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The broken bone, once set together, is stronger than ever.
JOHN LYLY (1554–1606)
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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.
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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 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.
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The usual rule is: if in doubt, X-ray. However, in response to over-ordering of X-rays in many circumstances where a fracture is very unlikely, handy algorithms have been developed, such as the Ottawa Ankle and Knee rules and the Canadian C-spine Rule.1
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There are many pitfalls involved in managing fractures and dislocations. Many injuries, such as fractures of the arm and hand, may seem trivial but can lead to long-term disability. This chapter presents guidelines to help avoid these pitfalls.
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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 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, one 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 are placed in proper alignment and then immobilised until union occurs.
Fractures prone to loss of position should be monitored radiologically, 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 ...