Chapter 135

### Introduction

The broken bone, once set together, is stronger than ever.

John Lyly (1554–1606)

Common fractures and dislocations usually apply to the limbs, the shoulder girdle and the pelvic girdle and their management requires an early diagnosis to ensure optimum treatment and to prevent complications. Early diagnosis depends on the physician being vigilant and on having knowledge of the less common conditions so that a careful search for the diagnosis can be made.

The diagnosis is dependent on a good history followed by a careful examination, good-quality X-rays appropriate to the injury (e.g. stress view) and, if necessary, special investigations. The golden rule is: if in doubt—X-ray. The family doctor should develop the habit of looking at a patient’s X-rays. Such a back-up to the radiologist’s report can help avoid missed diagnoses.

There are many pitfalls involved in managing fractures and dislocations. Many injuries, such as fractures of the arm and hand, may seem trivial but they can lead to long-term disability. This chapter presents guidelines to help avoid these pitfalls.

Key facts and checkpoints

• A fracture usually causes deformity but may cause nothing more than local tenderness over the bone (e.g. scaphoid fracture, impacted fractured neck of femur).

• The classic signs of fracture are:

• pain

• tenderness

• loss of function

• deformity

• swelling/bruising

• crepitus

• X-ray examination of the affected area of the upper limb should include views of joints proximal or distal to the site of the injury, and X-rays in both AP and lateral planes.

• If an X-ray is reported as normal but a fracture is strongly suspected, an option is to splint the affected limb for about 10 days and then repeat the X-ray.

• As a rule, displaced fractures must be reduced whereby bone ends should be placed in proper alignment and then immobilised until union occurs.

• Fractures should be monitored radiologically for loss of position, particularly in the first 1–2 weeks following reduction.

• Bone union is assessed clinically by reduced pain at the fracture site and reduced fracture mobility. It is assessed radiologically by X-ray features such as trabecular continuity across the fracture site and bridging callus.

• Non-union is caused by such factors as inadequate immobilisation, excessive distraction, loss of healing callus, infection or avascular necrosis.

• Stiffness of joints is a common problem with immobilisation in plaster casts and slings so the joints must be moved as early as possible. Early use is possible if the fracture is stable.

• A dislocation is a complete disruption of one bone relative to another at a joint.

• A subluxation is a partial displacement such that the joint surfaces are still in partial contact.

• A sprain is a partial disruption of a ligament or capsule of a joint.

• Always consider associated soft-tissue injuries such as neuropraxia to adjacent nerves, vascular injuries and muscle compartment syndromes.

• A stress fracture is an incomplete fracture resulting from repeated small episodes of trauma, which individually ...

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