15 Fractures and Joint

Injury-General
Features
GENERAL INCIDENCE AND
SIGNIFICANCE
Trauma remains the number one killer of
young people in North America. This
epidemic of fatal injuries merits more
research concerning both prevention and
treatment, even though advances in
traumatology during the past three
decades have significantly reduced the
morbidity and mortality from trauma
As a student, there is much you must
learn about musculoskeletal injuries,
including their production, complications,
diagnosis, and healing process, and the general
principles, as well as the specific methods of
their treatment. Later, during intensive
postgraduate hospital training, clinical
teachers will instruct you on the special
techniques of the various methods of
treatment through live demonstration, the
most effective way to teach the technical
details of treatment
FRACTURES AND
ASSOCIATED INJURIES
A fracture, whether of a bone, an
epiphyseal plate, or a cartilaginous joint
surface, is simply a structural break in
continuity.
You must constantly thinks in terms
of the fracture and of what has happened
to the surrounding soft tissues.
ometimes, the associated soft tissue
injury, particulary if it involves brain,
spinal cord, thoracic or abdominal
viscera, a major artery, or a peripheral
nerve, may assume much greater clinical
significance than the fracture itself.
Physcal Factors in the Production of
Fractures
!hy and "ow #
Normal living bone, rather than being
absolutely rigid, has a degree of elasticity
or fleibility, and is capable of being bent
slightly$ it is ore like wood in living tree
than it is like a nonliving material such
as a stick of chalk
Cortical bone $ compression%tension.
&n the fact majority of fracture represent
tension failure of bone'conve( side,
tranverse or obli)ue fractures*.
&n young children, cortical bone is like
green wood in a living young tree, may
produce tension failure in conve( side of
the bend and only bending on the
concave side of the greenstick fracture.
spiral fracture, avulsion fracture
Cancellous bone, having a spong+like
structure'spongiosa*, is more susceptible
to crushing'compression* than is cortical
bone. ,ay produces$ crush
fracture-compression fracture or impacted
&n young children, producing a buckle
fractures or .torus fracture/ 'Lat
projection*
Descriptive Terms Pertaining
to Fractures
0. Site $ diaphyseal, metaphyseal,
epiphyseal or intra+articular, fracture+
dislocaion
! E"tent $ complete or
incomplete'crack or hairline and
greenstick fractures
#! Con$guration $ transverse,
obli)ue or spiral and comminuted
fracture
%! Re&ations'ip o( t'e
(racture (ragments to eac'
ot'er ) undisplaced or displaced
'translated/shifted sideways,
angulated, rotated, distracted,
overriding, impacted*
*! Re&ations'ip o( t'e
(racture to t'e e"terna&
environment $ closed or open
+! Comp&ication $ uncomplicated
or complicated 'local or systemic and
original injury or iatrogenic*
Associated !n"ury to the
Periosteum
1eriosteum is an ostegenic sleeve
important structure to fracture healing.
The priosteum is thicker, stronger and
more osteogenic during the the growing
years of childhoods than in adults life
Intact periosteal hinge 'remain intact
periosteal in severe fracture displaced*, it
can be used to advantage in reducing the
fracture and in maintaining the reduction
These fact concerning the periosteum
help to e(plain why fractures heal more
rapidly and certainly in childhood$ why
relatively undisplaced fractures heal
more rapidly than severly displaced
fractures$ and why fractured of some
bones heal more rapidly than fractures of
bones at any age
#iagnosis of Fractures and
Associated !n"uries
PATIENT,S -ISTOR.
The history of a fall, a twisting injury, a
direct blow, or a road accident may
given but often the e(act details of the
mechanism of injury. The common
symptoms of a fractured are locali2ed
pain and decreased function and crepitus
P-.SICAL E/A0INATION
3n !nspection4swelling, deformity or
abnormal movement, ecchymosis'later*.
3n Palpation4 sharply locali2ed
tenderness as well as aggravation of pain
and muscle spasm during the slight
passive movement
DIAGNOSTIC I0AGING
At least two pro"ection$ AP and Lateral. 5or
certain fracture, particulary those of
small bones, the ankle, the pelvis, and
the vertebrae, special oblique projections
5or fracture of the spine and pelvis
that may be difficult to visuali2e by
conventional radiography
Normal $ealing of Fracture
They must always be respected, to avoid
the error of treating fractures as a
mechanic or a carpenter would, or of
treating the xra! picture/ at the risk of
interfering seriously with the normal
biological phenomenon of healing.
5ractures are wounds of bone and as
with all wounds, treatment must be
designed to cooperate with the .laws of
nature/ concerning biological healing.
A number of growth factors secreted by
local cells at the fracture site are
involved in the fracture healing.'%&F'(,
!&F, P#&F, )*Ps, rh)*P'+,!,--
-EALING OF A FRACTURE IN
CORTICAL 1ONE
2DIAP-.SEAL 1ONE)
TU1ULAR 1ONE3
!nitial .ffects of the Fracture
There is always a ring avascular, dead
bone at each fracture surface shortly
after the injury
.arly /tages of $ealing from
/oft %issue
The fracture hematoma'reaction of the
soft tissues around the
fracture*6external callus-deep layer
periosteum and internal
callus-endosteum'not contain bone and is
radioluscent,that is, not apparent
radiographically*6osteogenic cells
differentiated6osteoblast6primar! woven
t!pe of bone
/tage of 0linical 1nion
A temporary e(ternal and internal callus,
consisting of a mi(ture of primary woven bone
and cartilage, comes to surround the fracture site,
forming a/biological glue/ that gradually
hardens as the cartilaginous components of the
callus are replaces by bone through a process
endochondral ossification. 2hen fracture
callus becomes sufficiently firm that
movement no longer occurs at the fracture
site, the fracture is said to be clinically united
2c&inica& union3
/tage of 0onsolidation
34adiographic 1nion-
!hen all the immature bone and
cartilage of the temporary callus have
been replaced by mature lamellar bone,
the fracture said to be consolidated by
sound bony union "radiographic union#
-EALING OF A FRACTURE IN
CORTICAL 1ONE 4IT- RIGID
INTERNAL FI/ATION
7nder these circumstances, there is no
stimulus for the production of either
e(ternal callus from the periosteum or
internal callus from the endosteum and
consequently, the fracture healing occurs
directly between the corte of one fracture
fragment and the corte of the other fracture
fragment5 This process is reffered to by
the A3-A&5 fracture surgeons as
primar! bone healing, as opposed to the
secondary bone healing involving
e(ternal and internal fracture callus. &n
the area of precise contact'that under
compression*, osteoclastic/cutter heads/
cross the microscopic fracture site and are
followed by new bridging osteons. 8ven
when there is a tiny gap, the healing is
direct by the formation of new osteons
that become oriented through haversian
remodeling to the a(is of the bone.
As long as the metallic device, such
as a rigid plate, remains in place, the
bone underlying the plate continues to be
stress protected, because the normal
stressed bypass the bone through the
plate. Thus the bone in this region tends
to develop disuse osteoporosis, which is
sometimes referred asstress'relief
osteoporosis. 5or this reason, when the
fracture has been united, the plates and
screws may have to be removed to allow
reversal of this osteoporosis. In recent
years, the AO/ASIF surgeons have become
less rigid in their thinking about the need
for rigidity in their internal fixation devices.
-EALING OF A FRACTURE IN
CANCELLOUS 1ONE
20ETAP-.SEAL 1ONE AND
CU1OIDAL 1ONES*
The healing of a fracture in cancellous
bone occurs principally through the
formation an internal or endosteal callus,
although the external or periosteal callus
surrounding the thin shell of cortex does
play an important role, particularly in
children5
The resultant internal callus fills the
open space of the spongy cancellous
fracture surfaces and spread across the
fracture site wherever there is good
contact. 3nce union is established at a
point of contact, the fracture is clinically
united and union spreads across the
entire width of the bone. Then woven
bone is replaced by lamellar bone as the
fracture becomes consolidated$
&f the crushed surfaces are pulled
apart3during reduction of fracture*, a
space, or gap, is created healing is
delayed and there may be subse)uent
collapse at the fracture site before bony
union is consolidated
-EALING OF A FRACTURE IN
ARTICULAR CARTILAGE
The hyaline cartilage of joint surface is
etremely limited in its ability to either heal or
regenerate, a fracture through articular
cartilage either heals by fibrous scar
tissue or fails to heal at all5 !f the fracture
surfaces of the cartilage are perfectly
reduced, the thin scar leads to local
degenerative arthritis5 !f there is a gap, the
fibrous tissue that comes to fill this gap
will not withstand the normal wear and
tear of joint function and more
widespread degenerative change ensue.
5urthemore, any irregularity, such as a
.step/ in the fractured joint surface, that
produces "oint incongruity leads inevitably
to degenerative arthritis.
!n my laboratory, we have investigated the
biological effects of 0P* on the healing
of the articular cartilage in an e(perimental
model of an intra+articular fracture in
rabbit. The accurate reduction of the
fracture was maintened by metal screw.
At the 9 weeks postoperatvely, we found
that heal by cartilage amount of 678 of
the :1, group' not healed by cast $ ;<
cage activity* and we found degenerative
arthritis has develop of +78 of :1,
'=<> by cast$ ?@> by cage activity*
These eperimental investigation are
relevant to the immediate postoperative
management of patient with intra+
articular fractures after open reduction
and internal fi(ation.
-EALING OF A FRACTURE
IN5OL5ING T-E EPIP-.SEAL
PLATE 2T-E P-.SIS3
The inclusion is risk of local growth
disturbances
TI0E RE6UIRED FOR
UNCO0PLICATED FRACTURE
-EALING
&t is possible to estimate healing time by
considering the following important
factor 4
ge of !atient
5racture of the shaft of the femur serve
as an e(ample of this phenomenon 4
Airth united in B weeks$ the age of C
years united in C weeks$ the age of 0;
years in 0; weeks$ the age of ;< years to
old age united in ;< week
"ite and #on$guration of
the Fracture
Fracture through bones that are
surrounded by muscle heal more rapidly
than fracture through portions of bones
that lie subcutaneously or within "oint
5racture cancellous bone heal more than
cortical bone.$ .piphyseal separartions heal
appro(imately twice as )uickly as
cancellous metaphyseal fractures of the
same bone in the age group. ,ong oblique
fractures and spiral fractures of the shaft,
having a large fracture surfaces, heal
more readily than transverse fractures
having a small fracture surface.
Initial %isplacement of the
Fracture
1ndisplaced fractures, having intact
periosteal sleeve, heal appro(imately
twice as fast as displaced fractures.
&lood "upply to the
Fragments
!f , how ever, one fragment has lost its
blood supply and is dead, the living
fragment must become united, or fused
to the dead fragment in the same manner
as living bone in a host site becomes
united to a dead bone graft. nion !ill be
slo! and rigid immobili"ation of the fracture
!ill be re#uire. !f both fragment are
avacular, bony union cannot occur until
they are revasculari2ed, despite rigid
immobili2ation of the fracture
ASSES0ENT OF FRACTURE
-EALING IN PATIENT
Clinical 4 bending, twisting and compression
forces to the fracture to determine the
presence, or absence of movement.
Thus, if neither you nor the patient is
able to detect movement at the fracture
site, the fracture is clinicall! united
At the time of clinical union,
radiographic e(amination reveals
evidence of bony callus, but the fracture
line is still apparent because clinical
union precedes radiographic
consolidation, it must still be protected
from undue stress until radiographic
consolidation has been achieved, as
evidenced by a bony callus that
completely bridges the fracture and
obliterates the fracture line
Abnormal $ealing of Fractures
0. malunion
;. dela!ed union
B. nonunion with resultant formation of
either a fibrous union or a false joint
'pseudoarthrosis#
0omplication of Fractures
may be complicated early or late and
local or remote
CLASSIFICATION OF T-E
CO0PLICATIONS OF T-E
ORIGINAL INJUR.
I' Initial complication
A.Local 4 kin, vascular,neurological
,uscular, visceral injuries
A.Demote 4 ,ultiple injuries and
"emorrhagic shock
II' (arly
A.Local 4 e)uelae, joint and bone
:omplication
A.Demote 4 Fat embolism, Pulmonary
.mbolism, pneumonia,
%etanus, delirium tremens
III' )ate
A.Local 4 Eoint 'persistent stiffness,
posttraumatic degenerative
arthritis*, Aony'abnormal
fracture healing, &rowth
disturbance, persistent
infection, posttraumatic
osteoporosis, /udek9s post
traumatic painful osteo
porosis, refracture*
,uscular'posttraumatic
myositis ossificans, late
rupture of tendons*,
Neurological'tardy nerve
palsy*
A.Demote 4 Denal calculi, Accident
neurosis.
&eneral Principles of Fracture
%reatment
1' First, %o *o +arm
1revention of iatrogenic complication is
one of the important general principles
of fracture treatment
,' &ase -reatment on an
ccurate %iagnosis
and !rognosis
Accurate clinical and radiographic diagnosis,
reasonable estimate of the prognosis of the
injury 'importance in relation to the
healing of uncomplicated fractures*
The first decision is whether the
fracture re)uires reduction and if so,
what type is best+closed or open. The
second decision concerns the type of
immobili2ation, if any, re)uired+e(ternal
or internal.
.' "elect -reatment with
"peci$c ims
a* %o relieve pain 4 immobili2ation,
avoiding tight cast, analgesic
b* %o obtain and maintain satisfactor! position
of the fracture fragment 4 continous
traction, a plaster+of+1aris cast, e(ternal
skeletal fi(ation, and internal skeletal
fi(ation, depending on the degree of
instability of the reduction
c* %o allow and, if necessar!, to encourage
bon! union 4 autogenous bone
graft'serious tearing of the periosteum
and soft tissue, avascular necrosis*
d* %o restore optimum function 4 disuse
atrophy muscle'isometric-active static*
and 'isotonic-active dynamic*
The preservation of good muscle power
and tone throughout this period
improves local circulation and facilitates
subse)uent restoration of normal joint
motion and optimum function in the
fractured limb or spine and in the patient
as a whole person
/' #ooperate with the
0)aws of *ature1
5' 2a3e -reatment 4ealistic
and !ractical
a* 1recisely what am & aiming to
accomplish by this methods$ what is it
specific aim or goal
b* Am & likely to accomplish this aim or
goal by this methods of treatment#
'humerus fracture in children and neck
fracture+e(ternal immobili2ation alone*
c* !ill the anticipated end result justify
the means or methods$ will it be worth it
to your patient in terms of what he or she
will have to endure+the risk, the
discomfort, the period away from home,
work, or school# 'intertrochanteric
fracture in elderly+prolonged
immobili2ation+risk*
5' "elect -reatment for you
!atient as an
Individual
5racture give different problem for any
any individual 'age, se(, occupation,
coe(i(tent disease*
.mergency ,ife /upport /ystem
Airway. Areathing, :irculation, hock
Fracture and #islocation
Three priorities'AA:*, assessed vascular
impairment and nerve injury+splint
before (ray'film move than patient*
SPECIFIC 0ET-ODS OF
DEFINITI5E FRACTURE
TREAT0ENT
Indication and contraindication are
important.
%here is not alwa!s unanimit! of opinion,
even among fracture experts&, about
indications and contraindication in
relation to the treatment of various
fracture$ 'pinions are based on general
principles and on individual experience
and preference$ (ith continuing advances
in knowledge and improvement in methods
and techniques, indications and
contraindication become modified$
&n the broad spectrum of fracture
treatment: A;<A/!F system and
Americanfunctional fracture'
bracingsystem5 Although seemingly on
the surface the e(act antithesis of one
another, these two well+established
methods of fracture management have
one important common denominator,
namely the preservation of function and the
in"ured limb and prevention of iatrogenic
"oint stiffness5
Decent years $ A3-A&5 surgeon have
become less rigid in their thinking about
the need for rigidity in their internal
fi(ation devices.'healing in fracture
cortical bone with rigid internal fi(ation*
/pesific *ethods of %reatment
for 0losed Fractures
1. Protection alone (without
Reduction or Immobilization)
:an be accomplish in the upper limb
!ndication4 First$ undisplaced or relatively
undisplaced, stable fracture of the rib,
phalanges, metacarpals+ and in children,
of the clavicle. 4isks $displaced
2. Immobilization by
External Splinting (without
Reduction)
&s relative immobili2ation$ plaster'of'Paris
cast of varying design and occasionally
by metallic or plastic splints.
!ndication4 relatively undisplaced or
unstable,fracture long bone only
sideways shift of the fragment but good
contact and no significant angulation or
rotation does not re)uire
reduction'applied-molded6displaced===-
4isk$ muscle pull and gravitational
forces6displacement, pressure sores
over bony prominence, constriction of
limb'impairment of vascular circulation*
. !lo"ed Reduction by
#anipulation $ollowed by
Immobilization
&s usually under anesthesia, and re)uires
some knowledge of the likely mechanism
of the fracture as well as three+
dimensional appreciation of the
relationship of the fragment to one
another and to the surrounding soft
tissues'(ray+plaster cast*
!ndication > for displaced fracture that
re)uire reduction and when it is predicted
that sufficiently accurate reduction can be
both obtained and maintained by close
means
4isks$ arterial spasm+compartment
syndrome'e(cessive traction*,
impairment neuro+vascular'incorrectly
applied cast*
%. !lo"ed reduction by
!ontinou" &raction $ollowed
by Immobilization
kin traction for children$ skeletal
traction for adult and older children
'fixed traction) balanced traction*
!ndication$ unstable obli)ue, spiral, or
communited fracture of major long
bones, and unstable spinal fracture,
fracture with complicated by vascular
injuries, e(cessive swelling, skin loss in
which an encircling bandage or cast
would be dangerous
4isks: arterial spasm6FolkmannGs
ischemia-compartement syndrome,
superficial skin loss, pin track infection,
delayed union or even union.
'. !lo"ed Reduction
$ollowed by $unctional
$racture()racing
&n 0=@0, Hehne'early use of
weightbearing plaster cast*+two years
later+*armiento e(panded by conceiving
the principle of earl! function combined
with allowing motion at the +oints above and
below the fracture bone. armiento first
used plaster casts and more recently
plastic 3;rthoplast* splints, both of which
are hinged at the level of joints.
The principle is based on 4
?- that rigid immobili2ation of fracture
fragment is not only unnecessary but
also undesirable for fracture healing$ +-
that function and the resultant controlled
motion at the fracture site actually
stimulate healing through abundant
callus formation$ @- that such function
prevents iatrogenic joint stiffnes$ A- that
somewhat less than perfect 'anatomical*
reduction of a fracture of the shaft of a
long bone does not create significant
problems concerning either function or
appearance'cosmetic*
The !nitial treatment consist either
closed reduction or continous traction for a
few days followed by immobiliBation in a
plaster cast for a period of B to 9
weeks'until acute pain and swelling*. At
the .nd of this preliminary period, the
hinged cast'brace or plastic brace is applied
to splint the fracture.'non union 0>*
!ndication 4 5racture shaft of the tibia, the
distal third of the femur, the humerus,
and the ulna in adults$ contraindication >
intertrochanteric fracture,
subtrochanteric and mid+shaft femur, and
shaft radius and intra+articular fracture.
4isks > relatively risk free, there is a
possibility fail to maintainence position
*. !lo"ed Reduction by
#anipulation $ollowed by
External S+eletal $ixation
&n its imples form'not rigid* and
"offman type'more rigid*. At an early
stages of fracture healing, the e(ternal
fi(ator can be dynamiBed to allow a(ial
micromotion at the fracture site, either
active from weightbearing, or passive
from mechanical device, both of which
have a stimulating effect on fracture
healing as shown by Ioodships and
Jenright.
!ndication 4 severely comminuted'and
unstable* fractures of the shaft of the
tibia or femur, especially type B open
fractures with e(tensive injuries to soft
tissues including arteries and nerves, the
repair of which necessitates
immobili2ation of the fracture site. 5or
such fractures, this method offers the
distinct advantage of allowing changes of
the wound dressing as well as the
application of skin grafts. ,ay also for
unstable fractures of the pelvis, humerus,
radius and metacarpals
4isks: pin track infection, 'high+speed
power drill+ring sequestrum
,. !lo"ed Reduction by
#anipulation $ollowed by
Internal S+eletal $ixation
,anipulative reduction, can be
maintained by the percutaneous insertion
of metallic nails or intramedullary rods
across the fracture site for the purpose of
providing internal skeletal fi(ation of
fracture' .blind/ insertion using (+ray
control
!ndication> unstable fracture of the neck
of the femur'adult and children*
4isk: may fail satisfactory position of
fracture fragment and sufficiently rigid
fi(ation and infection
-. .pen Reduction $ollowed
by Internal S+eletal $ixation
6hen the results are good they
are very good, 7ut when they
are 7ad they are horrid-and may
even catastrophic. -o convert a
closed fracture to an infected is
a terri7le tragedy8. These metallic
devices, each of which has its special
uses and advantages, includes variations
types of transfi(stion screw, only plates
held by screws, intramedullary nails and
rods, smooth and threaded pins,
encircling bands, and wire sutures.
The current thinking, however, is that
many such devices should not be
removed because the risks of doing so are
greater than the risks of leaving them in place5
%he A;<A/!F /ystem of !nternal Fiation.
&n 0=KC a small group of wiss surgeons
including 2uller, llgower and
6illeneger, who were dissatisfied
with the e(isting systems and techni)ues
of internal fi(ation of fractures, formed a
sstudy group called A3, which was
subse)uently called A&5. These
innovation surgeons and their research
colleagues, who are concerned with
biomechanical improvements of the
internal fi(ation for the fractures, have
developed the best system, techni)ues,
have developed the best sytem,
techni)ues, and e)uipment available for
this purpose. ,ore recently, this group
of fracture surgeons has become less
fi(ed in their thinking about the need for
rigidity of their internal fi(ation device
The principle of the A3-A&5 system
is to achieve internal fxation of
fracture fragments rigid enough
that external immobilization is not
necessary and full active function
of muscles and joints is possible
very soon after operation.
!n essence, the aim of the A3-A&5
system is the rapid recover! of function in the
in+ured limb
!ndication 4 to obtain reduction$
displaced avulsion fracture, intra+
articular fracture, displaced fracture in
children that cross the epiphyseal plate,
and fracture in which soft tissue have
become interposed and trapped between
the fragments, intertrochanteric fractures
of the femur, fractures of both bones of
the forearm in adults and displaced
fractures of phalanges, fracture with
coe(istent vaccular injury that re)uires
e(ploration and repair, facilitate nursing,
pathological fracture.
!n general, combined open
reduction and internal fxation is
contraindicated in fractures of the
shaft tibia and shaft of the humerus
(both of which can usually be
adequately managed either by closed
nailing or by functional fracture
bracing
4isks: infection+contaminated, damage
to blood supply, metal failure,
postoperative adhesions
/. Exci"ion o0 a $racture
$ragment and Replacement
by an Endopro"the"i"
5or certain fractures of "ip and 8lbow
!ndication4 high incidence of avascular
necrosis of the femoral head and nonunion of
the fracture, displaced intracapsular
fractures of the neck of the femur in the
elderly cannot always be managed
satisfactory by internal fi(ation L
0ommunited fractures of the radial head in
adults'incongruity+post traumatic
arthritis+unstable+ligamentous injury*
4isks> infection, endoprothesis gradually
migrate through osteoporotic bone.
%reatment for ;pen Fracture
They merits special consideration, with
particular emphasis on the prevention of
infection and obtaining union of the
fracture
!la""i1cation o0 .pen
$racture
Ay, &ustilo and Anderson
%ype !' A clean wound less than 0 cm in
in length
%ype!!' A laceration more than 0 cm in
in length but without e(tensive
soft tissue damage, skin flap,
avulsion, muscle and nerve
injury
%ype!!!'
A 4 e(tensive soft tissue damage but
ade)uate bone coverage, segmen+
tal fractures, gunshot wounds
) 4 AMe(tensive periosteal stripping
And devasculari2ed bone that re+
Nuires skin flap or free graft
0 > M vascular injury, need repair
The authors recommended primary
closure of the skin in types 0 and ; open
fracture'this controversial*. !n many
trauma centers, open fractures are left open
initially, that is, for the first A to C days5 1sing
antibiotics before, during, and after operation5
3pen fractured represent a surgical
emergenc!. They re)uire e(pert treatment
based on well+establhised guidelines to
minimi2e the risk of infection. The
following aspect of treatment for open
fractures are particulary important4
Cleansing the Wound. Ay
e(tensive pulsating irrigation as well as
by mechanical cleansing with copious
amounts of sterile water or isotonis
saline
Excision of Devitalized
Tissue (Debridement), such as
skin, subcutaneous fat, fascia, muscle,
and loose fragment of bone, is essential5
5oreign material such as bits of clothing
and dirt should also be removed. &t also
is wise to obtain a culture of the wound at
the time of operation
Treatment of the Fracture.
3pen wound is small, usually treated by
closed means, after cleansed, debrided,
left open. .ternal fiator is often of
value. !nternal fiation'contraindication$
tend to traumati2e and devitali2ed more
tissue and increase the risk of infection.
7nder certain circumstances, such as
e(cessive instability of the fracture or an
associated vascular injury, 3D&5 is
completely "ustified because the risk of its
application are less serious than the risk
of alternative methods.
Closure the Wound. &mmediate
primary closure is usually
contraindicated. After the first 9 to ?
days, provided no infection has develop,
dela! primar! closure is indicated. Loss of
skin may necessitate the delayed
application of split thickness skin grafts.
/uction drainage should be used to
prevent accumulation of blood and
serum in the depths of the wound.
Antibacterial Drugs. *ust be
administered in large doses before,
during, and after treatment of the wound.
8ven so, antibacterial is no guarantee
against infection because many bacteria
are resistant to various drugs.
5urthermore, antibacterial drugs cannot
reach any wound tissue that has lost its
blood supply. The surgical care of the
wound is of even greater importance than
the antibacterial therapy.
Prevention of Tetanus. &f there
has been no previous immuni2ation, or if
inade)uate information is available,
immediate passive immunity can be
achieved by the use of ;K< units of
tetanus immune globulin'human*. Active
immunity with tetanus to(oid is initiated
at the same time.
After'0are and 4ehabilitation
for Patients with Fractures
CP, '3A post injury*, elevation of the
fracture limb during earl! phase of fracture
healing'join stiffness#, isometric and
isotonic'disuse arthropy*, ps!chological
consideration, occupational therap!.
0omplications of Fracture
%reatment
That are iatrogenic in that they are
caused by the treatment of the fracture 4.
0lassification
0. /kin 4 Tattoo effect, pressure sore,
Hecubitus ulcers, cast ulcers
;. Dascular 4 Traction and pressure lessi+
on, :ompartement syndrome, Iang
rene and gas gangrene, Fenous
thrombosis and pulmonary emboli
B5 Neurological 4 Traction-pressure lesion
9. Eoint > eptic arthritis 'open operative*
K. )ony 4 3steomyelitis 'open operative*
4ecognition and %reatment of
0omplication, from )oth the
!nitial !n"ury and !ts %reatment
The detection of complications re)uires that
you attend to every complaint of the
patient, eamine the patient clinically at
fre)uent intervals, asses any positive
clinical findings, and when necessary,
proceed with special investigations.
!nitial and .arly 0omplications
Local Complications
/kin complication4 abrasion+tattoo
effect,blister or bleb formation, bed sore,
cast sore. These iatrogenic preventable
Dascular complication
Arterial complication'injury to major
artery*$ uncommon, but serious because
of the se)uelae of persistent arterial
occlusion.
Arterial division $ complete'stop
bleeding* and incomplete'pulsating
hematom-false aneurysma*
Arterial spasm $ sudden and severe
traction result persistent spasm, there is
usually a tear in the intima that leads to
thrombosis.
Arterial thrombosis $ arterial
injury6persistent occlusion6potensial
se)uela-thrombosis'O arteriosclerosis*
-ecognition of arterial complication.
:omplete arterial occlusion in a limb is
associated with initial pallor of the skin
distally, loss of arterial pulse, coolness of the
skin, and later mottled, dark discoloration
that heralds gangrene. It should not be allowed
to delay surgical exploration and repair of the
arterial injury.
Compartement s!ndromes. The increased
pressure of progressive edema within a
rigid osteofacial compartment of either
the forearm or the leg threatens the
circulation to the enclosed
'intracompartmental* muscles and nerve
.olkmann/s ischemia, compartement
syndromes most fre)uently involve the
fle(or compartment of the forearm and
the anterior tibial compartment of the leg
.olkmann/s ischemia contracture 4edema+
ischemia'necrotic muscle replaced by
dense fibrous scar tissue that gradually
shortens
A compartment syndromes may be
secondary to one of two different
phenomena4 0* pro(imal
occlusion'extracomprtmental* occlusion of
main artery, ;* intracompartmental injury
to either bone, soft tissue, or both with
resultant hemorrhage
The clinical warning> pain, pallor,
puffines, and paresthesia, paralysis'later*
There is to measure intracompartment
pressure by trancutaneous insertion of
catheter'N4 < to C mm"g, "igh4%B<
mm"g$ its absolute indication for
immediately decompression by surgical
fasciotomy, fascia must be left wide
open, for at least ? days*
%reatment of vascular complications.
3cclusions of major artery represent a
surgical emergency in as much as within a
few hours of onset, the results of the
associated ischemia become reversible.
Artery divided'direct suture or if not
possible by autogenous vein graft or
plastic arterial prosthesis*, arterial
spasm3 warm papaverine if not relieve by
intra+arterial injection or by meticulous
microsurgical e(cision of the encircling
adventitia'out layer* of the spastic
segment of the artery
*equelae of arterial complication 4
&angrene, 0ompartment
syndrome'FolkmannGs ischemia
contracture*, !ntermittent claudication, &as
&angrene by an aerobic bacteria,
Clostridium (elchii treatment with
reopened, debrided, antibacterial
therapy, hyperbaric o(ygen chamber.
Denous complication> division of a
ma+or vein. hould be repaired surgically
to prevent the late se)uelae of persistent
venous congestion distally
.enous thrombosis and pulmonar!
embolism. The combination of both'HFT
and 18* is common cause of morbidity
and mortality in adult orthopaedic
patients. ,ain factor venous stasis, more
susceptible lower limbs and pelvic%upper
limb, adult%children.
After fracture venous lesion is usually a
phlebothrombosis, as opposed to an
inflammatory thrombosis
'thrombophlebitis*, the thrombus is only
loosely adherent to the wall of vein+it may
pass to the lung to produces pulmonary
embolism 3F smoker and oral contrsepsi-
0iagnosis$ &n the calf+local
pain,swelling,congestion-"omanGs sign$
in the thigh+swolen$ 'Hoppler
ultrasound*. &n pulmonary+varies
severity, embolus in moderate siBe is
manifest by the sudden onset of chest
pain, dyspnea, sometimes hemoptysis, (+
ray reveals triangular+shaped area.
A massive pulmonary embolus,
however, produces a dramatic onset of
severe chest pain. The patient
immediately blanches and literally drops
dead
Prevention of venous thrombosis, by
avoiding constant local pressure on veins
and by encouraging the patient to
actively contract all muscles in the injury
limb and to move about as much as
possible given the limits imposed by
treatment of the fracture' :1,, cyclic
e(ternal pneumatic compression, and
low+molecular Lweight heparin for high
risk*
%reatment of venous thrombosis.
Anticoagulant drug such as heparin or
warfarin, surgical thrombectomy in
femoral vien to P the risk of 18 and to
prevent late se)uelae 'HFT in below
knee%above knee, emboli2e to lung*
Neurological 0omplications. ,ay
cause either by the original injury or,
less often by inept treatment of the
fracture itself.
/ites of neurological complication in relation
to fracture 4 ?, brain+ skull fracture.
+, spinal cord+cervical and thoracic spines
fracture and dislocation. @, cauda equine+
lumbar spine fractures and dislocation.
A, sciatic nerve+posterior dislocation and
fracture+dislocation of the hip. G,medial
and lateral popliteal nerve+dislocation of
the knee. H, lateral popliteal nerve+
vulnerable to e(ternal pressure from
bandages and casts. C, ulnar nerve+
avulsion fracture Lseparation of medial
epicondyle. 6, median nerve+supra
condylar fractures of the humerus.
I, radial nerve+fractures of the shaft of
the humerus. ?7, circumfle nerve+
dislocations and fracture of the shoulder
Disceral complication.
Thoracoabdominal'penetration bone*,
cardiac tamponade'displace fracture of
rib*, hemopneumothora(, paralytic ileus
and gastric dilatation'fracture of thoracic
and lumbar spine*, rupture bladder or
urethra'displace fracture of pelvis*
Eoint 0omplication
Infection of a +oint "septic arthritis*. After
an open intra+articular fracture+less often
after open operation on a closed intra+
articular fracture
)ony 0omplication
Infection of bone "osteom!elitis*. Acute
osteomyelitis and its se)uale+chronic
osteomylitis, delayed union, nonunion.
Avascular necrosis of bone.
:ause by disruption of the nutrient
vessel 'posttraumatic*, iatrogenic itGs a
serious complication because it leads to
delayed union and to subse)uent joint
incongruity and degenerative arthritis

4emote 0omplication
Fat Em7o&ism S8n9rome. 5at
globulet can be found in circulation of
most adults after a major fracture of the
long bone6 respiratory distress syndrome
with severe arterial hypoia. ,ost
susceptible in healthy young adult with
multiple or polytrauma, elderly with
fracture upper end of femur 'rarely in
children*
1tiolog! and pathogenesis. 5rom bone
marrow, its precise pathogenesis is both
conjectural and controversial+ stress
induced6 changes in metabolism and in blood
coagulation6coalescence of
chylomicron6macroglobules of the fat6fat
embolization6 arterial hypoxia and respiratory
acidosis 'can to brain+cerebral
manifestation*
Clinical features. After latent period of
; or B days' few hours in severe cast*,
dyspnea, hemoptysis, tachypnea, cyanosis$
cerebral emboli are manifest, headache,
confusion, irritability followed by
delirium,stupor, and coma$ cardiac emboli
cause, tachycardia, drop in blood pressure:
petechial hemorrhages in the skin upper
chest and aillae, con"unctivae, also febrile.
5at embolism syndrome has been
estimated to be the major cause death in
+78 of fatalities associated with
fractures.
-adiographic features.
Deveals multiple areas of consolidation+
a *now storm& appearance.
Laborator! features$
1athognomonic '+*, clinically recogniBable
'%K<>*, 13; is P ' Q0<<, sometimes Q@<
mm"g*, Thrombocytopenia 'M*.
Prevention of fat embolism$ hould be
made to prevent metabolic and
respiratory acidosis by high carbohydrate
intake, plus constant maintenance of fluid
and electrolyte balance and early operative
fiation5
%reatment of established fat embolism$
The use of heparin increase the rate of
hydrolysis and removal of emboli. Large
doses on corticosteroid may decrease the
tissue injury in the lungs. ,ow'molecular'
weight detran infusion may improve
microcirculation. .ndotracheal tube or
tracheostomy 'respiratory distress*.
:onstant monitoring 13;'C<+0<<* and
1:3;'BK+9K* and p" '?,BC+?,99* is the
best appraisal of the patientGs metabolic
status and guides corrective therapy
Pneumonia! The convalescent
period may become complicated by
h!postatic pneumonia 'eldery*. Treatment$
antibiotic,deep breathing e(ercise,
fre)uent turning of the bedfast patient, if
necessary bronchoscopic suction.
Tetanus! Ay clostridium tetani, being
an anaerobic organism, thrives in
devitali2ed or dead tissue where it
produces a powerful neurotoin that is
carried by the lymphatics and
bloodstream to the central nervous
system and fi(ed in anterior horn cell
Clinical feature$ tetanic spasms,
opisthotonus, lock jaw, risus sardonicus.
Prevention$ "as been described
%reatment$ Large doses of tetanus
immune globulin 'human*, heavy
sedation, endotracheal tube,
antibacterial,.
#elirium %remens. Alcoholic sustained
trauma, during the ensuing few days, the
patient may e(hibit dramatic and even
alarming withdrawal symptoms,
characteri2ed by disorientation, aniety,
agitation, and disturbing visual
hallucinations.'mimic with such
complications head injury and fat
embolism
,ate 0omplication
Loca& :
2oint *tiffness$ immobili2ed during
fracture healing. &t can be minimiBed by
active contraction of all muscle groups
controlling the joint or active movement of
"oint has been discontinued. ,ost
common cause4 periarticular adhesions,
intra+articular adhesions, adhesion
between muscle and bone, post+
traumatic myositis ossificans
'ossification in muscle*
Periarticular adhesion $ After
fracture near the joint, adhesion may
develop between the fibrous capsule and
ligaments as well as between these
structure and nearby muscles and tendons,
impair normal the gliding between these structures,
forceful passive movement at this stage
may actually cause more adhesion. &f
with physiotherapy no change clinically,
gentle manipulation with general
anesthesia needed and follow by
physiotherapy or 0P*.
Intraarticular adhesion $ intra+
articular fracture, dislocation or
combined are invariably associated with
a hemarthrosis and subse)uent fibrinous
deposits on the synovium and articular
cartilage6 lead to firm adhesion within
the joint between folds of synovium and
between the synovium and cartilage6
physiotherapy if fail with manipulation if
fail with surgical e(cision of the
adhesion 'arthrolysis* is indicated and
followed 0P*5
Adhesion between muscles and
between muscle and bones $ like wise,
during open reduction of fractures, the
surrounding muscles may be damaged6
formation of fibrous scar tissue binds
muscle to each other as well as to
underlying bone. This phenomenon is
particularly common after fractures of
the lower end of the femur, where the
adhesion involving the quadriceps muscle
result in persistent limitation of knee
fleion5J physiotherapy helps to restore
joint motion6 manipulation is
contraindicated because it cause additional
muscle tears and adhesions6 surgically
and 0P* immediately
Posttraumatic degenerative +oint
disease or arthritis ) any residual
incongruity of joint surfaces after intra+
articular fracture, particulary in
weightbearing "oint, leads to degenerative
arthritis
1on8 :
Abnormal healing of fractures $
malunion,delayed union, nonunion
,alunion $ has united in
unsatisfactory position of significant
deformity 'angulation, rotation,
shortening, lengthening*
0ela!ed union $ healing of a
facture is much slower than estimated
rate of healing for that particular fracture
3onunion $ complete failure of a
fracture to unite by bone after a much
longer period than normal, there are two
type$ 0* healed by fibrous tissue only
'fibrous nonunion*, ;* continued
movement at the fracture site stimulates
the formation of a false joint
'pseudoarthrosis*. A variety of methods may
used to enhance fracture healing4
Autogenous bone grafts, allogeneic bone
graft, osteoconductive methods'such as
free2e+dried deminerali2ed allogeneic
bone combine with collagen, TI5+R,
1HI5*
1lectrical *timulation of 4racture
5ealing. &n during ; past decades,
electrical stimulation of osteogenesis as an
alternative to bone grafting in the
treatment of delayed union and nonunion
of fractures.
3n the basis of these biophysical
data, the following three system of
electrical stimulation have been
developed for the treatment of delayed
union and nonunion fracture of fracture.
All three system are effective in the
treatment of delayed
Another methods of treatment of
delayed unions and nonunion that is to
be as effective as bone grafting
operations is the local injection into the
fracture site of autogenous bone marrow
as reported by :onnolly and using 0
A,1 combined with autoly2ed, antigen+
e(tracted, allogeneic'AAA*'Ehonson*
%he factors that flavor delayed
union and nonunion 4
?- severe disruption of the periosteal sleeve at
the time of the original fracture$ +- loss of blood
supply to one or both fragments$ @- inade#uate
immobili"ation of the fracture$ shearing force
are particulary harmful$ A- an inade#uate
period of immobili"ation$ G- distraction of
fracture fragment by excessive traction$ H-
persistent interposition of soft tissue in the
fracture si"e$ C- infection at the fracture site
from an open fracture$ 6- local progressive
disease of bone%pathological fractures&
Persistent infection of 6one. Local
chronic osteomyelitis fre)uently leads to
delayed union or even nonunion'infected
nonunion* and the fracture cannot heal
until the infection is completely
controlled.
Posttraumatic 'steoporosis$ Hisuse
arthropy, disuse osteoporosis, because
bone resorption e(ceed bone deposition.
&ntensive physiotherapy and gradual
increase in the stresses applied to the
osteoporotic bones tends to reverse the
process
*udeck/s Posttraumatic Painful
'steoporosis "-eflex *!mpathetic
0!stoph!#$ The patient complains of
severe pain in the hand or foot and is
disinclined touse it. The joint become
stiff, the soft tissues are edematous, and the
skin is moist, mottled, smooth and shiny: '
ray reveals eaggerated degree of disuse
osteoporosis
&tGs a prolonged complication that is
difficult to treat. Local warmth and
active e(ercises are helpful, repeated
sympathetic bloks are re)uired to relieve
the symptoms. -ecover! is slow and may
take many months but is relatively sure.
-efracture$ during the relatively
long period between clininical union and
complete consolidation, is still relativel!
susceptible to fracture'uncommon in adult,
occurs in children*. 3ccurs not at the
e(act site of the original fracture but at
the site of a screw'weaker% normal*
,etal failure) with delayed union
and nonunion, there is persistent
movement, causing repeated stress on the
metal at the fracture site over a periode of
many months or even years. 7nder
circumstances, the metal mayfatigue as
a result of local rearrangement of its
molecular structure. A crack develops
and eventually the metallic device fails
completely and breaks5
*uscular 0omplication
%raumatic m!ositis ossificans
"posttraumatic ossification#) this new bone
formation in an abnormal site is referred
to as heterotopic ossification and develops
between 'rather than within* the torn
muscle fibers. 1atient with severe head
injury or paraplegia are particulary prone
to develop this complication 'limited of
motion$ elbow or thigh*. This
complication can be prevented to some
e(tent by the drug, indocid, or by
prophylactic radiation. The treatment
consist of local rest by splinting during
the active stage. The microscopic
appearance of the lesion at this stage is
dangerously similar to that osteosarcoma
for which it could be tragic mistaken. Left
completely alone, the heterotopic new
bone is to large e(tent resorbed
spontaneously over the ensuing
months.The residual lesion is no longer
painful and joint motion usually
improves
Late rupture of tendon) This
complication of fracture is uncommon,
but is occasioanally occurs in the etensor
pollicis longus tendon after a Colles/s fracture
of the distal end of the radius 'wrist+
ankle+glide+groove+smooth+fracture
metaphyseal+not smooth+friction+
rupture*
Neurological 0omplication
%ard! nerve pals!$ fracture of lateral
condyle6 malunion or non
union6residual valgus of the elbowJ
ecessive stretching of the ulnar nerve as
well as friction between the nerve and
distal end of the humerus during fle(ion
and e(tension of the elbow6 gradually,
over 0< to ;< years 6 the nerve
thickened by intraneural fibrosis6
symptom and sign.
The only effective treatment for this
complication is surgical transposition
'relocation* of the ulnar nerve to the
anterior aspect of the elbow.
4emote 0omplication
-enal calculi) who are confined to
bed for many weeks or month. Denal
calculi can be prevented by an increased
fluid intake ' at least 9<<< ml per day*
and fre)uent turning of the patient.
Accident 3eurosis) psychiatric
assessment is re)uired
SPECIAL T.PES OF
FRACTURE
5our type of fracture, are significantly
different from ordinary fracture.
/tress Fracture 3Fatigue
Fracture-
As a result of repeated stresses and
conse)uently may develop a small crack
or fatigue fracture 'long marches, track,
field activities, ballet dancing*.
The more common clinical 4 the second,
third, fourth metatarsal in military
recruits'.march fracture/*$ the lower end
of the fibula in runners$ and the upper
third of he tibia in jumpers and ballet
dancer. 0linicaly4 pain, aggravated by
activities n relieved by rest$ local deep
tenderness.
Treatment$ stop activities until the
crack heal.
Pathological Fracture:
That occurs through abnormal bone+
bone that is pathological, weaker, and
more susceptible to fracture than normal
bone, may be so weak that is fracture by
trivial njury, or even by normal use.
0lassification of #isorder %hat
Predispose )one to Pathological
Fracture
&. 0ongenital abnormal
'Lo(cali2ed-congenital defect of tibia$
Hisseminated-8nchondromatosis$
Ienerali2ed-3stegenesis
imperfecta-3steoporosis*
&&. *etabolic bone disease
'Dickets, 3steomalacia, curvy,
3steoporosis, "yperparathyroidism*
&&&5 #isseminated bone disorders of unknown
etiology
'1olyostotic fibrous dysplasia, keletal
reticulosis, Langerhans cell
histiocytoses, Iaucher disease*
&F. !nflammatory disorder
'"ematogenous osteomyelitis,
3steomyelitis secondary to wound,
Tuberculosis osteomyelitis, Dheumatoid
arthritis*
F. Neuromuscular disorder
'1aralytic disorder, Hisorder of muscle*
F&. Avascular necrosis of bone
F&&. Neoplasm of bone
'Neoplasm+like lesions of bone, True
primary Neoplasm of bone*
0linical Features and #iagnosis
Hepend on underlying disease
Prognosis of Pathological Fractures
*ost will unite. cause of osteomyelitis will
not unite until the infection has been
controlled: malignant primary union will
be markedly delayed and amputation is
indicated$ metastatic neoplasm will usually
unite and the patient, whose prognosis is
hopeless, will be spared much misery,
pain, and disability during the remain
months of life
DISLOCATIONS AND
ASSOCIATED INJURIES
Normal Eoint /tability
Three structural factors are responsible
for preventing an abnormal range of
motion and thereby, for providing +oint
stabilit!4 ?- the reciprocal contours of the
opposing 'oint surfaces$ +# the integrity of
the fibrous capsule and ligament$ @# the
protective po!er of muscles that move the
'oint. Thus, the defect in any one or
combination of these structures may
result in loss of "oint stability.
The relative importance of these
stabili2ing factors varies with each type
of joint '"ip+joint contour, Jnee+
ligament, houlder+fibrous capsule and
protective muscle power*
Physical factors in the
Production of Eoint !n"uries
Hislocation of a joint is a structural loss
of its stability. The physical factor that
suddenly force a joint beyond its normal
range of motion cause a tension failure,
either in the bony component of the
joint, in the fibrous capsule and ligament,
or in both the bone and the soft tissue
#escriptive %erms Pertaining to
Eoint !n"uries
Contusion'direct blow*, intraarticular
fracture'severe-, ligamentous sprain'minor
tears and some hemorrhage*, ligamentous
tear, ligamentous avulsion'avulse a fragment
of its bony attachment at either end*.
There are three degrees of joint
instability4 0* occult instabilit!'stressed*$
;* subluxation$ B* dislocation
Associated !n"ury to the Fibrous
0apsule
Intracapsular dislocation, extracapsular
dislocation, buttonhole dislocation
#iagnosis of Eoint !n"ury
$istory : patient say .gone out of place/,
pain and muscle spasm, decreased
function of the involved part. 1hysical
.amination $ swelling, deformity,
abnormal movement. Sray $ A1-Lat
Normal $ealing of ,igaments
Torn ligament heal by fibrous scar tissue
is not as strong as the normal ligament.
!ith complete tears of ligament, there is
usually a considerable gap between the
shredded ends of the ligament+a gap that
can heal only with fibrous scar tissue.
7nder these circumstances, even if the
torn ligament heals, it is both elongated
and relative risk.
The time healing ligament $ finger
joint+in @ weeks, major ligament of the
knee'@ months, shorter in child%adults
0omplications of #islocations
and Associated !n"uries
"as been described in an earlier section
of this chapter
&eneral Principles of %reatment
for Eoint !n"uries
The si( general principle in earlier
section are applicable for the joint.
Hislocation and sublu(ation must be
reduced perfectly to restore normal
congruity of the joint surfaces and
prevent posttraumatic arthritis.
/pesific %ypes of Eoint !n"uries
0ontusion 4 direct blow+synovial
membrane react6 producing effusion6
may synovial vessel rupture6
hemarthrosis5 '(ray$intra+articular T*
,igamentous /prain
:aused by a sudden stretching of the
ligament with a minor, incomplete tear and
local hemorrhage but no loss of continuity5
&ts manifest by local swelling,
tenderness, and pain that is aggravated
by movement of the joint that stretch the
sprain ligament, there is no joint
instability because ligament has not been
unduly elongated.
%reatment is aimed at protecting the
injured ligament from further stretching
during the healing process, applied
adhesive strapping can serve as a
temporary ligament that relieves pain by
restricing undesired motion while
permitting other movement of joint.
#islocation and /ubluations
To restore normal congruity to the joint
surface, perfect reduction must be
achievied, either by closed manipulation
and or open reduction
%orn ,igaments
A complete tear of certain major
ligaments of the knee, should be repaired
surgically as soon as possible after injuy,
because the results of delayed or late
repair are less satisfactory than those of
immediate repair.
0USCLE INJUR.
!hen severe tension is suddenly applied
to an already contrated muscle, some of
the muscle bundles may rupture and
produce the painful local lesion well
known to athletes and trainers.
A strain refers to a chronic
overstretching of a muscle or its tendon
due to overuse. The most common site
of a strain is the musculotendinous "unction5
TENDON INJURIES
0losed %endon !n"uries
A normal tendon seldom ruptures even
with strenuous activity. "owever, if it
has became frayed by friction or has
degenerated, it may rupture with even
normal activity. &n either case,
reconstructive operations are re)uired to
repair or replace the abnormal part of the
rupture tendon. udden tension on a
normal tendon may avulse a fragment of
its bony insertion. The most common
e(ample of this injury is the mallet finger
'baseball finger, cricket finger*
;pen %endon !n"uries
The comple( and intricate arrangement
of fleor tendons in the hand, however,
present special problem because
adhesions between injured tendons
interfere significantly with hand function.
The critical are for fle(or tendon
injuries in the hand 3no man lands-5 &n
this area, both the profundus and sublimus
tendons for each finger pass through an
unyielding fibrous tunnel. :onse)uently,
adhesions between repair tendons and the
fibrous tunnel are a potential complication5
Thurman.H.Silalahi/Residen Orthopaedic/FKUI
Thurman.H.Silalahi/Residen Orthopaedic/FKUI