in m a n y
c a s e s i t
fn a d u lts th e tim e u s u a ll y r e
q u ir e d f o r c o n s o li d a ti o n o f a f r a c t u r e d lo n g
I 2 n .
.
A s e fa r s m a lle r e ff e c t u p q t l th e r a t e o f
s o lid a te d in 4 o r 6 w e e k s (F ig . 1 . 8 ). In o ld e r c trild r e n , u n io n o c c u r s a littie le s s
o f te n b e in g
v is ib le r a d io 16 g
ic a ll y
w ith in 2 w e e k s a n d th e b o n e b e in g
c o n -
c a n n o t b e la id d o w n . In g c h i ld r e n u n io ir is n e a r l
y a lw a
y s r a
p i cl, c a llu s
T h e tim e t a k e n f o r a f r a c t u r e t o u n it e js s o v a r ia b le th a t h a r d a n d f a s t r u le s
R A T E O F U N IO N
o s te o b la s ts .
o f b o n e m a r r o w s t e m c e lls a n d a r e il o t , a s w a s o n c e t h o u g
h t, d e r iv e d fr o m
r e s o r p tio n , t h e m u lt in u c le a t e d o s t e o c la s t s , a r e fo r m e d f r o m a s e p a r a te lin e
d a m e n ta l p a r t o f th e p
t'" c e s s o f r e m o d e llin g
- T h e m o s t a c tiv e a g
e n t s o f b o n e
s n n a ll b lo o d v e s s e ls o f b o n e a r e iln p o r t a n t a
g e n t s in b o n e r e s o r
p tio n , a fu n -
w ith in th e c a n a lic u li o f th e H a v e r s ia n s y
s te m s . T r u e t a c la im e d f u r th e r t h a t th e
c y
te s , lo c k e d e a c h in it s o w n la c u n a , t h e fin e c y
to p
la s m ic fila m e n t s s t ill p
e r s is t
fin a ll y
s u r r o u n d th e m s e lv e s w ith in te r c e llu la r s u b s t a n c e a n d b e c o m e o s te o -
s u m a b l y
th e y
d e r iv e th e ir b lo o d - b o r n e n u tr im e n t . W h e n th e s e o s te o b la s ts
th e ir fila m e n t o u s p r o c e s s e s , w ith th e a n c e s tr a l e n d o th e lia l c e lls , w h e n c e p r e -
h e f o u n d th a t th e s e o s te o b l a s t s r e ta in a d ir e c t c y
to p
la s m ic c o n n e c t io n , t h r o u g h
m i g
'
in te r m e d ia te '
c e lls th a t a r e t h e p
r e c u r s o r s o f o s te o b ]a s ts . M o r e o v e r ,
th a t th e e n d o th e lia l c e lls t h a t lin e th e s e n e w b lo o d v e s s e ls c a n d iv id e t o f o r m
o r d e a d o s te o c y te s in th e is c h a e m ic b o n e a d ja c e n t t o th e f r a c t u r e . H e s h o w e d
p o s s ib l y u n d e r th e s tim u lu s o f a c h e in ic a l in d u c to r s u b s t a n c e lib e r a t e d b
y s ic k
a r e a ttr a c te d c e n tr i p
e ta ll y
t o w a r d s th e fr a c tu r e f r o m th e s u r r o u n d in g
a r e a ,
a n d s in u s o id s - in th e 1'" p a ir o f a f r a c tu r e . H e c o n c lu d e d t h a t n e w b lo o d v e s s e ls
e m p h a s is e d th e im p
o r t a n t p
a r t p la
y e d b y
th e s m a ll b lo o d v e s s e ls « a p illa r ie s
T h e w o r k o f T r u e t a (i§63), e m m a i t h th e e le c t r o n m ic r o s c o p e ,
p r o m o tio n o f in c r e a s e d p
e F io s te a l a n d e n c lo s te a l c e ll p
r o lif e r a t io n .
p a r a th w o id h o r m o n e in to th e c ir c u la t io n , a n d th a t th is m a y
b e a f a c to r in th e
s h o w n th a t s y s te m i c e ffe c ts o f a n in ju r y
m a y
le a d t o a n in c r e a s e d r e le a s e o f
It is th o u g
h t a ls o th a t e n d o c r in e f a c to r s m a y p
la y
a p a r t, a s il h a s b e e n
th e r e p
a ir p r o c e s s .
s p e c if ic m ito
g e n ic b o n e
g r o w th f a c to r s w h ic h m a
y b e im p
&'
l £ - . s t" p r o g
e n it" ' " ls . p la te le ts ) c a n p r o d u c e
r e c e n t w o r k s u g g e s ts th a t a v a r ie t
y o f d iffe r e n t
s u b s ta n c e lib e r a te d in th e r e g io n o f th e fr a c tu r e ,: P T X k
c e lls a r e s tim u la te d to d if fe r e n tia te in t o o s t e o b la s t s is b e li e v e d to b e a c h e m ic a l
p r o g
e n ito r , o r p r e c u r s o * c e lls , I. e . s te m c e lls . T h e m e c h a n is m b y w h ic h th e s e
e v id e n c e th a t o s te o b la s ts m a y
b e n e w l y
f o r m e d in th e b o n e m a r r o w f r o m
W h a te v e r m a y b e th e c o n tr ib u tio n o F th e s e s o u r c e s , t h e r e is a ls o c o n v in c in
g . -
G
1 2 0 U T L IN E O F F R A C T U R E S
lii
u n io n .
a d u lt w o u ld b e e x p e c te d to ta k e a t le a s t 3 m o n th s to re a c h th e s a m e s ta g e o f
© T h re e w e e k s la te r, s h o w in g a d v a n c e d c a llu s fo rm a tio n . A s im ila r fra c tu re in a n
c h ild re n . In itia l ra d io g ra p h s o f a fra c tu re d fe m u r in a c h ild o f a y e a rs .
F ig . 1 . 8 R a d io g ra p h s illu s tra tin g th e s p e e d w ith w h ic h fra c tu re s u n ite in y o u n g
s e c tio n o n d e la y
e d u n io n a n d n o n -
u n i o n o f fr a c tu r e s (p . 5 4 ).
tis s u e a c r o s s th e fr a c tu r e g a p
. T h e s e m a tte r s a r e c o n s id e r e d f u r th e r in th e s y
n o v ia l f lu id a b o u t th e s it e o f frsturenders th e fo r m a tio n o f g
r a n u la tio n lia1e th a n m o s t o th e r fr a c tu r e s to non\iniwNsibly b e c a u s e th e p
r e s e n c e o f ? in v o lv e m e n t o f th e b o n e b y a ,
tb m o u F . A fr a c f B r e w ith in a jo in t n 1 a y b e m o r e
m a y h in d e r u n io n a r e T n fe c t io n o f th e b o n e , ilerpositior o f s o ft t is s u e , o r
th e fe m u r , if th e fr a g
n w
ts a r e n o t p e r fe c tl
y im p °b ilis e c l . O th e r f a c to r s th a t
p a r tic u la r ly in f r a c t u r e s o f th e f o r e a r m b o n e s , s c a p h o id b o n e a n d th e n e c k o f
d e lic a te c a p
illa r ie s in th g c h m o v e m e n t is lia b le to o c c u r
th e f e m u r . In th e s e in s t a n c e s m o v e m e n t is g a n d d o e s n o t d a m a
g e th e
b e tw e e n th e f r a g m e n t s - fo r in s t a n c e , fr a c tu r e s o f th e r ib s , c la v ic le o r o f
h a r m f u l : m a n y
f r a c t u r e s u n it e r e a d ily d e s p
ite a lm o s t c o n s t a n t m o v e m e n t
b e tw e e n th e f r a g
m e n t s . T h a t is n o t to s a y , h o w e v e t , t h a t m o v e m e n t is a lw a
y s
' im
p a ir m e n t o iih t b io o d s u p p ly
e v e n t o o n e o f th e fr a g m e n ts , o r b y m o v e m e n t
L tr a c t u r e s , i n n u -
C o n v e i s e l y , u n io n m a y
b e h in d e r e d o r e v e n p r e v e n te d b y
le n tifu l s u p E
I x

C H A P T E R 1 1 3
ra
a b r u p t . T h e p a in iH n c r e a s e d b c o n tin u e d a c tiv it
y a n d r e lie v e d b
y r e s t .
fr a c t u r e . T h e o n s e t opain in th e a ff e c te d b o n e is g r a d u a l o r in s i d io u s , s e ld o m
fr a c tu r e i s i s nsingle s p e c if ic causive in ju r
y in c a s e s o t t a ti
g u e
" c te
fa ti g u e fr a c tu r e in h n i m b m e f e iT luT a # d o c c a s io n a lly
o th e r b o n e s m a y
T h e s e th r e e b o n e s , m e t a t a r s a l , fib u la a n d tib ia a r e th e m o s t c o m m o n s ite s o f
a n d r e p e a t e d r u n n in g
o ]. D a n c in g
in t h e c a s e o f f r a c tu r e s o f t h e f ib u la o r t ib ia .
p r o lo n g
e d w a lk in g o
r m a r c h in g
in th e c a s e o f f r a c t u r e s o f t h e in e t a t a r s a l b o n e s ,
is a h is to r y
o f o f t -
r e p e a t e d m in o r s tr e s s e s p r e c e d in g
th e o n s e t o f p a in
p r e d is p o s in g c a u s e is c o n c e r n e d . In m o s t c a s e s o f f a ti
w e fr a c t u r e o f b o n e th e r e
fa tig u e fr a c t u r e s in m e ta l a n d th o s e s e e n c lin ic a lly in h u m a n s is a
p t s o F a r a s th e
b o n e m a k e s it m a r e r e s is t a n t t o p r o p
a g
a tio n o f th e c r a c k s . T h e a n a lo g y b e tw e e n
a c c u m u la tio n is th o u g
h t to o c c u r in b o n e , a lth o u g h th e c o m p
o s ite n a tu r e o f
w e a k e n s th e m e ta l a n d p
e r m it s a c r a c k to o c c u r . A s im ila r m e c h a n is m o f c r a c k
r e p e a te d s t r e s s th e r e is a
g r a d u a l 1'" a r r a n
g e m e n t o f n i o l e c u la r s tr u c t u r e w h ic h
F a ti g
u e f r a c t u r e s in m e ta l a r e w e ll k n o w n to e n g
in e e r s . In c o n s e q u e n c e o f
-
&
14 0 U T L IN E O F F R A C T U R E S
th e w h o le s k e le to n .
c ir c u m s c r ib e d , o r it m a y b e a g
e n e r a lis e d d is o r d e r a ffe c tin g s e v e r a l b o n e s o r
b e fo r e th e fr a c tu r e . T h e u n d e r l y
in g d is e a s e o f th e b o n e m a y
b e lo c a l a n d s u ffe r e d
p a in o r d is c o m f o r t in th e r e g
io n o f th e a ffe c te d b o n e fo r s o m e ti m e In m a n
y c a s e s th e p a tie n t, w h e n d ir e c tly q
u e s tio n e d , w ill a d m it to h a v in g
d is e a s e . O fte n th e b o n e g iv e s w a
y f m m tr iv ia l v io le n c e , o r e v e n s p o n ta n e o u s l
y ,
.
A p a th o lo g ic a l f r a c tu r e o c c u r s th r o u
g h a b o n e th a t is a lr e a d
y w e a k e n e d b
y
P A T H O L O G IC A L F R A C T U R E S
s h o u ld n o t o c c u r if th e fe a tu r e s o f fa tig u e f r a c tu r e a r e p
r o p
e r ly u n d e r s to o d .
(F ig . 1 . 9), It h a s o c c a s io n a ll y
b e e n m is ta k e n fo r a b o n e s a r c o m a , a n e r r o r t h a t n e w b o n e m a
y e v e n tu a ll
y fo r m a d e n s e f u s ifo r m m a s s a b o u t th e s ite o f f r a c tu r e
c a liu s th a t s u r r o u n d s it . F a in t a t fir s t -
s e e n o n l y
a s a h a z e n e a r th e b o n v th is d is
p la c e m e n t o f th e f r a
g m e n ts . M o r e s tr ik in g
th a n th e fr a c t u r e is th e z o n e o f
c r a c k , u s u a lly m o r e o r le s s tr a n s v e r s e in d ir e c tio n : o n ly r a r e l
y is th e r e a n
y
(F ig s 1 . 9 & 1 . 10 ). E v e n th e n th e f r a c tu r e its e lf m a y
s h o w o n l y
a s a f a in t h a ir lin e
m a y
·
r a p
e s a p p e a r
! H W '
tib ia .
F ig . 1 . 1 0 F a tig u e fra c tu re o f lo w e r e n d o f
d 5
@ .
_
&
H a n d - S c h o lie r- C h ris tia n d is e a s e
G a u c h e r '
s d i s e a s e
p o ly o s to tic fib ro u s d y s p la s ia
p a g e t '
s d i s e a s e (o s te itis d e fo rm a n s )
M is c e lla n e o u s
D iffu s e m e ta s ta tic c a rc in o m a
M u ltip le m y e lo m a (m o s i )
D is s e m in a te d tu m o u rs
ld io p a th ic s te a to rrh o e a
N u tritio n a l o s te o m a la c ia
T 7/ C y s tin o s is (re n a l tu b u la r t ic k e ts ; F a n c o n i s y n d ro m e )
4 u ra e m ic o s te o d y s tro p h K (fe n a t ric k e ts )
T n o e lia c (g lu te n - in d t c e d lqc k e ts \ F '"
*
·
. -
f o s te o g e n e s is im p e rfe c ta (fra g ilita s o s s iu m )
G e n e ra l a ffe c tio n s o f th e s k e le to n
« O s tg o n e e ro s is a fte r irrn d ia tio n
T a b e s do r sn l i=
! B o n e a tro p h y in p a ra ly tic c o n d itio n s s u c h a s p o lio m y e litis @ . E o s in o p h ilic g ra n u qo r
a
. M o n o s to tic fib ro u s d y s p la s ia
q s im p le b o n e c y s t
M is c e lla n e o u s
y M e ta s ta tic s a rc o m a (fro m p rim a ry in a n o th e r b o n e )
e ta s ta tic c a rc in o m a (e s p e c ia lly fro m lu n g , b r e a s t , p r o s t a t e , t h
y r o i d o r
- k id n e y )
S o lita ry m y e lo m a '
v l E w in g
'
. . _
C M a lig n a n t tu m o u rs
n H a e m a n g io m a (s p in e )
G ia n t- c e ll tu m o u r (o s te o c la s to m a )
C h o n d ro m a (e n c h o n d ro m a )
B e n ig n tu rn o u rs
P y o g e n ic o s te o m y e litis (u s u a lly in c h ro n ic fo rm )
£ In fe c tio n s
L o c a l d is e a s e o f b o n e
6 0 U T L IN E O F F R A C T U R E S
c a u s e s
o f th e fe m o ra l s h a ft .
d e fo rm a n s ) . © F ra c tu re a t th e s ite o f a c a rc in o m a to u s m e ta s ta s is in th e u p p e r h a lf
th e ra d iu s . © F ra c tu re th ro u g h a tib ia a ffe c te d b y P a g e t '
s d i s e a s e (o s te itis
F ig . 1 . 1 1 E x a m p le s o f p a th o lo g ic a l fra c tu re s . F ra c tu re th ro u g h a b o n e c y s t in
1 7C H A P T E R 1
lim b s in a n in fa n t w ith o s te o g e n e s is im p e rfe c ta (fra g ilita s o s s iu m ) .
p h a la n x o f a fin g e r (a rro w ) . R e c e n t a n d o ld fra c tu re s o f th e b o n e s o f th e u p p e r
F ig . 1 . 1 3 P a th o lo g ic a l fra c tu re th ro u g h a b e n ig n c h o n d ro m a in t h e p ro x im a l
a ffe c te d .
V e rte b ra l fra c tu re fro m c a rc in o m a to u s m e ta s ta s is . A s in g le v e rte b ra l b o d y is
w ith m a rk e d b a llo o n in g o f th e d is c s a t th e e x p e n s e o f th e v e rte b ra l e n d p la te s .
g e n e ra lis e d o s te o p o ro s is . N o te th e p a rtia l c o lla p s e o f s e v e ra l v e rte b ra l b o d ie s ,
F ig . 1 . 1 2 F u rth e r e x a m p le s o f p a th o lo g ic a l fra c tu re s . V e rte b ra l fra c tu re s fro m
m ,
18 0 L I '
-
a fte r tr e a t m e n t .
m a li g n a n t tu m o u r o f te n r e m a in u n u n it e d , b u l u n io n m a
y s o m e tim e s o c c u r
fa il a lto g e th e r , u n le s s th e in f e c t io n is e r a d ic a t e d . F r a c tu r e s th r o u g
h t h e s i te o f a
th r o u g
h a b o n e w e a k e n e d b y
in f e c tio n , u n io n is o f te n s e r io u s l y
d e la y
e d o r m a y
g e n e r a 11 y u n ite , b u t t h e r e m a
y b e s o m e d e la y
. O n th e o th e r h a n d , in f r a c tu r e s
th a n u s u a l . A fr a c t u r e a t th e s ite o f a b o n e c y s t o r b e n i g
n t u m o u r w ill a ls o
e x p
e c te d to u n i te , o fte n in a b o u t th e u s u a l t im e b u t s o m e t im e s m o r e s lo w l y
o r o n e o f th e d if f u s e r a r e f y in
g d is e a s e s o f b o n e (T a b le 1 . 1 ), t h e fr a c tu r e m a y
b e
a ffe c tio n s u c h a s o s te o g
e n e s is im p e r f e c ta , p a
g e t
'
s d is e a s e (o s te itis d e f o r m a n s) ·
n a t u r e o f th e u n d e r l y in
g d is o r d e r o f th e b o n e . W h e n th is is a
g e n e r a lis e d
W h e th e r o r n o t a p
a th o lo g ic a l f r a c tu r e w ill u n i te d e
p e n d s la r g
e l y
u p o n th e
W ill th e fra c tu re u n ite ?
e
e _
C H A P T E R 1 1 9
fa ir ly c o n s ta n t a n d s h o u ld a lw a y s a r o u s e s u s
p ic io n o f a f r a c tu r e
r e q u ir e d h e r e . T h e fo llo w in
g fe a t u r e s , t h o u g h n o t in th e m s e lv e s d ia
g n o s tic , a r e
T h e o b je c tiv e s ig n s o f fr a c t u r e a r e s o w e ll k n o w n th a t o n ly a b r ie f s u m m a r
y is
C L IN IC A L E X A M IN A T IO N
G r e e n s t i ck fr a c t u r e s t he s e ar e co m m o n in t he fo r e a r m bo n e s of ch i ldr e n .
fr a c tu r e s s o m e tim e s g o u n r e c o
g n i s e d .
R i b fra c t u r e s : d e s p i te loc a l te n d e r n e s s an d re s t ri ct ion of re s p i
ra t i on , r i b
lia b le t o b e o v e r lo o k e d .
F r a c t u r e s o f c a r p
a l b o n e s f ra c t u r e s of the sc a p

m e ta ta r s a l b o n e s , a n d th e s h a ft o f th e tib ia o r f ib u la .
F a t ig u e f r a c t u r e s t h e m o s t c o m m o n s ite s a r e th e s e c o n d a n d t h ir d
th e lo w e r e n d o f th e r a d iu s , a n d th e n e c k o f th e f e m u r .
l Im p a c t e d f r a c h u e s th e m o s t c o m m o n s ite s a r e th e n e c k o f th e h u m e r u s ,
-
m a 1 s h o u ld b e a v o id e d
in c h ild r e n .
Tic k fr a c t u r e s . If th e c o m m o n s ite s o f s u c h fr a c tu r e s a r e
tu r e s , fr ¢ ,
tq r .
o f s m a ll b o n e s e s p e c ia ll
y in th e w r is t, fracture .
o f th g i b s a n d ,
th a t m a y b e o v e r lo o k e d in th i s w a
y in c lu d e im p
a c te d fr a . Tu ! .
E s , fa tig q e fr a c
-
r e a s o n a b le f u n c tio n is o fte n p r e s e r v e d d e s p ite a f r a c t u r e . T h e ty p e s o f fr a c tu r e
th a t th e p a t ie n t h a § r e t a in e d th e u s e o f th e p a in f u l lim b . In c e r ta in c a s e s
T h e d o c to r is s o m e tim e s m is le d in to b e lie v in g th a t n o fr a c t u r e e x is ts b
y th e f a c t
C o m m o n ly m is s e d fra c t u re s
m a y
b e a s p
o n ta n e o u s o n s e t o f p
a in a n d d is a b ilit y
w it h o u t a n y
c a u s a t iv e
r e m e m b e r e d th a t in c a s e s o f fa t i g
u e fr a c tu r e a n d o f p
a th o lo g
ic a l f r a c t u r e t h e r e
A lth o u g
h in m o s t fr a c tu r e s th e r e is a d is tin c t h is to r y
o f in ju r y , it s h o u ld b e
c o n tu s lo n .
e v id b n c e o n w h ic h t o d is tin w is h b e tw e e n a f r a c t u r e a n d a s im p
le s t r a in o r
s u g g
e s tiv e . In m a n y
c a s e s , h o w e v e r , t h e h is to r y
d o e s n o t p r o v id e r e lia b le
h is to r y
o f m p r u is i p g ·
a p p
a d a y
o r s o a f te r a n a c c id e n t , is a ls o
.
d b r rg j ty in a lim b b o n e is c le a r l
y d ia
g n o s tic o f fr a c t u r e . A
th e in ju r e d p a r t, m u s t a lw a y s a r o u s e s u s p
ic io n o f a f r a c t u r e . T h e im m e d ia te
T h e s ta te m e n t th a t a p a tie n t is unb! t9 a n d o r w a s a f te r a n in ju r y , o r u s e
H IS T O R Y
) h s a r e n e c e s s a r y t o e s t a b lis h it s
p r e c is e
lw a y s b e in f e r r e d f r o m t h e h i s t o r
y a n d
th e c lin ic a l f in d in g
s a lo n e , b u t r a d io g r a F
T h e p r e s e n c e o f a f r a c tu r e c a n n e a r ly a l
L fe a tu re s o f fra c tu re s
C lin ic a l a n d ra d io lo g ic a lr )
m p a iT f n m .

T h e p a r t o f th e lim b d is ta l t o t h e f r a c tu r e m u s t b e e x a m in e d fo r e v id e n c e o f
S ta te o f th e c irc u la tio n
n o t it c o m m u n ic a te s w ith th e b o n e a t th e s ite o f th e fr a c t u r e .
d iffic u lt y
in d e c id in g , fr o m th e p
o s itio n a n d n a tu r e o f th e w o u n d , w h e th e r o r
a n d d o e s n o t c o m m u n ic a te w ith it . W ith c a r e f u l e x a m in a tio n th e r e is s e ld o m
m Q p e h (c · In s o m e c a s e s a la c e r a tio n is in c id e n ta l to th e fr a c tu r e
T in e p r e s e n c e o f a s b la c e r a tio n d o e s n g t nEearily m e a n th a t tl] b ]a c tu r e is
S k in w o u n d
c a u s e d it b y th e tr e a tm e n t .
d is c o v e r e d a t t h e fir s t e x a m in a tio n , le s t th e s u r g
e o n b e a c c u s e d la te r o f h a v in g
n e c e s s a r il y
a ff e c t th e tr e a tm e n t o f th e fr a c tu r e , it is im p
o r ta n t th a t it b e
g r e a tly th e tr e a tm e n t o f th e f r a c tu r e its e lf . A lth o u g
h a n e r v e in ju r y d o e s n o t
b lo o d v e s s e l o r v is c u s , m a k e s th e c a s e a s u r g
ic a l e m e r g
e n c y , a n d m a
y in flu e n c e
p r e s e n c e o f a w o u n d c o m m u n ic a tin g
w ith th e f r a c tu r e , o r o f d a m a g
e to a m a jo r
T in e s e fa c ts s h o u ld a lw a y s b e a s c e r ta in e d b e fo r e tr e a tm e n t is b e g
u n . T h e
4 . Is th e r e a n y e v id e n c e o f v is c e r a l in ju r
y ?
?
2 . Is th e r e a n y im p a ir m e n t o f th e c ir c u la tio n d is ta l to th e fr a c tu r e ?
1 . Is th e r e a w o u n d c o m m u n ic a tin g
w ith th e f r a c tu r e ?
e x a m in a tio n to d e te r m in e th e a n s w e r s to th e f o llo w in g
f o u r q
u e s tio n s
W h e n a d ia g
n o s is o f f r a c tu r e h a s b e e n m a d e , t h e s u r g
e o n s h o u ld c o n tin u e th e
A D D IT IO N A L C L IN IC A L I N V E S T IG A T IO N S
g r a p h ic e x a m in a tio n .
C lin ic a l e v id e n c e o f f r a c tu r e m u s t a lw a y
s b e c o n f ir m e d o r r e f u te d b y
r a d io -
r a t ing
w h e n the inj ur e d p
a r t is mo v e d .
fr a g
m e n t s)
a b n o r m a l m o b i lity
(tha t is, d e m o n s t ra b l e mo v e m e n t be t we e n t he
s h o u ld n o t b e d e lib e r a t e l y e lic ite d
T h e f o llo w in g
fe a tu r e s g
iv e u n m is ta k a b le e v id e n c e o f k a c tu r e , b u t th e y
m a r k e d im p a ir m e n t o f f u n c tio n .
/ m a r k e d lo c a l te n d e r n e s s o v e r b o n e
s u r f a c e s a n d p
e r io s te u m
v i si bl e br u i si ng
(ec c h y m o s i s) fro m es c a p e of bl oo d fr o m t he fra c t ur e
y o c a l s w e llin g
D v is ib le o r p a lp a b le d e f o r m ity
C H A P T E R 2
o d e ill, e s p e c ia ll y
if th e lim b is e n c a s e d in a c ir c u la to r y
f lo w , t h o u g
h it m a y
b e s lu g g
is h .
'" " ' " " " . . . I. L e I' " " g " " [' " " e c ¢e d rn J · , I' " lh " p i. . I . r d . .
u ltr a s o n o g
r a p h y
o r a r te r io g
F a p
d e s p
ite th e c lin ic a l te s ts a lr e a d y d e s c r ib e d , r e s o r t r T i a y b e h a d to D o
p p le r
S p e c ific te s ts . If d o u b t s till e x is ts a b o u t t h e in te g
r it y o f th e a r te r ia l c ir c u la t io n ,
d is ta l p a r t o f th e lim b .
m a y th e r e f o r e , c o n t in u e to m o v e th e d i
g it s d e s
p ite c o m p
le t e is c h a e m ia in th e
a n d e x te n s o r s o f th e d i g
its a r e im n e r v a te d h i g h u
p in th e f o ]. E a n n a n d le g
a n e l
c o n d u c tiv it y
a r e le s s r e lia b le th a n te s ts o f s e n s ib ility b e c a u s e th e lo n g
f le x o r s
th e te r r it o r y
o f a s in g le n e r v e d e n o te s m e c h a n ic a l in ju r
y . M o to r t e s t s o f n e r v e
b ility o f a h a n d o r f o o t , t h e r e f o r e , s u g g e s ts is c h a e m ia , w h e r e a s in s e n s ib ili t y
in
(e x c e p t in b r a c h ia J p
le x u s in ju r ie s a n d c a u d a e w in a in ju r ie s ). T o ta l in s e n s i-
a f f e c te d , w h e r e a s il is u n u s u a l f o r a ll th e tr u n k s t o b e in v o lv e d in a n in ju r y
th a t in is c h a e m ic le s io n s a ll th e n e r v e tr u n k s in th e lim b a r e lik e l y
to b e
, b y p h y s ic a l tr a u m a t o a n e r v e o r b y
is c h a e m ia i t s h o u ld b e r e m e m b e r e d
. th e n e r v e s , s u g g e s ts is c h a e m ia . In d e c id in
g w f i t l i e r s e n s o r y im p
a ir m e n t is
c ir c u la t io n . L o s s g f s e n s ib ility in th e m ts , in th e a b s e n c e o f p
h y
to
im p u ls e s -
-
p u t t o a d v a n t a g
e w h e n e x a m in in g
t h s ta te o t tli e
N e rv e c o n d u c tiv ity . A n is c h a e n ic n e r v e q u ic k l y
lo s e s i ts a b ilit y
t o tr a n s m it
in te g r ity o f th e c ir c u la tio n .
returning flu s h I a s r a p
id a s in th e s o u n d lim b , a n d p in k , d o e s it te s tif y
to th e
c ir c u la t io n is o c c li d e d , if th e v e n o u s r e tu r n is a ls o o b s tr u c te d . O n ly w h e n th e
U n o r m a l a n d d u s k y
in c o lo u r ) m a y
b e o b s e r v e d e v e n w h e n th e a r t e r ia l
in te r p r e te d w ith c a u tio n , b e c a u s e a c a p illa r
y f lu s h (a lb e it le s s b r is k th a n
c o b s tr u c tio n o f t h e c ir c u la t io n s h o u Jd b e s u s
p e c te d . T h is te s t s h o u ld b e
lo p in k f lu s h , t h e c ir c u la tio n is a d e q u a te . Tf th e r e tu r n is s lu
g g is h o r a b s e n t,
« r e le a s e o f th e p r e s s u r e th e b lo o d f lo w s b a c k b r is k l y
in to th e b ]a n c h e d a r e a in a
g fin g e r n a il a n a r e a o f b la n c h in
g c a n b e s e e n a r o u n d t h e
p o in t o f
p r e s s u r e . If o n
C a p illa ry re tu rn . Th e d i g
ita l p u l
p o r a n a il b e d is c o m p
r e s s e d w ith a
o )
U n r e m
d . A m e r im p o r ta n t fe a tu r e is t
[a m e a
iuinpih-i a n im p o r ta n t c lu e to
j X . X
E a r e n o l r e a d if
y a c c e s s ib le . If n e c s s a r v ,
t h e p la s te r s h o u ]c ig u id e to th e s ta te o iT m cil c u la tio u , b u t w h e n th e lim b is e n c a s e d in
p la s te r th e
y
A rte ria l p u ls e s . T h , if a v a ila b le f o r p
a l p
" ' " ' " u l e
o fr e s h
p la s te r U ra l is s till d a m p
.§ C o ld d i g
its u a n u t. n e c e s s a r ily . b r
{ n @ w a rm th . W a r m d i g
its s u g g e s t a l
2 2 0 U T L IN E O F F R A C T U R E S
e \ I
o r o f a n e i g
h b o u r in g b o n e ?
5 . Is th e r e e v id e n c e o f a n y a s s o c ia te d in ju r y , fo r in s ta n c e o f th e a d ja c e n t jo in t
r e c e n t , is th e r e a n y e v id e n c e o f u n io n ?
4 . D o e s th e f r a c tu r e a p p e a r to b e a r e c e n t o n e , a n d if it d o e s n o t a p p e a r to b e
3 . A r e th e f r a g
m e n ts in s a t is fa c to r y
a lig n m e n t ?
2 . A r e th e f r a g m e n ts d is p
la c e d , a n d , if s o , in w h a t d ir e c tio n ? p a th o lo
g ic a l f r a c t u r e ?
1 . Is th e f r a c t u r e a n o r d in a r y
tr a u m a tic f r a c t u r e , a fe tig u e fr a c t u r e o r a
q u e s ti o n s
a r y , a d d itio n a l f ilm s m u s t b e o b ta in e d to p
r o v id e a n s w e r s to th e f o llo w in g
tio n s h o u ld n o t e n d th e r e . T h e film s m u s t b e f u r th e r s c r u tin is e d a n d , if n e c e s s -
W h e n r a d io g
r a p h s s h o w e v id e n c e o f a f r a c t u r e o r d is lo c a tio n , t h e e x a m in a -
.
c a v it y (F ig . 2 . 1 ). O n l
y in a la te r a l v ie w is it e v id e n t th a t th e h u m e r a l h e a d h a s
g r a p h ic s h a d o w t ir a t s u p
e r im p
a c c u r a t e l y
h p
o n th a t o f th e g
le n o id
h d is p
la c e d b a c k w a r d s o u t o f th e s o c k e t, m a y s till c a s t a r a d io -
if o n l y a n a n te r o -
p o s te r io r p r o je c tio n is m a d e . T h is is b e c a u s e th e h u n n e r a l
te r io r d is lo c a t io n o f th e s h o u ld e r th e r a d io g
r a p
e a r v ir t u a ll y
n o r m a l
o f fr a c t u r e o r d is lo c a tio n m a y
e a s il y
b e m is s e d . F o r in s ta n c e , i n a c a s e o f p o s -
s in g
r a p
r a p
h ic e x a m in a tio n is in a d e q
u a te , t h e d ia g
n o s is
M a n y
le s c o u ld b e g
iv e n to illu s tr a te th e d a n g
e r o f r e l y
in g
s u r g
ic a l tr e a t m e n t m u c h e a s ie r .
v ie w e d in th r e e p la n e s a n d e v e n in th r e e - d im e n s io n s , m a k in g
th e p la n n in g
o f
e v a lu a tio n o f d if fic u lt f r a c tu r e s h a s b e e n m a d e m u c h e a s ie r . Im a g
e s c a n b e
th e in c r e a s in g
a v a ila b ilit y
o f i o m p u te d
-
tfiography (C T ), t h e d e te c tio n a n d
d iffic u lt to d e te c t , s u c h a s th e .
A d o f th e r a d iu s a n d th a p
h o id b o n e . W ith
r e q
u ir e d . T h e s e a r e h e l p
f u l pqRcularly a t s ite s w h e r e a W r e is n o to r io u s l y
In s p e c ia l s itu a ti o n s , a d d itio n a l o b h o r ta n g e n t ia ! p
r o je c tio n s m a y
b e
in c lu d in g
th e a d ja c e n t jo in ts .
in c lu d e a g
o o d le n g th o f b o n e a b o v e a n d b e lo w th e s ite o f s u s
p e c te d in ju r y ,
o n e a n o th e r -
u s u a lly a n te r o -
p o s te r io r a n d la te r a l . T h e fi lm s s h o u ld a lw a y
s
T in e s t a n d a r d te c lm iq u e is to ta k e t w o p r o je c tio n s in
p la n e s a t r i
g h t a n gle s t o
R a d io g ra p h ic te c h n iq u e
fo r th e p a tie n t, it is a ls o im p o r ta n t f r o m th e m e d ic o - le
g a l p o in t o f v ie w .
is n o t o v e r lo o k e d . N o t o n ly is t h e fa ilu r e to d ia g
n o s e a f r a c t u r e a s e r io u s -
m a tte r
b e n e g
a tiv e , t h e c o s t is o n e th a t m u s t b e p
a id fo r t h e a s s u r a n c e th a t a f r a c t u r e
s u s p
ic io n o f a f r a c tu r e . A lth o u g h in a h i
g h
p r o p o r tio n o f c a s e s th e fin d in g
s w iil
R a d io g r a p
h ic e x a m in a tio n m u s t a lw a y
s b e in s is te d u p
o n w h e n th e r e is a n y
£ A D IO G R A P H IC E X A M IN A T IO N
V is c e r a l in ju r ie s w ill g
iv e c h a r a c te r is t ic s y
m p
to m s a n d s i g
n s w h ic h m u s t b e
S ta te o f t h e v is c e ra
C H A P T E R 2 2 3
a d v a n c e s th a t h a m b e e n m a d e in c o m p
u tin g te c h n 6 J o
g y in r e c e n t y
e a r s n o w
Capab]e»aling a fr a c tu r e w h e n it is n o t s h o w n b y ji15in r a d io
p a p
h f 1 J1 e
e n c r o a c h m e n t u p o n th e s p
in a l c a n a l (F ig . 2 . 2 A ). t & g j -
r e s o lu tio n s c a n n in g is
d is lo c a tio n s o f th e s p in e it c a n s h o w v e r
y c le a r l y to w h a t e x te n t th e r e h a s b e e n
tio n o f fr a c tu r e s o f th e s p in e a n d
-
C T s c a n n in g h a s a n in c r e a s in
g l y
im p o r ta n t
p la c e , p a r tic u la r l
y in th e in v e s tig
a -
n o s is m a y b e a id e d b
y r a d io is o to
p e s c a n n in g
in c lu d e f r a c tu r e s o f th e s c a p
h o id
a r e a o f in c r e a s e d u p ta k e in th e s c a n . E x a m
-
e x is te n c e o f a f r a c tu r e is in d o u b t . T h e p r e s e n c e o f a f r a c tu r e is e v id e n c e d b y a n
te c h n e tiu m - 9 9 '
d i p h o s p h o n a te ) is o c c a s io n a ll
y o f v a lu e , e s p e c ia lly w
h e n th e
B o n e s c a n n in g a f te r th e in je c tio n o f a s u i ta b le b o n e - s e e k in
g is o to p
e (u s u a lly
R a d io is o to p e s c a n n in g
r a d io g r a p
h s a lo n e .
im a g
u e s m a y
a d d in f o r m a tio n t h a t c a n n o t b e o b t a in e d f r o m p
la in
a ll th a t a r e r e q u ir e d , b u t th e r e a r e o c c a s io n s w h e n o n e o r m o r e o f th e n e w e r
In th e w
a t m a jo r ity o f c a s e s o f fr a c tu r e a n d ctis lo c a tio n , p la in r a d io
g r a
p h s a r e
O T H E R IM A G IN G T E C H N IQ U E S
d is c o u n te d .
ra d io g ra p h s in tw o p la n e s b e fo re th e p o s s ib ility o f d is p la c e m e n t c a n b e
re d u c e d p o s itio n s h o w n in . T h is c a s e e x e m p lifie s t h e n e e d to o b ta in
p o s te rio rly . (A c lu e is th a t th e a rm is h e ld in m e d ia l ro ta tio n .) C o m p a re w ith t h e
h e a d o f th e h u m e r u s n o rm a lly s itu a te d in th e g le n o id fo s s a . In fa c t it is d is lo c a te d
F ig . 2 . 1 T h e ro u tin e a n te ro -
@

. _
_
_
2 4 0 U T L IN E O F F R A C T U R E S
}b
p la c in g
t h e e n t ir e p a t ie n t in a w h o le b o d
y m a c h in e .
in u o d u c t io n o f s m a lle r s c a n n e r s t h a t a llo w im a g
in g
o f th e a r m o r le g , w ith o u t
m o v e m e n t a n d r e p o s itio h in
g . A m o r e r e c e n t d e v e lo p m e n t h a s b e e n th e
a s s e s s m e n t o f th e p
a t ie n t w ith m u l tip le in ju r ie s w ith o u t th e n e e d f o r fr e w e n t
e x p e n s iv e , b u t is n o w a v a ila b le in M a jo r T r a u m a C e n tr e s a n d a llo w s r a p
id
in th e a s s e s s m e n t o f s p in a l a n e l p
e lv ic f r a c tu r e s (F ig . 2 . 3 ). T h e te c h n o lo g y
is
o f s o f t tis s u e s , in c lu d in g n e u r o lo g
ic a l s h ·
u c tu l'" s , a n d p la y
s a n im p o r t a n t r o le
Th i s t ec h n i qu e is l es s w i de l y a
v a i lab l e t h a n c T . b u t o f f e r s i mp r o v e d i ma g i
ng
M a g n e tic re s o n a n c e im a g in g
in th r e e p la n e s a n d in t h r e e - d im e n s io n s (F ig . 2 . 2 B ) .
a llo rn ' m o r e s o p h is tic a t e d im a
g jn g , w ith th e a b ilit
y to r e c o n s tr u c t to m o
g r a p h s
e b ra l le v e l . N o te th e d o u b le im a g e o f th e v e rte b ra l b o d y in th e a x ia l v ie t
o n a t r e c o n s tr u c t io n to s h o w c o m p le te d is lo c a tio n a t t h e C 4 /C 5
C o m p u te d to m o g ra p h ic s c a n s o f t h e c e rv ic a l s p in e . A x ia l ; th re e -
in te rv e r t
d im e n s io
F ig . 2 . 2 (
C H A P T E R 2
im p r e s s io n o f tr a b e c u la r c o n t in u it
y w h e n in f a c t i t d o e s n o t e x is t .
o v e r la p p in g
o f th e r a d io g
r a p h ic s h a d o w s o f th e t w o f r a g m e n t s m a
y g iv e a fa ls e
T r a b e c u la r c o n tin u it y
a c r o s s th e fr a c t u r e is e v id e n c e o f m a t u r e u n io n , b u t
O f th e s e , v js ib le c a llu s is g
e n e r a ll y th e e a r lie r a n d th e m o r e r e lia b le s ig n .
2 . c o n t i n u i ty o f b o n e tr a b e c u l a e a c r o s s t h e f r a c h i r e (F ig . 2 . 5 B ).
(F ig . 2 . 5 A )
1 . v is i b l e c a ll u s b r i d g in g t h e f r a c t u r e a n d b le n d in
g w ith b o th f r a g
m e n ts
D T h e r e a r e tw o r a d io lo
g ic a l f e a tu r e s th a t in d ic a t e u n io n
R a d io lo g ic a l c rite r ia o f u n io n
r a d io lo g
ic a l s t u d ie s .
T h e s e te s t s to g
e th e r a r e r e lia b le , b u t th e y s h o u ld a lw a
y s b e c o n f ir m e d b y
(F ig . 2 . 4 ).
3 . A b s e n c e o f p a in w h e n a n g
u la tio n s tr e s s is a p p
lie d a t t h e s it e o f f r a c tu r e
2 . A b s e n c e o f t e n d e r n e s s o n f ir m p a l
p a tio n o v e r th e s ite o f f r a c tu r e
1 . A b s e n c e o f m o b il it y b e tw e e n th e fr a
g m e n ts
T h e r e a r e th r e e c lin ic a l te s ts o f u n io n
C lin ic a l te s ts o f u n io n
T -
fo T ie s tin g
s tif fn e s s , b u t a t p
r e s e n t t h e s e h a v e li ttle p r a c tic a i a
p p lic a tio n .
. - r o n a n c e o f th e b o n e e le c tr o n ic a ll y , o r b y o th e r d e v ic e s s
p e c if ic a ll
y d e s i
w e d
p o s s ib le t o a s s e s s u n io n o f a lo n g b o n e s h a f t f r a c t u r e b
y d e t e r m in in g
th e
b in a t io n o f c lin ic a l a n d r a d io lo g
ic a l e v id e n c e . In th e f u tu r e i t m a y
a ls o b e
w h e th e r o r n o t s o u n d u n io n h a s o c c u r r e d . T h e d e c is io n is m a d e f r o m a c o m -
A t a c e r t a in s ta g
e in th e tr e a tm e n t o f a f r a c t u r e it i s n e c e s s a r y
t o a s c e r ta in
T E S T S O F U N IO N
C 4 v e rte b ra w ith c o m p re s s io n o f
s c a n o f th e c e rv ic a l s p in e
@
_
-
-
-
_
_
_
_
@
© C o n tin u ity o f b o n e tra b e c u la e a c ro s s a fra c tu re o f th e s c a p h o id b o n e .
F lg . 2 . 5 R a d io lo g ic a l c rite ria o f u n io n . B rid g in g o f th e fra c tu re b y c a llu s .
a p p lie d ,
p a lp a tio n o v e r t h e b o n e ; a n d (3 ) a b s e n c e o f p a in a t t h e fra c tu re s ite w h e n s tre s s is
a re : (1 ) a b s e n c e o f m o v e m e n t a t th e fra c tu re s ite ; (2 ) a b s e n c e o f te n d e rn e s s o n
F ig . 2 . 4 T e s tin g fo r u n io n a fte r a fra c tu re o f th e tib ia . T h e c lin ic a l s ig n s o f u n io n
C H A P T E R 2 2'
_
_
_
_
8 in te r f e r e w ith th e a c c u r a c y
o f th e m e th o d .
E n o n - u n io n in d o u b tf u l c a s e s , b u t th e v a r ia b ilit y
o f th e s o f t - tis s u e in te r fa c e m a y
g r a d u a ll y
in c r e a s e s . T h is c o u ld b e c o m e a u s e f u l m e th o d o f c o n fir m in g u n io n o r
E tr a c tu r e r e s o n a te s a t a lo w e r f r e q u e n c
y . A s u m o n D e C O m e s n r m e m n e rr e
q u e n c y
g T h is n e w te c h n i q
u e is s till e x p
e r im e n ta l . A n in ta c t lo n g
b o n e s u c h a s th e tib ia
q T e s ts o f re s o n a n c e
to e n s u r e th a t th e to u r n i q
u e t is n o t in a d v e r te n tl y
le f t in p
.
its a p p lic a tio n . If n e c e s s a r y , a n o t e t o t h is e ffe c t s h o u ld b e s e n t w ith th e
p a tie n t
th o s e a tte n d in g th e p
a tie n t s h o u ld b e m a d e a w a r e o f th e fa c t a n d o f t h e t im e o f
o f th e lim b m a y
b e a p p lie d to c o n tr o l th e b le e d in
g x 'f a to u r n i
q u e t is a p p
lie d ,
p e n d in g
its a p p lic a tio n , fir m m a n u a l
p r e s s u r e o v e r th e rT ra in a r t e r
y a t th e r o o t
w o u n d , w ith -
th e p a tie n t r e c u m b e n t, d o e s th e n e e d fo r a to u m i
q u e t a r is e .
w ith c a r e to a v o id b o th f le x io n a n d e x te n s io n . if . irvealcw i§ a v a ila b le . it to th e c o r d . A c c o r d in
g ly th e p a tie n t s h o u ld h i ifte d