Special Surgery Fractures and Dislocations (2020-2021) PDF

Fractures and dislocations general principles I __, Forms the shafts of long bones Forms the vertebrae & the ends - Definition of - Metabolic turnov er is slow...

Fractures and dislocations general principles I __, Forms the shafts of long bones Forms the vertebrae & the ends - Definition of - Metabolic turnov er is slow of Ion bones Metab olic turnover is rapid fracture: structural break in the normal It can withstand torsional and It can withstand compression continuity of a bone. - bending stresses (contributes to pliability of -Classification of bones: - contributes to ri idi of bone Blood supply of bones bone a) According to shape 1. Long bones A) Long bones , is derived from: (femur) 1. Nutrie nt artery: 2. Short long bones (carpal & tarsal - Enters the shaft through the nutrien t foram en bones) V then runs obliquely through the cortex - Divides into ascending & descending branches - in medul lary cavity._,.........,._ -·- 3. Flat bones (sternum, ribs, and scapula) - - Terminates in the adult metaphysis by anasto mosing with the 4. Irregular bones epiphyseal, metaphyseal and periosteal arteries. (vertebrae & hip - Supplies the medul lary cavity, inner '2/3 of cortex & metap hysis bone) 2. Periosteal arteries: b) According to - Nume rous beneath the muscu lar and ligamentous attachments. mechanism of - Branch beneath the periosteum -. supply outer 1/3 of the cortex. ossification 3. Epiphyseal arteries: derive d from periarticular vascular arcades. 1. Membranous 2. Cartilaginous 4. Metaphyseal arteries: 3. Membrane- - Derived from the neighbouring system ic vessels. - Before epiphyseal fusion, the metap hysis is richly supplied with cartilaginous blood by end arteries. c) According to B) Short long bones , (e.g., metacarpals and metatarsals) maturity 1. Immature -The nutrient artery breaks up into a plexus immed iately upon (woven) bone._ reaching the medul lary cavity. ·eo11agen is laid down irregularly" Etiology of fracrnres 2. Mature (lamellar) bone "Collagen A) Traumatic fractures fibres are arranged 1. Direct trauma parallel to each - E.g., fracture of the tibia if the bumper of a motor car strikes the bone. other" and it has 2 -The fracture occurs at the point of impac t types: - In the leg or forearm, if both bones involved - fractured at same level. i)Com pact 2. Indirect trauma (cortical) bone - E.g., i) twisting of the leg - fractures the tibia ii) Cance llous ii) Compression applied vertically on head or feet - fracture the spine B) Pathological fractures (bones have abnormal fragility) (trabea.tlar) bone - more porous - Trivial trauma - break \,.,,,," -The causes might be: - The metaphysis is 1. Local bone diseases as: osteomyelitis, cysts, primary tumours or the zone of active "-" secondaries growth 1 2. Generalized bone diseases as: osteogenesis imperfecta, osteoporosis, - No history of hyperparathyroidism, Paget's disease and multiple myelomatosis. trauma in stress (These diseases may lead to multiple fractures) fractures & some '- C) Stress (fatigue) fractures -They occur secondary to repeated minor loads applied to the skeleton cases of - E.g., march fractures which occur in 2 nd & 3rd metatarsals due to pathological prolonged walking Clinical feature and diagnosis fractures - Never intentionally look - A) History of trauma for crepitus & B) Symptoms: abnormal mobility 1. Local pain: ranges from mild to severe. as: 2. Swelling 1. Their 3. Loss of function of injured part (varies from minimal to complete) confirmation adds nothing to the C) Signs: diagnosis....,, Inspection ~ 1- Swelling & ecchymosis 2. Causes pain & Due to effusion of blood from broken bone ends & torn soft tissues may result in 2-Deformity due to displacement of bone fragments. further soft tissue Palpation: damage 1. Tenderness over a localized point on the surface of the bone. - Examine the 2. Crepitus when the bone ends are moved against each other. motor & sensory 3. Abnormal mobility (except with incomplete & impacted fractures) innervation of D) Radiological diagnosis a limb and its - Radiographs of whole bone including joints in which it participates circulation, for a -X-rays obtained in at least 2 planes (antero-posterior and lateral) complete clinical -In certain circumstances, other views may also be required. diagnosis of a Fracture description fracture 1-Site of the fracture Intra-articular, epiphyseal, metaphyseal or diaphyseal 2- Extent of the fracture a) Complete fractures: the bone is broken into 2 or more fragments '-- ~tend to displace with loss of opposition & alignment../ b) Incomplete fractures: the bone is incompletely broken~ no displacement occurs, as in fissures & greenstick fractures of children 3-Fracture line a) Transverse: due to direct violence. b) Oblique or spiral: due to indirect violence. -- - c) Comminuted: due to severe compression~ >2 bone fragments d) Avulsion: separation of a bony process with its attached muscles. d) Epiphyseal separation in children. 2 -  4-Displacement Li 1 -. - Describes the position of the distal fragment in relation to the - proximal one, the possible types are: 1. Lateral displacement -+ distal fragment deviates to one side with loss of opposition. 2. Angulation -+ loss of the normal longitudinal axis of the shaft. -It may occur in 1 of 4 directions (anterior, posterior, medial & lateral) 3. Over-riding -+ distal fragment overlaps the proximal fragment with shortening of the limb. 4. Rotation -+The distal fragment is rotated along its long axis 5. Distraction -+ fragments are separated either by: Us i) Over vigorous traction during treatment (more commonly) ii) Excessive muscle pulls at the time of injury (rare) 6. Impaction. 5-Stability 1- Stable fracture: further displacement after reduction is unlikely. 2-Unstable fracture: displacement is likely to occur as in Oblique, - The chances of spiral and comminuted fractures. significant bacterial 6- Skin dama ge (practically the most important description) contamination is 1-Simple (closed)fractures: The skin surface is intact. greater in case it is 2- Compound (open) fractures: A laceration in the skin compound from communicates with the fracture haematoma -+ bacteria can reach without. the fracture site. -Fractures of tibia & -The skin wound may be caused by: mandible are commonly compound i) Fracture fragment penetrating the skin from its deep surface "compound from within" or ii) By direct injury to the skin "compound from without" Fracture healing - 1. Repair by granulation tissue (lasts for a few weeks) - A haematoma forms between the bone ends underneath the '--" raised periosteum which become invaded by vascular granulation ~ tissue and bridges the fracture gap ~:J 2. Union by primary callus (ends at 2-3 months) '---' - Trabeculae of cartilage invade & replace the granulation tissue. -- "-" - Bone cells & matrix gradually appear -+ formation of an irregu mass of vascu lar bone and calcified cartilage at the site of the lar - -C.. fracture (primary callus) It first appears on the outer aspect of the fragments (external ~ - i..... callus). then along the medullary canal (internal callus) & finally between the cortex of the bone ends (intermediate) 3  - All fractures are 3. Formation of mature bone (ends at 4-6 months) associated with -The intermediate callus is gradually replaced by lamellar trabeculae some blood loss laid down along the lines of stress and strain. that might be -The external and internal calluses are absorbed with restoration of massive as in the medullary cavity. fractures of major long bones, the Factors affecting union of fractures pelvis & the spine 1-Age: -Bleeding may not..._ - Fractures of children heal in a much shorter time than adults. be immediately - Osteoporosis in elderly people retards the union of fractures. obvious. - A patient with a 2- Type of fracture: fracture of pelvis or -Oblique & spiral fractures heal rapidly than transverse fractures shaft of the femur 3-Position of the fragments: can lose up to 2 - If the fragments are impacted, union occurs rapidly. liters of blood - Distraction of the fragments markedly delays healing. - The management 4- Vascularity of the fragments: of internal - Impaired blood supply -+ ischemia -+ avascular necrosis haemorrhage and -+delayed healing visceral injury takes - Examples: a) Fractures of the lower thirds of the tibia and ulna priority over a limb b) lntracapsular fracture of the neck of femur (head of femur fracture becomes avascularized) 5- Immobilization of the fragments (vital for proper healing) - Reduction is not necessary when the Lack of proper immobilization -+ repeated movement at the fracture displacement is: site -+interfere with the process of union 1.trivial (e.g. a 6- Infection (disastrous to the healing process) fractured Infection -+ granulation tissue destruction & decalcification of bone metacarpal --+ ends.-nonunion neighbouring bones Treatment of fractures & soft tissue splint the fragments) I) General management 2. Displacement will 1-Follow the guidelines of trauma life support: ABCD not leave functional 2- Pain: should be immediately relieved by local splinting (at the or cosmetic accident site) and by analgesics disability (e.g., 3-Blood loss: must be replaced most fractures of 4- Attention to associated injuries the clavicle). - Reduction is - e.g., injuries of the urinary bladder in fractures of the pelvis urgent in fractures 5- Tetanus toxoid & antibiotics for patients with compound fractures with complicated II) Local management (reduction, fixation and rehabilitation) vascular or nerve 1. Reduction of the fracture injury. - Aim: restoration of normal (not always achieved especially when - Accuracy of using closed means) or acceptable anatomy reduction is desired -Time: Early before the part gets swollen in any fracture, particularly -Methods: fractures involving a) Closed reduction articular surfaces. i) Gravity : The muscle power of the upper limb is not very strong. 4 - -Angulation, rotation -Fractures like surgical neck or shaft of humerus can be reduced & overlap are not relying on the weight of the limb by placing it in a collar and cuff permissible in the -A plaster of Paris cast may be applied to increase weight and lower limb & forearm prevent side-to-side displacement..However, partial ii) Closed manipulation side displacement is - Better done under general anaesthesia --+painless & allow muscle accepted in a relaxation --+ good alignment of fracture fragments. transverse fracture iii) Traction of long bone shafts - Used for fractures of long bones of LL, e.g. fracture shaft femur. -Compartment - Types --+ Skin or skeletal traction syndrome: b) Open (surgical) reduction. 1. In the first few hours after -Indications: application of the 1. Inability to achieve closed reduction due to interposition of soft plaster, edema tissues between the fractured segments. occurs at the 2. If it is impossible to reduce the fracture because of inability to fracture site and as hold one of the fracture fragments. the plaster is 3. Intra-articular fractures as closed reduction will be inaccurate inelastic - tissue 4. late unreduced fracture pressure rises 5. When internal fixation is needed - venous obstruction- arterial 2. Fixation of the fracture obstruction (if the -Aim: keep the two ends of the fracture in position after reduction condition is not until solid healing occurs. treated) - ischemic - Types: necrosis of the a) External fixation, methods: muscles i) Plaster of Paris 2. To avoid this : Should include the joints adjacent to the fracture site. complication, the - Advantages: it is cheap, safe & does not need extensive facilities. limb should be - Disadvantages: padded with wool & V the plaster should Joint stiffness. not be tightly Muscula r atrophy (due to prolonged immobilization) applied. Inability to maintain reduction during the immobilization perio 3. The patient Liability to cause compartment syndrome or Volkmann's should be kept in ischemic contracture. hospital for 24 hours ii) Traction. to observe - Types: skin or skeletal traction peripheral limb Skin traction circulation & if any -Method: an adhesive bandage is applied to the skin and then a sign of ischemia weight is attached to the bandage. appear- - Disadvantage: only a small weight (not> 2.25 Kg) can be applied, immediately remove therefore, it is suitable only for children. the plaster Skeletal traction -Method: a special pin is passed into the bone and then a weight is applied to the pin. -Indications: in adults for fractures of the lower limb. -Immobilization continue until there is evidence of clinical healing tndion 5  iii) External skeletal (metal) fixation. :~~~·.·~" ~ -Indication: useful for compound fractures. - Method: Special pins are introduced in the bone proximal and distal to the site of the fracture and the pins are connected to a , ·-. '-- special metal frame ·:' - ~-. ~:'~ -Advantages: 1.avoids operative internal fixation with the possibility of infection....... \~-- 7 2. Leaves the wound accessible for inspection. b) Internal fixation 2 -Methods: 1. Screws 2. Plate and screws 3. lntramedullary nail 4. Compression screw and plate -Indications: i) Difficult fractures 1. Those prone to non-union, especially the femoral neck. 2. Those prone to malunion, e.g. fracture-subluxation of the ankle - Fracture fixation and wrist (are often unstable) and mid-shaft fractures of forearm. should precede 3. Those prone to be pulled apart by muscle action, e.g. vascular or neural repair, or else the transverse fractures of patella and olecranon. site of repair would ii) Pathological fractures (2ry to metastasis or osteoporosis) be subject to iii) Multiple fractures (with 2 major fractures in one limb, fixation of disruption. one facilitates closed treatment of the other) - In compound iv) Unstable fractures fractures: v) Nursing difficulties 1- Nerve injury -+ E.g., elderly patient, Internal fixation allows early ambulation in order mark it for delayed to reduce the risks of DVT, bed sores and pneumonia repair VI) Associated soft tissue injuries, e.g. vessels or nerves 2-blood vessel - Advantages: injury - ligate, 1. Very accurate reduction of the fracture segments. repair or graft 2. Strict immobilization of the fractured bones. 3. Early mobilization of the patient thus avoiding all the problems of prolonged immobilization particularly in elderly persons. 4. Protection of vascular anastomoses in vascular injury. 3 -Rehabilitation -Aim: restore function of injured part & that of the patient as a whole. -All unsplinted joints must be used from the very start and the muscles controlling these joints are kept active by exercises. -After removal of the splints, residual joint stiffness is treated by graduated exercises. 6 - Mana geme nt of compound fractures -Treatment is urgent surgery-. debridement (excision) of dead -Fat embolism: tissues followed by external fixation. May follow multiple -Steps: 1-Done in an operating theatre under general anaesthesia or major fractures. 2-The wound is thoroughly cleansed. where fat droplets 3- The deep fascia is widely opened. from bone narrow 4- Any foreign bodies, necrotic tissue, necrotic muscles, or necro or adipose tissue tic skin edges are removed. enter an artery - 5-Any soft tissue injury is dealt with according to the rules distal embolization. 6-Bleeding points are tied but a major vessel injury is repaired - Timing : usually one day after injury 7-The deep fascia and skin are closed if there is no contaminat ion. -C/p: (if contamination is suspected or surgery is delayed for more than a 1. Cerebral few hours , they are best left open) embolization 8-Stabilize the fracture externally by a plaster slab or external make s the patient skeletal fixators (internal fixation is avoided for fear of infection) drows y, restless & 9-Prophylactic antibiotics and prophylaxis against tetanus finally, coma tose. 2. PE - dyspnoea Complications of fractures and cyano sis. 3. Petechial rash I) General Complications -Diagnosis is 1:_Shock essentially clinical. - Neurogenic and hypovolaemic shock may accompany major However, it may be fractures as those of the spine, pelvis or femur. confirmed by - Blood loss with a fractured pelvis may be up to 2-2.5 liters finding fat droplets z- Respiratory complications in sputum & urine -Treat ment: by - Prolonged recumbency (particularly in elderly) -. aspiration respiratory pneumonia and pulmonary embolism. support, - Incidence reduced with early mobilization of patients following heparinization and recent techniques of open reduction and internal fixations low molecular 3-Deep vein thrombosis weight dextran 4- Fat embolism 5-Urinary calculi - Cause: Prolonged immobilization -. demineralization of the - It is essential to skeleton -. formation of calcium phosphate calcu li. check the -Prevention: High fluid intake and early mobilization circulation in the 6- Bed sores distal part of the -Cause: secondary to prolonged immobilization especially in elderl limb and if there is y suspicion of a -Prevention: Frequent change of the position, massage, assurance vascular injury, an of dry bed sheets and the use of an air-mattress angiography may 7- Tetanus (in compound fractures) be performed. - If an arterial injury is diagnosed, open reduction & internal fixation are performed prior to vascu lar repair. -Venous injuries are also repaired 7 II) Early local complications 1. Skin injury -The fractured bone ends may injure the skin from inside (internal compound fracture), but fortunately the risk of infection is not high 2. Vascular injuries -Causes:... '- i) The fractured bone ends may injure the adjacent vessels As in: a) Injury of the brachia! vessels following a '-" supracondylar fracture of the humerus b) Injury of the popliteal vessels as a consequence to Delayed healing supracondylar fracture of the femur -Bone ends are '-...., ii) Tense haematoma may damage the artery decalcified and iii) Contusion with 2ry thrombosis the fracture line is.__, 3- Nerve injuries widened into a._,, -Mechanism of injury: excessive traction or compression gap full of fibrous - Result: neurapraxia, axonotemesis or neurotemesis (less common) tissue. __,, -Examples: a)circumflex nerve injury in fracture neck humerus b) -Clinically: still abnonnal.__,, radial nerve injury in fracture shaft humerus movement& 4- Tendon or muscle injury tenderness at the '--' 5- Infection (serious complication) site of fracture -Cause: may complicate compound fractures. -Spontaneous '--" -Effect: leads to delayed healing, non-union or osteomyelitis. healing is possible \....-- 6-Avascular necrosis of bone with prolonged, - Cause: some fractures damage blood supply to some bone areas -The commonest example is intracapsular fracture of the neck of the uninterrupted Immobilization - femur -* avascular necrosis of femur head -* delayed union or non- \.J union of the fracture or osteoarthrosis of hip joint (later) Nonunion......... 7- Visceral injury - Bone ends are -Example: pelvic fracture -* injury to the bladder or Urethra sclerosed & the...__..., 111) Delayed local complications medullary canal is closed by dense -..../ 1- Malunion Bone -Definition: union but with some deformity as angulation -Spontaneous '-...., -Cause: a) Inadequate reduction b) Failure of immobilization healing is -Avoided by: Open reduction and internal fixation impossible..J -Effect: lead to cosmetic and functional disability -Treatment of ___,, 2- Delayed union and nonunion delayed union & -Causes: non-union done ,._,, a) Impaired blood supply of one or both fragments (as in intra by some fonn of capsular femoral neck fracture) -* poor invasion of the fracture internal fixation ~ haematoma by cells that have osteogenic potential with decreased ability to produce bone due to low oxygen tension b) Inadequate immobilization-* cutting of granulation tissue and application of autogenous bone graft (from - cancellous tissue c) Interposition of soft tissue between the fragments. of the iliac crest) d) Over-distraction of the fragments due to excessive muscle pull e) Infection which destroys the granulation tissue. d) Pathological fractures, e.g. due to malignant disease - __, 8..J -J  3- Sudek 's atrop hy -Definition: This is a syndro me of osteop orosis , swelling of the soft tissue, vascu lar stasis, pain & joint stiffne ss compl icating a fracture. - __, -Etiology: unkno wn, suppo sed to be due to: a) Reflex vascu lar stasis due to sympa thetic overac tivity b) Disuse atroph y (patien t relucta nt to use limb after splint remov al) -Comm onest examp le: following Colles' fracture. -Treat ment: splinting, sympa thetic block, analge sics & physio therap y 4- Myositis ossificans -Mech anism : a) extens ive strippi ng of the perios teum & ossification of the subperiosteal haema toma b) or due to hetero topic bone format ion in adjace nt muscles. -Comm onest examp les: after disloc ation of elbow , should er or hip. -Treatment: a) Avoid Massa ge b) Immob ilizatio n (allow haema toma stabilization & new bone resorption) 5- Joint stiffness and osteoarthrosis -Causes: a) comm on after intra-articular fractur es espec ially in elbow, should er & hip b) After prolon ged immob ilizatio n 6-Gro wth disturbance if fractur e affects epiphy seal plate in children 7- Osteoporosis: due to prolon ged immobilization - - 9  Injuries of j,oints 1- Ligament injuries Sprain Complete tear / '\ Definition Some fibers injured All fibers injured - Assessment of C/P 1. Limited movement Haemarth rosis joint stability is 2. Severe pain done under 3. Tender injury site Joint Stable Unstable anaesthesia \... stability Treatment Joint is firmly 1. Haemarthrosis is aspirated. bandaged until pain 2. Plaster of Paris cast for 6-8 subsides weeks. 3. Later active exercises avoiding tension on the ligament. 4. In young individuals- early surgical repair is favored 2- Traumatic effusion - Source: synovial membrane produces effusion following Joint injury - Timing: usually several hours after the injury - The commonest joint affected: knee. - Treatment: a) Bandage or splint is applied to limit the effusion & relieve pain b) If effusion tense - aspiration 3- Haemarthrosis - Definition: bleeding inside the joint - Etiology: severe injury (gross ligament injury or intra-articular fracture) -C/P: swollen joint with severe pain & limited mobility - Treatment: a) Aspiration of blood. b) Joint immobilization for a few days by a bandage or a splint. c) Active muscular exercises 4- Internal derangement of a joint - Definition: various injuries which impair joint movements & stability. - The commonly affected joint: knee - Types of injuries: a) Injury of the medial, lateral or cruciate ligaments. b) Injury of the menisci. c) Loose bodies. d) Recurrent dislocation of the patella. 5- Dislocation and subluxation - Dislocation: joint surfaces are completely displaced and are no longer in contact - Subluxation: there is partial disruption of the joint and the articular surfaces are still opposed 10 - Upper limb Incidence The commonest fracture in the whole body Trauma Indirect ~ fall on the outstretched hand - Always occurs in the middle third (the weakest part) Displacement The outer fragment: displaced downwards & inwards by arm weight The inner fragment: pulled up by the sternomastoid In children, the fracture is often of the greenstick variety. Complications 1- Malunion (common) - -Of no functional significance, rarely has cosmetic problem 2- Non-union (uncommon) 3 I · f th bclavian vessels and brachia! plexus (rare) Clinical picture 1-The shoulder is sagging and deformed. 2- Characteristic posture (position of lactating mother) -The patient usually supports his elbow with the opposite hand and bends his head to the affected side (to relax the sternomastoid) -- Treatment 1- A broad arm sling for 3 weeks and analgesics. 2- Internal fixation (If there is associated vascular or nerve injury) -The shoulder joint has sacrificed stability for mobility. - Anterior dislocation -Shoulder instability is due to: a) Shallow glenoid Incidence The commoner type (Posterior dislocation is rare) cavity with a relatively large humeral head. Forced extension and external rotation of the abducted arm b) Lax capsule c) Lack of support by strong ligaments &..__ muscles 11  Displacement -The head of humerus: dislocates forward -----+ subcoracoid position - ,. the humerus is locked in place by muscle spasm Recurrent -The capsule of the shoulder: ruptures its anterior aspect shoulder - The labrum qlenoidal: avulses from the glenoid. -The humerus passes over the anterior margin of the glenoid - dislocation - lure of posterior part of articular surface of the head -Etiology: due to detachment of labrum glenoidal 1-Axillary nerve injury: mostly neurapraxia -----+ spontaneous recovery & the anterior 2- Avulsion of the supraspinatus tendon capsule from the - Discovered by inability of the patient to initiate abduction anterior margin - Treatment: repair of the musculotendinous cuff. of the glenoid 3- Associated fracture of greater tuberosity or humeral neck. --+the humeral 4- Recurrence (a common problem) head slips easily through the torn Clinical picture capsule - Mechanism: with shoulder Inspection abduction & 1-The outer aspect of the shoulder is flattened. external rotation 2-The arm appears to take origin from a point under the junction of (occurs with the middle and outer thirds of the clavicle. increasing ease 3-The patient supports the elbow of injured arm by the other hand in & frequency) slight abduction of the arm during minor 4-The distance between the point of the elbow and the axillary skin event as is reduced and the axillary concavity is obliterated. combing hair Movement - Reduction is The shoulder cannot be moved equally easy and usually patient Investigation can reduce the J dislocation X-rays in anteroposterior views-----+ diagnostic himself Treatment -Treatment: Surgically by Reduction under general anaesthesia with muscle relaxation repair of the Kocher's technique anterior capsule.,, 1. Downward traction (to disengage the head) & subscapularis 2. External rotation (to overcome subscapularis muscle spasm) muscle if it were 3. Adduction (bringing the elbow across the chest) also torn. 4. Internal rotation (carrying the hand to the opposite shoulder) - Reduction is confirmed by putting the shoulder through a full range of movement under anaesthesia - 12 - - Immobilization - For 3 weeks in adduction & internal rotation of the Fractures that shoulder by a sling and bandaged occur due to - Allow healing of torn capsule and minimize recurrenc fall on the e tend ency Rehabilitation outstretched hand At the end of 3 weeks, the sling is removed and prog 1. Clavicle fract ure ressive 2. Supracondylar mobilization of the shoulder is done for 3 more week s (avoid only (extension type) external rotation in abduction ~ position of shoulder dislocates) 3. Posterior elbow dislocatio n Fractures of the humerus. I 4. Calles' fractu re 5. Scaphoid Fractures of the neck of humerus fracture Mechanism of injury - Indirect: by a fall on the outstretched hand "- - Direct: fall on the point of the shoulder. Classification 1- Stable 2- Unstable (caused by comminution) Clinical picture Type of patient 1- Common in the elderly (Usually associated with osteoporosis & only need minor trauma) 2-ln younger adults (Require a considerable force &fracture dislocation may occur) Symptoms Pain in the shoulder and inability to move the joint Complications 1-Shoulder stiffness -Common especially in the elderly who may neve r rega in a full range - Diagnosis is of movements. made -Treatment ~ early passive followed by active mob ilization. radiologically 2- Axillary nerve injury. 3- Axillary artery and brachia! plexus injury. - Limited 4- Malunion (common but with excellent functions ). movement may 5- Avascular necrosis of the humeral head. be possible in __, 6- Nonunion (not common). mino r impacted ?-Associated shoulder dislocation (dislocation shou fractu res ld be treat ed first) 13  Treatment 1- In stable fractures (particularly in the elderly) - By an arm sling and as pain diminishes within days-➔ gently move the shoulder (to avoid stiffness) 2- In unstable comminuted fractures (in young patients) a) Mild or no displacement -➔ closed reduction under anaesthesia b) Marked displacement-➔ an open reduction and internal fixation Fractures ·of the shaft of the humerus ~~ Trauma I 1- Indirect : a) Arm twisting -➔ spiral fracture with or without a butterfly fragment. b) Fall onto the outstretched hand. 2- Direct: Blow over the shaft -➔ transverse fracture(+/- butterfly fragment) Displacement Upper 1/3 Middle 1/3 Lower 1/3 - ijust below the neck) Proximal fragment abducted by the adducted and pulled abducted by the supraspinatus inwards by the deltoid pectoral is major Distal fragment adducted by the abducted by the adducted and pulled pectoralis major deltoid upwards by the coracobrachialis - Complications -- 1- Delayed union and nonunion. -.___ '- 2- Joint stiffness ,. C / 3- Radial nerve injury ___, - Mostly neurapraxia -➔ full recovery in most cases. 'I___,, - Motor: wrist drop and finger drop -Sensory: localized to snuff box '-..,._.. 14 - Treatm ent I-Closed methods A) Reduction & fixation using - U-shaped plaster slab (for 8 weeks ) - Reduction obtained by gravity acting on the arm and exerting steady traction -correct any angulation & overriding that may occur -The bandage runs from the top of acromion, down the lateral side of the arm, under the elbow and up the medial side of the arm to axilla. -For further stability - the arm bandaged to the chest wall. B) Alternatively -a hanging cast U slab (A complete cast extending from the axilla to the wrist) - Advantages: the action of gravity is more because of its heaviness - Disadvantages: the elbow cannot be mobilized during treatment 11- Open reduction and internal fixation (rarely needed) -Indication: when closed methods not obtain a satisfactory reduction Ill-Treatment of complications Radial nerve injury Avoid development of fixed flexion of the wrist and fingers by a combination of a removal cock-up splint and passive mobilization Supracondylar fractures Extension type - The fracture ecommonest line runs Trauma Fall on the outstretched Fall on a flexed transversely hand with the elbow slightly elbow. through the flexed distal Displacement -The distal fragment is The distal fragment metaphysis of displaced and angulated the humerus. is displaced posteriorly in relation to the - The fracture is anteriorly by biceps roximal one. greenstick in & brachialis 50% and B complete in 50% of cases. - Clinica l picture Type of patient More frequent in children Symptoms 1- Pain 2- Swelling at the elbow region. 3- The child is not able to move the elbow. 15 Signs 1-Swelling (occurs rapidly within 3 to 4 hours -obscure other signs) - If no significant 2- Limited both active and passive movements swelling- posterior --~ 3- Normal relation between 3 bony points at elbow 4- Vascular injury - the brachia( artery prominence of - The vascularity should be examined initially and then at intervals the point of the...... elbow is obvious for the next 2 or 3 days & can palpate -May be injured at time of trauma by the anterior aspect of the distal.__/ the medial and end of proximal fragment - radial pulse is not felt from the start lateral........ - More commonly the radial pulse is palpable at the time of the injury but is lost by swelling and flexion of the elbow following reduction. epicondyles and the point of the olecranon - - Complications normally related to each other (to 1-Nerve injury differentiate from -Injury of the median, ulnar and radial nerves may occur. 12osterior elbow._,, - It is usually of the neurapraxia type - conservative treatment dislocation) 2- Brachia! artery injury - Effect: a) Gangrene b) Volkmann's ischemic contracture -Throughout the c) Acute compartment syndrome (may occur with adequate distal gradual reduction pulse) - treated by Fasciotomy process the 3- Elbow stiffness..___.. radial pulse is 4- Malunion - producing cabitus varus felt and if it is -Cause: improper reduction obliterated by 5- Myositis ossificans flexion -+gradual elbow extension Treatment until the pulse '--- returns I-Closed reduction and fixation (the standard treatment) - Hospitalization ---✓ - By a posterior slab for 3-4 weeks followed by gentle mobilization -Done urgently under anaesthesia before gross swelling makes palpation of the normal anatomy impossible. for 48 hours for observation of hand circulation - ~ -The usual extension type is fixed inflexion. *If at any time -Then above elbow packed posterior slab is applied the circulation is../ -The reduction is checked radiographically, if satisfactory - add felt to be collar and cuff impaired -+ II-Closed reduction and percutaneous pinning remove the slab 111- Open reduction and internal fixation (using wires) and elbow is extended, - Indications: unsatisfactory reduction by closed methods If there is no Rehabilitation improvement -+ v Active elbow movement and physiotherapy explore the.., brachia! artery 16 - - -- - - -- - -- Elbow ---- dislocation - - - Trauma and displacement Posterior dislocation (the usual type) -Trauma: fall on the outstretched hand with the elbow slightly flexed. - The coronoid process of the ulna is displaced posteriorly behind the distal end of the humerus. ,.~ -Spasm of the triceps muscle then locks the elbow in a position ymptoms Inability to move the elbow from a position of slight flexion ---- -➔ Signs -The point of the olecranon felt posterior to the humeral condyles - The triangle formed by the tip of the olecranon and the condyles is no longer equilateral (to differentiate from supracondylar fracture) Complications 1- Associated fracture of the coronoid process 2- Irreducible dislocations (rare & treated by open reduction) 3- Median or ulnar nerve damage. 4- Brachia! artery injury (unusual) 5- Myositis ossificans. Treatment Closed reduction and fixation 1- Under general anaesthesia ~ traction in the long axis of the slightly flexed forearm. 2-The reduction is stable because of the elbow bony configuration. 3- Immobilization for 3 weeks in an above the elbow posterior slab (To allow healing of the capsule and ligaments) 4- Followed by gradual mobilization - Fractures of - - the forearm bones Fracture of olecranon process -- - - - - - - -- - -Displacement Fall onto the point of the elbow Separation of fracture ends depends on integrity of the triceps expansion: a) If the triceps expansion is intact~ no separation b) If the expansion is torn~ the proximal fragment will be pulled up producing a wide gap. - 17  Intact triceps Torn triceps ex ansion and tenderness '-- Lost There is great Not detected Detected similarity '---- Treatment - No need for By open reduction between Reduction and internal fixation fractures of - An above elbow followed by early olecranon plaster cast for 6 movement of the and those of '-' weeks is followed by elbow the patella '-..,, mobilization J Fractures of the shafts of radius and ulna.. Fracture of both bones A) Direct: blow to the forearm (break the bones at the same level) B) Indirect: twisting of the forearm ---.oblique fractures situated at different levels in the two bones. Displacement Besides overlap, angulation and side displacement, rotation may J occur (due to unbalanced pull of the supinator and pronator muscles attached to the radius) - Fracture of one bone without angulation The upper, middle or lower thirds of the forearm. -Trauma: by direct trauma. I Treatment -Treatment: immobilization in A) Undisplaced fractures an above elbow By a full arm plaster cast with 90° elbow flexion and neutral rotation , plaster for approximately 6-9 weeks. a) In an adult-. B) Displaced fractures. for 6 weeks 1- In adults---. open reduction and compression plating is done b) In a child -.for (If reduction is not perfect ---. loss of pronation and supination) 3 weeks. 2- In children ---.closed reduction and plaster fixation (Residual angulation of about 5° accepted - will be corrected by remodeling) 18  Complications 1- Malunion 2- Nerve injury (uncommon) 3-Acute compartment syndrome (treated by Fasciotomy) 4- Synostosis (cross-union) between radius and ulna Monteggia fracture dislocation ,.. __ Definition - Fracture of the ulna and dislocation of the superior radioulnar joint Complications: Posterior 1111 1-Extension type 60% interosseous nerve injury - The fracture It consists of anterior angulation (apex anterior) of the ulna and may be missed anterior dislocation of the radial head. in children, the 2- Flexion and lateral types (less common) ulna may not fracture. It may Treatmen t just bend enough to 1- ORIF of the ulna and closed -reduction of the radial head allow the radial 2- If closed reduction fails - t open reduction of the radial head and head to repair of the annular ligament dislocate. - 3- Followed by the application of a full-arm plaster cast for 6 weeks Colles' fracture Definition This is a fracture of the distal end of the radius with fracture line The fracture is within one inch of the lower end of the radius in its cancellous part. often V - Fall on the palm of the outstretched hand Displacement comminuted, and commonly associated with injury to the Inferior The distal fragment shows the following displacement radioulnar joint & 1- Dorsal displacement and tilt. ulnar styloid 2- Radial displacement. process, which is 3- Upward displacement and impaction. avulsed Clinical picture Type of patient: - Uncommon in < 50 years old -Later, it becomes increasingly common particularly in women (due to postmenopausal osteoporosis) Symptoms Pain and swelling Lat., vtew Cotte fracture of dl tat rac:llua ("dlnM< lottl _,,,hy ) 19 Signs - Inspection: The characteristic 'dinner fork' deformity -Palpation: 1-The fracture site is tender. Dinner fork '-- 2-The radial styloid process is no longer distal to the ulnar styloid deformity (Both at the same level - reflecting shortening of radius) - From the side -+dorsal aspect Investigations - - of the wrist is - X-rays is diagnostic prominent -From the Complications · Dorsum --+ ---~ lateral aspect of '-- the wrist is 1-Malunion prominent & -There is often some residual deformity because: hand is radially a) Re-displacement inside the cast especially in comminuted deviated J posterior cortex J b) A Colles' plaster does not control the supination element of the deformity -In most cases physiotherapy is all that is needed. 2- Stiffness of the wrist, shoulder and fingers.. ,/ 3- Carpal tunnel syndrome (late complication) - Diagnosed by - nerve conduction studies. - Treated by - surgical division of the flexor retinaculum 4- Rupture of the extensor pollicis longus tendon 5-Sudeck's atrophy Treatment I) Reduction 1-Done under anaesthesia 2-An assistant grasps the upper arm while the surgeon grasps the injured hand as if 'shaking hands'. 3-The manipulation is carried out by 3 grips C muhodhcmrty.com -- a) Traction along the long axis of the limb ---+ disimpact the fragments - The patient should be b) Pushing the distal fragment towards the ulna - correct the instructed to radial displacement and tilt. elevate the arm c) Pressing the distal segment anteriorly with palmar flexion and above the head pronation- correct the posterior displacement and tilt several times II) Fixation daily --+ prevent A below elbow plaster cast is applied for 6 weeks holding the wrist stiffness--+ in palmar flexion and ulnar deviation improve Ill) After care functional 1- Watch the fingers circulation in the initial 24 hours for fear of a outcome (more tight plaster cast important than 2-The fingers should be actively mobilized immediately after the the treatment of injury the fracture itself) 20  Fractures of the hand - Fracture of the scaphoid Fall on the outstretched hand -+fracture usually at the bone waist Physical signs Clinical picture are often slight and suggest a Type of patient: typically in young adults sprained wrist Symptoms rather than a 1-Pain in the wrist region fracture-+ 2-The joint function may not be markedly impaired. Signs often missed 1-Tenderness over the scaphoid in the anatomical snuff box and wrongly 2- Little swelling 3- No bruising diagnosed Investigations X-ray (AP, lateral and oblique views) -May not be informative immediat ely after the injury because no i i l i i l i i i"rs at the fracture site. 1- Non-union (treated by bone grafting +/- internal fixation) - 2- Avascula r necrosis of the proximal fragment (because blood supply to the proximal part of the bone enters through distal end) Treatment 1-lf suspected -+ scaphoid plaster should be applied for 2 weeks then the wrist is re-x-rayed(by this time, bone resorption occurred at the fracture site -+radiologically evident) 2-The wrist is fixed in a below elbow cast, including the proximal phalanx of the thumb for 8 weeks (Bony union occur in 90% of uncompli cated cases) Fractures of the phalanges -Fracture lines: usually transverse -Displacement: forward angulation by the tension of the lumbrical - and interosse ous muscles. -Treatment: correct the angulation & the finger is immobilized in semi flexion over a finger wire splint incorporated in a forearm plaster cast Mallet finger...._, -Definition: This is avulsion of the extensor expansion from the base of the terminal phalanx resulting inflexion deformity of that phalanx. '-- -C/P: The patient cannot actively extend the DIP joint -Treatment: The finger is immobilized with the PIP joint inflexion '--' (so as to relax the lateral slip of the extensor expansio n) and the --- DIP joint hyperexte nded (so as to approximate the end of the tendon to the raw area) for 6 weeks. ---................ 21  Fractures and dislocations of lower limb --- - - -- --- Fractures of the pelvis Incidence -The pelvis is a 1- Constitute about 1.5% of all fractures. rigid osseo- 2- Mortality rates vary from 5% to 50% depending on: ligamentous ring a) Severity of disruption b) Associated injuries. with considerable 3-Most fractures occur in young adults involved in high energy stability. -It consists of the trauma as road traffic accidents. 2 hip bones & 4- Often associated with other serious injuries sacrum linked Classification by: a) Posteriorly: According to the very strong A) Type of trauma sacroiliac, / 1- Forces directed from the front or the back -- anteroposterior sacrotuberous compression or open book injuries & sacrospinous 2- Laterally directed force -- lateral compression ligaments 3- Vertically directed force -- vertical shear (unstable injuries) b) Anteriorly: the 4- Combined mechanical injuries. symphysis pubis B) Stability of the fracture & related I- Stable fractures ligaments -Definition: fractures stable in rotational & vertical directions do not usually cause complications -Examples: 1-Fractures outside the pelvic ring as a) Avulsion injuries of the ASIS or AILS or ischial tuberosity b) Fractures of the sacrum c) Fractures of the coccyx 2- Single fractures of the pelvic ring II-Unstable fractures 1- Open book fracture (Hinge subluxation) -It is rotationally unstable but vertically stable -Cause: trauma that is either -- a) direct anteroposterior b) Lateral compression from a crushing injury c) Indirect lateral compression through the lower limb -Effect: Disruption of the symphysis pubis with wide separation in addition to disruption of one sacroiliac joint with little separation 2- Vertical shear fracture (has highest mortality and morbidity) - Both rotationally and vertically unstable -Consists of: a) Posteriorly- fracture of ilium or sacrum or sacroiliac joint disruption b) Anteriorly- fracture of either rami or symphysis pubis disruption - The anterior & posterior trunk muscles pull the mobile hemi-pelvis upwards - It also opens up like a book by the weight of the leg. 22  Examination A) General Shock B) Local - Hemor rhage is - Inspec tion: the main cause of 1- Massiv e flank or buttock contus ions and swellin g with hemor rhag death in pelvic injuries. 2- Lower limb deform ity (shorte ning , externa l rotation withou t long -Sources of bone fractur es) bleeding include: - Palpati on: (alway s examin e the patient 's back when log rolled ) a) The posterior 1- Manua l stress examin ation ~ flexible pelvis sacral plexus of 2- Palpab le displac ement throug h posteri or ring veins - Neurol ogic examin ation: b) Osseou s & - Sciatic nerve, L5 and S1 roots especi ally with sacral fractur es. visceral bleeding - Viscera l injuries 1- GIT abdom inal and rectal examin ation. - Fracture of the 2- Genito urinary ~ scrotal hemato ma, urethra l and bladde r injuries pelvis may lead to 2-2.5 liters of Investigations blood loss 1-Plain X rays (AP, inlet and outlet views) 2- CT ~ define the fractur e lines especi ally posteri or involve ment of sacrum & pelvis Complications 1- Shock (Most importa nce) - Injury of pelvic vessel s ~ severe interna l haemo rrhage 2- Renal failure due to hemor rhagic shock 3- Injury of pelvic structures as injury of: a) Poster ior urethra b) Urinary bladde r c) Rectum d) anal canal 4- Injury to pelvic nerves 5- Complications of prolonged recumbency as a) DVT b) Pulmo nary emboli sm c) Pneum onia d) Decub itus ulcers..._ ier 6- Secondary osteoarthrosis disruption of sacroiliac joints & acetab ular fractures A) General principles 1- Patien t primar y assess ment (ABCD E) & full trauma evalua tion 2- Correc tion of the hypovo laemic shock is vital. Remem ber that 3- Associ ated injuries treatm ent take priority over the bony injuries. B) Treatment of fracture Stable fractur es 1- Rest in bed, analge sics and physio therap y _, 2- After few days, the patient starts moving out of bed. 23 Unstable fractures 1- Initial stabilization should be performed either by simple pelvic binders or external pelvic fixators 2- If there is still vascular instability -4do angiography & embolization 3- If this is unsuccessful -4 exploration, surgical homeostasis and packing of the pelvis 4- Open reduction and internal fixation (the final management) Hip dislocation Posterior dislocation Trauma - When hip is flexed and adducted (In this position, the femur head is covered posteriorly by the capsule rather than bone) / - A force applied in the long axis of femoral shaft -4 head dislocates -The hip joint is backwards over the posterior lip of the acetabulum stable (unlike -Caused by two common accidents: shoulder joint) 1-A weight falling on the back of a person in a stooping position. because of: 2- In car accidents, when the knee hits the dashboard "dash-board a) The depth of dislocation".. r----- the acetabular Clinical picture ~ - cavity b) Strong Symptoms: Severe pain and swelling.\<.. support by its Signs - Inspection -40eformity: [~.... ligaments and muscles. a) The hip is flexed, adducted and internally rotated -Therefore less..__ b) Shortening of the affected limb. frequent to be injured - Palpation: 1- greater trochanter is raised - Types of 2- Femoral head is palpable in the gluteal region (empty femoral f:i) dislocation: -Movement: Hip movements are painful and limited. a) Posterior (the Investigations commonest) b) Anterior X-ray shows: c) Central. 1-The femoral head lies outside the acetabulum. -The hip 2- Interrupted Shenton's Hne (curve formed by the lower margin of commonly the superior pubic ram us and the lower border of femoral neck) displaces 3- The lesser trochanter is less apparent (due to internal rotation) posteriorly while 4- Associated fractures as chip fracture of acetabular posterior wall the shoulder commonly displaces anteriorly _/ 24  Complications 1-Sciatic nerve injury 2- Femoral head avascular necrosis (especially in delayed reduction) 3- Associated fractures: a) Posterior acetabular rim fracture (the commonest) b) Of the patella and femoral shaft. 4- Secondary osteoarthritis Treatm ent 1-Closed reduction (done under general anaesthesia) 2- The patient is placed supine and an assistant steadies the pelvis 3-The hip and the knee are flexed ---+ bringing the head of the bone posterior to the acetabulum. 4. The femur is then adducted and pulled vertically upwards ---+ draw the head forwards into its socket. 5. The hip is then extended and the reduction is maintained by skin traction for 3 to 6 weeks Central dislocation -Cause: a blow Fractures of the femu r neck on the greate r trochanter - lntracapsular fractures of femoral neck Drives the head - Portion of the neck of femur which lies within the hip capsule Classification A) According to fracture site: of the femur through the floor of the acetabulum-+ comminuted fracture of the 1-Subcapital ---+ at the junction of the head and neck acetabulum 2- Transcervical ---+ somewhere in the neck. (may be B) According to displacement: Either impacted or displaced - accompanied by other pelvic fractures) Most commonly in the elderly (because of senile osteoporosis) after trivial trauma as a fall when the foot catches the edge of a carpet Clinical picture A) Displaced fractures 1- The hip is adducted &externally rotated (by weight of the limb) 2- Shortening of the limb. 3- The patient is unable to lift the leg off the examination couch. B) Impacted fractures No abnormal physical signs other than tenderness over the fracture site ---+ so easily missed clinically 25  Complications 1- Avascular necrosis - In a displaced fracture due to damage of femural neck blood supply The blood 2- Delayed or non-union, may occur due to supply of the a) Adequate immobilization is difficult (even by internal fixation) head of the b) Poor blood supply to the proximal fragment. femur 3- Secondary osteoarthrosis. From 3 sources 4- Thromboembolism in 25% of patients. 1. An 5- Mortality is :::,; 20% during 1st 3 months after fracture in elderly extracapsular arterial ring Investigations -Site: at the base X-ray of the neck _, Impacted fractures with minimal displacement - Formed from : m b · ed Branches of the medial & lateral Treatment circumflex Operative because: femoral arteries./ - Gives rise to a) The proximal fragment can neither by properly manipulated nor ascending immobilized by conservative means cervical b) Internal fixation helps early mobilization of these elderly patients branches (on the who are prone to the complications of prolonged recumbency surface of the I-For impacted fractures neck, known as 1- No reduction is required the retinacular 2- Internal fixation with 2 cannulated screws. vessels) II-For displaced fractures 2- Arteries of the 1-Patient < 65 ~ Closed reduction, if failed ~ ORIF fixation as ligamentum teres 2- Patient > 65 ~ Hemiarthroplasty (treatment of choice) (not always - The head & neck of the femur are replaced with a metal prosthesis patent in adults, - Used because chance of non-union or of avascular necrosis is high and if are, only - Postoperative supply a small area of bone) Early ambulation to all cases once the general condition allows 3-Terminal branches of the ascending nutrient artery 26  Extracapsular fractures of femoral neck - F ractur es extend ing from the base of the neck of the femur to 8 cm below the lesser trocha nter Il l 1- Troch anteri c fractu res: down to the level of lesser trocha nter 2- Subtro chante ric fractu re: from the lesser trocha nter to 8 cm below Trauma -In young perso n: Troch anteri c & subtro chante ric usuall y result from major traum a. Extracapsular -In the elderl y: fractures differ A fall on the side over greate r trocha nter --+ trocha nteric fractu re from intracapsular Clinical picture fractures in: 1-The blood Symptoms: Inabili ty of the patien t to raise his leg. supply of the 2 Signs: fragments is -Inspe ction --+ External rotatio n and shorte ning of the limb. good - no - Palpa tion --+ Tende rness over the fractu re site. avascu lar necrosis & no Complications nonunion \....,.· 2- The proximal fragment can be 1- Throm boem bolism controlled 2- Malun ion leadin g to shorte ning and extern al rotatio n. conservatively Treatm ent -+SO ORIF is not manda tory A) Trochanteric fractures - In the elderl y (most freque nt) The best treatm ent is to do intern al fixatio n by a dynam ic hip screw -In young perso ns --+ immob ilizatio n and tractio n. B) Subtrochanteric fractures --+ intern al fixatio n by plate & screw s Fractures of the shaf t of femur Incidence Occur in childre n and adults Trauma Resul t from sever e violen ce (assoc iated injurie s are comm on) 27  Displacement U er third Lower two thirds Proximal fragment -Flexed by: iliopsoas Anteriorly angulated by - Abducted by: the gluteal muscles quadriceps -Everted by: the external rotators Distal fragment -Adducted by: the adductor muscles Posteriorly angulated by - Pulled up by: the hamstrings Hamstring - Everted by: weight of the limb. _,..,.,, ,._........ aNI---.., Investigations X-ray Performed to the pelvis and knee to rule out associated injuries Complications 1- Vascular injury Lower third displaced fractures -+ injure femoral or popliteal vessels 2- Nerve injury The outer bar of a Thomas splint may injure common peroneal nerve 3- Non-union (uncommon) 4- Malunion 5- Knee stiffness (serious complication) Especially after treatment by closed reduction and traction The strong muscles of the Treatment thigh cause overriding of I-General principles the fragments 1- Proper alignment is important to avoid knee joint osteoarthrosis - consequent 2- Shortening > 2 cm should not be allowed shortening. 11- Conservative treatment - Reduce the fracture then keep it immobilized by applying traction to the distal segment and counter traction to the proximal fragment 28  - There are two methods: 1) Sliding traction - Distal fragment tracti on by weights and pulleys attached to the -The tendency limb either by: for backward a- skin strapping in children b- skeletal tractio n in adults angulation of 2 By inserting special pins in the upper end of the tibia fragments of - Coun ter traction depen ds upon the weigh t of the body acting by the femur is elevation of the foot of the bed. controlled by - In children < 2 years ,the same principle applied using gallows' slings under splints (strapping of the legs and slinging them to a cross bar, so the thigh. - If the applied - the pelvis is lifted from the mattress) 2) Fixed traction using a Thom as splint -Distal fragm ent traction by attaching to it cords that are tied to the weight is not adjusted accurately -+ foot of the splint distraction of 2 - Counter-traction by pressure of the ring of the Thom as splint fragments -+ against the ischial tuberosity and the soft tissues. delayed union - Disadvantages of conservative treatment 1-Prolonged immob ilization with all its side effects especially in elderly 2- Liability to stiffness of the knee. 3- If there is soft tissues interposition between the fragm ents-+ impossible to perform reduction 4- Ideal traction is difficu lt (excess traction -+distraction ) 5- The Comm on peroneal popliteal nerve injury by compression of the side bar of a Thomas splint. 111- Operative treatm ent (ORIF ) -- -~ - This avoids the disadvantages of conservative treatment. -Indications: 1- Can't perform closed reduction due to soft tissues interposition 2- Associated vascu lar injury (to avoid disrup tion of vascular repair) 3- Double-level fractures. -Methods of ORIF 1-Fractures of the proximal shaft -+ fixed by plate and screws 2- Fractures of t