Bone Anatomy and Physiology

ANATOMY OF BONE

Bones may be classified into four types on the basis of their shape i.e., long,

short, flat and irregular. For practical purposes, anatomy of a typical long bone

only is being discussed here.

Structure of a typical long bone: In children, a typical long bone, such as the

femur, has two ends or epiphyses (singular epiphysis), and an intermediate

portion called the shaft or diaphysis. The part of the shaft which adjoins the

epiphysis is called the metaphysis – one next to each epiphysis. There is a thin

plate of growth cartilage, one at each end, separating the epiphysis from the

metaphysis. This is called the epiphyseal plate. At maturity, the epiphysis fuses

with the metaphysis and the epiphyseal plate is replaced by bone. The articular

ends of the epiphyses are covered with articular cartilage. The rest of the bone is

covered with periosteum which provides attachment to tendons, muscles,

ligaments, etc. The strands of fibrous tissue connecting the bone to the

periosteum are called Sharpey's fibres. Microscopically, bone can be classified

as either woven or lamellar. Woven bone or immature bone is characterized by

random arrangement of bone cells (osteocytes) and collagen fibres. Woven bone

is formed at periods of rapid bone formation, as in the initial stages of fracture

healing. Lamellar bone or mature bone has an orderly arrangement of bone cells
and collagen fibres. Lamellar bone constitutes all bones, both cortical and

cancellous. The difference is, that in cortical bone the lamellae are densely

packed, and in cancellous bone loosely. The basic structural unit of lamellar

bone is the osteon. It consists of a series of concentric laminations or lamellae

surrounding a central canal, the Haversian canal. These canals run

longitudinally and connect freely with each other and with Volkmann's canals.

The latter run horizontally from endosteal to periosteal surfaces. The shaft of a

bone is made up of cortical bone, and the ends mainly of cancellous bone. The

junction between the two, termed the cortico cancellous junction is a common

site of fractures.
Structural composition of bone: The bone is made up of bone cells and extra-

cellular matrix. The matrix consists of two types of materials, organic and

inorganic. The organic matrix is formed by the collagen, which forms 30-35

percent of dry weight of a bone. The inorganic matrix is primarily calcium and

phosphorus salts, especially hydroxyapatite [Ca10(PO4)6(OH)2]. It constitutes

about 65-70 percent of dry weight of a bone.

Bone cells: There are three main cell types in the bone. These are:

a) Osteoblasts: Concerned with ossification, these cells are rich in alkaline

phosphatase, glycolytic enzymes and phosphorylases.

b) Osteocytes: These are mature bone cells which vary in activity, and may

assume the form of an osteoclast or reticulocyte. These cells are rich in

glycogen and PAS positive granules.

c) Osteoclasts: These are multi-nucleate mesenchymal cells concerned with

bone resorption. These have glycolytic acid hydrolases, collagenases and acid

phosphatase enzymes
Multi-Scale Approach to Bone Study – Summary
BLOOD SUPPLY OF BONES

There is a standard pattern of the blood supply of a typical long bone. Blood

supply of individual bones will be discussed wherever considered relevant. The

blood supply of a typical long bone is derived from the following sources:

a) Nutrient artery: This vessel enters the bone around its middle and divides

into two branches, one running towards either end of the bone. Each of these

further divide into a leash of parallel vessels which run towards the respective

metaphysis.

b) Metaphyseal vessels: These are numerous small vessels derived from the

anastomosis around the joint. They pierce the metaphysis along the line of

attachment of the joint capsule.

c) Epiphyseal vessels: These are vessels which enter directly into the epiphysis.

d) Periosteal vessels: The periosteum has a rich blood supply, from which

many little vessels enter the bone to supply roughly the outer-third of the cortex

of the adult bone. Blood supply to the inner two-thirds of the bone comes from

the nutrient artery and the outer one third from the periosteal vessels
 FRACTURE
A fracture is a break in the continuity of a bone.

CLASSIFICATION OF FRACTURES

It can be classified on the basis of aetiology, the relationship of the fracture with

the external environment, the displacement of the fracture, and the pattern of the

fracture.

ON THE BASIS OF AETIOLOGY

Traumatic fracture: A fracture sustained due to trauma is called a traumatic

fracture. Normal bone can withstand considerable force, and breaks only when
subjected to excessive force. Most fractures seen in day-to-day practice fall into

this category e.g., fractures caused by a fall, road traffic accident, fight etc.

Pathological fracture: A fracture through a bone which has been made weak

by some underlying disease is called a pathological fracture. A trivial or no

force may be required to cause such a fracture e.g., a fracture through a bone

weakened by metastasis. Although, traumatic fractures have a predictable and

generally successful outcome, pathological fractures often go into non-union.

Stress Fracture: This is a special type of fracture sustained due to chronic

repetitive injury (stress) causing a break in bony trabeculae. These often present

as only pain and may not be visible on X-rays.

ON THE BASIS OF DISPLACEMENTS

Undisplaced fracture: These fractures are easy to identify by the absence of

significant displacement.

Displaced fracture: A fracture may be displaced. The factors responsible for

displacement are: (i) the fracturing force; (ii) the muscle pull on the fracture

fragments; and (iii) the gravity. While describing the displacements of a

fracture, conventionally, it is the displacement of the distal fragment in relation

to the proximal fragment which is mentioned. The displacement can be in the

form of shift, angulation or rotation

ON THE BASIS OF RELATIONSHIP WITH EXTERNAL

ENVIRONMENT

Closed fracture: A fracture not communicating with the external environment,

i.e., the overlying skin and other soft tissues are intact, is called a closed

fracture.

Open fracture: A fracture with break in the overlying skin and soft tissues,

leading to the fracture communicating with the external environment, is called

an open fracture. A fracture may be open from within or outside, the so called

internally or externally open fracture respectively.

a) Internally open (from within): The sharp fracture end pierces the skin from

within, resulting in an open fracture.

b) Externally open (open from outside): The object causing the fracture

lacerates the skin and soft tissues over the bone, as it breaks the bone, resulting

in an open fracture. Exposure of an open fracture to the external environment

makes it prone to infection. This risk is more in externally open fracture.

ON THE BASIS OF COMPLEXITY OF TREATMENT

Simple fracture: A fracture in two pieces, usually easy to treat, is called simple

fracture, e.g. a transverse fracture of humerus.

Complex fracture: A fracture in multiple pieces, usually difficult to treat, is

called complex fracture, e.g. a communited fracture of tibia.

ON THE BASIS OF QUANTUM OF FORCE CAUSING FRACTURE

High-velocity injury: These are fractures sustained as a result of severe trauma

force, as in traffic accidents. In these fractures, there is severe soft tissue injury

(periosteal and muscle injury). Thereis extensive devascularisation of fracture

ends. Such fractures are often unstable, and slow to heal.

Low-velocity injury: These fractures are sustained as a result of mild trauma

force, as in a fall. There is little associated soft tissue injury, and hence these

fractures often heal predictably. Lately, there is a change in the pattern of

fractures due to shift from low-velocity to high-velocity injuries. The latter

gives rise to more complex fractures, which are difficult to treat.

ON THE BASIS OF PATTERN

Transverse fracture: In this fracture, the fracture line is perpendicular to the

long axis of the bone. Such a fracture is caused by a tapping or bending force.

Oblique fracture: In this fracture, the fracture line is oblique. Such a fracture is

caused by a bending force which, in addition, has a component along the long

axis of the bone.

Spiral fracture: In this fracture, the fracture line runs spirally in more than one

plane. Such a fracture is caused by a primarily twisting force.

Comminuted fracture: This is a fracture with multiple fragments. It is caused

by a crushing or compression force along the long axis of the bone.

FRACTURES WITH EPONYMS

Some fractures are better known by names, mostlyNof those who first described

them. Some such fractures are as follows:

Monteggia fracture-dislocation: Fracture of theproximal third of the ulna, with

dislocation of the head of the radius.

Galeazzi fracture-dislocation: Fracture of the distal third of the radius with

dislocation of the distal radio-ulnar joint.

Night-stick fracture: Isolated fracture of the shaft of the ulna, sustained while

trying to ward off a stick blow.

Colles’ fracture: A fracture occurring in adults, at the cortico-cancellous

junction of the distal end of the radius with dorsal tilt and other displacements.

Smith's fracture: A fracture occurring in adults, at the cortico-cancellous

junction of the distal end of the radius with ventral tilt and other displacements

(reverse of Colles').

Barton's fracture (Marginal fracture): Intra-articular fractures through the distal

articular surface of the radius, taking a margin, anterior or posterior, of the distal

radius with the carpals, displaced anteriorly or posteriorly.

Chauffeur fracture: An intra-articular, oblique fracture of the styloid process of

the radius.

Bennett's fracture-dislocation: It is an oblique, intraarticular fracture of the base

of the first metacarpal with subluxation of the trapezio-metacarpal joint.

Boxers' fracture: It is a ventrally displaced fracture through the neck of the 5th

metacarpal, usually occurs in boxers.

Side-swipe fracture: It is an elbow injury sustained when one's elbow,

projecting out of a car, is ‘sideswept’ by another vehicle. It has a combination of

fractures of the distal end of the humerus with fractures of proximal ends of

radius and/or ulna. It is also called baby car fracture.

Bumper fracture: It is a comminuted, depressed fracture of the lateral condyle of

the tibia.

Pott's fracture: Bimalleolar ankle fracture.

Cotton's fracture: Trimalleolar ankle fracture.

Massonaise's fracture: It is a type of ankle fracture in which fracture of the neck

of the fibula occurs.

Pilon fracture: It is a comminuted intra-articular fracture of the distal end of the

tibia.

Aviator's fracture: Fracture of neck of the talus.

Chopart fracture-dislocation: A fracture-dislocation through inter-tarsal joints.

Jone's fracture: Avulsion fracture of the base of the 5th metatarsal.

Rolando fracture: Fracture of the base of the first metacarpal (extra-articular).

Jefferson’s fracture: Fracture of the first cervical vertebra.

Whiplash injury: Cervical spine injury where sudden flexion followed by

hyperextension takes place.

Chance fracture: Also called seat belt fracture, the fracture line runs horizontally

through the body of the vertebra, through and through, to the posterior elements.

March fracture: Fatigue fracture of the shaft of 2nd or 3rd metatarsal.

Burst fracture: It is a comminuted fracture of the vertebral body where

fragments ‘‘burst out’’ in different directions.

Clay-Shoveller fracture: It is an avulsion fracture of spinous process of one or

more of the lower cervical or upper thoracic vertebrae.

Hangman's fracture: It is a fracture through the pedicle and lamina of C2

vertebra, with subluxation of C2 over C3, sustained in hanging.

Dashboard fracture: A fracture of posterior lip of the acetabulum, often

associated with posterior dislocation of the hip.

Straddle fracture: Bilateral superior and inferior pubic rami fractures.

Malgaigne's fracture: A type of pelvis fracture in which there is a combination

of fractures, pubic rami anteriorly and sacro-iliac joint or ilium posteriorly, on

the same side.

Mallet finger: A finger flexed at the DIP joint due to avulsion or rupture of

extensor tendon at the base of the distal phalanx.

PATHOLOGICAL FRACTURES

A fracture is termed pathological when it occurs in a bone made weak by some

disease. Often, the bone breaks as a result of a trivial trauma, or even

spontaneously.

CAUSES

A bone may be rendered weak by a disease localised to that particular bone, or

by a generalised bone disorder. Osteoporosis is the commonest cause of

pathological fracture. The bones most often affected are the vertebral bodies

(thoracic and lumbar). Other common fractures associated with osteoporosis are

fracture of the neck of the femur and Colles' fracture. A local or circumscribed

lesion of the bone, responsible for a pathological fracture, may be due to

varying causes in different age groups. In children, it is commonly due to

chronic osteomyelitis or a bone cyst. In adults, it is often due to a bone cyst or

giant cell tumour. In elderly people, metastatic tumour is a frequent cause.

DIAGNOSIS

A fracture sustained without a significant trauma should arouse suspicion of a

pathological fracture. Often the patient, when directly questioned, admits to

having suffered from some discomfort in the region of the affected bone for
some time before the fracture. The patient may be a diagnosed case of a disease

known to produce pathological fractures (e.g., a known case of malignancy),

thus making the diagnosis of a pathological fracture simple. At times, the

patient may present with a pathological fracture, the cause of which is

determined only after a detailed work up.

TREATMENT

Treatment of a pathological fracture consists of:

(i) detecting the underlying cause of the fracture; and (ii) making an assessment

of the capacity of the fracture to unite, based on the nature of the underlying

disease.

A fracture in a bone affected by a generalised disorder like Paget's disease,

osteogenesis imperfecta or osteoporosis is expected to unite with conventional

methods of treatment. A fracture at the site of a bone cyst or a benign tumour

will also generally unite, but the union may be delayed. Fractures occurring in
osteomyelitic bones often take a long time, and sometimes fail to unite despite

best efforts. Fractures through metastatic bone lesions often do not unite at all,

though the union may occur if themalignancy has been brought under control

with chemotherapy or radiotherapy. With the availability of facilities for

internal fixation, more and more pathological fractures are now treated

operatively with an aim to: (i) enhance the process of union by bone grafting

(e.g. in bone cyst or benign tumour); or (ii) mobilise the patient by surgical

stabilisation of the fracture. Achieving stable fixation in these fractures is

difficult because of the bone defect caused by the underlying pathology. The

defect may have to be filled using bone grafts or bone cement.

INJURIES TO JOINTS

Joint injuries may be either a subluxation or a dislocation. A joint is subluxated

when its articular surfaces are partially displaced but retain some contact

between them.

A joint is dislocated when its articular surfaces are so much displaced that all

contact between them is lost. A dislocated joint is an emergency, and should be

treated at the earliest.

INJURIES TO LIGAMENTS

An injury to a ligament is termed as a sprain. This is to be differentiated from

the term ‘strain’ which means stretching of a muscle or its tendinous

attachment.

CLASSIFICATION

Sprains are classified into three degrees:

First-degree sprain is a tear of only a few fibres of the ligament. It is

characterised by minimal swelling, localised tenderness but little functional

disability.

Second-degree sprain is the one where, anything from a third to almost all the

fibres of a ligament are disrupted. The patient presents with pain, swelling and
inability to use the limb. Joint movements are normal. The diagnosis can be

made on performing a stress test as discussed subsequently.

Third-degree sprain is a complete tear of the ligament. There is swelling and

pain over the torn ligament. Contrary to expectations, often the pain in such

tears is minimal. Diagnosis can be made by performing a stress test, and by

investigations such as MRI or arthroscopy.

PATHOLOGY

A ligament may get torn in its substance (midsubstance tear) or at either end. In

the latter case, it often avulses with a small piece of bone from its attachment.
DIAGNOSIS

A detailed history, eliciting the exact mechanism of injury, often indicates the

likely ligament injured. The examination helps in finding the precise location

and severity of the sprain, which can then be confirmed by investigations.

Clinical examination: A localised swelling, tenderness, and ecchymosis over a

ligament indicates injury to that ligament. Usually, a haemarthrosis is noticed in

second and third-degree sprains within 2 hours. It may be absent* despite a

complete tear, or if the torn ligament is covered by synovium (e.g., intra-

synovial tear of anterior cruciate ligament).

Stress test: This is a very useful test in diagnosing a sprain and judging its

severity. The ligament in question is put to stress by a manoeuvre. The

manoeuvre used for testing of individual ligaments will be discussed in

respective chapters. When a ligament is stressed, in first and second degree

sprains, there will be pain at the site of the tear. In third-degree sprain, the joint

will ‘open up’ as well.

INVESTIGATIONS

A plain X-ray of the joint is usually normal. Sometimes, a chip of bone may be

seen in the region of the attachment of the ligament to the bone. An X-ray taken

while the ligament is being stressed (stress X-ray) may document an abnormal

opening up of the joint in a third-degree sprain. Other investigations required in

a few cases are MRI or arthroscopy.

TREATMENT

There has been a significant change in the treatment of sprains. All sprains are

treated initially with rest, ice therapy, compression bandage, elevation (RICE).
Suitable analgesics and anti-inflammatory medication is given. This is enough

for first-degree sprains. Second and third-degree sprains are immobilised in a

brace or a plaster cast for a period of 1-2 weeks, mainly for pain relief. No

longer is plaster immobilisation advised for long periods. In fact, early

obilisation and walking with support enhances healing of ligaments. In some

third-degree sprains, surgery may be required.

INJURIES TO MUSCLES AND TENDONS

Muscles are ruptured more often than tendons in young people, while the

reverse is true in the elderly. The most frequent cause of partial or complete

rupture of a muscle or a tendon is sudden vigorous contraction of a muscle. It

may be by overstretching of a muscle at rest. Such an injury to muscle is termed

strain (and not sprain, which is ligament injury). A muscle or tendon injury may

also be produced by a sharp object such as a sword.

PATHOLOGY

A rupture occurs within a tendon only if it is abnormal and has become weak,

either due to degeneration or wear and tear. Degenerative tendon ruptures

commonly occur in rheumatoid arthritis, SLE, senile degeneration, etc. Tendon

rupture related to wear and tear commonly occurs in the biceps (long head), and

in extensor pollicis longus tendons. Some tendons known to rupture commonly.

Diagnosis of a ruptured tendon is usually easy. The patient complains of pain

and inability to perform the movement for which the tendon is meant.
TREATMENT

The best treatment of a fresh rupture is to regain continuity by end-to-end

repair. When the gap is too much, it can be filled with the help of a tendon graft.

In cases where the repair is not possible, a tendon transfer may be performed. In

some old tendon ruptures, especially in the elderly, there may be only a minimal

functional disability. These patients do well without treatment.

FRACTURE HEALING

The healing of fractures is in many ways similar to the healing of soft tissue

wounds, except that soft tissue heals with fibrous tissue, and end result of bone

healing is mineralised mesenchymal tissue, i.e. bone. A fracture begins to heal

soon after it occurs, through a continuous series of stages described below.

STAGES IN FRACTURE HEALING OF CORTICAL BONE (FROST, 1989)

• Stage of haematoma

• Stage of granulation tissue

• Stage of callus

• Stage of remodelling (formerly called consolidation)

• Stage of modelling (formerly called remodelling)

Stage of haematoma: This stage lasts up to 7 days. When a bone is fractured,

blood leaks out through torn vessels in the bone and forms a haematoma

between and around the fracture. The periosteum and local soft tissues are

stripped from the fracture ends. This results in ischaemic necrosis of the fracture

ends over a variable length, usually only a few millimetres. Deprived of their

blood supply, some osteocytes die whereas others are sensitised to respond

subsequently by differentiating into daughter cells. These cells later contribute

to the healing process.

Stage of granulation tissue: This stage lasts for about 2-3 weeks. In this stage,

the sensitised precursor cells (daughter cells) produce cells which differentiate

and organise to provide blood vessels, fibroblasts, osteoblasts etc. Collectively

they form a soft granulation tissue in the space between the fracture fragments.

This cellular tissue eventually gives a soft tissue anchorage to the fracture,

without any structural rigidity. The blood clot gives rise to a loose fibrous mesh

which serves as a framework for the ingrowth of fibroblasts and new capillaries.

The clot is eventually removed by macrophages, giant cells and other cells

arising in the granulation tissue. From this stage, the healing of bone differs

from that of soft tissue. In soft tissue healing the granulation tissue is replaced

by fibrous tissue, whereas in bone healing the granulation tissue further

differentiates to create osteoblasts which subsequently form bone.

Stage of callus: This stage lasts for about 4-12 weeks. In this stage, the

granulation tissue differentiates further and creates osteoblasts. These cells lay

down an intercellular matrix which soon becomes impregnated with calcium

salts. This results in formulation of the callus, also called woven bone. The

callus is the first sign of union visible on

X-rays, usually 3 weeks after the fracture. The formation of this bridge of

woven bone imparts good strength to the fracture. Callus formation is slower in

adults than in children, and in cortical bones than in cancellous bones.

Stage of remodelling: Formerly called the stage of consolidation. In this stage,

the woven bone is replaced by mature bone with a typical lamellar structure.

This process of change is multicellular unit based, whereby a pocket of callus is

replaced by a pocket of lamellar bone. It is a slow process and takes anything

from one to four years.

Stage of modelling: Formerly called the stage of remodelling. In this stage the

bone is gradually strengthened. The shapening of cortices occurs at the

endosteal and periosteal surfaces. The major stimulus to this process comes

from local bone strains i.e., weight bearing stresses and muscle forces when the
person resumes activity. This stage is more conspicuous in children with

angulated fractures. It occurs to a very limited extent in fractures in adults.

HEALING OF CANCELLOUS BONES

The healing of fractured cancellous bone follows a different pattern. The bone is

of uniform spongy texture and has no medullary cavity so that there is a large

area of contact between the trabeculae. Union can occur directly between the

bony trabeculae. Subsequent to haematoma and granulation formation, mature

osteoblasts lay down woven bone in the intercellular matrix, and the two

fragments unite.

PRIMARY AND SECONDARY BONE HEALING

Primary fracture healing occurs where fracture haematoma has been disturbed,

as in fractures treated operatively. The bone heals directly, without callus

formatiom, and it is therefore diffcult to evaluate union on X-rays.

Secondary fracture healing occurs in fractures where fracture haematoma is not

disturbed, as in cases treated non-operatively. There is healing, with callus

formation, and can be evaluated on X-rays. It also occurs in fractures operated

without disturbing the fracture haematoma, as in fractures fixed with relative

stability (e.g. comminuted fractures).

FACTORS AFFECTING FRACTURE HEALING

a) Age of the patient: Fractures unite faster in children. In younger children,

callus is often visible on X-rays as early as two weeks after the fracture. On an

average, bones in children unite in half the time compared to that in adults.

Failure of union is uncommon in fractures of children.

b) Type of bone: Flat and cancellous bones unite faster than tubular and

cortical bones.

c) Pattern of fracture: Spiral fractures unite faster than oblique fractures,

which in turn unite faster than transverse fractures. Comminuted fractures are

usually result of a severe trauma or occur in osteoporotic bones, and thus heal

slower.

d) Disturbed pathoanatomy: Following a fracture, changes may occur at the

fracture site, and may hinder the normal healing process. These are: (i) soft

tissue interposition; and (ii) ischaemic fracture ends. In the former, the fracture

ends pierce through the surrounding soft tissues, and get stuck. This causes soft

tissue interposition between the fragments, and prevents the callus from
bridging the fragments. In the latter, due to anatomical peculiarities of blood

supply of some bones (e.g. scaphoid), vascularity of one of the fragments is cut

off. Since vascularised bone ends are important for optimal fracture union, these

fractures unite slowly or do not unite at all.

e) Type of reduction: Good apposition of the fracture results in faster union. At

least half the fracture surface should be in contact for optimal union in adults. In

children, a fracture may unite even if bones are only side-to-side in contact

(bayonet reduction).

f) Immobilisation: It is not necessary to immobilise all fractures (e.g., fracture

ribs, scapula, etc). They heal anyway. Some fractures need strict immobilisation

(e.g., fracture of the neck of the femur), and may still not heal.

g) Open fractures: Open fractures often go into delayed union and non-union

h) Compression at fracture site: Compression enhances the rate of union in

cancellous bone. In cortical bones, compression at the fracture site enhances

rigidity of fixation, and possibly results in primary bone healing.

Treatment of Fractures
Treatment of a fracture can be considered in three phases:

• Phase I - Emergency care

• Phase II - Definitive care

• Phase III – Rehabilitation

PHASE I - EMERGENCY CARE

At the site of accident: Emergency care of a fracture begins at the site of the

accident. In principle, it consists of RICE, which means:

• Rest to the part, by splinting.

• Ice therapy, to reduce occurrence of swelling

• Compression, to reduce swelling

• Elevation, to reduce swelling

Rest to the part (splinting) is done by splinting. 'Splint them where they lie'.

Before applying the splint, remove ring or bangles worn by the patient. Almost

any available object at the site of the accident can be used for splinting. It may

be a folded newspaper, a magazine, a rigid cardboard, a stick, an umbrella, a

pillow, or a wooden plank. Any available long piece of cloth can be used for

tying the splint to the fractured limb. Some of the examples of splinting a
fractured extremity at the site of the accident are shown in Fig-3.1. One may

correct any gross deformity by gentle traction. Feel for distal pulses, and do a

quick assessment of nerve supply before and after splinting. The advantages of

splinting are:

• Relief of pain, by preventing movement at the fracture.

• Prevention of further damage to skin, soft tissues and neurovascular bundle of

the injured extremity.

• Prevention of complications such as fat embolism and hypovolaemic shock.

• Transportation of the patient made easier.

Ice therapy: An immediate application of ice to injured part helps in reducing

pain and swelling. This can be done by taking crushed ice in a polythene bag

and covering it with a wet cloth. Commercially available ice packs can also be

used. Any wound, if present, has to be covered with sterile clean cloth.

Compression: A crepe bandage is applied over the injured part, making sure that

it is not too tight.

Elevation: The limb is elevated so that the injured part is above the level of the

heart. For lower limb, this can be done using pillows. For upper limb, a sling

and pillow can be used.

In the emergency department: Soon after a patient with a musculo-skeletal

trauma is received in an emergency department, one has to act in a coordinated

way. It is most important to provide, if required, basic life support (BLS). If in

shock, the patient is stabilised before any definitive orthopaedic treatment is

carried out. A quick evaluation of the extent of injury at this stage enables a

doctor to understand the seriousness of the problem. Particular attention is paid

to head injury, chest injury and abdominal injury. These can be cause of early

fatality. Any bleeding is recognised and stopped by local pressure. The

fractured limb is examined to exclude injury to nerves or vessels. As soon as the

general condition of the patient is stablised, the limb is splinted. It is important

to check the bandaging done elsewhere, as it may be too tight. Some of the

splints used in the emergency department. In addition to splintage, the patient

should be made comfortable by giving him intramuscular analgesics. In a case

with suspected head injury, narcotic analgesics should be avoided. A broad

spectrum antibiotic may be given to those with open fractures. It is only after

the emergency care has been given, and it is ensured that the patient is stable.

He should be sent for suitable radiological and other investigations, under

supervision.
PHASE II - DEFINITIVE CARE

Philosophy of fracture treatment: Over the years, treatment of fractures has

undergone change in philosophy. In the past, the aim of treatment was a mere

fracture union. This could be achieved in most cases by immobilisation, which

would cause joint stiffness, muscle wasting etc., and may result in less than

optimal functional recovery. The aim now is to get the limb functions back to
pre-injury level. For this, early mobilisation of the limb is desirable, as this

helps in preserving joint movements and muscle functions. Perfect anatomical

reduction and stable fixation is preferred for intra-articular fractures, as only

then early mobilisation can be done. In diaphyseal fractures, the aim is to

achieve union in good alignment and length. This can be done by non operative

methods, if the fracture is stable. Operative methods are required for unstable

fractures. With currently available techniques of surgery, the trend is towards

treating more and more fractures operatively as this gives more predictable

results, early recovery and better functions. The discussion that follows will

give the reader a guideline.

Fundamental principles of fracture treatment:

The three fundamental principles of treatment of a fracture are: (i) reduction;

(ii) immobilisation; and (iii) preservation of functions.

Reduction is the technique of ‘setting’ a displaced fracture to proper alignment.

This may be done open reduction respectively.

Immobilisation is necessary to maintain the bones in reduced position. This may

be done by external immobilisation such as plaster etc., or by internal fixation

of the fracture using rods, plates, etc.

To preserve the functions of the limb, physiotherapy all throughout the

treatment, even when the limb is immobilised, is necessary.

Methods of treatment: Not all the three fundamental treatment principles

discussed above apply to all fractures. Treatment of a particular fracture can fall

in one of the following categories:

a) Treatment by functional use of the limb: Some fractures (e.g., fractured ribs,

scapula) need on immobilisation. These fractures unite despite functional use of

the part. Simple analgesics and splinting are needed for the initial few days,

basically for pain relief.

b) Treatment by immobilisation alone: In some fractures, mere immobilisation

of the fracture in whatever position, is enough. Fractures without significant

displacement or fractures where the displacement is of no consequence (e.g.,

some fractures of surgical neck of the humerus) are treated this way.

c) Treatment by closed reduction followed by immobilisation: This is required

for most displaced fractures treated non-operatively. The reduction could be

done under mild sedation or under anaesthesia. Immobilisation is usually in a

plaster cast. There is trend towards use of image intensifier to aid closed

reduction.
d) Closed reduction and percutaneous fixation: This is done for fractures, which

though can be reduced by closed manipulation, but are unstable, and are likely

to displace subsequently. These fractures are reduced under image intensifier,

and fixed with percutaneous devices such as K wire, rush pins etc., which hold

the fracture in position. External support of a plaster or splint is usually

required, in addition.

e) Open reduction and internal fixation: There are some fractures, such as intra-

articular fractures, where accurate reduction, stable fixation and early

mobilisation are very important to regain joint functions. Such fractures are best

treated by open reduction and internal fixation. Some unstable fractures are also

treated by this method.

f) Minimally invasive surgery (MIS): There is trend towards treating fractures

with minimally invasive techniques. In this, image intensifier is used to aid

reduction without opening the fracture. The fracture is, then stabilised internally

using special devices such as rods, plates etc. These devices are introduced

through small incision using special instrumentation. MIS has the advantage

that the blood supply of the bone is preserved, and thus early union occurs. Less

pain, early recovery and cosmesis are other advantages. Which of the above

method is used in a particular fracture depends upon a number of factors such as

patient's profession, whether the injured limb is dominant or not, surgeon's

experience, availability of facilities, patient's affordability etc. It is therefore

common to see differing opinions on the treatment of a particular fracture.

Discussed below are the three fundamental principles of fracture treatment:

reduction, immobilisation and preservation of functions.

REDUCTION OF FRACTURES

Indications: Not all fractures require reduction, either because there is no

displacement or because the displacement is immaterial to the final outcome.

For example, a child's clavicle fracture does not need reduction because normal

function and appearancewill be restored without any intervention. be accepted

more readily than imperfect angulatory anatomical reduction is desirable in

some fractures, even if for this an operation is required (e.g. intraarticular

fractures).

Methods: Reduction of a fracture can be carried out by one of the following

methods:

a) Closed manipulation: This is the standard initial method of reducing most of

the common fractures. It is usually carried out under general anaesthesia* and

requires experience. It is an art of realigning a displaced bone by feeling

through the soft tissues. The availability of an image intensifier has greatly
added to the skills of closed reduction. It is not necessary that perfect

anatomical reduction be achieved in all cases. Displacements compatible with

normal functions are considered 'acceptable'. Most fractures reduced by closed

manipulation need some kind of immobilisation (PoP, brace, bandaging etc.)

discussed subsequently.

b) Continuous traction: It is used to counter the forces which will not allow

reduction to happen or would cause redisplacement. These are muscle forces

and the force of gravity. A common example is that of an inter-trochanteric

fracture, in which the muscles attached to different fragments cause

displacements. A continuous traction can counter this force, and bring the bones

in proper alignment. Continuous traction has its own problem of keeping the

patient in bed for long time with its complications such as bedsores etc. It is for

this reason that once the fracture so treated becomes 'sticky', and has little

possibility of redisplacement, the traction is discontinued and the fracture

supported in a plaster cast till healing occurs. It is because of uncertainty of

result and need for in-bed immobilisation that many of these fractures are now

treated operatively.

c) Open reduction: In this method, the fracture is surgically exposed, and the

fragments are reduced under vision. Some form of internal fixation is used in
order to maintain the position. This is commonly referred as 'open reduction

and internal fixation' or ORIF.

This is one area of fracture treatment which is continuously evolving. There

used to be times when orthopaedic wards used to be full of patients in traction

and huge plaster casts for months. Today, with advancement in surgical

treatment, the paradigm has shifted to operative treatment. The big deciding

factor for adopting ORIF as the treatment of choice is the facilities available and

training of the surgeon. The potential risks of surgery are sometimes worse than

the disadvantages of non-operative treatment. One reason to do open reduction

is when other methods of achieving reduction have failed. There are fractures

which are so unstable that one knows that these fractures will redisplace in due

course. In such fractures, open reduction and secure internal fixation is carried

out in the first instance.

Indications: Not all fractures require immobilisation. The reasons for

immobilising a fracture

may be:

a) To prevent displacement or angulation:In general, if reduction has been

necessary, immobilisation will be required.

b) To prevent movement that might interfere with the union: Persistent

movement might tear the delicate early capillaries bridging the fracture. More

strict immobilisation is necessary for some fractures (e.g., scaphoid fracture).

c) To relieve pain: This is the most important reason for the immobilisation of

most fractures. As the fracture become pain free and feels stable, guarded

mobilisation can be started.

Methods: Immobilisation of a fracture can be done by non-operative or

operative methods.

NON-OPERATIVE METHODS Most fractures can be immobilised by one of

the following non-operative methods:

Strapping: The fractured part is strapped to an adjacent part of the body e.g., a

phalanx fracture, where one finger is strapped to the adjacent normal finger.

Sling: A fracture of the upper extremity is immobilised in a sling. This is

mostly to relieve pain in cases where strict immobilisation is not necessary e.g.,

triangular sling used for a fracture of the clavicle.

Cast immobilisation: This is the most common method of immobilisation.

Plaster-of-Paris casts have been in use for a long time. Lately, fibreglass casting

tapes have become popular. The latter provide durable, light-weight, radiolucent

casts. Plaster of Paris (Gypsum salt) is CaSO4. ½ H2O in dry form, which

becomes CaSO4.2H2O on wetting. This conversion is an exothermic reaction

and is irreversible. The plaster sets in the given shape on drying. The setting

time of a plaster varies with its quality, and temperature of the water. Types of

plaster bandages: There are two types of plaster bandages in use—one prepared

by impregnating rolls of starched cotton bandages with plaster powder (home-

made bandages); the other are readymade bandages available as a proprietary

bandage.

Use of Plaster of Paris: It can be applied in two forms i.e., slab or a cast. A

plaster slab covers only a part of the circumference of a limb. It is made by

unrolling a plaster bandage to and fro on a table. An average slab is about

twelve such thicknesses. The slab is used for the immobilisation of soft tissue

injuries and for reinforcing plaster casts. A plaster cast covers the whole of the

circumference of a limb. Its thickness varies with the type of fracture and the

part of the body on which it is applied. Some of the fundamental principles to be

remembered while applying a plaster cast are as follows:

• Immobilise the joints above and below the fracture.

• Immobilise joints in a functional position.

• Pad the limb adequately, especially on bony prominences.

After care of a plaster: This involves noticing any cracks in the plaster, avoiding

wetting the plaster, and graduated weight bearing for lower limb fractures.

Exercising the muscles within the plaster and moving the joints not in the

plaster, is necessary to ensure early recovery.

Complications of plaster treatment: The following are some of the common

complications of plaster treatment:

• Impairment of circulation (tight cast) A plaster cast is a closed compartment.

Haematoma and tissue oedema following a fracture can result in increased

pressure inside the cast, leading to impaired circulation of the extremity. Early

diagnosis, by a high index of suspicion, can prevent disastrous complications

like gangrene. Unrelenting pain, especially stretch pain, swelling over the

fingers, inability to move the fingers, hypoaesthesia and bluish discolouration of

the digits are signs of a tight cast. A tight cast can be prevented by adequately

padding the cast and elevating the extremity for the first 2-3 days following a

cast application.

• Plaster sores: These are caused by inadequate padding, irregularity of the inner

surface of the cast, or foreign bodies in the plaster. A sore formation within a

plaster cast can be suspected by the following:

• Pain, out of proportion to fracture

• Fretfulness

• Disturbed sleep

• Recurrence of swelling over toes or fingers

• Low grade fever

• Patch of blood/soakage over the cast.

A plaster sore can be prevented by examination of the suspected area through a

window in the cast. It is possible to dress a small sore through this window.

Occasionally, the plaster has to be removed and reapplied.

Functional bracing: A brace is a type of cast where the joints are not included,

so that while the fracture is kept in position, the joints can also be mobilised.

This method is commonly used for stable fractures of the tibia and humerus. It

is based on the principle that continuous use of the affected limb while the

fracture is kept adequately supported, encourages union and prevents joint

stiffness. The brace is usually applied after the fracture becomes 'sticky'. In

experienced hands, the rate of fracture healing by this method is comparable to

other methods. It is a useful option at places where facilities for surgical

treatment are not available.

Splints and traction: Splints of various designs are used for the definitive

treatment of fractures. Thomas splint is still very popular for the treatment of

fractures of the lower limb. Disadvantages of this method of treatment are

prolonged hospitalisation and confinement to the bed. This can be hazardous,

especially in elderly people who develop complications secondary to

recumbency (e.g. bed sores, chest infection etc.).

OPERATIVE METHODS

Wherever open reduction is performed, fixation (internal or external) should

also be used. External fixation is usually indicated in situations where for some

reason, internal fixation cannot be done.

Internal fixation: In this method, the fracture, once reduced, is held internally

with the help of some metallic or non-metallic device (implant), such as steel

wire, screw, plate, Kirschner wire (K-wire), intra-medullary nail etc. These

implants are made of high quality stainless steel to which the body is inert.

Indications: Internal fixation of fractures may be indicated under the following

circumstances:

a) When a fracture is so unstable that it is difficult to maintain it in an

acceptable position by nonoperative means. This is the most frequent indication

for internal fixation.

b) As a treatment of choice in some fractures, in order to secure rigid

immobilisation and to allow early mobility of the patient.

c) When it has been necessary to perform open reduction for any other reason

such as an associated neurovascular injury.

Methods: A fracture can be fixed internally by any one or combination of

implants,

a) Steel wire: A gauge 18 or 20 steel wire is used for internal fixation of small

fractures (e.g., fracture of the patella, comminuted fragments of large bones

etc.).

b) Kirschner wire: It is a straight stainless steel wire, 1-3 mm in diameter. It is

used for the fixation of small bones of the hands and feet.

c) Intra-medullary nail: It is erroneously called 'nail', but in fact is a hollow rod

made of stainless steel. This can be introduced into the medullary cavity of the

long bones such as femur and tibia. Different shapes and sizes of these nails are

available.

d) Screws: These can be used for fixing small fragments of bone to the main

bone (e.g., for fixation of medial malleolus).

e) Plate and screws: This is a device which can be fixed on the surface of a bone

with the help of screws. Different thicknesses, shapes and sizes are available.
f) Special, fracture specific implants: These are used for internal fixation of

some fractures

g) Combination: A combination of the above mentioned implants can be used

for a given fracture.

Advantages of internal fixation: With the use of modern techniques and

implants, there is minimal need for external immobilisation. It allows early

mobility of the patient out of bed and hospital. Joints do not get stiff and the

muscle functions remain good. The complications associated with confinement

of a patient to bed are also avoided.

Disadvantages: The disadvantages of internal fixation are infection and non-

union. It needs a trained orthopaedic surgeon, free availability of implants and a

good operation theatre; failing which, the results of internal fixation may not

only be poor but disastrous.

External fixator: It is a device by which the fracture is held in a steel frame

outside the limb. For this, pins are passed percutaneously to hold the bone, and

are connected outside to a bar with the help of clamps. This method is useful in
the treatment of open fractures where internal fixation cannot be carried out due

to risk of infection.

These are of the following type:

i. Pin fixators: In these, 3–4 mm sized pins are passed through the bone. The

same are held outside the bone with the help of a variety of tubular rods and

clamps.

ii. Ring fixators: In thesethin ‘K’ wires (1–2 mm) are passed through the bone.

The same are held outside the bone with rings.

PHASE III - REHABILITATION OF A FRACTURED LIMB

Rehabilitation of a fractured limb begins at the time of injury, and goes on till

maximum possible functions have been regained. It consists of joint

mobilisation, muscle re-education exercises and instructions regarding gait

training.

Joint mobilisation: The joint adjacent to an injured bone tends to get stiff due

to:

(i) immobilisation;

(ii) inability to move the joints due to pain; and

(iii) associated injury to the joint as well. To prevent stiffness, the joint should

be mobilised as soon as possible. This is done initially by passive mobilisation

(some one else does it for the patient). Once the pain reduces, patient is

encouraged to move the joint himself with assistance (active assisted), or move
the joint by himself (active mobilisation). Motorized devices which slowly

move the joint through a predetermined range of motion can be used. These are

called continuous passive motion (CPM) machines.

Techniques such as hot fomentation, gentle massage and manipulation aid in

joint mobilisation.

Muscle re-education exercises: Because of lack of use, the muscles get wasted

quickly. Hence, it is desirable that muscle activity be maintained all through the

treatment. This can be done even during immobilisation (static contractions) or

after removal of external immobilisation (dynamic contractions), as discussed

below:

a) During immobilisation: Even while a fracture is immobilised, the joints

which are out of the plaster, should be moved to prevent stiffness and wasting

of muscles. Such movements do not cause any deleterious effect on the position

of the fracture. The muscles working on the joints inside the plaster can be

contracted without moving the joint (static contractions). This maintains some

functions of the immobilised muscles.

b) After removal of immobilisation: After a limb is immobilised for some

period, it gets stiff. As the plaster is removed, the following care is required:
• The skin is cleaned, scales removed, and some oil applied.

• The joints are moved to regain the range of motion. Hot fomentation, active

and active-assisted joint mobilising exercises are

required for this.

• The muscles wasted due to prolonged immobilisation are exercised.

Functional use of the limb: Once a fracture is on way to union, at a suitable

opportunity, the limb is put to use in a guarded way. For example, in lower limb

injuries, gradual weight bearing is started – partial followed by full. One may

need to support the limb in a brace, caliper, cast etc. Walking aids such as a

walker, a pair of crutches, stick etc. may be necessary.

MANAGEMENT OF OPEN FRACTURES

A fracture is called open (compound) when there is a break in the overlying skin

and soft tissues, establishing communication between the fracture and the

external environment. Three specific consequences may result from this.

a) Infection of bone: Contamination of the wound with bacteria from the

outside environment may lead to infection of the bone (osteomyelitis).

b) Inability to use traditional methods: A small wound can be managed

through a window in a plaster cast. But, it may not be possible to manage a big

wound through a window. The presence of a wound may also be a deterrent to

operative fixation of the fracture.

c) Problems related to union: Non-union and malunion occur commonly in

open fractures. This may be because of one or more of the following reasons:

(i) a piece of bone may be lost from the wound at the time of the fracture, the

gap thus created predisposes to non-union;

(ii) the fracture haematoma, which is supposed to have osteogenic potential, is

lost from the wound;

(iii) the 'vascular' cover by the overlying soft tissues, so important for fracture

union, may be missing;

(iv) the bone may get secondarily infected, and thus affect union. It is because

of these possible consequences that open fractures deserve utmost care

throughout their management.

Open fractures have been classified into three types, depending upon the extent

of soft

tissue injury.
TREATMENT

The principle of treatment is to convert an open fracture into a closed fracture

by meticulous wound care. Thereafter, the treatment of open fracture is

essentially on the lines of closed fractures. The following discussion emphasises

the points pertinent to the treatment of open fractures.

Phase I - Emergency Care

At the site of accident: The following measures are taken at the site of the

accident:

a) The bleeding from the wound is stopped by applying firm pressure using a

clean piece of cloth. At times it may be necessary to use a tight circular bandage

proximal to the wound in order to stop bleeding.

b) The wound is washed with clean tap water or saline, and covered with a clean

cloth.

c) The fracture is splinted. At times, a piece of bone devoid of all soft tissue

attachments may be lying out of the wound. It should be washed and taken to

the hospital in a clean cloth. It may be useful in reconstruction of the fracture.

In the emergency department: Open fractures are known to be associated with

neurovascular injuries more often than the simple fractures. Hence, one should

carefully look for these associated injuries. The following treatment is

performed in the emergency department :

a) Wound care: Care in the emergency room consists of washing the wound

under strict aseptic conditions and covering it with sterile dressing. Sometimes,

the bone may be jetting out of the skin, causing stretching of the skin around the

wound. Replacing the projecting bone is necessary in order to prevent

devascularisation of the skin. A piece of bone with intact soft tissue attachments

hanging out of the wound, should be washed and put back in the wound. All this

is done under proper aseptic conditions.

b) Splintage.

c) Prophylactic antibiotics should be given to all patients. Cephalexin is a good

broad spectrum antibiotic for this purpose. In serious compound fractures, a

combination of third generation cephalosporins and an amino-glycoside is

preferred.

d) Tetanus prophylaxis is given after evaluating the tetanus immunisation status

of the patient.

e) Analgesics to be given parenterally to make the patient comfortable.

f) X-rays are done to evaluate the fracture in order to plan further treatment.
Phase II - Definitive Care

Definitive care of an open fracture is possible at a place equipped with a high

class aseptic operation theatre, plenty of orthopaedic instruments and implants,

and a competent orthopaedic surgeon. In some compound fractures, the damage

to soft tissues is so much that it is wise to consult a plastic surgeon right at the

beginning. The patient may need plastic surgery techniques, such as flap

reconstruction, at the time of the first operation itself. Longer a bone is exposed

to outside environment, more it gets desicated, resulting in subsequent non-

union.

In principle, in the treatment of open fractures, care of the wound goes hand in

hand with that of the fracture.

Wound care: This consists of early wound debridement and subsequent care.

a) Wound debridement:

Wound debridement is needed in all cases. There may be only a puncture

wound, needing minimal debridement, irrigation and wound closure; or the limb

may be so badly crushed that repeated debridement may be required. While

debriding the wound, the skin should be excised as little as necessary. The
muscles and fascia can be excised liberally. The most reliable indicator of the

viability of a muscle is its contractility, on pinching it with a forceps. Only

badly lacerated tendons are excised. The ends of a cut tendon are approximated

with non-absorbable sutures so that they can be identified at a later date, and a

definitive repair performed. Bone ends are cleaned thoroughly with normal

saline. The margins of the fractured ends may be nibbled. A bone fragment with

attached soft tissues is replaced at the fracture site. Small fragments without soft

tissue attachments can be discarded. Sometimes, the limb is so badly injured

that the prospects of salvaging the limb to a reasonable function is poor. In such

cases, amputation, straight away, may be a better option. It is recommended that

opinion of at least one more surgeon be taken before taking such a drastic

decision.

b) Definitive wound management:

Once the wound is debrided, decision regarding its closure is to be made.

Primary closure by suturing the skin edges or by raising a flap, can be okay for

clean wounds. In all wounds debrided after 6-8 hours, immediate closure should

not be done. The wound, in such cases should be covered with sterile dressings,

and subsequently treated by delayed primary closure or be allowed to heal by

secondary intention. Whenever in doubt, it is best to leave the wound open.

Fracture management: In spite of the best debridement, an open fracture is a

potentially infected fracture. Non-operative methods of treatment, as in closed

fractures, usually give good results. In case an operative reduction of the

fracture is considered necessary, it is safer to wait for the wound to heal before

intervening. In cases where there is extensive damage to soft tissues, external

fixation provides fixation of the fracture and allows good care of the wound.

Some of the commonly used methods in the definitive care of an open fracture

are as follows:

a) Immobilisation in plaster: For cases with moderate size wound, where a

stable reduction of the fracture can be achieved, treatment by Plaster of Paris

cast is as appropriate as for closed fractures. Care of the wound is possible

through a window in the cast. Once the wound heals, the window is closed and

the fracture treated on the lines of closed fractures.

b) Pins and plaster: For cases where the wound is moderate in size and is

manageable through a window in a plaster cast, but reduction is unstable; the

fracture can be stabilised by passing pins in the proximal and distal fragments,

achieving reduction, and applying

plaster cast with pins incorporated in it. This method is useful in open, unstable

tibial fractures c) Skeletal traction: In cases where there is circumferential loss

of skin or the wound is big, it may not be possible to treat them in plaster. In

such cases, skeletal traction can be used to keep the fracture in good alignment

until the wound heals. After healing of the wound, one can continue traction

until the fracture unites, or change over to some other form of immobilisation

such as plaster cast.

d) External skeletal fixation: It provides stability to fracture and permits access

to virtually the whole circumference of the limb

e) Internal fixation: Approach to management of open fractures has become

very aggressive in last few years. In trauma centres in developed countries,

more and more open fractures received early enough are treated with primary

internal fixation. Closed methods of intramedullary fixation have been

particularly useful. If everything goes well, the rehabilitation of the patient is

highly accelerated. Such facilities are fast becoming available in most centres in

India and other developing countries.

Phase III - Rehabilitation

Rehabilitation consists of joint mobilisation, muscle exercises during

immobilisation, after removal of immobilisation, and advice regarding

mobilisation of the injured limb.

Complications of Fractures

Complications inevitably occur in a proportion of fractures. With early

diagnosis and treatment, the disability caused by these complications can be
greatly reduced.
CLASSIFICATION
Complications of fractures can be classified into three broad groups depending
upon their time of occurrence. These are as follows:
a) Immediate complications – occurring at the time of the fracture.
b) Early complications – occurring in the initial few days after the fracture.
c) Late complications – occurring a long time after the fracture.

HYPOVOLAEMIC SHOCK

Hypovolaemic shock is the commonest cause of death following fractures of

major bones such as the pelvis and femur. Its frequency is on the increase due to
a rise in the number of patients with multiple injuries.
Cause: The cause of hypovolaemia could be external haemorrhage or internal
haemorrhage. External haemorrhage may result from a compound fracture with
or without an associated injury to a major vessel of the limb. Internal
haemorrhage is more difficult to diagnose. It is usually massive bleeding in the
body cavities such as chest or abdomen. Significant blood loss may occur in
fractures of the major bones like the pelvis (1500–2000 ml), and femur (1000–
1500 ml).
Management: This begins even before the cause can be ascertained. An
immediate step is to put in at least two large bore intravenous cannulas (No. 16
or No. 14). If there is peripheral vasoconstriction, no time should be wasted in
performing a cut down. 2000 ml of crystalloids (preferably Ringer lactate),
should be infused rapidly, followed by colloids (Haemaccel) and blood. At the
earliest opportunity, effort is made to localize the site of bleed – whether it is in
the chest or in the abdomen. Needle aspiration from the chest, and diagnostic
peritoneal lavage provide quick information to this effect. If possible, a plain X
ray chest, and X-ray abdomen may be done. A chest tube for chest bleeding,
laparotomy for abdominal bleeding, may be required. Excessive blood loss from
fractured bone may be prevented by avoiding moving the patient from one
couch to another. For fractures of the pelvis, temporary stabilisation with an
external fixator has been found useful in reducing haemorrhage. In advanced
trauma centres, an emergency angiography and embolisation of the bleeding
vessel is performed to control bleeding from deeper vessels.

ADULT RESPIRATORY DISTRESS SYNDROME

Adult respiratory distress syndrome (ARDS) can be a sequelae of trauma with

subsequent shock. The exact mechanism is not known, but it is supposed to be
due to release of inflammatory mediators which cause disruption of
microvasculature of the pulmonary system. The onset is usually 24 hours after
the injury. The patient develops tachypnoea and laboured breathing. X-ray chest
shows diffuse pulmonary infiltrates. Arterial PO2 falls to less than 50.
Management consists of 100 percent oxygen and assisted ventillation. It takes
from 4-7 days for the chest to clear, and the patient returns to normal. If not
detected early, patient's condition deteriorates rapidly, he develops cardio
respiratory failure and dies.

FAT EMBOLISM SYNDROME

This is one of the most serious complications, the essential feature being
occlusion of small vessels by fat globules.
Causes: The fat globules may originate from bone marrow or adipose tissue.
Fat embolism is more common following severe injuries with multiple fractures
and fractures of major bones. The pathogenesis of the syndrome is not clear, but
it seems likely that two events occur: (i) release of free fatty acids (by action of
lipases on the neutral fat), which induces a toxic vasculitis, followed by platelet-
fibrin thrombosis; and (ii) actual obstruction of small pulmonary vessels by fat
globules.
Consequences: Symptoms are evident a day or so after the injury. Presenting
features are in the form of two, more or less distinct types: (i) cerebral; and (ii)
pulmonary. In the cerebral type, the patient becomes drowsy, restless and
disoriented and gradually goes into a state of coma. In the pulmonary type,
tachypnoea and tachycardia are the more prominent features. The other
common feature of fat embolism is a patechial rash, usually on the front of the
neck, anterior axillary folds, chest or conjunctiva. If untreated, and sometimes
despite treatment, the patient develops respiratory failure and dies.
Diagnosis: In a case with multiple fractures, early diagnosis may be possible by
strong suspicion. In addition to the classic clinical features, signs of retinal
artery emboli (striate haemorrhages and exudates) may be present. Sputum and
urine may reveal the presence of fat globules. X-ray of the chest may show a
patchy pulmonary infiltration (snow storm appearance). Blood PO2 of less than
50 mmHg may indicate impending respiratory failure.
Treatment: This consists of respiratory support, heparinisation, intravenous
low molecular weight dextran (Lomodex-20) and corticosteroids. An
intravenous 5 percent dextrose solution with 5 percent alcohol helps in
emulsification of fat globules, and is used by some.

DEEP VEIN THROMBOSIS (DVT) AND PULMONARY EMBOLISM

Deep vein thrombosis (DVT) is a common complication associated with lower

limb injuries and with spinal injuries.
Cause: Immobilisation following trauma leads to venous stasis which results in
thrombosis of veins. DVT proximal to the knee is a common cause of life
threatening complication of pulmonary embolism. DVT can be recognised as
early as 48 hours after the injury. Embolism occurs, usually 4-5 days after the
injury.
Consequences: DVT can be diagnosed early with high index of suspicion. The
group of patients ‘at risk’ include the elderly and the obese patients. Leg
swelling and calf tenderness are usual signs. The calf tenderness may get
exaggerated by passive dorsiflexion of the ankle (Homan’s sign). Definitive
diagnosis can be made by venography. One should keep a patient of DVT on
constant watch for development of pulmonary embolism. This can be suspected
if the patient develops tachypnoea and dyspnoea, usually 4-5 days after the
accident. There may be chest pain or haemoptysis.
Treatment of DVT is elevation of the limb, elastic bandage and anticoagulant
therapy. For pulmonary embolism, respiratory support and heparin therapy is to
be done. Early internal fixation of fractures, so as to allow early, active
mobilisation of the extremity is an effective means of prevention of DVT, and
hence of pulmonary embolism.

CRUSH SYNDROME

This syndrome results from massive crushing of the muscles, commonly

associated with crush injuries sustained during earthquakes, air raids, mining
and other such accidents. A similar effect may follow the application of
tourniquet for an excessive period.
Causes: Crushing of muscles results in entry of myohaemoglobin into the
circulation, which precipitates in renal tubules, leading to acute renal tubular
necrosis.
Consequences: Acute tubular necrosis produces signs of deficient renal
functions such as scanty urine, apathy, restlessness and delirium. It may take 2-
3 days for these features to appear.
Treatment: In a case with crushed limb, first aid treatment may necessitate the
application of a tourniquet, which is gradually released, so that deleterious
substances are released into the circulation in small quantities. If oliguria
develops, the patient is treated as for acute renal failure.

INJURY TO MAJOR BLOOD VESSELS

Blood vessels lie in close proximity to bones, and hence are liable to injury with
different fractures and dislocations. The popliteal artery is the most frequently
damaged vessel in musculoskeletal injuries.
Causes: The artery may be damaged by the object causing the fracture (e.g.,
bullet), or by a sharp edge of a bone fragment (e.g., supracondylar fracture of
the humerus). The damage to the vessel may vary from just a pressure from
outside to a complete rupture.
Consequences. Obstruction to blood flow will not always lead to gangrene.
Where the collateral circulation is good, the following may result:
• No effect: If collateral circulation of the limb around the site of vascular
damage is good, there will be no adverse effect of the vascular injury.
• Exercise ischaemia: The collaterals are good enough to keep the limb viable
but any further demand on the blood supply during exercise, causes ischaemic
pain (vascular claudication).
• Ischaemic contracture: If the collaterals do not provide adequate blood supply
to the muscles, there results an ischaemic muscle necrosis. This is followed by
contracture and fibrosis of the necrotic muscles, leading to deformities (e.g.,
Volkmann’s ischaemic contracture.
• Gangrene: If the blood supply is grossly insufficient, gangrene occurs.
Diagnosis: The pulses distal to the injury should be examined in every case of a
fracture or dislocation. Some of the features which suggest a possible vascular
injury of a limb are listed below:
a) Signs at the fracture site: The following signs may be present at the fracture
site:
• Rapidly increasing swelling
• Massive external bleeding (in open fractures)
• A wound in the normal anatomical path of the vessel
b) Signs in the limb distal to the fracture: The following signs may be present in
the limb distal to the fracture (five P’s):
• Pain – cramplike
• Pulse – absent
• Pallor
• Paraesthesias
• Paralysis
As a matter of rule, absent peripheral pulses in an injured limb should be
considered to be due to vascular damage unless proved otherwise. The
confirmation of obstruction to blood flow in a vessel and its site can be easily
done by Doppler study. In the absence of such a facility, there is no need to
waste crucial time by ordering an angiogram merely for confirmation of
diagnosis. An angiogram may be justified in cases with multiple fractures in the
same limb, where it may help in localising the site of the vascular injury.
Treatment: Early diagnosis and urgent treatment are of paramount importance
because of the serious consequences that may follow. Correct treatment at the
site of first contact followed by referral to a centre equipped with facilities to
treat vascular injuries is essential. In case exploration of the vessel is required,
the fracture should be suitably stabilised using internal or external fixation.
INJURY TO NERVES

Nerves lie in close proximity to bones, and hence are liable to damage in
different fractures or dislocations. The radial nerve is the most frequently
damaged nerve in musculoskeletal injuries. Nerves and vessels lie together in
limbs, and so are often injured together.
Causes: A nerve may be damaged in one of the following ways:
• By the agent causing the fracture (e.g., bullet).
• By direct pressure by the fracture ends at the time of fracture or during
manipulation.
• Traction injury at the time of fracture, when the fracture is being manipulated
or during skeletal traction.
• Entrapment in callus at the fracture site.
Consequences: Damage to the nerve may be neurapraxia, axonotmesis, or
neurotmesis. It may result in a variable degree of motor and sensory loss along
the distribution of the nerve
Peripheral Nerve Injuries
Treatment: This depends upon the type of fracture, whether it is closed or
open. When the nerve injury is associated with a closed fracture, the type of
damage is generally neurapraxia or axonotmesis, and nerve recovery is good
with conservative treatment. In case the fracture per se needs open reduction for
other reasons, the nerve should also be explored. When associated with an open
fracture, the type of nerve damage is often neurotmesis. In such cases, the nerve
should be explored and repaired as per need, and the fracture fixed internally
with nail, plate etc.

INJURY TO MUSCLES AND TENDONS

Some degree of damage to muscles and tendons occurs with most fractures. It
may result from the object causing the fracture (e.g., an axe), or from the sharp
edge of the fractured bone. Often these injuries are overshadowed by more
alarming fractures, and are detected only late, when the joint distal to the
fracture becomes stiff and deformed due to scarring of the injured muscle. Rest
to the injured muscle and analgesics is enough in cases with partial rupture. A
complete rupture requires repair. Rarely, if rupture of a tendon or muscle is
detected late, reconstruction may be required.

INJURY TO JOINTS

Fractures near a joint may be associated with subluxation or dislocation of that

joint. This combination is becoming more frequent due to high-velocity traffic
accidents. Early open reduction and stabilisation of the fracture to permit early
joint movements has improved the results.

INJURY TO VISCERA

Visceral injuries are seen in pelvic and rib fractures.

INFECTION – OSTEOMYELITIS

Causes: Infection of the bone is an early complication of fractures. It occurs

more commonly in open fractures, particularly in those where compounding
occurs from outside (external compounding). The increasing use of operative
methods in the treatment of fractures is responsible for the rise in the incidence
of infection of the bone, often years later. Infection may be superficial,
moderate (osteomyelitis), or severe (gas gangrene).
Treatment: Proper care of an open fracture can prevent osteomyelitis. Once
infection occurs, it should be adequately treated.
COMPARTMENT SYNDROME

The limbs contain muscles in compartments enclosed by bones, fascia and

interosseous membrane. A rise in pressure within these compartments due to
any reason may jeopardize the blood supply to the muscles and nerves within
the compartment, resulting in what is known as “compartment syndrome”.
Causes: The rise in compartment pressure can be due to any of the following
reasons:
• Any injury leading to oedema of muscles.
• Fracture haematoma within the compartment.
• Ischaemia to the compartment, leading to muscle oedema.
Consequences: The increased pressure within the compartment compromises
the circulation leading to further muscle ischaemia. A vicious cycle is thus
initiated and continues until the total vascularity of the muscles and nerves
within the compartment is jeopardized. This results in ischaemic muscle
necrosis and nerve damage. The necrotic muscles undergo healing with fibrosis,
leading to contractures. Nerve damage may result in motor and sensory loss. In
an extreme case, gangrene may occur.
Diagnosis: Compartment syndrome can be diagnosed early by high index of
suspicion. Excessive pain, not relieved with usual doses of analgesics, in a
patient with an injury known to cause compartment syndrome must raise an
alarm in the mind of the treating doctor. Injuries with a high risk of developing
compartment syndrome are as follows:
• Supracondylar fracture of the humerus
• Forearm bone fractures
• Closed tibial fractures
• Crush injuries to leg and forearm.
Stretch test: This is the earliest sign of impending compartment syndrome. The
ischaemic muscles, when stretched, give rise to pain. It is possible to stretch the
affected muscles by passively moving the joints in direction opposite to that of
the damaged muscle’s action. (e.g., passive extension of fingers produces pain
in flexor compartment of the forearm). Other signs include a tense
compartment, hypoaesthesia in the distribution of involved nerves, muscle
weakness etc. Compartment syndrome can be confirmed by measuring
compartment pressure. A pressure higher than 40 mm of water is indicative of
compartment syndrome. Pulses may remain palpable till very late in impending
compartment
syndrome, and should not provide a false sense of security that all is well.
Treatment: A close watch for an impending compartment syndrome and
effective early preventive measures like limb elevation, active finger
movements etc. can prevent this serious complication. Early surgical
decompression is necessary in established cases. This can be performed by the
following methods:
• Fasciotomy: The deep fascia of the compartment is slit longitudinally (e.g., in
forearm).
• Fibulectomy: The middle third of the fibula is excised in order to decompress
all compartments of the leg.

DELAYED AND NON-UNION

When a fracture takes more than the usual time to unite, it is said to have gone
in delayed union. A large percentage of such fractures eventually unite. In
some, the union does not progress, and they fail to unite. These are called non-
union. Conventionally, it is not before 6 months that a fracture can be declared
as non-union. It is often difficult to say whether the fracture is in delayed union,
or has gone into nonunion. Only progressive evaluation of the X-rays over a
period of time can solve this issue. Presence of mobility at the fracture after a
reasonable period is surely a sign of non-union. Presence of pain at the fracture
site on using the limbs also indicates non-union. Non-union may be painless if
pseudo joint forms between the fracture ends (pseudoarthrosis).
Causes: In any given case, there may be one or more factors operating.
Types of non-union: There are two main types of non-unions:
• Atrophic, where there is minimal or no attempt at callus formation.
• Hypertrophic, where though the callus is present, it does not bridge the
fracture site.
Common sites: Sites where non-union occurs commonly are neck of the femur,
scaphoid, lower third of the tibia, lower third of the ulna and lateral condyle of
the humerus.
Consequences: Delayed and non-union can result in persistent pain, deformity,
or abnormal mobility at the fracture site. A fracture in delayed union, if stressed,
can lead to refracture.
Diagnosis: Delayed union is a diagnosis in relation to time. The fracture may
not show any abnormal signs clinically, but X-rays may fail to show bony
union. The following are some of the clinical findings which suggest delayed
union and non-union:
• Persistent pain
• Pain on stressing the fracture
• Mobility (in non-union)
• Increasing deformity at the fracture site (in nonunion).
The following are some of the radiological features suggestive of these
complications:
• Delayed union: The fracture line is visible. There may be inadequate callus
bridging the fracture site.
• Non-union: The fracture line is visible. There is little bridging callus. The
fracture ends may be rounded, smooth and sclerotic. The medullary cavity may
be obliterated. It is sometimes very difficult to be sure about union of a fracture
where internal fixation has been used. Evaluation of serial X-rays may help
detect subtle angulation, non-progress of bridging callus, resorption of callus,
loosening of screws and bending of the nail or plate. Excessive rotation may be
the only abnormal mobility in a case with intramedullary rod in situ. Oblique
views, done under fluoroscopy may show an unhealed fracture better than
conventional AP and lateral X-rays. It may be possible to demonstrate mobility
at the fracture by stress X-rays or weight bearing X-rays. 3-D CT scan is
sometimes helpful in differentiating between delayed and non-union.
Treatment: Most fractures in delayed union unite on continuing the
conservative treatment. Sometimes, this may not occur and the fracture may
need surgical intervention. Bone grafting with or without internal fixation may
be required. Treatment of non-union depends upon the site of non-union and the
disability caused by it. The following possibilities of treatment should be
considered, depending upon the individual cases.
• Open reduction, internal fixation and bone grafting: This is the commonest
operation performed for non-union. The grafts are taken from iliac crest.
Internal fixation is required in most cases.
• Excision of fragments: Sometimes, achieving union is difficult and time
consuming compared to excision of one of the fragments. This can only be done
where excision of the fragment will not cause any loss of functions. An excision
may or may not need to be combined with replacement with an artificial mould
(prosthesis). For example, the lower-end of the ulna can be excised for non-
union of the fracture of the distal-end of the ulna without much loss. In non-
union of fracture of the neck of femur in an elderly, the head of the femur can
be replaced by a prosthesis (replacement arthroplasty).
• No treatment: Some non-unions do not give rise to any symptoms, and hence
require no treatment, e.g., some non-unions of the fracture scaphoid.
• Ilizarov’s method: Prof. Ilizarov from the former USSR designed a special
external fixation apparatus for treating non-union.

MALUNION

When a fracture does not unite in proper position, it is said to have malunited. A
slight degree of malunion occurs in a large proportion of fractures, but in
practice the term is reserved for cases where the resulting disability is of clinical
significance.
Causes: Improper treatment is the commonest cause. Malunion is therefore
preventable in most cases by keeping a close watch on position of the fracture
during treatment. Sometimes, malunion is inevitable because of unchecked
muscle pull (e.g., fracture of the clavicle), or excessive comminution (e.g.,
Colles’ fracture).
Common sites: Fractures at the ends of a bone always unite, but they often
malunite e.g., supracondylar fracture of the humerus, Colles’ fracture etc.
Consequences: Malunion results in deformity, shortening of the limb, and
limitation of movements.
Treatment: Each case is treated on its merit. A slight degree of malunion may
not require any treatment, but a malunion producing significant disability,
especially in adults, needs operative intervention. The following treatment
possibilities can be considered:
a) Treatment required: Malunion may require treatment because of deformity
(e.g., supracondylar fracture of the humerus), shortening (e.g., fracture of the
shaft of the femur) or functional limitations (e.g. limitation of rotations in
malunion of forearm fractures). Some of the methods for treating malunion are
as follows:
• Osteoclasis (refracturing the bone): It is used for correction of mild to
moderate angular deformities in children. Under general anaesthesia the fracture
is recreated, the angulation corrected, and the limb immobilised in plaster.
• Redoing the fracture surgically: This is the most commonly performed
operation for malunion. The fracture site is exposed, the malunion corrected and
the fracture fixed internally with suitable implants. Bone grafting is also
performed, in addition, in most cases e.g., malunion of long bones.
• Corrective osteotomy: In some cases, redoing the fracture, as discussed above
may not be desirable due to variety of reasons such as poor skin condition, poor
vascularity of bone in that area etc. In such cases, the deformity is corrected by
osteotomy at a site away from the fracture as the healing may be quicker at this
new site, e.g. supra-malleolar corrective osteotomy for malunion of distal-third
tibial fractures.
• Excision of the protruding bone: In a fracture of the clavicle, a bone spike
protruding under the skin may be shaved off. Same may be required in a spikey
malunion of fracture of the shaft of the tibia.

b) No treatment: Sometimes malunion may not need any treatment, either

because it does not cause any disability, or because it is expected to correct by
remodelling. Remodelling of a fracture depends on the following factors.
• Age: Remodelling is better in children.
• Type of deformity: Sideways shifts are well corrected by remodelling. Five to
ten degrees of angulation may also get corrected, but mal-rotation does not get
corrected.
• Angulation in the plane of movement of the adjacent joint is remodelled better
than that in other planes e.g., posterior angulation in a fracture of the tibial shaft
remodels better.
• Location of fracture: Fractures near joints remodel better.
Cross union is a special type of malunion which occurs in fractures of the
forearm bones, wherein the two bones unite with each other.

SHORTENING

Causes: It is a common complication of fractures, resulting from the following

causes:
• Malunion: The fracture unites with an overlap or marked angulation e.g., most
long bone fractures.
• Crushing: Actual bone loss e.g., bone loss in gunshot wounds.
• Growth defect: Injury to the growth plate may result in shortening.
Treatment: A little shortening in upper limbs goes unnoticed, hence no
treatment is required. For shortening in lower limbs, treatment depends upon the
amount of shortening.
• Shortening less than 2 cm is not much noticeable, hence can be compensated
by a shoe raise.
• Shortening more than 2 cm is noticeable. In elderly patients, it may be
compensated for by raising the shoe on the affected side. In younger patients,
correction of angulation or overlap by operative method is necessary. Limb
length equalisation procedure is required to correct shortening in an old, healed,
remodelled fracture.

AVASCULAR NECROSIS

Blood supply of some bones is such that the vascularity of a part of it is

seriously jeopardized following fracture, resulting in necrosis of that part.
Consequences: Avascular necrosis causes deformation of the bone. This leads
to secondary osteoarthritis a few years later, thus causing painful limitation of
joint movement.
Diagnosis: Avascular necrosis should always be suspected in fracture where it
is known to occur. Pain and stiffness appear rather late. Radiological changes as
given below appear earlier.
• Sclerosis of necrotic area: The avascular bone is unable to share disuse
osteoporosis as occurs in the surrounding normal bones. Hence, it stands out
densely on the X-ray.
• Deformity of the bone occurs because of the collapse of necrotic bone.
• Osteoarthritis supervenes giving rise to diminished joint space, osteophytes
(lipping of bone from margins) etc. It is possible to diagnose avascular necrosis
on bone scan before changes appear on plain X-rays. It is visible as ‘cold area’
on the bone scan.
Treatment: Avascular necrosis may be prevented by early, energetic reduction
of susceptible fractures and dislocations. Once it has occurred, the following
treatment options remain:
• Delay weight bearing on the necrotic bone until it is revascularised, thereby
preventing its collapse. It takes anywhere from 6-8 months for the bone to
revascularise.
• Revascularisation procedure by using vascularised bone grafts (e.g.
vascularised bone pedicle graft from greater trochanter in an avascular femoral
head in fracture of the neck of the femur). • Excision of the avascular segment
of bone where doing so does not hamper functions e.g. fracture of the scaphoid.
• Excision followed by replacement e.g., in fracture of the neck of the femur, the
avascular head can be replaced by a prosthesis.
• Total joint replacement or arthrodesis may be required once the patient is
disabled because of pain from osteoarthritis secondary to avascular necrosis.
STIFFNESS OF JOINTS

It is a common complication of fracture treatment. Shoulder, elbow and knee

joints are particularly prone to stiffness following fractures.
Causes: The following are some of the causes of joint stiffness:
• Intra-articular and peri-articular adhesions secondary to immobilisation,
mostly in intraarticular fractures.
• Contracture of the muscles around a joint because of prolonged
immobilisation.
• Tethering of muscle at the fracture site (e.g. quadriceps adhesion to a fracture
of femoral shaft).
• Myositis ossificans
Consequences: Stiff joints hamper normal physical activity of the patient.
Treatment: The treatment is heat therapy (hot fomentation, wax bath,
diathermy etc.) and exercises. Sometimes, there may be a need for manipulating
the joint under general anaesthesia. Surgical intervention is required in the
following circumstances:
• To excise intra-articular adhesions, preferably arthroscopically.
• To excise an extra-articular bone block which may be acting as a 'door
stopper'.
• To lengthen contracted muscles.
• Joint replacement, if there is pain due to secondary osteoarthritis

REFLEX SYMPATHETIC DYSTROPHY

(SUDECK’S DYSTROPHY)

This is a term given to a group of vague painful conditions observed as a

sequelae of trauma. The trauma is sometimes relatively minor, and hence
symptoms and signs are out of proportion to the trauma. Consequences:
Clinical features consist of pain, hyperaesthesia, tenderness and swelling. Skin
becomes red, shiny and warm in early stage. Progressive atrophy of the skin,
muscles and nails occur in the later stage. Joint deformities and stiffness ensues.
X-ray shows characteristic spotty rarefaction.
Treatment: It is a difficult condition to explain to the patient, and also the
treatment is prolonged. Physiotherapy constitutes the principle modality of
treatment. Further trauma in the form of an operation or forceful mobilisation is
detrimental. In some cases, beta blockers have been shown to produce good
response. In resistant cases, sympathetic blocks may aid in recovery. Prolonged
physiotherapy and patience on the part of the doctor and the patient is usually
rewarding.

MYOSITIS OSSIFICANS (POST-TRAUMATIC

OSSIFICATION)

This is ossification of the haematoma around a joint, resulting in the formation

of a mass of bone restricting joint movements, often completely.
Causes: It occurs in cases with severe injury to a joint, especially when the
capsule and the periosteum have been stripped from the bones by violent
displacement of the fragments. It is common in children because in them the
periosteum is loosely attached to the bones. It is particularly common around
the elbow joint. There is also a relatively high incidence in patients with
prolonged or permanent neuronal damage from head injury, and in patient with
paraplegia. Massage following trauma is a factor known to aggravate myositis.
Consequences: The bone formation leads to stiffness of the joint, either due to
thickening of the capsule or due to the bone blocking movement. In extreme
cases, the bone bridges the joint resulting in complete loss of movements (extra-
articular ankylosis). Radiologically, an active myositis and a mature myositis
have been identified. In the former, the margins of the bone mass are fluffy in
the latter the bone appears trabeculated with welldefined margins.
Treatment: Massage following injury is strictly prohibited. In the early active
stage of myositis the limb should be rested, and NSAID is given. In late stages,
it is possible to regain movement by physiotherapy. In some cases, once the
myositic mass matures, surgical excision of the bone mass may help regain
movement.