SPECIAL FEATURE OF FRACTURES AND DISLOCATIONS IN ADULTS

1. Fractures Less Common but More Serious

Buckle and greenstick fracture do not occur in adults. When fracture
occurs, it tends to be displaced and to be associated with extensive soft
tissue injury.
2. Weaker and Less Active Periosteum
In adults the periosteum is relatively thin and weak. Consequently, it is
readily torn across at the time of fracture, often with no intact periosteal
hinge left. The periosteum is much less osteogenic in adults than in
children, an important biological factor that accounts largely for the less
rapid fracture healing in adults
3. Less Rapid Fracture Healing
Throughout adult life, the rate of normal fracture healing is constant, but
always considerably slower than during childhood. It is also related to
delayed union and nonunion
4. Fewer problems of Diagnosis
Because in adults there are no separate centers of ossification and all
epiphyseal plates have closed, there are fewer problems of radiographic
diagnosis of fractures than in children.
5. No Spontaneous correction of residual fracture deformities
The deformity of a malunited fracture is permanent because residual
angulation, shortening or rotation at the site of a healed fracture cannot
correct spontaneously.
6. Differences in complications
Open fractures are more common in adults, as are major arterial injuries,
gangrene, venous thrombosis, pulmonary embolism, fat embolism,
pneumonia and renal calculi. Delirium and accident neurosis are confined
to adult life. Persistent joint stiffness after fracture is more common
complication. Delayed union and nonunion are also common in adults.
 7. Different emphasis on methods of treatment
Displaced and unstable fracture in adults need ORIF. A severely displaced
fracture of the neck of the femur with disruption of blood supply to the
femoral head, the most reasonable initial method of treatment may be
excision of the femoral head and neck fragment and replacement by an
endoprosthesis.
8. Torn ligaments and dislocation more common
Ligaments and fibrous joint capsules are less resilient in adults than in
children. Consequently, they are more often either completely torn across
or avulsed with a small fragment of attached bone.
9. Better tolerance of major blood loss
When in a child represents 33% blood loss, adults only represent 10%
blood loss. The elderly do not tolerate major blood loss as well as young
and middle-aged adults.

SPECIFIC FRACTURES AND DISLOCATIONS

The Hand
Mallet Finger (baseball finger, Cricket Finger)
 The distal interphalangeal joint remains flexed and can no longer be
actively extended.
 Treatment: splinting the finger in a molded plaster cast with the distal
interphalangeal joint extended and proximal interphalangeal joint flexed.
Immobilization for 3 weeks.
Middle and Proximal Phalanges
 Undisplaced phalangeal fractures are stable and treated by strapping the
injured finger to an adjacent finger.
 Displaced phalangeal fractures tend to be unstable. After closed
manipulation, the reduction is maintained by means of a padded malleable
aluminum splint that extends above the wrist.
  Unstable oblique fractures tend to slip. This need a continuous traction
through finger tip or preferably, ORIF with fine Kirschner wires.
 Intra articular phalangeal fractures, if displaced, it should be treated by
ORIF with fine Kirschner wires or tiny AO screws.
Sprain and Dislocations of the Interphalangeal Joints
 A sudden abduction or adduction injury to a finger may cause partially or
completely tear a collateral ligament. If the ligamentous tear is
incomplete, the finger is painful and swollen. The sprained finger should be
immobilized in flexion by means of a malleable aluminium splint for 3
weeks
 Lateral or medial dislocation of the interphalangeal joint indicates a
complete tear of a the collateral ligament. After reduction of dislocated
interphalangeal joint, the finger is immobilized in the flexed position for 3
weeks.
Dislocations of the Metacarpophalangeal Joints
 It is caused by a severe hyperextension injury. Because of the buttonhole
effect, so the treatment is ORIF then immobilization in a position of flexion
for 3 weeks.

Metacarpals
 Metacarpals are covered with a large extent of muscle, so they have a good
blood supply and therefore, metacarpal fracture usually heal rapidly.
Fracture of the Neck of the Fifth Metacarpal (boxer’s fracture or streetfighter’s fx)
 It is characterized by depression of the metacarpal head and posterior
angulation at the fracture site.
 Reduction is done by flexing the MCP joint and the PIP joint to a right angle
and then pushing the MC head back into position by means of pressure
along the long axis of the proximal phalanx.
 The reduced fracture should be immobilized for no longer than 2 weeks for
fear of a flexion contracture of the finger.
  If fracture is unstable, do a transverse percutaneous Kirschner wire to the
fourth and third MC.
Fracture-Dislocation of the First Carpometacarpal joint (Bennett’s Fracture)
 It usually produce a serious intra articular fracture-dislocation of the CMC
joint.
 It is usually treated by closed reduction. If the reduction can’t be
maintained in a cast, continuous tape traction on the thumb may have to
be added.
 Occasionally, the fracture-dislocation is so unstable that open reduction
and internal fixation with either a Kirschner wire or a small AO screw are
indicated.
Fractures of the Scaphoid
 It is relatively common, particularly in males. It is usually caused by a fall on
the open hand with the wrist dorsiflexed and radially deviated.
 Clinical feature: the patient experiences pain on the radial side of the wrist,
particularly on dorsiflexion and radial deviation. Swelling and local
tenderness in the region of the anatomical “snuff box”
 It required special oblique projections. An undisplaced fracture of the
scaphoid may not be apparent in the initial radiographs but becomes
apparent after a week or more
 No reduction is required. Only immobilization in a below-elbow cast.
Because of the scaphoid has no muscle attachments and is covered to a
large extent by articular cartilage, so its blood supply is precarious and
fracture union my be seriously impaired.
 Complications: AVN, delayed union, nonunion, and posttraumatic
degenerative joint disease. Delayed union can be assumed if the fracture
has not united within 4 months. It is indication for an inlay bone graft.
Dislocation of the Lunate
 Uncommon but serious injury. The mechanism is similar with fracture of
scaphoid.
  Clinically, the wrist is swollen and painful when attempting to extend the
fingers. There may be evidence of a median nerve lesion from compression
within the carpal tunner.
 Treatment is direct pressure over the lunate. But occasionally, open
reduction is required to replace the lunate to its normal position in the
carpus.
 Complications: median nerve compression, AVN of the lunate (similar to
Kienbock’s disease).

The Wrist and Forearm

Distal End of the Radius (Colles’ Fracture)
 Most common fracture in adults older than 50 years; more frequently in
women than in men.
 Mechanism of injury: the patient fall and lands on her open hand with the
forearm pronated, breaking her wrist.
 This fracture frequently is referred to as a dinner deformity.
 Undisplaced Colles’ fractures require only immobilization in a below-elbow
cast for 4 weeks. Displaced fractures can usually be well reduced by closed
manipulation, but the major problem is maintenance of reduction,
particularly in the unstable type of Colles’ fracture.
 The blood supply to bone is excellent, so bony union is assured. The main
problem is not union but malunion.
 Plaster cast must be applied to hold the reduced position of the fracture,
for 3 weeks. Repeat radiographs are obtained 1 and 2 weeks after
reduction.
 Sarmiento recommends immobilizing the reduced Colles’ fracture in
supination for 2 weeks and subsequent use of functional fracture-bracing.
 For extremely comminuted and extremely unstable, particularly in patients
younger than 60 years old, the method of external skeletal fixation is of
value in maintaining the reduction.
  Most colles’ fracture are well united in an acceptable postion within 6
weeks. The complication include finger stiffness, shoulder stiffness,
malunion with deformity and residual subluxation of the distal radioulnar
joint.
Smith’s Fracture of the Distal End of the Radius
 Less common than Colles’ fracture, sometimes inaccurately referred to as a
“reverse Colles’ fracture”
 Occurring predominantly in young men, this fracture is a pronation injury,
caused by a fall or blow on the back of the flexed
 Reduction requires strong supination of the wrist but ORIF are frequently
necessary. An above-elbow cast is usually required during the 6-week
period of immobilization to maintain the position of supination.
Fractures of the shafts of the radius and ulna
 These two bones are firmly bound to one another by the interosseous
membrane, a fracture of only one bone is likely to be accompanied by a
dislocation of the nearest joint.
 Fracture of the distal radius of the radius is frequently associated with a
dislocation of the distal radioulnar joint (Galeazzi fracture-dislocation),
whereas a fracture of the proximal half of the ulna is usually associated
with a dislocation of the proximal radioulnar joint (Monteggia fracture-
dislocation).
 The shafts of the radius and ulna have a relatively small cross-section, are
composed of dense cortical bone, and are covered by rather thin
periosteum. So, fractures of the forearm bones are much more likely to be
displaced in adults in children. Consequently they tend to be more unstable
and heal much more slowly in adults than in children.
Fracture of the shaft of the Radius and Dislocation of DRUJ (Galeazzi)
 Radiographically, the nature of the fracture-dislocation is more apparent in
the lateral projection.
  The optimum form of treatment for the Galeazzi is ORIF of radius, with
either a plate and screws or an intramedullary nail. When the radius is
perfectly reduced, so also is the dislocation of the distal radioulnar joint
reduced.
Isolated fractures of the Proximal two Thirds of the Radial Shaft
 Usually results shortening of the radius.
 Isolated fractures of the radial shaft are difficult to reduce by closed means
and reduction, if obtained is difficult to maintain.
 The most suitable form of treatment is ORIF with either an AO compression
plate and screws or an intermedullary nail.
Fractures of the Radius and Ulna
 In general, fractures of the distal third are most stable in pronation, those
in the middle third are most stable in the midposition, and those in the
proximal third are most stable in supination.
 Sarmiento recommends treating fractures of both bones of the forearm by
functional fracture-bracing (after 3 to 5 weeks in above-elbow cast) and
has found that the position of supination is satisfactory regardless of the
level of the fractures.
 ORIF is usually required, particularly in adults. Internal fixation for these
fractures is an AO compression plate and screws. The radius usually heals
more rapidly than the ulna.
 Complications: delayed union and nonunion.
Fracture of the shaft of the ulna and dislocation of PRUJ (Monteggia)
 Monteggia in adults are best treated by open reduction of the ulna so that
its length and alignment may be perfectly restored. Internal fixation of the
fracture should be obtained by means of either a compression plate and
screws or an intramedullary nail.
 The limb should be immobilized by in an above-elbow cast with the
forearm in supination for 3 months
  A rare variation of Monteggia fracture-dislocation is the flexion type, which
is caused by a flexion injury and characterized by posterior angulation of
the fractured ulna and posterior dislocation of the PRUJ. This type of injury
is treated using the same principles as the extension type of Monteggia

The elbow and Arm

Fracture of the Olecranon
 Occurs as the result of a fall with sudden passive flexion of the elbow
combined with a sudden powerful contraction of the triceps muscle. This
also an avulsion type of fracture.
 The elbow should be immobilized in complete extension in a plaster cast
for 6 weeks.
 The usual form of treatment is ORIF using the AO principle of compression.
Unless the fixation is completely rigid, the elbow should be immobilized at
a right angle for at least 3 weeks. This form of treatment is suitable even in
the elderly and is more satisfactory than excision of the olecranon and
suture of the triceps to the ulna.
 Complications: nonunion with the resultant pain and weakness of
extension and occasionally degenerative joint disease of the elbow
secondary to the joint incongruity.
Fracture of the radial head
 Common injury in young adults. It is caused by a severe valgus force
applied to the extended elbow.
 The patient experiences progressive pain in the elbow as a hemarthrosis
develops. Supination and pronation are limited by pain and there is local
tenderness over the radial head.
 Undisplaced fractures without loss of joint congruity only require
protection in a sling for 2 weeks, during which time active exercise
(pronation and supination) are encouraged. Single displaced fractures of
the radial head can be treated by ORIF with a mini AO screw.
  Markedly depressed and comminuted fractures of the radial head are best
treated by excision of the entire head. Postoperatively, the elbow should
be treated by CPM for 3 weeks.
 Complications: posttraumatic degenerative joint disease of the elbow.
Posterior dislocation of the elbow
 The brachial artery and median nerve also be struck by the distal end of
humerus as it is driven forward.
 Reduction of the dislocation is readily accomplished by applying traction to
the flexed elbow through the forearm, which is then brought forward.
 Complications: stiffness may persist for many months. The stiffness must
be treated by active exercises only, because intermittent passive stretching
of the soft tissues may aggravate the soft tissue injury and actually
perpetuate the stiffness.
 The complications of myositis ossificans may occur after posterior
dislocations of elbow in adults, particularly if reduction is delayed of if the
elbow has been repeatedly manipulated.
Fracture-Dislocations of the Elbow
 The sideswipe injury: the elbow is dislocated and there are multiple
comminuted fractures of the humerus, radius, and ulna
 Treatment: ORIF
Fractures of the Shaft of the Humerus
 More readily in adults than in children.
 Direct injury tends to be transverse, whereas indirect injury produce a
spiral fracture
 It must be remembered that the humeral shaft is a common site for
metastases in the adult.
 Fractures of the shaft of the humerus respond well to closed treatment.
Two indications for ORIF are a coexistent injury to the brachial injury that
requires arterial repair and a progressive loss of radial nerve function.
  Transverse fractures of the humeral shaft should be reduced under
anesthesia to get the fracture ends in contact and provide some stability.
When alignment and rotation have been corrected, a U-shaped plaster slab
(sometimes referred to as a “sugar-tong splint”) is applied and bandaged to
the arm.
 Clinical union is usually achieved within 6 weeks.
 Spiral and comminuted fractures of the humeral shaft do not require
reduction or anesthesia. With the patient sitting upright, gravity alone is
adequate to provide alignment of the fracture fragments, after which the
above mentioned U-shaped plaster sugar-tong splint with collar and cuff
may be applied.
 Complications: radial nerve injury. The lesion usually either neuropraxia or
axonotmesis, so recovery may be anticipated. Other complications are
delayed union or nonunion.
Fractures of the Neck of the Humerus
 Usually impacted fracture
 Because impacted fractures of the neck of the humerus are stable, the
fracture need not be immobilized and requires only protection from further
injury by sling during 6 weeks for union.
 Fractures that are not impacted require ORIF. (usually young patients).
 For the frail and the elderly, a more appropriate treatment is immediate
prosthetic shoulder replacement of hemiarthroplasty type.
 Complications: persistent shoulder stiffness.
Fractures of the Greater Tuberosity of the humerus
 In younger adults, the greater tuberosity is more often avulsed by an
indirect injury such as a fall on the hand with the arm adducted.
 Reduction needs abduction of the humerus and immobilization of the
upper limb and trunk in a shoulder spica cast or abduction splint for 6
weeks.
The Shoulder
Dislocations of the shoulder
 The glenoid cavity, being small in relation to the head of the humerus,
provides little bony stability. For this reason the shoulder joint is more
often dislocated than any other joint in adults.
 The dislocation usually is anterior and medial (subcoracoid), or less often,
posterior. Rarely, the injury is the inferior type of dislocation, in which the
head of the humerus becomes caught under the glenoid cavity and the
patient can’t bring his or her arm down to the side from the erect position
(luxation erecta).
Anterior Dislocation of the shoulder
 Usually caused by forced external rotation and extension of the shoulder
 The humeral head is driven forward and frequently avulses the
cartilaginous glenoid labrum and capsule from the anterior margin of the
glenoid cavity (the Bankart lesion). When dislocation is occurred,
circumflex (axillary) nerve function should always be assessed during the
initial examination because this nerve may have been injured.
 Radiographic examination: the humeral head has lost contact with the
glenoid cavity and is lying in the subcoracoid position.
 Treatment: the dislocation should be reduced soon. Patient lies face down
in operating room, with the injured arm hanging over the padded table
edge. When the shoulder muscle relax, the humeral head usually slips back
to its normal position. if this method fail, anesthesia need to be given. The
surgeon can apply lateral and backward pressure on the dislocated
humeral head with his or her hands.
 After reduction, the limb should be supported in a sling and bandaged to
chest to keep the shoulder adducted and internally rotated for 3 weeks.
 Complications: recurrent anterior dislocation, traction injury of circumflex
nerve, coexistent tear of the musculotendinous cuff of the shoulder
 complicates a dislocation. Rarely, interposition of the tendon of the long
head of biceps necessitates open reduction of the dislocation
Fracture-Dislocation of the Shoulder
 Usually treated by closed reduction of the dislocation.
 As with an associated tear of the musculotendinous cuff, fracture-
dislocations of this type require immobilization of the reduced shoulder in
a position of abduction.
 When there is a completely displaced fracture through the neck of the
humerus and complete dislocation of the humeral head, ORIF is necessary.
 In elderly, hemiarthroplasty needed
Posterior Dislocation of the Shoulder
 Less common than anterior. Usually caused with shoulder adducted and
internally rotated.
 Under anesthesia, the posterior dislocation can be reduced by externally
rotating the shoulder and applying forward pressure on the dislocated
humeral head.
Recurrent and Habitual Posterior Dislocation of the Shoulder
 Surgical repair of the posterior soft tissue is indicated.
Subluxation and Dislocation of the Acromioclavicular Joint
 The acromion is driven downward while the clavicle is pulled upward by
the action of the trapezius and sternomastoid muscles. The capsule of AC
joint is torn. The coracoclavicular ligaments normally bind the clavicle to
the coracoid process of the scapula, and if these are not torn, the AC joint
is merely subluxated. If these ligaments are completely torn, the result is a
complete dislocation of AC joint.
 Nonoperative methods of strapping and plaster casts to depress the
clavicle and elevate the acromion are frequently used and may relieve the
acute symptoms.
 For a subluxation, support of the arm in a sling for a few weeks is adequate.
  For a complete dislocation with severe displacement, most nonoperative
methods are ineffectual. The most satisfactory form of treatment is ORIF,
capsular repair, and the insertion of a threaded wire through the acromion,
across the AC joint and well into the clavicle.
Fractures of the Clavicle
 The common site is the middle third of the clavicle and the lateral fragment
is usually pulled inferiorly and medially by the weight of the shoulder and
upper limb.
 Treatment: closed reduction. Both shoulder are pulled back as far as
possible and are held in this position for 3 weeks by means of a stout figure
of eight padded bandage with or without a sling.
 Complications: malunion.

The Spine
Fracture of the atlas (C1)
 Caused by falls from a height and lands on the top of the head with the
cervical spine straight, the occipital condyles of the base of the skull may
split or burst the ring of the atlas.
 Radiographic examination should include an anteroposterior view through
the open mouth.
 Because a burst type fracture of the atlas is a stable injury, the only
treatment is immobilization of the cervical spine in a plaster collar for 3
months
Compression Fracture of a Cervical Vertebral Body
 A flexion injury of the cervical spine without disruption of the posterior
spinal ligaments may cause a compression or crush-type fracture of the
cancellous bone of a vertebral body
 Treatment: support of the cervical spine in a plastic collar for 3 weeks
Flexion Subluxation of the Cervical Spine
 Caused by suddenly moved an individual’s head forward.
  The posterior longitudinal ligaments are disrupted, but provided the
posterior facet joints do not override, the injury is classified as a
subluxation.
 Treatment: passive extension of the cervical spine reduces the flexion type
of subluxation and the reduction should be maintained by immobilization
of the extended neck in a plastic collar for at least 2 months.
Flexion Dislocation and Fracture-Dislocation of the Cervical Spine
 Posterior longitudinal ligaments are torn and the posterior facet on one or
both sides has lost contact with its mate. The facet joints may be overriding
and locked or they may be widely separated.
 This unstable injury is frequently complicated by either complete
transection or severe contusion of the spinal cord with resultant paraplegia
 If the dislocation or fracture-dislocation is at the C7-T1 level, it is difficult to
visualize in a lateral radiograph because the patient’s shoulders block the
view. This problem can be overcome by taking the lateral radiograph with
one shoulder elevated and the other depressed (swimmer’s projection).
 The reduced dislocation or fracture-dislocation should then be immobilized
in extension in a halo cast brace for at least 2 months
Fracture of the Seventh Cervical Spinous Process
 The spinous process of the seventh cervical vertebral is longer than others
in the cervical spine and to it are attached a multitude of muscles.
 The fracture is sometimes referred to as a “clay shoveler’s fracture”,
because it relatively common in workmen who are shoveling wet clay that
unexpectedly sticks to the shovel at the end of the backward throw.
 Treatment: pain can be relieved by cervical ruffs that prevent flexion and
extension of the cervical spine, but bed rest may be necessary for a few
days. Occasionally surgical excision of the avulsed spinous process is
required to relieve persistent pain.
Injuries of the Thoracic and Lumbar Spine
 It is relatively common, particularly in the thoracolumbar region.
  The most common fx are of the compression type and are stable injuries.

The Thorax
Fractures of the Ribs
 Clinically there is local pain that is aggravated by deep breathing, coughing,
and sneezing.
 Treatment: strapping of the chest.
 Complications: puncture of the pleura with a resultant hemothorax,
puncture of the lung with resultant pneumothorax, contusion of the
underlying lung.

The Foot
Fractures of the Metatarsals
 Frequently more than one metatarsal is fractured.
 Treatment: a well padded plaster cast is preferable. Kirschner wire fixation
is required to stabilize multiple fractures. After a period of at least 4 weeks
of nonweightbearing, a walking cast can be worn for an additional 4 weeks.
Fractures of the os calcis (calcaneum)
 The major problem related to these fractures is coexistent intra-articular
injury to the subtalar joint.
Fractures of the Neck of the Talus
 The talus has no muscles attached to it, is largely covered by articular
cartilage, and has a precarious blood supply. It is not surprising therefore,
that fractures of the neck of the talus are associated with a high incidence
of avascular necrosis of one fragment (the body) and nonunion.
 Closed reduction can usually be achieved by bringing the foot, and with it
the head of the talus into equinus. The foot and ankle are then immobilized
in this position in a below-knee cast for at least 8 weeks and no
weightbearing is permitted during this time.
 Complications: AVN of the body of the talus.
The Ankle
Sprains of the Lateral Ligament
 Always the result of an inversion injury. The lateral ligament is severely
stretched a few fibers may even be torn, but the inherent stability of the
ankle is not lost.
 Clinically, the ankle is painful. Radiographic examination is necessary.
 Simple sprains of the lateral ligament require only adhesive strapping of
the ankle to provide external support for 3 weeks.
Tears of the Lateral Ligament
 Same mechanism with the sprains of the lateral ligament. But clinically, this
has swelling that more greater and the joint is unstable. Radiographic
examination is necessary to exclude a fracture.
 The foot and ankle should be immobilized in a below knee walking cast in a
position of eversion and valgus for at least 8 weeks. No evidence that
surgical repair needed.
 Complications: recurrent subluxation or even dislocation of the ankle.
Total Rupture of the Achilles Tendon
 Sudden passive dorsiflexion of the ankle that is resisted by a powerful
contraction of the calf muscle in an adult may result in a complete rupture
of the Achillles’ tendon.
 Clinical examination reveals a gap in the tendon approximately 5 cm
proximal to its insertion.
 Normally when an individual’s calf is squeezed, the ankle plantar flexes but
not when the tendon is ruptured (Thompson’s sign).
 Treatment: surgical repair

The Leg
Fractures of the shafts of the Tibia and Fibula
 When both the tibia and fibula are fractured, treatment is aimed at
reduction of the tibia.
  Unstable oblique and spiral fractures of the tibia are prone to angulate and
shorten after closed reduction. So, this need ORIF using AO system of
internal fixation.
 Complications: osteomyelitis. Ankle stiffness is common and may require
vigorous exercise for 1 year or longer. Arterial injury, a serious complication
of high tibial fractures, must be recognized early and treated adequately to
avoid gangrene. Nerve injury is common, particularly to the lateral
popliteal nerve, with high fractures of the fibula, and occasionally from the
local pressure of a plaster cast. Delayed union and nonunion are common,
particularly in severely displaced fractures.

The Knee
Fractures of the proximal end of the tibia
 Caused by a severe abduction injury.
 The most serious complication of tibial plateau fractures is residual knee
stiffness from both intra-articular and periarticular adhesions.
Tears of the medial meniscus
 Predominantly in young men.
 Mechanism: when an individual takes weight on the partially flexed knee
and the tibia is externally rotated in relation to the femur, the medial
meniscus is drawn toward the center of the joint.
 The most common injury to a medial meniscus is the bucket handle tear.
The term “locked knee” is often used to described this phenomenon.
 Treatment: partial meniscectomy.
Fractures of the Patella
 The patella is vulnerable to two entirely different types of injury. In the
indirect type, a transverse avulsion fracture of the patella produced.
Whereas in the direct type, the patella is forcibly jammed against the lower
end of the femur and sustains a crush fracture.
  In the avulsion fractures, patient can’t actively extend the knee and
because the fracture is intraarticular, a hemarthorsis is inevitable. Avulsion
fracture require ORIF. Kirschner wires crossing the fractures and a figure-
eight-wire provide the most effective type of internal fixation.
 In the comminuted crush fractures, the patient is able to extend the knee
because the medial and lateral quadriceps expansions are intact.
Undisplaced crush fractures require aspiration of the hemarthrosis
followed by 3 weeks of immobilization in a cylindrical walking cast.
 Complications: chondromalacia of the patella and also posttraumatic
degenerative joint disease of the patellofemoral component of the knee.

The Thigh
Fractures of the Femoral Shaft
 When it occurs, massive internal hemorrhage may lead to profound shock.
Although union of fracture can usually be achieved by closed treatment, it
normally requires 20 weeks and sometimes much longer.
 During emergency treatment, the limb should be immobilized in a
temporary splint to relieve pain and to prevent further injury to the soft
tissues.
 Nonoperative treatment: Thomas splint. Traction is continued for
approximately 12 weeks. An alternative method for treatment for fractures
of the distal third of the femur is functional fracture-bracing after a period
of approximately 5 weeks of traction.
 Operative treatment: internal fixation with a large intramedullary nail.
 Complications: shock and fat embolism. Late complication is persistent
knee stiffness.