DISLOCATION

DISLOCATION IS THE COMPLETE OR PARTIAL ABSENCE OF

(luxatio)
CONTACT BETWEEN THE ARTICULAR SURFACES OF BONES,
WHICH TAKE THE PART IN THE FORMATION OF THE JOINT. TOTAL
ABSENCE OF CONTACT IS CALLED – COMPLETE DISLOCATION
(LUXATIO COMPLETA), PARTIAL - INCOMPLETE (DISLOCATIO
INCOMPLETA, SEU SUBLUXATIO). USUALLY, DISLOCATION IS
ACCOMPANIED WITH THE RUPTURE OF THE JOINT CAPSULE AND
LIGAMENTS. MOST COMMON IS THE SHOULDER (55%), ELBOW
(25%), WRIST AND FINGERS PHALANX (9%) DISLOCATIONS.
 Classification of the dislocations
1. CONGENITAL (LUXATIO CONGENITA);
2. ACQUIRED (LUXATIO ACQUISITA);
3. CLOSED - SIMPLE (WITHOUT INJURY OF SKIN AND
SOFT TISSUES; ARTICULAR SURFACE ISN’T DEVELOPED
IN THE WOUND);
4. OPENED (THE ARTICULAR SURFACE OF THE BONE IS
DEVELOPED IN THE WOUND);
5. RECENT (NEW, FRESH) - DISLOCATIO RECENS - AFTER
THE FEW HOURS UP TO 1-2 DAYS;
6. NEGLECTED DISLOCATION (LUXATIO) INVERTERATA
NON-RECENS, FROM 3 DAYS UP TO 2-3WEEKS;
7. HABITUAL (LUXATIO HABITUALIS) VERY FREQUENT,
REPEATED (RECURRENT) DISLOCATION IN CASE OF
WEAKNESS OF JOINT BURSA AND LIGAMENTS AND IT MAY
BE HAPPEN IN THE MOMENT AS PATIENT WISHES;
Classification of the dislocations
8. IRREDUCIBLE – IF REDUCTION IS IMPOSSIBLE;
9. PARALYTIC (IN CASE OF PARALYSIS OF THE
MUSCLES);
10. PATHOLOGIC (IN CASE OF BONES AND JOINTS
TUBERCULOSIS, CHRONIC OR ACUTE INFLAMMATORY
DISEASES, TUMORS) - IN 10-20% OF CASES;
11. TRAUMATIC (NON-PATHOLOGIC) - IN 80-90%;
12. COMPLICATED (WITH THE INJURY OF THICK
BLOOD VESSELS, NERVOUS TRUNKS, FRACTURE OF
THE BONES);
13. UNCOMPLICATED.
 Mechanism of the dislocations
USUALLY, INDIRECT TRAUMA, FALLING ON THE
STRAIGHTENED HAND OR ELBOW, MORE RARELY
DIRECT TRAUMA OF THE JOINT AREA.
THE MORBID ANATOMY:
MOST COMMONLY ALTERATIONS TOUCHES ONE JOINT,
RARELY, NEAR LAYING TISSUES ALSO. THE TYPICAL IS
THE TRAUMATIC RUPTURE OF JOINT CAPSULE WITH
FORMATION OF THE WHOLE IN IT. DISLOCATIONS OF
KNEE, ELBOW AND ANKLE ARE ACCOMPANIED WITH
THE RUPTURE OF THE LIGAMENTS. THERE IS THE
WOUND NEAR THE JOINT IN THE CASE OF THE OPENED
DISLOCATION.
 Clinical picture
PAIN AND IMPOSSIBILITY TO PERFORM MOVEMENT IN THE
JOINT, FORCED POSITION OF THE EXTREMITY, DEFORMATION OF
THE JOINT AREA, THE HEAD OF THE DISLOCATED BONE MAY BE
PALPATED IN THE UNUSUAL PLACE, WHEN IT’S USUAL PLACE IS
EMPTY SPACE. EXTREMITY RETURNS (LIKE BY SPRING) IN IT’S
PATHOLOGICAL POSITION IN CASE OF PASSIVE MOVEMENT.

X-RAY CONFIRMS THE DIAGNOSIS OF THE LUXATION AND

HELPS TO EXCLUDE THE FRACTURE OF THE BONE NEAR THE
JOINT.

LENGTH OF THE LIMB MAY BE INCREASED (IN CASE OF LOWER

DISLOCATION OF THE SHOULDER AND ANTERIOR DISLOCATION
OF THE HIP) OR DECREASED (IN CASE OF ANTERIOR
DISLOCATION OF THE SHOULDER AND POSTERIOR DISLOCATION
OF THE HIP).
 THE GREATER TROCHANTER IS DISLOCATED
UPPERSIDE OF ROSER-NELATON’S LINE (IN
CONNECTS THE ANTERO-SUPERIOR SPINAL
PROCESS TO THE ISCHIAC SPINE) IN CASE OF
DISLOCATION OF THE HIP (FEMUR).
SCHEMAKER’S LINE (IN CONNECTS THE
GREATER TROCHANTER TO THE ANTERO-
SUPERIOR SPINAL PROCESS) USUALLY,
TRANSECTS THE UMBILICUS OR GOES UPPER
SIDE OF IT, BUT BELOW THE UMBILICUS IN
CASE OF HIP DISLOCATION /FIG.109/.
FIG 109. DISPLACEMENT OF SCHEMAKER’S LINE
 THE HUNTER’S LINE NORMALLY CONNECTS THE HUMERUS CON­
DYLES AND TRANSECTS THE OLECRANON (TIP OF THE ELBOW).
THE TIP OF THE ELBOW TAKES UPPER OR LOWER POSITION TO
THIS LINE IN CASE OF IT’S DISLOCATION.

TREATMENT: THE TREATMENT OF TRAUMATIC DISLOCATION IS

THE IMMEDIATE REDUCTION OF DISLOCATION (REPOSI­TIO) BY THE
SPECIALIST. IT IS NECESSARY TO TAKE THE PATIENT INTO THE
CLINIC, IMMOBILIZATION OF A LIMB BY THE HELP OF FIXING
BANDING OR THE SPLINTAGE, INJECTION OF ANALGESICS.
REDUCTION OF THE DISLOCATION NEEDS GOOD MUSCLE
RELAXATION, THAT’S WHY IT IS PREFERABLE TO CHOICE
NARCOSIS AND MYORELAXANTS. THE DISLOCATED BONE MUST
REPEAT THE MOVEMENTS, THAT HAPPENED AT THE MOMENT OF
DISLOCATION, BUT IN THE REVERSE CONSECUTIVENESS.
 Types of shoulder dislocation
(luxatio humeris)
1. ANTERIOR (L. SUBCORACOIDEA - FIG. 110,
A);
2. LOWER (L. AXILLARIS - FIG. 110, C);
3. POSTERIOR (L. SUBACROMIALIS
INFRASPINATA - FIG.110 , D);
4. SUBCLAVICLE (L. SUBCLAVICULARIS - FIG.
110, B).
FIG 110. TYPES OF SHOULDER DISLOCATION
 Methods of reduction of shoulder
dislocation

HIPPOCRATES'S METHOD:
PATIENT IS LYING ON THE SPINAL POSITION,
SURGEON IS SITTING NEAR THE PATIENT, HE
FIXES THE PATIENT’S UPPER EXTREMITY
GIRDLE WITH THE PLACEMENT OF HIS HEEL IN
THE AXILLIAR FOSSA AND PULLS THE UPPER
LIMB TO HIMSELF (IN HIS DIRECTION).
 Kocher’s method /fig. 111/:
patient is lying on the table or sitting on the chair. Surgeon is
standing at the side of the dislocation, face to face with the patient.
Kocher’s method includes four stages:

I stage: assistant of the surgeon fixes the shoulder girdle with the
towel, surgeon takes the shoulder of the patient over the elbow with
one hand and the wrist with another one and at first performs the
flexion of the forearm under the 90° angle, pulls down the shoulder
and slowly brings the elbow to the trunk. This stage provides the
lateral turn of head of the humerus/fig. 111, A/.

II stage: surgeon performs the rotation of the forearm to the lateral

direction until palmar surface of the forearm takes the frontal
position/fig. 111, B/, reduction of dislocation usually happens at this
moment, otherwise the III stage is necessary.
FIG 111. KOCHER’S METHOD OF SHOULDER DISLOCATION REDUCTION
 Kocher’s method :
III stage: surgeon moves slowly the compressed to the
trunk elbow to the midline and upside. This stage provides
bringing the head of the humerus in front of the rupture of
the joint bursa/fig. 111, C/.

IV stage: forearm must be quickly turned inside and pushed

on the chest in such way, that hand must be put on the
healthy shoulder/fig. 111, D/. The limb must be fixed in the
functional position with plaster of Paris or Desault’s
bandage for 6-10 days ,after the repeated X-ray. Therapeutic
exercises are indicated after 2 weeks.
 Djanelidze’s method /fig. 112/:
patient is lying on the edge of the table with a
hung hand. The patient’s head is placed on another
table. Patient stays in this position during 25-30
min, until muscles will be tired and relaxed. The
surgeon performs the flexion of the forearm in the
elbow joint and with force, but not quickly pulls
it down and performs slight external rotation.
Typical sound (crack) is heard at the moment of
reduction of dislocation and the joint becomes
mobile.
FIG 112. DJANELIDZE’S METHOD OF
SHOULDER DISLOCATION REDUCTION
 Chachava’s method:
the surgeon and patient are sitting in front of each other.
The surgeon puts the hand of the patient into his axillar
fossa and fixes it. With the same hand the surgeon takes the
elbow of the patient and fixes the shoulder girdle with
another hand, performing the strong and quick traction
(pulling) and reduction of the dislocation.

Mothie’s method /fig. 113/:

the trunk must be fixed with the contraction by the sheet,
putted under the axillary fossa. At the same time surgeon
performs the pulling of altered extremity. Characteristic
sound indicates the reduction of the dislocation.
FIG 113. MOTHIE’S METHOD OF SHOULDER
DISLOCATION REDUCTION
 Types of femur (hip, thigh) dislocation
(luxatio femoris )

1. ISCHIAC (LOWER, POSTERIOR) - LUXATIO

ISCHIADICA /FIG. 114 , B/;
2. ILIAC (LOWER, UPPER) - LUXATIO ILIACA
/FIG. 114, A/.
3. SUPRAPUBIC (ANTERIOR, UPPER) - LUXATIO
SUPRAPUBICA /FIG. 114, C/.
4. INFRAPUBIC (OBTURATORIAL) - LUXATIO
INFRAPUBICA, S. OBTURATORIA /FIG. 114, D/.
FIG 114. TYPES OF FEMUR (HIP, THIGH)
DISLOCATION
 There are two methods of femur dislocation reduction:
KOCHER’S METHOD:
GENERAL ANESTHESIA MUST BE USED. PATIENT IS LYING ON THE
TABLE. ASSISTANT FIXES THE PELVIS TO THE TABLE - WITH THE
BOTH HANDS. SURGEON TAKES THE SHIN (SHANK), FLEXED IN
THE KNEE UNDER THE 90° ANGLE AND PULLS THE FEMUR
UPSIDE WITH BIG FORCE WITH IT’S SIMULTANEOUS ROTATION
INSIDE. APPEARANCE OF FREE ACTIVE AND PASSIVE
MOVEMENTS CONFIRMS THE REDUCTION OF DISLOCATION.
DJANELIDZE’S AND COLLER’S METHOD /FIG. 115/ :
PATIENT IS LYING ON THE EDGE OF THE TABLE IN THE
ABDOMINAL POSITION WITH HANGED LEG DURING 15-20MIN.
ASSISTANT IS FIXING PELVIS TO THE TABLE. THE SURGEON
COMPRESS THE FLEXED IN THE KNEE JOINT OF THE PATIENT’S
SHIN WITH HIS KNEE IN THE SLIGHTLY ABDUCTED POSITION AND
REDUCES THE DISLOCATION.
FIG 115. DJANELIDZE’S AND COLLER’S METHOD OF
REDUCTION OF FEMUR DISLOCATION
 Mandible dislocation (luxatio mandibulae) reduction
PATIENT IS SITTING ON THE CHAIR. THE
ASSISTANT IS STANDING BEHIND OF THE
PATIENT AND HOLDING HIS HEAD. SURGEON
BENDS HIS THUMBS WITH THE GAUZE, INSERTS
THEM INTO THE ORAL CAVITY AND PUTS ON THE
LATERAL (MAIN) TEETH, HOLDS THE MANDIBLE
WITH THE OTHER FINGERS, COMPRESS IT DOWN
AND STRAIGHT AHEAD AND THAN UPSIDE.
TREATMENT OF NEGLECTED DISLOCATION IS
OPERATION. SOMETIMES IN CASE OF NEGLECTED
DISLOCATION FORMATION OF NEW JOINT FOSSA
OCCURS (NEARTHROSIS).
 FRACTURES
(fractura)
FRACTURE (“FRANGERE”- TO BREAK) IS THE BREAK
OF UNITY OF THE BONE, CAUSED BY THE MECHANICAL
ACTION OR PATHOLOGICAL PROCESS (TUMOR,
INFLAMMATION). FRACTURES COMPOSE 6-7% OF ALL
CLOSED TRAUMAS. FRACTURES OF THE WRIST (HAND)
AND THE FOOT ARE MOST COMMON (MORE, THAT 60%),
FOREARM AND SHIN FRACTURES TAKE 10-10% (BOTH-
20%), FRACTURES OF THE STERNUM (BREAST BONE) AND
RIBS - 6%. RARE FORMS OF FRACTURE ARE OF SCAPULAR
– 0.3% VERTEBRAL - 0.5%, PELVIC - 0.6% , FEMUR - 0.9%.
 Classification of the Fractures
CLASSIFICATION, FOLLOWING TO THE ORIGIN OF
FRACTURES:
CONGENITAL (PATHOLOGIC ALTERATION OF THE FETAL BONES
OR INTRAUTERINE TRAUMA OF FETUS, AS A RESULT OF
ABDOMINAL TRAUMA OF PREGNANTS);

ACQUIRED (FRACTURA ACQUISITA) - ARE DIVIDED ON THREE

SUBGROUPS:
A) TRAUMATIC;
B) PATHOLOGIC (IN CASE OF ALTERATION OF BONES BY
TUMORS, OSTEOMYELITIS, TUBERCULOSIS, ECHINOCOCCUS,
LUES);
C) OBSTETRICAL.
 Classification, following to the type of injuring
agent:
1. Gunshot (bullet, splinter or fragmentation
effect, blast) /fig. 116, G/;
2. Non-gunshot .

Classification, following to the type of alteration:

1. Complete - fractura completa;
2. Incomplete (crack), subperiostal, perforating,
marginal -fractura incompleta - infractio.
FIG 116. TYPES OF MECHANISM OF FRACTURES
 Classification, following to the origin of mechanism:
1. After the flexion /fig. 116, A, B, C/;
2. After the torsion /fig.116, E/;
3. After distension, abruption /fig. 116, F/;
4. After compression /fig.117/;
5. Direct (at the place of applying of injuring agent);
6. Indirect (at the distance of applying of injuring
agent).
Classification, following to the number of the injury:
1. Single;
2. Multiple (Fractura multiplex).
FIG 117. COMPRESSION FRACTURE OF VERTEBRAL BODY
 Classification, following to the condition of skin
and mucosal membranes:
1. Opened (with the wounding of the skin and
covering tissues);
2. Closed (without injury of the covering tissues).
Classification, following to the localization of
fracture:
1. Epiphysar - f. intraarticulorum;
2. Metaphysar - f. paraarticulorum;
3. Diaphysar (of the upper, middle and lower
third).
 Classification, following to the type of fracture:
1. Transverse - fractura transversa;
2 . Length ways (longitudinal) - f. longitudinalis;
3. Oblique - f. oblique;
4. Compressive;
5. Impacted - f. gomfosis - dislocatio ad
longitudinem cum implantationeum;
6. Spiral - f. spiralis;
7. Abrupted.
 Separate types of fractures:
1. Epiphysar - epiphysiolysis;
2. Comminuted - f. communitiva;
3. Fragmented – f. multiplex;
4. Y-or T-shaped.

Classification, following to the attendant injuries:

1. with the injury of thick blood vessels, nervous trunks and
joints;
2. with the injury of soft tissues;
3. penetrating injuries;
4. with the injuries of visceral organs.
 Classification, following to the presence or
absence of displacement (dislocatio):
1. Lateral displacement of the fragments
(dislocatio and latum) /fig. 118, B/;
2. Longitudinal displacement of fragments, or
along the length (dislocatio ad longitudinem) /fig.
118, C/;
3. Displacement of fragments at an angle
(dislocatio ad axin) /fig. 118, A/;
4. Peripheral displacement of fragments (dislocatio
ad periferiam) /fig. 118, D/.
 
FIG 118. TYPES OF DISPLACEMENT OF BONE FRAGMENTS
 Union (consolidation) of the fracture

THE MECHANICAL INJURY OF TISSUES AT THE SITE OF

THE FRACTURE CAUSES ASEPTIC INFLAMMATION WITH
PASSING THROUGH PHASES OF ALTERATION,
EXUDATION AND PROLIFERATION. MESENCHYMAL
TISSUE FORMATION STARTS 2-3 DAYS LATER AND
LASTS 10-14 DAYS (I STAGE OF THE CONSOLIDATION). II
STAGE OF THE CONSOLIDATION STARTS AFTER 10-14
DAYS AND LASTS 5 WEEKS. THE RESULT OF IT IS
FORMATION OF PRIMARY OSTEOID CORN (CALLUS
PROVISORIUS). IT IS ELASTIC AND THAT’S WHY A BONE
FRAGMENTS AREN’T FIXED WITH EACH OTHER FIRMLY.
 The osteal corn includes the following layers:
1. Periostal - callus extrenus /fig. 119, A/;
2. Intermedial - callus intermedius (formed from the
Howerse’s tubules) /fig. 119, B/;
3. Endostal - callus internus (formed from the endosteum
and bone marrow) /fig. 119, C/;
4. Paraossal - callus paraosalis (formed from the injured
soft tissues and hematoma) /fig. 119, D/.
After the ossification of the primary osteoid corn (it lasts
3-4 months) it transforms into the firm definite ossal corn
(callus definitus). Blood loss accompanies the fracture (in
case of femur fracture – 1500-2000 ml, shin-600-700 ml,
humerus - 300-400 ml, forearm bones - 100-200ml).
FIG 119. STRUCTURE OF OSTEAL CORN
 The clinical picture of fractures:
it includes general and local signs. General
symptoms are determined with following
complications of the fractures: bleeding,
traumatic shock, fatty embolism.

The local clinical symptoms of fractures:

It is very important to make X-ray film of
the extremity in the straight an lateral view.
 Conditions, determining the consolidation of bone
fragments
General conditions:
old patient’s bones heel more slowly, as in case of tuberculosis, amylodosis,
chronic inflammatory processes, metabolic disturbances (diabete, obesity),
hypoproteinemia, avitaminosis.
Local conditions decrease the ability of bone fragment’s consolidation:
a) grave trauma, vast injury of soft tissues, periosteum, bone;
b) alterations of blood circulation, caused by the injury of thick blood vessels,
chronic arterial and venous insufficiency;
c) denervation of the area of the fracture, caused by the nerve injury;
d) intra-articular (epiphysial) fractures, where there is no periosteum and
synovial liquor destroys the process of osteogenesis;
e) incomplete reposition of bone splinters and immobilization;
f) infectious complications, common in case of opened fractures;
g) interposition of soft tissues, existence of muscles, fascia and aponeurosis
between the fragments of the bones.
 Treatment of Fractures
(basic methods)
IT INCLUDES:
I. FIRST AID; II. BASIC METHOD OF TREATMENT;
III. PROSTHETICS; IV. SPLINTAGE.
A) NON-OPERATIVE METHODS:
1. TRACTION, EXTENSION, PULLING;
2. PLASTER BANDAGE;
3. IMMOBILIZATION.
B) OPERATIVE METHODS:
OSTEOSYNTHESIS (EXTRAFOCAL COMPRESSION-DISTRACTION
METHOD WITH THE HELP OF O.GUDUSHAURI’S AND ILIZAROV’S
APPARATUS, EXTRAMEDULAR OSTEOSYNTHESIS WITH A BONE PLATE,
OSTEOSYNTHESIS WITH AN OSSEOUS LAMINA, METAL PINS, NAILS,
INTRAMEDULLAR OSTEOSYNTHESIS WITH METAL ROD, THREE-FLANGE
NAIL).
 TREATMENT OF FRACTURES

First aid in case of fractures includes

transport immobilization /fig. 120/ with the help
of splint (frame), anesthesia with the help of
injection of 20ml of 1-2% Novocain into the
hematoma, formed around of the fractured
bones /fig 121/.
 FIG 120. IMMOBILIZATION IN CASE OF
POTENTIAL CERVICAL VERTEBRA INJURY
FIG 121. INJECTION OF NOVOCAIN INTO
THE HEMATOMA
 Types of splints (frames)
1. WOODEN (PLYWOOD);
2. WIRE (CRAMER’S ) - FOR UPPER AND LOWER
EXTREMITY /FIG. 122/;
3. DIETERICH’S TRANSPORTATION SPLINT /FIG. 123/
4. PLASTER (CAST);
5. LIGHT METAL;
6. PNEUMATIC /FIG. 124/;
7. IMPROVISED;
8. ABDUCTION ARM;
9. COCONUT;
10. BECTORAL;
11. FUNCTIONAL;
12. BOHLER’S SPLINT /FIG. 125/;
FIG 122. WIRE (CRAMER’S) SPLINT
FIG 123. DIETRICH’S TRANSPORTATION SPLINT
FIG 124. PNEUMATIC SPLINT
FIG 125. BOHLER’S SPLINT
 The General principles of treatment of fractures
THE GENERAL PRINCIPLES OF TREATMENT OF FRACTURES:
1.REDUCTION OF THE DISPLACEMENT (REPOSITION) - TO
RESET (REPLACE) THE BONE FRAGMENTS IN THE CORRECT
POSITION;
2. IMMOBILIZATION OF A LIMB (AN EXTREMITY) IN THE
FUNCTIONAL POSITION;
3. APPLYING OF REMEDIES FOR QUICK FORMATION OF
OSTEIOD CORN (CALLUS) AND UNITING OF BONE FRAGMENTS.
REDUCTION OF DISPLACEMENT MAY BE PERFORMED AT ONE
MOMENT, OR GRADUALLY (BY THE HELP OR TRACTION OR
RECLINATION - IN CASE OF COMPRESSION FRACTURE OF
VERTEBRA DURING FEW DAYS.
 Immobilization with the help of plaster
bandage

SULPHATE OF CALCIUM (CASO4 - GYPSUM) IS

WHITE, HYGROSCOPIC POWDER. IT IS NECESSARY TO
CHECK IT’S QUALITY BEFORE APPLYING OF PLASTER
BANDAGE: 5PART OF GYPSUM MUST BE MIXED WITH
3PART OF WATER. IT MUST BE HARDENED DURING 5-
10MIN.GAUSE TAPES WITH 2.5-3M LENGTH MUST BE
USED FOR PREPARATION OF PLASTER (OF PARIS)
BANDAGES (THIN - FOR UPPER EXTREMITY -3-4
LAYERS AND THICK - FOR THE LOWER EXTREMITY - 6-
8 LAYERS).
 Rules of applying of plaster bandage
1. The limb must be immobilized in a functional position;
2. Good reduction of broken bone fragments (reposition)
must be maintained during the applying of plaster bandage,
before their hardening;
3. Two nearest joints of broken bones must immobilized.
Exceptions from this rule is fracture of shin bones, which
needs immobilization not only the knee and ankle but hip
joint also;
4. Tops of fingers must be left open (free from bandage) for
their monitoring;
5. Non-hygroscopic cotton wool must be put near the bone
eminences in aim to avoid compression;
Plaster bandage shape must be moulded thoroughly in aim not
to compress the limb;
 6. It is necessary to put the data on the plaster bandage
after it’s applying and data of removal of it; It is necessary to
put the dry rolls of plaster bandage tapes into the 20°C water
for 1.5-2 min, what is enough to get wet through. Then it is
necessary to take it out from the water and compress it with
both hands in aim to remove excessive amount of water.
Plaster bandage dries up during 1-3days on the room
temperature. To make it quicker electric heating fan may be
used. It is necessary to check the color, sense, coldness of
fingers in aim not to miss the compression of extremity with
the plaster bandage and dissect it in time with plaster knife
or Still’s shears (scissors), with subsequent fixation with few
tours of plaster gauze. Plaster bandage must be dissected in
case of occurrence of bedsores (decubitus) and remove in
case of anaerobic infection development.
 TYPES OF PLASTER BANDAGES
1. Plaster bandage without padding;
2. Witman-Turner’s bandage with a stirrup plastered
in solid plaster bandage (closed) /fig. 126, A/;
3. Plaster bar /fig. 128/;
4. Bridged plaster bandage /fig. 126, B/;
5. Fenestrated plaster bandage /fig. 126, C/;
6. Open plaster bandage (plaster splint);
7. Removable plaster bandage;
8. Hip plaster bandage;
9. Plaster bandage for padding;
FIG 126. VARIOUS TYPES OF PLASTER BANDAGE
FIG 127. PLASTER BAR
FIG 128. THORACOBRACHIAL PLASTER
BANDAGE
 TYPES OF PLASTER BANDAGES
10. Thoracobrachial plaster bandage /fig. 128/;
11. Circular (solid) plaster bandage;
12. Plaster cast (splint) bandage;
13. One-step (stage) plaster bandage;
14. Plaster bed of Lorenz;
15. Plaster bandage for head support;
16. Full-length plaster cast on a hand (leg);
17. Plaster jacket;
18. Plaster boot (shoe).
 TYPES OF PLASTER BANDAGES

The plaster bandage must be removed

after the healing of the fractures of the bones
with the help of circular (semicircular plaster
saw, Still’s shears (scissors) or plaster knife.
Margins must be flexed out with the plaster
banding forceps and removed.
 METHODS OF CONTINUOUS (CONSTANT,
PROLONGED, PROTRACTED)
TRACTION (EXTENSION, PULLING)
This method of treatment of fractures includes:
1. Skeletal traction;
2. Dermal (glue traction, adhesive plaster) traction and
also:
a)short-time (one-moment) extension;
b)underwater traction;
c)gravity traction;
d)board traction;
e)axis traction.
 The surgeon must follow the following rules, providing the
skeletal traction:
1. The limb must be immobilized on the Bohler’s or
Bogdanovich’s frame (splint) in a functional position (in the
condition of equilibrium between of antagonist muscles). It is
semi-flexed position of the limb /fig. 129/;
2. Reposition (reduction of the displacement) must be
performed following to the axis of central fragment of the
broken bone (peripheral fragment must be put following to the
axis of central fragment);
3. Weigh for traction must be increased gradually and it
provides painless pull of muscles and reduction of displacement;
4. It is necessary to provide contraction with the help of body
mass, what may be reached with the elevation of one end of the
bed (site of legs).
FIG 129. CONTINUOUS TRACTION OF THE
LIMB ON THE BOHLER’S SPLINT
 Surgical instruments, necessary to provide skeletal traction:
1. Kirschner’s or “CITO” wire (pin) for skeletal traction
/fig. 130, B/;
2. Drill for passing a wire (pin) - electric or mechanical;
3. Wrench (to pass and tighten a pin) /fig. 130, C/;
4. Stirrup (for skeletal traction) /fig. 130, A/.
Skin, subcutaneous fat and periosteum must be infiltrated
with 0.5% sol. of Novocain. Wire must be passed with the
help of drill through:
1. the eminention of the hip condyles or tibial tuberculum (in
case of fracture of the femur);
2. the calcaneous bone (in case of fracture of shin bones);
3. the tip of the elbow (olecranon) in case of fracture of
humerus
FIG 130. KIRSCHNER’S WIRE, WRENCH AND
STIRRUP FOR TRACTION
 METHODS OF CONTINUOUS (CONSTANT,
PROLONGED, PROTRACTED)
TRACTION (EXTENSION, PULLING)

After the abovementioned procedures the wire (pin)

must be fixed into the stirrup for the skeletal traction with
the help of wrench for pressing and tightening a pin.The
patient must be transported from the operative room into the
ward. Fractured limb must be put on the Bohler’s frame.
Appropriative weigh must be 15% of body mass in case of
fracture of femur and 10% in case of shin bones. The site of
the legs of the bed must be elevated:
a) on 30cm – if the weight for traction is 6-10kg;
b) on 70cm - if the weight of traction is 11-15kg.
 METHODS OF CONTINUOUS (CONSTANT, PROLONGED,
PROTRACTED)
TRACTION (EXTENSION, PULLING)
Reduction of the displacement lasts 1-3days,after which
reparation starts and lasts with bone fragments healing (uniting,
consolidation) for 4-6weeks.
Increasing of traction weight must started from 4-5kg gradually
(adding 1-2kg in every hour). Weight must be reduced down to 4-5kg,
as soon as reduction of dislocation is reached, in aim to avoid
hypertraction of muscles and new displacement of bone fragments.
Skeletal traction may last for two months. Food of patient must
contain enough amount of proteins, vitamins, minerals (Centrum,
Vitrum, Unicap may be added), calcium-D3 and phosphates.
Kinesitherapy (therapeutic gymnastics, massage, mechanotherapy,
occupational therapy) is very useful in aim to train extremity (limb),
as early going on crutches.
 Operative Treatment of Fractures
(osteosynthesis)
ABSOLUTE INDICATION FOR THE OPERATIVE TREATMENT
OF FRACTURES:
1. OPENED FRACTURES;
2. INJURY OF VITAL ORGANS (BRAIN, SPINAL CORD, THORACIC
AND ABDOMINAL ORGANS, THICK NERVOUS TRUNKS AND BLOOD
VESSELS);
3. INTERPOSITION OF SOFT TISSUES (PRESENCE OF MUSCLES,
FASCIA, TENDON BETWEEN OF BONE FRAGMENTS), WHAT MAKES
IMPOSSIBLE CONSOLIDATION;
4. PSEUDOARTHROSIS (NON-UNITED FRACTURES);
5. INFLAMMATORY AND PURULENT COMPLICATIONS OF
FRACTURES;
6. IMPERFECTLY UNITED FRACTURE WITH MARKED
DISTURBANCE OF THE FUNCTION OF THE ORGAN.
 Relative indications for the operative
treatment of fractures:
1. Unsuccessful repeated reslting (replace) of
bone fragments;
2. Slow consolidation of fracture;
3. Lateral displacement of fragments, when it is
impossible to reset and fix them;
4. Imperfectly united fractures with insignificant
disturbance of function of the extremity.
 Osteosynthesis (operative uniting of the bone fragments) may be
performed with the help of metal pins, nails, wires, screws). Metal
rod for osteosynthesis may be inserted inside of the bone
fragments /fig.131/ (intramedular, intraosseous osteosynthesis) or
metal plate may be fixed on the external surface of the bone
fragments with the help of the screws (extramedular or
extraosseous osteosynthesis /fig. 132/).
Distraction-compres­sion apparatus (of O.Gudushauri (A), Ilizarov
(B), Volkovich-Oganezian (C)) avoids abovementioned negative
sites and provides performing of extrafocal osteosynthesis
(metallic wires are passed into the bone fragments far from the site
of fracture), resetting, fixing and compression of bone fragments.
They are useful for the treatment not for only fresh fractures, but
for pseudarthrosis, slow consolidation of fractures, osteomyelitis of
tops of fragments.
FIG 131. INTRAMEDULAR OSTEOSYNTHESIS
FIG 132. EXTRAMEDULAR OSTEOSYNTHESIS
OPERATIVE TREATMENT OF FRACTURES
(OSTEOSYNTHESIS)
Distraction-compres­sion apparatus /fig. 133/ (of
O.Gudushauri (A), Ilizarov (B), Volkovich-
Oganezian (C)) avoids abovementioned negative
sites and provides performing of extrafocal
osteosynthesis (metallic wires are passed into the
bone fragments far from the site of fracture),
resetting, fixing and compression of bone
fragments. They are useful for the treatment not
for only fresh fractures, but for pseudarthrosis,
slow consolidation of fractures, osteomyelitis of
tops of fragments.
FIG 133. DISTRACTION-COMPRES­SION
APPARATUS
 Outcomes of treatment of fractures:
1. Full restoration of anatomical integrity and function of
extremity;
2. Full restoration of anatomical integrity with disturbance
of function (muscle atrophy, contractures);
3. Imperfectly united fracture with the disturbance of shape
of bone or organ (shortening, deformation) with it’s
dysfunction (limitation of the wideness of the movement,
lameness);
4. Imperfectly united fracture with restorated functions;
5. Non-united fractures-pseudartrosis;
6. Posttraumatic osteomyelitis.
 COMPLICATIONS IN THE TREMENT
FRACTURES
Imperfect transport immobilization may cause injury of blood
vessels, nervous trunks, transformation of closed fracture into the
opened one.
Treatment of slow consolidation includes-immobilization with
plaster bandage or compression osteosynthesis, removal of scar tissue
between fragments, good resetting, massage, therapeutic exercises,
injection of anabolic steroids.

Treatment of pseudoarthrosis is operative (excision of scar

tissues, opening of bone marrow canals, refreshing of ends of bone
fragments, resetting and immobilization with the help of bone auto
transplant (autografts) or compression apparatus.
 COMPLICATIONS IN THE TREMENT
FRACTURES

Incomplete reset (lateral fracture, interposition of soft tissues)

cause non united fracture or imperfectly united fracture. Time of
formation of pseudoarthrosis compose 9-10 months after the fracture.
Consolidation is called slow if it isn’t finished in the double time.
The reasons of slow uniting may be: imperfect resetting,
immobilization, interposition, existence of defects after little bone
fragments removal, osteomyelitis, trophic disturbances (local
reasons), also bad nourishment, depletion, diabetes, elderness
(general reasons). Symptoms of slow uniting are –pathologic
movement, skin hyperemia, muscle atrophy, tenderness in case of
axial loading, sclerosis of both ends of fragments and presence
ofclosed ends of bone marrow canals in case of pseudoarthrosis.
 Probable symptoms Undoubtful symptoms

* pain * presence of bone fragments in the wound

* swelling * crepitation of bone fragments

* subcutaneous hematoma * pathologic movements in unusual place

* dysfunction * deformation disfiguration and anatomic shortening of the limb

direction of the wound canal (in case of

opened and gunshot fractures)
 Duration of
Localisation of fracture invalidity
fixing and consolidation
upper extremity

digital phalanx 21 28-49

bones of the wrist 28 42

Radius:distal part 28-35 42-63

diaphysis 56-70 70-84

Elbow 60-75 60-90

Shoulder

head of the humerus 45-60 60-75

diaphysis 45-90 60-75

clavicle 21-28 30-45

Lower extremity

calcanous bone 35-42 45-75

metatarsal bone 21-42 30-60

both ankles 45-60 60-75

the same with partial dislocation of foot 60-75 75-105

diaphysis of tibia 60-75 75-105

diaphysis of both bones of shin 60-90 90-135

knee-cap(patella) 30 45-90

Hip (thigh, femur)

diaphisis 60-120 105-180

neck 90-120 150-240