Ortopedy Course Full

Course Orthopaedics Traumatology
FOREWORD
The importance of osteoarticular pathologye is increasing continuously in recent decades,
in while increasing the degree of civilization and the accidents of various etiologies . As such ,
knowledge of this subject is very important in the training of future physicians. although
Department of Orthopaedics , Traumaology at the University Western ,, Vasile Goldis \" is
young , one of our first concerns was the development of a first required course to prepare
students, Being published since 1996 ( under the supervision of Prof. Dr. Alexandru Pop) . We
felt that this first course should be improved and updated in accordance with the progress of
orthopedics in the last decade and didactic and pedagogical experience gained in this period .
We chose a synthetic paper , type compendium , which urge the student to make the
minimum necessary properties of our specialty . According to the syllabus , I approached the
whole trauma and two important chapters of orthopedics : bone tumors and infections bone . The
student must know and other important diseases ( coxartoza , osteoarthritis , congenital hip
dislocation , congenital club foot , spine deformations , etc.) that will be addressed in stages
gussetice .
For those who want to deepen the study are handy manuals and courses included in the
bibliography.
We hope that our effort to prepare students to benefit .
I.
GENERAL ISTORIC-
HISTORY
Orthopaedic term was first used by Andry N. French physician who published , in 1741 ,
the work entitled \" L' Orthopedic ou l' art et de corriger prevention dans les enfants, les
difformitis du corps \" ( \" Art prevention and treatment of orthopedic body deformations in
children \" ) and a symbol recognized and adopted after of orthopedics ( \" tree strmb supported
by a stake \" ); the term \"orthopedics\" derivedUm from the Greek words an ( Ortho ) =
right and (Paid ) = child.
Fig . one.1- Simbolul orthopedics

orthopedics - Is the science that prevents and treats tothread deformities congenital and
acquired locomotion .
traumatologia - represents the science that deals pathologiststo all organs and body
systems etiology secondary trauma .
Orthopedics and Traumatology are interrelated disciplines as musculoskeletal system has
a specific way of reacting to the aggression ( different from the other organs and systems ) , and
many of the methods of treatment of osteoarticular disorders ( traumatic or orthopedic ) is
based on biological and biomechanical principles common .
The first medical treatise ( the concepts were presented and orthopedics ) was written by
the father of medicine , Hippocrates of Cos ( 460-370 BC ) , who described a process of
scapular- humeral dislocation reduction and designed the first \" mass orthopedic \" ( fracture
reduction device ) .
Cast immobilisation of the fractured limb was used since ancient times by the Arabs , but
the first descriptions of plaster bandages were made by Antonius Mathysen , Pirogov in 1852 and
, in 1853 .
At first conservative orthopedic traumatology surgery has become , thanks to medical
advances in the field of anesthesia and general surgery; first fixation ( fixation of fractures of the
leg plate screwed ) was attributed to William Lane, in 1890 . Osteosynthesis ( surgical
stabilization of fractures) experienced a great development during the twentieth century ,
2
defendWhen a wide variety of osteosynthesis material , along with concern surgeons to improve
surgical techniques osteosynthesis ; For these reasons , due to which address particular pathology
, as well as due to the accumulation of a large number of specific surgical techniques , the early
twentieth century , orthopedics , traumatology surgery was formed as a separate branch ,
detachNDU out of the general surgery . In 1925 , L. Bhler opened Traumatology Hospital of
Vienna (the first modern hospital for the treatment of traumatic injuries ) , and in 1929 published
the book \" fracture treatment technique \" , a monograph reference in the field.
Orthopedics development was done simultaneously with other surgical branches, benefit
from greater knowledge of anatomy , the discovery of X rays (by Rentgen , 1895 ) , anesthetic
substances ( Morton - first ether anesthesia , in 1846 ), the discovery of bacteria ( Pasteur , 1857 )
aseptic intake ( Liston ) and antisepsis ( Semelweiss ) , the introduction of antibiotic ( Flemming
discovered penicillin in 1940 ); also technological advances in the field of metallurgy and
biomaterialsu allowed the introduction in orthopedic practice ,
new
osteosynthesis
materialMore resilient and better tolerated in the body ( titanium alloys , screws biodegradable
synthetic bone substitutes , etc. ) ; occurred in orthopedics , new surgical fields such as
arthroplastythe various joints (shoulder , elbow, hip , knee, ankle , etc.) and methodit's the
fashione exploration and articular treatment (arthroscopy shoulder , elbow , hip, knee , ankle ) .
Bone Surgery became a separate specialty in surgical procedures ( osteosintezele , osteotomy ,
arthroplasty , etc.) are made after a careful preoperative planning and biomechanical principles
based on solids. An outstanding contribution to the development of methods and materials for
osteosynthesis had a Swiss AO group (founded in 1958 by Muller, Allgower and Willengger ) ,
which is currently the promoter of modern fixation techniques . Progress in recent decades have
radically transformed orthopedic traumatology in a reconstructive surgery , which focuses on
minimally invasive and osteosintezele osteosintezele 'organic' ( ct less aggressive bone substrate
) , the complex processes of bone and joint reconstruction with modular prostheses and
personalized with synthetic substitutes or allograft bone from bone banks . Also, advances in
genetics have allowed the development of procedures for reconstruction of damaged articular
cartilage ( cartilage cells, Osteoblasts, etc.) .
Father orthopedics in our country is considered Alexandru Radulescu, who in 1921
founded the first Spital of Onertopedie in Cluj , and Society Onertopedie the first specialized
magazine . He was a prolific scientific activity and teaching .
Department of Orthopaedics and Traumatology of Arad was founded in 1946 by Dr. John
GeorgescuTrainer of Orthopaedic Traumatology school Arad .
Clinic of Orthopaedics Traumatology Arad, who works in the County Hospital has a total
of 80 beds and is headed by Prof. Dr. Alexandru Pop ; in the clinic , surgery is performed most
modern in the industry osteosynthesis , hip arthroplasty interventions , treatment interventions
arthroscopic knee , shoulder , elbow .
BACKGROUND
1. Anatomy and Physiology BONE
A. Bone structure
bone the organ, is made up of bone , cartilage , vascular tissue and fibrous tissue .
Bone tissue , any tissue, is made up of cells , collagen fibers and intercellular
fundamental substance .
bone cells There are three types:
osteocytes - mesenchymal in origin , oblong shaped , flat, central nucleus,
cromatiniene large masses , 1-2 nucleoli . They are the most numerous cells in the mature bone (
approx. 10 times higher in Decembert osteoblasts ) . Protoplasm is basophilic , with few
organelles , a sign of reduced metabolism , apparently in a state of relative rest . Osteocytes are
located in some \" gaps\" in the matRice boneIrregularly shaped and look plexiform ( called
osteoclast )sentWhen protoplasmic extensions in several directions , which anastomoses with
protoplasmic extensions of neighboring osteocytes , achievementsWhen such a threedimensional network of branching , Volkmann located within the channels ( see FIG . 1 .6); the
network plays an important role in transmitting intercellular signals and bone adapt to external
stimuli ( in their roleanwhatpyou ). Osteocytes are not metabolically inert , but in addition to the
ability to synthesize bone matrix ( December low capacityYour osteoblasts ) and has a capacity
of bone resorption limited ( less than Decembert of osteoclasts ) . Osteocytes \" mbtrnite \"
are replaced by osteoblasts cyclic young in the process of reworking permanent physiological
mature bone tissue .
Fig . 1.2 - osteocyte incorporated into the bone

matrix
( after Lieberman - Bone regeneration and repair )
Osteoblasts - hematopoietic in origin , being derived from pluripotent stem cell
line ( with probable origin in the bone marrow ); osteoblasts are cells young bone , active,
secretory organ, thatintetizeaz substances that underpin future osteoid tissue , non-mineralized (
type I collagen , alkaline phosphatase, osteocalcin , bone sialoprotein ); surface- osteoblasts have
receptors for parathyroid hormone , -D3 , Estrogen yeardRogen , glucocorticoids , thyroid
hormones, calcitonin, etc. , participateactive when the permanent reshuffling weaveution of
bone and calcium homeostasis regulate the body. In mature bone , osteoblasts are in various
stages of evolution . As mineralization, osteoblasts is converted into osteocytes . Osteoblasts
and osteocytes exist between multiple \" cells connected \" with gap junction type , with active
transmission role of mediators and other cellular pulse . When a physiological process of
osteoporosisUm or pathologicalUm, osteocyte returns to form osteoblastUnder the influence of

endocrine and autocrine stimulation.
Fig . 1.3 - Osteoblasts blade bone surface ( after Meyer - Bone and cartilage
engineering )
Osteoclasts - derivative din pluripotent hematopoietic cells ( with origin
probabil in the bone marrow ), have a similar structure macrophages presentWhen more than
one nucleus and some intracellular role secretory vesicles ( containing an acidic environment and
proteolytic enzymes ) ; receptors on the surface of the membrane has calcitoninBeing in strnLet
osteoblasts and osteocytes functionally related (which can inhibit proliferation and activation of
osteoclasts through mediators such osteoprotegerin ). Osteoclastele are responsible for osteolytic
function , resorption , which precedes the cycle of Reman reosificareapermanent era of bone;
cWhen there is a local process of bone resorption , osteoclasts migrate to the site ( under the
influence of specific chemotactic factors ) , adhere to the site of resorption and, the cell
membrane (developing some \" intussusception \" increase its contact surface and joined by
intracellular vesicles fuse ) , release proteolytic enzymes that dissolve the mineralized bone
matrix ; Finally, the degradation of the extracellular matrix in the space are eliminated by means
of specific transport systems .
Fig . 1.4 - osteoclastic bone resorption with a lacunar area

collagen fibers is 85% of the bone protein matrix; eit is characterized by argentic
impregnation . The structure of the collagen molecule consists of three polypeptide chains ,
arranged helix containing amino acids . Between moleculele collagen parallel ( the helix ) are
many \" pores \" , and between the ends of the molecules are \" vesicle areas \" shall in these
spacesNDU the hydroxyapatite crystals ( in the process of mineralization of bone matrix ) .
Fig . 1.5- picture collagen fibers in bone structure (

electron microscopic appearance ) - after Meyer Bone and cartilage engineering
This structure is responsible for the mechanical strength of bone, in particular at the The
shear modulus of elasticity imparting a certain bone.
fundamental substance 5% of the bone protein matrix . chemical, it consists of a protein
- polysaccharide complex ( proteoglycan Decorin type , Fibromodulin , etc.) and
mucopolysaccharides free .
non-collagenous proteins - is approx. 10% of bone matrix protein , is secreted mainly by
osteoblasts and mineralization functions and bone cells mediating link matrix protein ; There are
a strnLet link to the bone matrix protein , collagen and non-collagenous proteins between .
Srecent tudi have shown that bone contains a special category of collagenous polypeptide ,
known as \" growth factors \" that mediate cell growth and differentiation and synthesis of matrix
proteins. These oligopeptides ( which represents only 1% of non-collagenous proteins ) are BMP
( series bone morphogenic proteins ), Osteocalcin , osteonectina , osteopontin , fibronectin , etc.
chemical composition new bone is 50 % minerals, 25 % protein and 10-25% water
substances . Containing 70% dry bone minerals, calcium and phosphorus are best represented;
bone also contain small amounts of carbonates , chlorides and fluorides.
B. bone structure as organ

It is so designed, to match function that ensures bone. From the macroscopic point of
view , ittwo varieties are donor bone morphology: Compact and spongy .
1. bone compact and cortical - is on the peripheryto bone and is richly mineralized . It
consists of microscopic concentric bone lamellae, like cylinder, arranged around a central
channel, called Haversian canal ( See Fig . 1 .6).
This provision is osteon or Haversian systemunitto morphofunctional bone compact. A
osteon is composed of a central Haversian canal , surrounded by the adjacent bone blades ( the
content of osteocytes , osteoblasts, osteoclasts , Volkmann canaliculi and adjacent vascular nerve
branches within them ) . Osteonii are ready with their long axis parallel to the axis of the bone.
Haversian canals communicating with the neighboring, by transverse Volkmann ducts containing
extensionsthey protoplasmic of osteocytes, Capilatihas blood and nerves; she system of these
channels haversian is anastomoses with each other , forming a network openis on the one hand
the medullary cavity , and on the other hand the surface of the bone , under the periosteum ,
through the holes in order III. SSpecial STRUCTURE cortical bone impart increased resistance
6
to biomechanical forces ( Shear , tensile , compression, torsion ) and a lower metabolic role (
compared to that of cancellous bone ) .
Fig.1.6 - Systemmany Haversian - Graphic and electron microscopic appearance

( after Miep - Bone Research Protocols )
Compact bone is included in long bones and diafizelor to tbliilor bonestheir plate.
2. cancellous bone - has a porous structure and consists of spans marrowis crossed
dimensional , forming a grid, the meshes of which is marrow and vascular tissue ( see Fig . 1.7).
The bays can be a functional structure, because in some situations demand biomechanical, they
are oriented in the sense lines force the needleoperates the bone. Spongy bone has a satisfactory
mechanical strengthIn particular to the forces of compression ( in some cases , as at the femoral
neck , organized as cancellous bone trabeculae has similar mechanical strength of cortical bone )
and a metabolic role ( phospho- calcium homeostasis ) more intense than cortical bone ( the
turnover of cancellous bone metabolism is about. December 8 times more intenset of cortical
bone ) .
Fig . 1 .7 - Trabecular structure of the cancellous bone in the calcaneus

Cancellous bone is found in bones short , flat and metaphyseal regions and long bone
epiphyseal; strengthening cancellous bone ossification is done by primary (direct ) .
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Inside the medullary canal of the long bone epiphyseal - metaphyseal area thereof, as in
the trabecular meshwork of short bones , flat tissue is bone marrow . There are three types of
bone marrow, depending on age :
bone marrow until the age of 7 years with abundant hematopoietic cells ;
yellow marrow , lipoidica present after this age and in adults ;
gray and fibrous bone seen in the elderly.
Medullary tissue has a function osteoformatoare , mineral reserves and hematopoietic activity,
which diminishes with age.
Fibroconjunctiv has a collar bone , periosteum, which is made up of two layers : an outer
layer of fiber, rich in collagen fibers , vessels and nerves and an inner layer composed of
connective tissue with many osteoblastic cells ( osteogenic layer ) . In the case of a fracture, is
considered damaged cells from the periosteum are departing from initiating stimuli consolidation
process.
Vascularization bone
The bones of the skeleton is considered \" absorb \" physiologically , approx. 5-10% of
cardiac output current .
Arterial blood bone is provided by :
arterthey nutritive ( The number one or two for each bone in part ) penetrating the corticala
through hole nutritional enter the medullary cavity , where divid into two branches (branch
upward and downward branch ) that the rndul their branches into com systemplexus of
arterioles and capillaries , cit enters in cantoliculele inside center channel Volkmann and
Haversian; vascular system endosteal is considered that is responsible for the irrigation of 2/3
innal cortex bony (see fig . 1.8)
Fig . 1.8 - vascularization of bone - after Meyer - Bone and cartilage

engineering
arteries
periosteal subperiosteal form a plexus , where it branches into the available crosscollateral branches arranged at regular intervals ; in this system a system arises transverse
8
longitudinal axis parallel to the bone that connects the various branches cross . This network
peripheral vascular contained in the periosteum , divides into numerous branches radial
perpendicular to the axis of the bone, which penetrate the cortical pMrs to the haversian canals ;
intraosseous this network is responsible for the irrigation of External 1/3 cortical bone ;
Metaphyseal - epiphyseal arteries ( upper and lower ) give rise articular arterial circle of
epiphysis and metaphysis entering the collateral branches at right angles , achievementsWhen a
vascular system comparative with an arch ; this system is anastomosed with the system diaphysis
.
Arterial branches of the three systems (endosteal, Periosteal epiphyseal - metaphyseal )
are anastomosed with each other and , in addition, each of these systems has anastomoses with
the arteries and arterioles, the muscular inserts from the neighboring bone.
venous network is made after the same pattern as arterial network , intraosseous very
fine veins .
Intraosseous arterial circulation is predominantly centrifuge , while the venous drainage
is centripetal ; presence of anastomoses between the periosteal and endosteal system makes it
possible to change the meaning of blood circulation periodicallyAccording to the physiological
demands being placed on the bone .
Of great importance in strengthening fractures Eastis the factor vascular ; it is considered
that , in a first stage , callus formation is ensured by extraosseous arterial intake , derived from
surrounding soft tissues; Week 5us to produce fracture , endosteal circulation is restored and
takes the dominant role in the consolidation process .
innervation bone - is provided by many nerves, medullary vessels and accompanying
nutrients osteon, and a subperiosteal nervous plexus .
B. bone physiology
Bone is not an organ of metabolically inert , but undergoes permanent remodeling (
shuffle ) physiological , under the action of internal factors ( metabolic , endocrine , vascular ,
immunological , etc.) and external factors ( demands biomechanical during daytime, Bone
adaptNDU the mechanical stress under the laws of Wolff) .
reshuffle ( remodeling ) bone, cyclic alternation of ossification of the bone resorption, is
characteristic bone growthBeing included in the genetic program of the organism.
a) ossification is a complex process training , development and repair of bone tissue .
It consists of two successive phases and confounding : building protein matrix ( osteoid )
and calcificationto ( salt build phosphocalcic ) .
osteogenesis ( skeletal bone formation process ) began in embryonic life as a
mesenchymal tissue concentration (axial and lateral ) of embryoOutlining the future shape of the
bone ; this pattern will be invaded by connective cartilage cells and is covered by a fibrous
connective sheath called pericondru ( which will become the future periosteum )- See Fig . 1.9.
Most skeletal bone develops after a cartilage intermediate pattern ( enchondral
ossification ) except skull and internal 1/3 collarbone (formed by direct ossification ossification
membrane or DesmaWithout cartilaginous stage) . The first osteogenic processes of embryonic
life occur in the clavicle in sevennile intra- uterine life 6-7 . Further , the bones will develop the
pattern of embryonic cartilage in two ways: osteogenesis surface ( realized by pericondrului )

inside the mold cartilage and bone formation ( osteogenesis enchondral ).
Fig.1.9 - stages of bone formation

Onesteogeneza continues throughout intra- uterine life , transform pericondrulNDU into

the periosteum and marrow in the center shaftit appears a primary ossification center , which
extends the volume , dnd diaphyseal bone birthday song; whole process embryonic and fetal
bone formation is genetically encodedDifferentiation and cell proliferation , angiogenesis ,
ossification processes are coordinated by specific genes. Cartilaginous epiphyses of long bones
are in the newborn; will occur within them , in time, secondary ossification centers , which will
gradually develop att BCnspre epiphysis , ct and into the diaphysis , gradually replacing
cartilage TEpercent bone .
In childhood , we We arguewe are a small disc of cartilage in areas metaphyseal bone (
cartilage growth or conjugation ) that will ensure thatRester the length of the bone ( see Figure.
1.10 )
Fig . 1.10 - cartilage growth in the

proximal third of the femur ( cephalic
cartilage , the greater trochanter and the
small trochanter) - after Sobotta ,
Clinical Interactive Atlas
Cartilajele increase gradually ossify and will closeAt that time was completed cRester
skeletal ( around youages 20-25 years ) . Since then, only bones suffer physiological remodeling
processes , sub various internal and external factors influence .
of protein synthesis texture bone , adult , is responsible osteoblasts. Thereafter functional,
Osteoblasts are transformed into osteocytes, included in the bone . Factors influencing the
formation of osteoid are vascular , hormonal ( anterior pituitary , estrogen and androgens
stimulate osteoblasts ), mechanical ( physiological stress exerted on the bones activates
ossification ) and biochemical .
mineralization has an intimate mechanismExtremely complex ,
yet unclear completely.
With the advent of substance preosoase, start gradual precipitation of salts phosphocalcic
10
(hydrated tricalcium phosphate , prepared as crystalstheir hexagonal hydroxyapatite Such

As10 (PO 4 )6 ( OH )2 ) in the collagen matrix; mechanism is influenced enzymatic and hormonal
immunomodulators .
b ) Bone resorption consists in reducing the levels of bone ( rarefaction ), until complete
bone ( osteolysis ), is carried out osteoclast, which is influenced rndul 's Hair
hormoneAtirandsheepdian and physical inactivity .
Normally there is a balance between resorption and ossification, with predominance of
the first trial in children during growth and the second process in old age.
There are situations in which there is an imbalance between the intensity of the processes of
resorption and ossification; Thus, some disfuncii endocrine ( hyperthyroidism , hypogonadism ,
etc.) , some pathological conditions (immobilizedtorit prolongedUm bed due to paralysis, post menopausal hormone imbalance syndrome senile involution, Chronic renal failure) May be
followed by installation of a generalized osteoporosis , while other diseases ( genetic diseases )
can be accompanied by increased bone density (osteopetrosis ) . There are also forms of
osteporoz located ( osteolysis in some forms of osteosarcoma ) , as well as localized forms of
osteocondensri ( m osteocondromatozaultipl ) .
2. CONSOLIDATION OF FRACTURES
Bone is one of the few organs that is able to \" save \" sequences regeneration and healing
, so that , when properly treated fractures , bone healing body is made \"restitutio ad integrum\".
Process and building turnover bone fractures is coordinated genetic ( by certain genes through
DNA and RNAm) .
callus - morphofunctional formation is a complex process resulting from histochemical
, vascular and biomechanical, which restores the broken bone integrity .
Consolidation of fractures , with appearance of callus, is a pathological process that takes
place four steps; These four stages are available for secondary ossification ( indirect )While
primary ossificationdirect ( If a fracture operated with compaction fragments ) is just three steps
(lipsete cartilaginous intermediate stage) .
1. Hemoragico - phase hyperemia
Bleeding triggered by fracture lead to a fracture hematomarIn which the particles are to
be found in the bone, the periosteum and the marrow ( See Fig . 1 .11). The ends of the fractured
bone fragments undergo partial necrosis and necrotic cells release biodegradation local products .
Fracture hematoma has a pO 2 low pH acid (due to decrease intake of snge arterial ) and an
increased content of quinine , prostaglandins, Phospholipase A and non-collagenous proteins (
resulting in tissue destruction ). cells injured the outbreak of fracture ( periosteal cellsthey, Bone
marrow cells , bone cellsEndothelial cells) Issued a number of mediators (TNF - , TNF - , IL
- 1, IL -6 , BMP -2 , BMP -4 , PDGF , IGF -1 , etc.)Such as kinins such as prostaglandins (
PGE2 , PGF2 ) , Prostacyclin , thromboxane , mediators which cause a local inflammatory reaction
aseptic hyperemia, vasodilatoryourtion and increased capillary permeability , followed by
extravasation blood capillaries
and the accumulation of blood cells such as neutrophils ,
platelets , lymphocytes, monocytesmacrophages in the fracture hematoma . It operates astfel
coagulation cascade (by means of the complement system and thromboxane )And bruising of the
fracture site is converted to a fibrin clot protein , which has two functions: on the one hand
11
bleeding off ( the effect of plugging the vessels of periosteal and endosteal ) and, on the other
hand , forms a bridge link between bone fragments fractured . Fibrin clot protein will be
progressively penetrated by capillary neoformation an important role in their development
having , according to the latest research , vascular endothelial growth factor (VEGF - vascular
endothelial growth factor ) and Angiopoietin , mesenchymal cells release mediators endVascular
oteliilor . Along with his revascularization , fibrin clot protein will be populated by pluripotent
mesenchymal cells ( with probable origin in muscles adjacent the fracture and bone marrow )
who are attracted by chemotactic factors specific local .
to
bc
Fig . 1 .11 - A) - accumulation fracture hematoma

Electron microscopy
b ) - hematoma invasion by fibroblasts
aspects
c ) - callus formation fibrin protein
( after Lieberman - Bone regeration and repair )
These mesenchymal cells have the ability to reshuffle the fibrin clot structure protein
synthesizedWhen a network of non-collagen protein and collagen ( collagen type of prevailing I
, III , V , IX and X ) and to produce a progressive retraction of the clot .
The inflammatory reaction is primed , the final polypeptide molecule acts on the target
cells ( TGF - , IGF - II , etc.) .
The process takes approx. For 7 days at the end of the itstake fracture fragments being
fragile anchored by a network of fibrin ( callus fibrinoproteic ) .
2. Phase fibro - condroid
mesenchymal cells, after they invaded the fracturerUm, multiply (as the action of growth
factors and multiplication specific ) and osteoblasts and chondroblasts in metaplaziaz , bone
forming cells, cartilage that ( metaplasia occurs under the action of specific factors, such as IGF I, IGF- II , BMP -2 , BMP -4 , etc.). It follows a callus fibrous tissue containing islands of
osteoid tissue condroid tank collagen protein fibers and the fundamental substance ( See Fig . 1
.12). Phenomena occur due to a local hipervascularizaii influenced by hormonal factors,
enzymatic and mechanical .
12
Fig . 1.12 - condroid fibrous phase , which ended with the former
fracture hematoma is invaded islands of cartilage cells and osteoblastic
At the end of this phase (after approx. 14 days), fragments of the fracture is stabilized by
collagen fibersAnd from the clinical point of view , there is a significant regression of pain and
swelling at the fracture site.
3. Phase provisional ossification
This results in a primitive bony callus ( young ) . Mineralized osteoid tissue begins to
slow at the end of this phase is 80 % by depositing the mineral material existing in the bone .
At this time , the pH of the fracture site is neutral , and alkaline becoming conducive for
activitiesit alkaline phosphatase (enzyme secreted by osteoblasts and chondroblasts , role in the
mineralization of callus ) . Both cartilage ( by enchondral ossification ) and the fiber ( by Desma
ossification , membrane ) is transform in bone primitive , immature since functionally (
Figure.1.13 ).
Fig . 1.13 - Morphological aspects of primitive callus

the process of mineralization of bone matrix protein is not fully elucidated;
mineralization takes place in two stages: the initiation phase ( nucleation ) , with the
development of hydroxyapatite deposits in the first collagen matrix and the step of proliferation (
addition of mineral deposits at the level of the original ) ; the two phases are confounding the
overall process bearersWhen the multiplier name . Mineralization is considered that starts by
accumulating calcium ion and alkaline phosphatase in the matrix vesicles (produced by
13
chondrocytes and osteoblasts cytoplasmic membrane and released to the extracellular ) , vesicles
adhering to the pores and vesicular zones of collagen matrix structure , with release ions of
calcium and phosphate and hydroxyapatite crystal formation ( under the action of enzymes
contained in vesicles systems , which combine with the calcium ions to phosphate ions ); the
mechanism of calcification is strnLet phospho- calcium homeostasis correlation with the body,
mediated by parathyroid hormone active form of vitamin D3 , neuroendocrine factors and other
autocrine .
Sis considered the three-dimensional network of collagen fibers , as well as certain noncollagenous proteins from the matrix ( osteonectina , osteopontin , bone sialoprotein ) have a
special affinity to bind , integrate and stimulate the growth of hydroxyapatite crystals that
precipitated the the matrix. Front matrix ossification progresses multidirectional leadWhen
mineralization of collagen lamellae structure haversian systems , along with their reorganization
(Fig . 1.14 ) .
Fig . 1.14 - Progression of bone

matrix mineralization processes (
electron microscopy issues ) - after
Meyer - Bone and cartilage
engineering
During this phase , the islands of cartilage is gradually phagocytosed by osteoclasts and
are penetrated by capillary neoformation , which bring with them osteoblasts metabolically
active (which will take the dominant role in continuing the ossification of the collagen matrix ) .
At the end of the interim phase of ossification ( which extends pMrs 4-6 Weeks of the
production according fracture and depends on theiguraia outbreak fracture ), fragmentele
fractured bone are fixed , consolidated fracture , but the resulting callus, although voluminous, is
still fragile.
primitive callus is presented in four types morphological ( see Fig . 1.15):

periosteal callus, surrounding the the first fragments fracture ;
endosteal callus ( bone marrow ) - occurs in the spinal canal right;
callus units ( cortical ) - occurs later between the two fragments;
callus parosteal, surrounding the old fracture site ( and Tagged last).
14
Fig . 1.15- callus morphological primitive

types
( radiographic appearance after a fractured
femur)
4. Calcification final phase and remodeling

In this phase, bone young, immature will be replaced by mature bone tissue ( see Fig .
1.16). Osteoclastic resorption occurs by reshaping ( stimulated by prostaglandins ) and by
submitting osteoblastic bone lamellar cortical . In a period of months or years, submit the
remaining 20 % of mineral material and architectural bone is organized along the lines of force .
Fig . 1.16 - remodeling phase , the morphological appearance of mature

callus
During this stage , primitive abundant callus ( endosteal , cortical and parosteal )
undergoes structural reshuffle , tabs irregular bone available, plexiform ( the primitive callus )
adoptWhen a regulator device as a pre- production of the fracture ( Fig . 1.17); at the end of this
step, the outline is re-established , and the shaft diameter of the bone biomechanics .
15
Fig . 1.17 - structural remodeling of callus ( callus callus grown primitive )

( aspects of electron microscopy ) - after Meyer - Bone and cartilage engineering
The evolution of fractures to strengthen - may occur in two ways:

by primary ossification ( primary callus ) ;
through secondary ossification ( secondary callus )
primary ossification - Is characteristic fracture osteosynthesis who received the farm,
with compaction (eg compression plate screwed ), In which at the fracture site no longer exists
movement between the bone fragments - See Fig . 1.18
Fig . 1.18 - ulna fracture operated ( plate screwed ) , reinforced by primary ossification
this type of ossification is achieved without midway cartilage , the prevalence of vascular
factors, with the advent of a unit or endosteal callus; consolidation period is shorter (Dec.t for
secondary ossification ) and the resulting callus is less bulky .
From the histological point of view , the primary callus formation , cortical bone necrosis
at the ends of the fracture fragments is not rezorbit , it is revascularized the adjacent medullary
capillaries ( fracturing the bone fragments in contact strns , due to fixation ) ; osteoclasts to the
ends of the fractured bone across the fracture line on the opposite side , forWhen the bone
tunnels , tunnels which are then invaded by capillary neoformation and osteoblasts (see Fig. 1.19
) ; haversian bone osteoblasts will synthesize blades , with the formation of new osteons , which
will restore the continuity of the fractured bone .
16
Fig 1.19 - histological aspects of primary ossification

( after Meyer - Bone and cartilage engineering )
secondary ossification - is the most frequent being strengthenfamiliar for this kind
fractures immobilized in plaster , operated by osteosynthesis elastic fracture ( in these cases,
small amplitude movements from the outbreak of fracture stimulationWhen forming a bulky
external callus ) ; secondary callus develops in four phases characteristic ( with cartilaginous
intermediate stage ) and is well radiographic , assureWhen the outbreak of fracture fixation
solid , though sometimes at the cost of secondary derivations (see Fig. 1.20 ) .
Fig . 1.20 - bifocal fracture of the leg , healed by

secondary ossification with moderate misalignment
A particular case is that of a total fractures treated by bone fun ( fun external fixator ) , in
which the fracture consolidation is done by direct ossification of the membrane.
I. Fracture - GENERAL
17
definition: FRACTURE is a lack of break in the bone, produced after of trauma .
Fig.2.1 - Types of fractures ( bone normal and pathological

bone )
As the field of occurrence, fractures can be produced on normal or pathological bone
bone ( architectural bone can be affected by osteoporosis , osteomyelitis , bone tumors , etc.).
Frequency: 10% of fractures and injuries are a Patholangy growing. Meet all ages, with
a peak between 20-50 years . The children are rare, due to the high elasticity of the bone , and are
frequently in the elderly due to osteoporosis.
etiology: criminalizing traffic accidents , work, home , sports and natural disasters .
pathogensfractures
after the mechanism is , there is two great categories of fractures (see Figure 2 .2):
direct fractures
indirect fracturi
Figforce
. 2.2 -trauma,
Classification
fter
meet: of fractures after mechanismThe
production
Low-energy trauma fractures ( low velocity trauma - LVt );
high-energy trauma fractures (high velocity trauma - HVT ) .
18
direct fractures, at the height of the forces acting, can tovea transverse paths (
low energy - LVT ) or comminuted paths ( high energy - HVT ); tocups latter has significant
associated injuries ( the soft parts ) and are common in accidentsthey serious ( polytrauma ) .
indirect fractures, depending on the mode of action of traumatic agent , may
be produced by the following mechanisms :
prin compression, axial thrust forces produced by symmetrical and evenly
distributedWith the following consequences (see Figure 2.2 ) :
disruption occurs in the bone diaphysis as a

longitudinal cracks or explosion ;
subsidence occurs in the epiphysis ;
Fig .2.2in- Compression
the vertebral body fractures meet subsidence (sometimes looking comminution ) .
by flexion: eccentric loading proleading compression forces that result in the concavity
traction and convexity ; resulting fracture with third
fragment ( ,, cone bending\") - See Fig . 2.3
Fig . 2.3 - deflection
19
by torsion ( twist ) are produced

opposing forces parallel offset , oblique ( forces forfecare ) ; tracts are spiroide or fracture
helical - see Fig . 2.4
Fig . 2.4 - Torsion
prin traction ( avulsion, avulsion):

the ligament inserts (eg
cruciate
ligaments of the knee level
r
truancy or tuberosity of the tibia earlier ) ;
the muscle inserts (eg
small trochanter or trohiterului ) -see
fig.2.5
Fig . 2.5 - Thrust
In some cases of fractures, traumatic mechanisms acting agent can be mixed ( +

avulsion torsion , bending + compression, etc. ) .
pathology
After the outbreak of fracture appearance and relations between the fractured bone
fragments , fractures are classified into two broad categories :
incomplete fractures
Complete fractures 20
I. fracturesthey incomplete:
A. In children:
deformarea bone thickness
compression , resulting radiographic
bony ring or ,, capital\" -see Fig. 2.6.
Fig . 2.6 - metaphyseal compression \" in

capital \"
Incomplete rupture ( by bending ) , when
have a radiological image of fracture
in ,, green wood\" - See Fig . 2.7
Fig . 2.7 - Fracture in ,, green
wood\"
B. In adult:
nfundarea ( compression ) meets the
skull fractures and epiphyseal
( ex . tibial plateau , calcaneus ) - Figure 2.8 ;
Fig . 2.8 - compression fractures in the external tibial

plateau
21
fisura ( compression ) , resulting from

low energy trauma affects only one bone
cortices - fig. 2.9
Fig . 2.9 - carpal scaphoid crack
II . complete fractures:
A. after OFFICE may be:
epiphyseal (intra-torticulare )
diaphyseal
metaphyseal ( juxta -articular )
Usually , if a diaphyseal fractures with headquarters , to locate accurate as of the

outbreak fracture , diaphyseal bone segment is divided into three anatomical portions:
1/3 upper ( proximal ) ;
1/3 medium ;
1/3 lower ( distal ) .
In children, the presence ( in the metaphyseal areas ) cartilage growth (which increased
vulnerability costituie areas where trauma ) , there is a special category metaphyseal - epiphyseal
fractures , known as \" decolri epiphyseal\" (classified by Salter 5 groups )- Fig . 2.10:
Type I: departure pure
Type II: Takeoff - nose fracture diaphyseal
Type III : Departure billed epiphyseal
Type IV: Takeoff - marginal fracture
( metaphyseal - epiphyseal )
22
Type V: compression cartilage
B. after TRAIECT may be:

transversale - path may be:
single (horizontal plain or notched appearance ) ;
two short tracks , resulting in a
intermediate fragment ( the so-called ,, con
bending\" or ,, butterfly\" ) - Fig . 2.11
Fig . 2.11 - transverse fractures
oblique: short or long ( fig.2.12 )
Fig . 2.12 - fracture with oblique

trajectory
spiroide: with unique paths or

the third portion of the torsion ,,\"
( fig . 2.13)
Fig . 2.13 - Fractures

spiroide
longitudinale - diafizelor longitudinal cracks in the ( rare )
B. after Bone fragments NUMBER OF OUTBREAK, we have:

fracturi with two fragments ;
fractures with three fragments (third fragment ,, bending\" or ,, torsion\");
fracturi comminuted ( multifragmentation )
23
comminuted fractures - they are generally the result of high intensity trauma and thus
subclasific ( Fig . 2.14 and Fig . 2.15 ):
comminuted itself - with
The main bone fragments in contact
complex comminuted - NoUm

inter- fragmentary contact
Fig . 2.15
Fig . 2.14
There is a modern classification, created by AO schoolDeveloped - each of them

corresponding bone segment 27 subgroups, depending on the degree comminution outbreak of
fracture. It is adaptable to your computer and aims to provide a method of treatment as
differentiated and allow a standardized reporting of results; we shall return to AO classification
at the end of this chapter.
C. after Fracture fragments displacement, meet :
Fractures without displacement : incomplete (cracks ) or complete - Fig . 2.17
Fig . 2.17 - fracture without displacement distal 1/3 M2
24
Displaced fractures :
with angulation ( angle ) : presenting Oand amendments of the bone axis - Fig . 2.18 :
- The frontal (anterior or posterior );
- In the sagittal plane (internal or external ) ;
- Combined ( in many plans )
Fig . 2.18 - fractures of the thigh bone and shin

angular
with translation, that is, the movement

( lateral or anterior-posterior ) of
fragments; translation may be Osidered ( the thickness of the cortical )
or total (Fig . 2.19) .
Fig . 2.19 - The translation of fracture

fragments
with sliding fractured fragments: their movement is produced for the purpose of longitudinal
axis
Dinal of the bone (fig . 2.20 ):
- Overlapping fragments leads to shortening fractured segment;
- Removing parts is accompanied by diastasis interfragmentar ( eg: fractures
patella , olecranon ) .
Fig.2.20 - overlapping fragments and removing parts of
fracture ( diastasis inter- fragmentary )
25
cu rotation ( shift rotation ) - Fig . 2.21

- rotation occurs in the transverse plane around the longitudinal axis of the bone ;
- sensul rotation (by positionto fragmentfracture site distal) can be externalUm
and
internalUm;
- cthis rotation can be heard : the initial trauma , muscle forces and weight
member;
- toprecierea radiation is shifted position after fracture trajectory irregularities
after differences between the diameters fragments bone and joint position after
neighbors.
Fig . 2.21 - rotating gap

impaction ( telescoping fragments fracture) - The result of traumatic compressive forces (
examples: tibial plateau fractures , tibial plafond , calcaneus ) - Fig . 2.22
Fig . 2.22 - impaction

fracture in the tibial
plafond
In reality and in most cases of fracture, fracture fragments movements are

complex and occur in several levels (eg: + + angular translation ofchocking rotation ) .
26
AO Classification of Fractures
Association AO / ASIF (Association for the Study of fixation ) , an internal
bodyannal based in Switzerland , has developed , since 1962 , a detailed guide for
classifying fractures guide developed in order to achieve a standardized classification of
fractures and allow a comparison of results between different therapeutic orthopedic
centers; This guide has been permanently improved over time.
According to this
classification, each type of fracture corresponds to a numeric code as follows :
first digit is skeletal fracture
location, As follows ( fig . 2.23 ) :
arm is numbered with 1 ;
forearm with number 2 ;
thigh with figure 3;
leg with figure 4;
backbone of figure 5; basin
figure 6;
hand figure 7;
foot figure 8;
girdle with number 9 .
Fig . 2.23 - Classification

AO
the second digit is the location of
the fracture at of bone; Each bone was divided
into three segments , numbered as follows (
Fig . 2.24 ) :
proximal epiphysis is numbered
with 1 ;
shaft corresponding to the number 2
;
distal figure 3;
malleoli are numbered with number
4
Fig . 2.24 - bone segments (AO )
The first two digits specify the diagnosis and therefore the location of the seat
frame fracture (eg , a femoral shaft fracture in the encode 3.2 ) . For a full diagnosis of fracture is
also used one letter and two numbers , as follows .
27
point defines type of fracture (A, B , C ) thus ( fig . 2.25 ):
A
FRACTURA CU DOU
FRAGMENTE
A2
A3
OBLIC SIMPL CU
NCLINARE PESTE 300
TRANSVERSAL SIMPL CU
NCLINARE SUB 30 0
A1
SPIROID
C
FRACTURA
COMINUTIV
B
FRACTURA CU TREI
FRAGMENTE
OU FRAGMENTE
B1
B2
B3
FRAGMENT INTERMEDIAR
PRIN TORSIUNE
PRIN FLEXIUNE
FRAGMENTAT
Fig . 2.25- AO
fracture type
28
C1
C2
C3
COMPLEX
SPIROID
COMPLEX
BIFOCAL
COMINUTIV
NESPECIFIC
(ATIPIC)
in turn , diaphyseal fractures (ies 1.2 . , 3.2 . , 4.2 . - A or B or C ) are subclassified again , according to the diaphyseal fracture location of the furnace , as follows:
with 1 1/3 fractures located proximal shaft ;
figure 2 fractures of the shaft located 1/3 medium ;
figure 2 1/3 fractures located in the distal shaft .
Example final: A femoral diaphyseal fractures , located in the middle third of the shaft and
looking spiroid with 3 fragments are coded as follows: 3.2 . B. 1.2.
AO fracture classification has the advantage of being adaptable to the computer
and to provide a universal language ortopezilor work worldwide .
Soft tissue lesions

At the time of fracture , traumatic agent by its kinetic energy determines , in
addition to bone injuries ( fractures outbreaks of various configurations ) and injuries \"
tire \" soft parts surrounding bone segment respectively .
Here summarized the most important lesions:
skin - may present:
primitive openings ( plagues );
side openings (necrosis ).
These openings skin performs communication with the outside of the fracture , resulting in \"
Open fracture \" ( primary or secondary) , with increased risk of septic contamination of the
fracture ; From this point of view ( the fracture communication with the outside ) , fractures are
classified into two categories: closed fractures and open fractures (Fig . 2.26 )
Fig . 2.26 - closed fracture open fracture

muscles , fasciatheytendonsthey: Bruises, fractures ,
between fracture fragments;
periosteumthe: Tears , takeoffs , interpoziii;
potstheir blood: Bruises , punctures , tearscompression;
rupturile small vessels causes local hematoma;
29
tearing , with possible interpoziii
lesions great vessels causes severe haemorrhage (pool in complex fractures , bleeding
may exceed 3 l by massive bleeding from a. obturator , a. buttock or upper . Internal iliac );
severe compression of large vessels may cause peripheral ischaemia ( Fig . 2.27 ) .
Fig . 2.27 - compression of the brachial

artery in a supracondylar fracture of
humerus
nervesand - can suffer injuries of varying degrees , with or without neurological deficit ( fig
. 2.28 ):
contusions ( neurapraxia ) ;
elongation ( axonotmesis );
rupture ( neurotmesis ) .
Fig . 2.28 - Elongation n . Radial

fracture in humerus distal 1/3
jointsthey: Intra-articular fractures , wounds resulting articulation joint communication with
the outside;
viscerathey: in polytrauma (for exempu , hip fractures may be associated with damage to the
bladder, bowel , etc. ).
symptomsfractures
Examination of a patient with a fracture is by classic semiological criteria ,
including multistage:
history - should be specified :
circumstances of the accident , the mechanism for producingl fracture , the time of the
accident;
seat and character of pain;
flaws associated with the patient ( diabetes, cardiovascular , neurological, drug
allergies , etc. );
inspection - highlights vicious attitudes , deformations, localized swelling ,
trophic skin disorders , muscle abnormalities , biomechanical axis deviations , bruises ,
30
wounds member present in the segment affected by trauma and the entire musculoskeletal
system ( fig . 2.29 -a, B , c);
Fig . 2.29 - a - localized

swelling
Fig . B- 2.29- muscle

hypotrophy
Fig . 2.29 - cOffset shaft ( genu Valguma )
palpation - Carrying out gently ; states:

headquarters and location of fracturePoints or painful areas ( fig . 2.30 - a);
detected the presence of bony crepitus ;
testing ( gently and cautiously ) abnormal mobility at the fracture ( fig . 2.30 - b
);
sensitivity testing and distal to the fracture mobility( Fig . 2.30 c );
evaluating the condition of the affected Member circular segment ( peripheral
arterial pulses , filling vascular venous return );
Fig . 2.30 -apainful palpation

points
Fig . 2.30 -BTesting abnormal

mobility
painful
31
Fig . 2.30 -CSkin sensitivity test
assessment of joint mobility (if possible) - By measurement with the

goniometer ( Fig . 2.31);
Fig . 2.31 - Measurement of joint mobility
examination orthostatism and walking ( if available) , indicating the

pathological changes ;
overall assessment of the degree of functional impairment ( functional
impotence ) Membership in the segment affected by trauma;
detailed examination of the fracture outbreak radiography - states:
seat of fracture;
configuration of the fracture ( tracks , number of fragments , deplasri
the fragments of the fracture , bone quality , etc. ) ;
fracture classification in a classification accepted.
an Radiographic examination correctly, have made the following rules ( fig . 2.32 ):
- Correct exposure ( to obtain a clich radiographic quality , allowing
assessing the quality and bone structure );
- at least two incidents (front and profile ) , sometimes oblique incidence ;
- Mandatory catching two neighboring joints (over and underlying hinge
fracture );
the child is carried out comparative radiographs, due to difficult
interpretation, determined by put forward cartilajelor growth;
X-rays may be repeated after 10-14 days, because some fractures are
evident late ( eg . carpal scaphoid fracture ) .
Fig . 2.32 - Radiography of forearm (front + profile ), which shows a fracture with
transverse trajectory with moderate external translation , located in the ulna shaft (
the union average 1/3 shaft distal 1/3 ) - Coding 2.2.A. 3.2 for ulna ( after AO
classification )
32
Additional imaging exams ( bone scan , CT - Possibly with 3D

reconstruction, Arthrography , MRI , bone scan , etc. )Necessary in the case of complex
or complicated fractures with neurovascular injuries or parenchymal (eg , comminuted
fractures in the spine , pelvis, tibial plateaus , etc.) situations where these brain imaging
provides accurate information on the fracture configuration , neighborly relations with
neurovascular structures , being useful for decision optimal therapeutic ( fig . 2.33 );
Fig . 2.33 - L3 unstable fracture - Radiographic appearance after reconstruction

CT- 3D
exploration methods osteoarticular special ( arthroscopy for diagnostic and
treatment , ultrasound musculoskeletal and joint) .
Diagnosis of fractures is on the basis of signs of the probability ( the number 5 ) and signs
of certainty (also the number of 5 ) .
A. Signs of probability:
1. Pain : strong initially , subsequently diminish returns as deep pain ,
localized exacerbated by movement ;
2. bruising late : occurs 24-48 hours after injury and
away from the fracture ( fracture hematoma due fuzrii
along the muscle sheaths ) ;
3. Deformation region : may be characteristic (eg , deformation in
\" Dos fork \" Colles fracture - Pout ) or misleading ( ex.n fractures
Intraarticular , you can increase hemarthrosis massive deformation ) ;
4. Shortening region : valuable (eg . in diaphyseal fractures ) or misleading
( ex . in fracture - dislocation ) ;
5. Functional Impotence : partial - incomplete fractures without displacement or
all - in displaced fractures .
33
B. Safety Signs :
1. Abnormal mobility : Complete fractures ;
2. Bone crepitation : rough (as opposed to hematoma, which is crepitation
Fine ) ;
3. Interruption of bone continuity: By palpation evidenced a goal interfragtional (eg . fractures of patella , olecranon , clavicle , tibia , etc.) ;
4. Failure movements: Complete fractures objective liability or/and active;
5. Radiographic examination - conclusively established diagnosis of fracture , precizeaz outbreak fracture configuration and allows diagnostic classification of fracture .
- In general, looking for signs of security can be dangerous , causing the patient pain and
complications can generate ; preferable to abstain search for them .
Developments fractures
In general , the development of fractures is favorable, towards consolidation.
clinical Findings outbreak fracture consolidation is done by :
pain and functional impotence;
disappearance of abnormal movements in the outbreak;
perception callus on palpation .
Radiographic examination - who confirming the outbreak of fracture ( endosteal callus
presence , united cortical and periosteal parosteal ) .
effects fracture on the body:

A. local disorders:
1. Muscle : weaknessie reduced or increased muscle (due to trauma and / or
immobilization prolonged ) ;
2. articulation : Early ( articular effusionThe type effusion or haemarthrosis) And late
( stiffness joint , with fibrous ankylosis or bone);
3. circulatory : early edema (post -traumatic , due to local vasomotor reactions ) or
swelling late ( transient or persistent, Due to possible venous thrombosis) .
B. General disorders:
minor (\"traumatic disease\") : Insomnia , fatigue , anorexia , fever ( 380 - 390 ) ,
Transient symptoms that fail after 3-7 days ;
major ( trauma after high intensity ) : traumatic shock and hemorrhagic, cu
fall TA and alteration of vital functions.
34
Complications
fractures
General
immediat
e
local
late
A. general
The presence of a fracture in a patient with associated strong (pre -existing fracture ) may
result in decompensation these conditions (due to metabolic imbalances trained trauma and
prolonged bed rest ).
1. Pulmonary Mechanics defectuoas pulmonary stasiscongestie pulmonary
bronchopneumonia decubitus respiratory failure acute;
2. disorders drain urinary urinary stasis urinary infections renal acute;
3. Diabetes latent worsening diabetic com;
4. Cardio -vascular decompensation ( aggravation of hypertension , decompensation
of heart failure) ;
5. s SyndromeMbolthey grsoase - complication rare but very serious;
politarumatizai occurs primarily in patients and in patients with fractures of the
femur;
leGate traumatic shock and explained by the appearance of disturbances in lipid
metabolism ( free fatty acids , release from the bone marrow of trauma , the endothelial
lesion, capillary);
rthe lungs are the main epercusiunile ( \" shock lung \" ) and brain;
clinical signs appear 24-48 hours after injury and consist of acute respiratory failure
( tachypnea, cyanosis, expectoration muco - bloody ), neurological symptoms (headache,
photophobia , seizures and coma ) and skin ( petechiae rush located on the neck ,
shoulders , armpits, abdomen );
CXR reveals flocculent opacities in both lung fields;
pulse oximetry highlights the major decrease in pO 2 ;
fundus examination reveals bleeding assuand eyes ( through micro- infarctions of
the retinal arterioles );
examination of urine indicates the presenceYour blood fat ;
The treatment is supportive , neurotrophic metabolic surgery in some situations (
thrombosed artery catheterization and dezobstrucia ) .
35
B. Local
1. Immediate :
1.1 . open fracture
the opening mechanism can be: from the inside and from the outside .
Characteristic is
that evuluia open fracture is more serious than the fracture closed due to aggravating factors (
fig . 2.34 ):
presence of associated soft tissue injuries ( to varying degrees ) Additional
devascularisation outbreak of fracture;
leakage fracture hematomar ntrziere nonunion consolidation ;
bacterial contamination of the wound nonunion suppurative osteitis .
Fig.2.34 - Open Source type IIIB

fracture of forearm
Avoiding infection ( osteitis post- fracturing ) is the main concern in this category norms care
of fractures, from this point of view is important presentation schedule the patient to the
hospital becausee it is considered that :
fractures shown in the first 6-8 hours are only slightly contaminated ( by germs
trivial aggressively low ) and only on the surface;
fracture presented at 8-12 hours , exponential multiplication of germs already
startedExtending deep into plans;
to submitted after 12:00Plans deep ( including the fracture ) infected sure .
Framing fractures oftencHise is by Gustillo -Anderson classification ( which will be
presented in chapter \" broken bones \" ) .
Treatment of open fractures is an emergency and consists of three main time :
\" debridement \" wound ( thorough cleaning of the wound with excision of
devitalized tissue , abundant lavage in order sanitizing wound );
fixation of the fracture ( internal or external fixation , depending on the
characteristics of fracture );
closing ( covering ) the focus of the fracture , which may be primary or secondary
(depending on the extent of lesions of the soft tissues ) .
1.2 . nerve damage:
common levelster radial nerve , median , external popliteal;
constau in nerve contusion ( NeuranPrax ) fiber rupture intrathecal ( axonotmesis )
and interrupttotal erea nerve ( Neuroticamesis );
36
manifested by paresis ( partial motor deficit ) or paresthesia ( total motor deficit )

headquarters distal nerve lesion , manifestations depend on the location , severity and length of
nerve injury .
1.3. vascular lesions: rare (1.7 % of all fractures are associated with vascular damage);
pfemoral- popliteal lesions redomin shaft ( supracondylar fractures associated with
comminuted fractures of the femoral or tibial plateaus ).
1.3.1. arterial lesions - mechanism can be: compression ( moved by a bone fragment ),
traction ofzinserie , puncture and tear ( Fig . 2.35); necesit early detection
(
distal vascular exam headquarters of a fracture is obligatory !) and emergency treatment .
Fig .
2.35
lesions
pressure
clinical- describes three syndromes :
Acute ischemia total (IAT )Pain, pallor, cold , paralysis , lack of pulse , oscillometric index
0; angiography confirmed the diagnosis ;
Acute ischemia partial ( IAP); Skin signs : blistering sores ; nervous signs : paralysis ;
muscle signs : infarction ginvolved .
acute localized ischemia (GET IT) acute syndrome lodge Volkmann syndrome
maybe tails occurs after the shank and forearm (lower leg and forearm have a special
compartment structure with musculo - fascial lodges less extensible );
hematoma causes a compression fracture of vascular and nerve elements of the
compartment , with the decrease tissue perfusion , ischemia and edema; These changes may be
caused or exacerbated by an external cause ( gypsum constrictive ) ; infarcted muscle ndelungat
a period (6-12 hours) fibrosing processes suffer irreversible ischemic contracture Volkmann
installation ;
semne clinical:
increase in the volume segment membership pain , paresthesia ,
pallor , paralysis , lack of pulse ( presence pulse nu rule out the diagnosis );
diagnosticul certainty is done by measuring the pressure intracompartimentale with a
needle gauge ( p \u003e 40MMHg = Compartment syndrome) - Fig . 2.36
37
Figure 2.36 - Measuring intracompartmental pressure

compartmental
Treatment :
IAT- Osteosynthesis farm;
- Restoring vascular axis ( dezobstrucie , suture , plastic) .
IAP: - fracture reduction remission of symptoms ;
- Persistence IAP: restoring vascular axis ..
IAL: - Emergency aponevrotomie - fig. 2.37
Fig . 2.37 - Incisions for aponevrotomia forearm
1.3.2 . venous Injury - Rarely require surgical recovery .
1.3.3 . venous Thrombosis ( superficial or deep - DVT)
ffavoring actors are: age , obesity , varicose veins , heart disorders, Prolonged
immobilisation in bed;
potential increased risk of pulmonary embolism (PE) or cerebral venous thrombosis
have it (DVT ) - localized thrombosis in vv . tibial deep, v. deep or superficial femoral ,
v. external iliac , v. common iliac ;
tprophylactic Treatment of DVT make type anticoagulants heparin ( fractionated
heparins ), means External contention ( sock antiembolic ) , mechanical methods (
passive mobilization devices - \" Continuous Passive Motion\" ) , surgical ( selective
catheterization with implantation of \"filters \" in v. cava , v. external iliac ) ;
venous thrombosis (DVT ) , documented by peripheral venous Doppler ECHO
benefit from treatment curative drug ( heparinization in classical heparin loading dose or
fractionated heparin followed by oral anticoagulation with vitamin K antagonists , long time,
periodic control clotting time ) or surgery ( thrombectomy ) .
1.4. Interposition of soft parts (muscle , fascia , periosteum )
semnele probability are: no crepitation bone and removing bone fragments
(diastasis - radiological observation );
tTreatment is surgical and consists in suppressing interpoziiei and firm fixation .
2. tardive :
1. Late consolidation
is neconsolidarea in interval time environment required for certain type of fracture;
care heard and imperfect reduction/or insufficient immobilization;
cLinic meet painful mobility in focus;
radiologia shows lack of focus or a callus callus in early;
38
tTreatment consists of further asset (1-3 months) or, in case of failure, in intervention
surgicalUm ( osteosynthesis farm, decortication , spongy grafts ) .
2. nonunion ( \" false joint \") - PS:
is neconsolidarea in interval time maximum required for a certain type of fracture;
care heard General (related to landpatient);
local - mechanical - by defect stabilization outbreak;
- biological - due to poor blood supply to tissues;
cLinic meet painless mobility in focus;
radianGraphic : no callus or callus between the fragments of the fracture insufficient .
Classification PS:
etiological : PS infection ( chronic osteomyelitis ) ;
uninfected ( \" actual pseudarthrosis )
evolutionary : PS hypervascular (hipertrofice ) ;
PS avascular ( atrophic )
a) PS hypervascular ( hypertrophic ):
capetele bone are capable of biological reaction, dsuch consolidation was stopped at
the stage of provisional callus (fibrous) , Well vascularized ; mechanical failure prevents
the continuation of consolidation;
subdivided into 3 types anatomic-pathological:
PS \" elephant foot \" (fig. 2.38 - A)
PS \" horse hoof \" (fig. 2.38 - B )
PS oligotrophic (fig . 2.38 - C )
prognosis of this group of PS is good;
osteo- periosteal peeling treatment is the focus of nonunion , osteosinfarm sentence cast immobilisation .
Fig.2.38 - hypertrophic nonunion
b) PS avascular ( atrophic ):
39
capetele bone are inert , incapable of biological reaction, and strengthening the
inflammatory phase is stopped;
subdivided into four subtypes ( see Fig . 2.39) , Of which The most serious is the
type C ( PS \" floating \" with inter- fragmentary bone defect important );
treatment is the osteo- periosteal peeling the outbreak of nonunion , osteoplasty
spongy bone defect grafts (autografts or allografts from the bone bank ) or synthetic bone
substitutes , segmental bone transport ( Ilizarov method ) firm fixation cast immobilisation;
prognosticul this category of PS is reserved .
Fig . Atrophic nonunion 2.39 ,
3.vicious callus
is consolidation of a fracture in a position that is not anatomically (the persistence of
travel between fracture fragments );
vicious calluses are generallylWell tolerated gussetsc, cfunctional onsecinele being
Worst to angular of 15-20 and significant differences bone fragments ( large deviations of the
biomechanical axise a member arthrosis lead to the installation of a fast moving ); vicious
consolidation is poorly tolerated in the leg (which is supporting Member um ) than the upper
limb ;
vicious callus is presented in two morphological aspects :
callus vicious Hypertrophic ( excessively bulky ) without misalignment outbreak of
fracture , which generally undergo remodeling naturally over time (see Fig . 1.15) ; only in
situations where the callus compresses the nerve - elements vasulo or is unsightlyIt is necessary
remodeling to surgicalWith release neurovascular elements ;
callus vicious significant misalignment - tTreatment consists of osteoclazie (
refracturarea callus ) , osteotomy and osteosynthesis farm ( method of choice ) or resection of the
outbreak ( significant misalignments ) - Figure 2 .40
40
Fig . 2.40 - horsevicious us with misalignment after a supracondylar fracture

of femur treated by corrective osteotomy and plate fixation screwed
4.Osteoporosis post-traumatic \"algo - neurodystrophic syndrome\" Sudeck Leriche syndrome
is due to neuro - regional vasomotor exaggerated ( with excessive stimulation of osteoclastic
activity ) that occur after trauma ;
fdeterminant actor is trauma, and predisposing factors are psychological and endocrine land
the particular patient ( anxious patient with increased sympathetic tone );
cLinica is in pain mobilization ( after the suppression of plaster immobilization ), Warmth ,
edema , cyanosis and contracture muscle; BCn joint stiffness and muscular atrophy appear
evolution;
radiografia found bone demineralization; towhattosit there andnition as osteoporosis
incomplete (,, white clouds on blue sky ') and late as global osteoporosis ( bone transparent
contours marked = ,, sign gouache \" ) - Fig . 2.41;
Fig . 2.41 - Sindman algo - neurodystrophic

after a sprain punch
tTreatment is to combat regional vasomotor disorders (analgesicsAntihistamines ,
sympatholytic sedatives) , Restoring bone matrix ( anabolic , calcium , magnesium , vitamin
therapy ), Physio and kinetoterapie; in exceptional cases, can call on infiltration anesthetics and
corticosteroids ( Xilin , Dexamethasone ) stellate ganglion ( for upper limb ) or lumbar
sympathetic plexus ( the leg ) .
41
5.osteomas periarticular posttraumatic Myositis ossificans

osteoamele are bone formations of varying sizes that appear 2-3 weeks after injury,
the muscles around the joints and periarticular thickness;
is formed by ossification of hematoma posttraumatic ( containing small fragments
osteo- periostitis );
examples : osteoma brahialului above ( appears after elbow trauma ) - fig.2.42
andndromul Pellegrini - Stieda ( internal collateral ligament calcification
of knee ligament injuries after repeated );
Fig.2.42 - Solid osteoma previous

brachial after elbow trauma
trayourlation can be : drug (anti -infLamat ) ;

rntgenterapic ;
Surgery (Subject ossification Big blocky joint movements
or compresses neurovascular elements ) - is performed after maturation osteoma
(6-12 months) and consists of the removal of ossification.
6. joint stiffness
means less joint mobility (assets and liabilities) , with reduced joint range of
motion;
causes changes are given intra-articular ( synovial hypertrophy , fibrosis and
retraction joint capsule ) and peri -articular ( muscular hypotrophy , periarticular
ossification hematoma ), Arising from a joint inactivity prolonged ( lasting plaster
immobilization due to trauma or surgery) ;
to avoid the stiffness of joints, should be performed as firm fixation of the
fracture , which shorten plaster immobilization and allow early resumption of joint
movements;
Once installed , stiffness receive :
functional rehabilitation treatment ( physio and physical therapy ,
medication and antalgic decontracturant );
orthopedic treatment ( joint mobilization under anesthesia);
surgical treatment:
artroliz = surgical excision of fibrous adhesions and periarticular
joint with joint mobilization ( achieved by classic approach or
arthroscopic ) ;
42
excision periarticular ossification .

7. Avascular bone necrosis ( ischemic aseptic)
occurs as a result of itsntreruperii blood circulation a bone segment;
May are common:
Avascular necrosis (aseptic ) of the femoral head ( NACF ) , which occurs after
fractures of the femoral neck ;
carpal scaphoid proximal pole necrosis ( after fractures of the scaphoid ) - Fig .
2.43 ;
necrosis of the talus (which appears after fracture-dislocation of the talus ) .
Fig . 2.43 - ischemic necrosis of the

proximal pole of the scaphoid carpal
carpal scaphoid fracture after
factor favoring blood circulation is the type that bone segment ( movement type
terminal with small diameter vessels and few anastomoses );
bone segment devoid of suffering vascular contributionAfter a variable period of
time, necrosis phenomena ( showne the occurrence of osteoporosis areas alternating
with areas of osteosclerosis ) , accentuated by biomechanical demands being placed;
consequence is the emergence of a joint mismatch , resulting time in osteoarthritis ;
din clinically , advanced necrosis ( ajuNSA stage arthrosis ) is manifested by
appearance of mechanical type pain in the joint in question, decrease joint mobility;
radiographic bone segment affected by necrosis occurs denser ( ostecondensat or
osteoscleros ) ; in some situations ( NACF ) and depending on the stage of necrosis
may occur mixed images ( osteosclerosis + osteoporosis);
trament ( depending on the stage of necrosis and clinical manifestations ) is
surgically ( Early decompressive drilling for NACF , torNACF hip TROPLAST for
advanced radial styloid or resection arthrodesis fist - carpal scaphoid necrosis ,
astragalectomie , tibio - calcaneal artodez - necrosis of the talus ) .
8. osteoarthritis posttraumatic
are therefore,target posttraumatic degeneration of joints ( by degradation of
articular cartilage , articular surfaces incongruency secondary or higher deviations
biomechanical axis );
maybe appears as : articular fractures ( leading to joint incongruity ) ;
ischemic bone necrosis ( ex . NACF ) ;
vicious calluses with significant misalignments (over 20 0 ) ,
Leading to eccentric loading jointWith early secondary cartilage wear;
43
clinically advanced osteoarthritis pain is manifested by a mechanical (

pronounced activity and gives the rest) , decreased joint mobility , with alterations of
joints ( functional impotence );
radiographically advanced osteoarthritis is characterized by alterations in shape
and structure of articular surfaces , narrow (up to extinction) joint space , bone cysts ,
etc. - see Fig . 2.44;
Fig.2.44 - osteoarthritis
secondary to acetabular fractures
advanced forms of osteoarthritis treatment (associated with severe pain and

functional impotence ) consists of surgery with prosthetic replacement arthroplasty or
arthrodesis of various types ( fusion = merger bone articular surfaces , functional position
, in pain relief and quality of life ) .
9. bone infection ( osteitis post - traumatic )
complication can be infected open fracture or surgery that did not adhere to strict
aseptic;
describe three forms antomo-clinical :
acute posttraumatic osteitis ;
callus osteitis ;
infected nonunion Fistulising .
clinicalPain, local inflammatory phenomena , fever, fistula drainage which
removes sero -purulent secretions ( chronic osteomyelitis )
radiographic: Local alteration of bone structure (Osteoporosis areas alternating
with areas sclera sometimes bone attachment ) - Fig . 2.45
Fig . 2.45 - chronic Osteitis after a fracture of the

distal third of the leg , operated plate screwed (
osteosynthesis material extracted )
44
treatment is difficult and lengthy , comprising:

surgery ( sometimes multiple ) consisting of debridement outbreak osteitis (for
sanitation ), followed by the remaining bone defect osteoplasty ;
targeted antibiotic therapy in combination (as evolving pathogen susceptibility )
;
anbolizant medication (vitamins , calcium , etc. ) .
General principles in the treatment

Principles: local precedence over the general treatment of fractures and purpose of
treatment is to restore first function osteo -articular and only the second form bone.
treatment of a fracture starts when the accident and ends with the resumption of the
patient ;
3 stages of compulsory treatment of fractures :
First - aid from the accident and correct transport patient to the hospital;
appropriate specialized treatment in hospital;
specific function recovery therapyantional and vocational rehabilitation .
First aid at the accident scene
is particularly important because it can facilitate or complicate (if incorrectly applied)
Evolution of fractures;
ideal is to be performed by specialized personnel ( extrication units );
consists of: the correct release of the patient, to avoid movement that can cause
complications (e.g. , forced hiperflexia spine );
control and the patient's vital functions , in the case of multiple trauma (
following the algorithm ABC) ;
pain killers ( analgesics ) ;
sterile dressing of a wound or open fractures;
correct application of a tourniquet in case of heavy bleeding ( of timed
application of tourniquet ) ;
temporary immobilization of fractures ( improvised - bandages, boards ,
etc. or qualified - pneumatic splints , cervical collar , special stretcher column) .
Transport patients to hospital
efficient, fast , ideally with an ambulance unit ;
measures of resuscitation and first aid continues during transport (monitoring of vital
parameters , providing ventilation , providing thermal comfort , control hemorrhage with
hemodynamic balance , combat shock with analgesics , soil . infusion \" shock trousers \" ) ;
specialized immobilization of fractures .
Fracture treatment in hospital

45
first steps consist of careful examination of the patient's general condition assessment ,
level of consciousness, vital signs ( BP , pulse, respiratory rate , urinary output) and accurately
determine inventory lesion (especially in the case of polytrauma and polifracturilor ) ; continue
cardiopulmonary resuscitation measures , traumatic and hemorrhagic shock combat is requested
(if necessary ) inter- disciplinary checkups (ICU , surgical, neurosurgical , neurological , etc. );
patient is sent to the investigation as complete imaging ( radiographs of segments
trauma, cerebral CT , abdominal ECHO , etc. ), investigations laboratory and laboratory ( blood
count , glucose , urea , creatinine , Astrup parameters , ECG, pulse oximetry , peripheral Doppler
ECHO , ECHO cardiac Doppler , etc.);
Once the inventory complete lesion , provides a ranking of the severity of lesions and
is determined stepwise therapeutic conduct ; prevail injuries immediately life -threatening patient
such as: head trauma with hematoma intra- cranial compression , thoracic trauma with hemo /
pneumothorax compressive intra- abdominal injuries severe hemorrhagic or septic risk (
ruptureA spleen , deziserie midgut , liver fracture , etc. );
major orthopedic emergencies they are:
open fracture ( must be operated within 6 hours of production ) ;
fracture complicated with major arterial lesion ( necessary to stabilize the fracture , restore
continuity with vascular axis ) , including complicated by compartment syndrome ( required
decompressive aponevrotomie ) ;
dislocations and fracture-dislocation ( must be resolved within 24 hours of injury ) ;
unstable pelvic fractures associated with hemodynamic some instability ( necessary to stabilize priMara pelvic fracture - external fixator in order to reduce bleeding ) ;
wounds with heavy bleeding ( hemostasis required surgery ) ;
plagues concussion intra-articular (requires debridement due to the risk of septic arthritis ) ;
any fracture or traumatic musculoskeletal , which in the context of a politraumaSemitism , adversely affect the patient's vital prognosis .
Once the therapeutic conduct , a fracture may benefit from three therapeutic alternatives :
orthopedic treatment ( conservative ) ;
surgical treatment ;
Functional treatment
A. orthopedic treatment ( conservative)

orthopedic treatment has 3 times :
reductionthe outbreak of fracture;
Contenta ( immobilization ) fracture ;
re-educationto functional .
1. orthopedic reduction fracture = All nesngernde specific orthopedic maneuvers
performed on each fracture , in order to obtain a satisfactory focus ( as close as possible to its
original anatomical position ) fracture fragments;
reduction may be :
extemporaneous - By extension contraextensie and

handling the outbreak ( preferably achieved
under
46 anesthesia ) ; information is represented by
stable fractures ( Fig . 2.46 ) ;
8
Tools: by extension continues transskeletal (Figure 2.47 ) ;
reduction on orthopedic table
( fig . 2.48 )
e
Fig . 2.46 - orthopedic
reduction maneuvers for a
fractured forearm
Fig . 2.47 - Method trans - sceletic extension

for a fractured femur
Fig . 2.48 - Reduction of

fractures orthopedic table
2. restrained - can be done by various types of devicee plastere , soft bandages -for
limb ( Desault bandage , bandage \"8\", etc.);
application is made after casting apparatus strict rules (which will be detailed clinical
rotations ) , the devices being monitored evolution ( co- evolution of the outbreak clinicoradiological fracture ).
3. physiotherapy - basically starts after curing machine gypsum plaster and continues
after suppression ; is tn:
isometric muscle contractions as gypsum ( to combat muscle hypotrophy );
active mobilization of the joints not immobilized ;
47
segment immobilized limb resting position proclaim ( to combat circulatory

disorders as gypsum ), alternating with periods of mobilization (depending on indications
).
B. Surgery
fixation = method of surgical treatment aimed at restoring continuity broken bone or
metal implants using biological materials.
indications of surgical treatment fractures they are:
Absolute indications :
irreducible fractures prin orthopedic methods ;
displaced intra-articular fractures ;
fractures associated with neurovascular injuries .
relative indications :
secondary displaced fractures ;
pathological bone fractures ;
known as impossible fractures treated by conservative methodstore (
forearm, Monteggia , Galeazzi , etc);
various combinations fracture ( fracture storied polifracturi ) .
two broad categories

osteosynthesis :
Internal : opening the fracture ;

without opening the furnace (
techniques \" on closed hearth \" Rx -Tv
control ) ;
mini - invasive techniques (eg .
MIPO )
External - osteotaxia with external fixator
fixation is the reduction (closed, open or mini - invasive ) and the outbreak of fracture
fixation with metal implants (screws , plates, rods , etc. ); benefits include the reduction of good
, solid fixation and early recovery ; disadvantages are the risk of infection and complications of
general ( metallosis ) ;
osteosynthesis implants range is very wide ; implants are adapted to different types of
fractures and are constantly upgraded ( fig . 2.49 );
As implant is characterized by three parameters :
stiffness (given the characteristics of the alloy and implant design ) ;
stability ( implant ability to stabilize the fracture ) ;
biotolerabilitate ( titanium alloys are basically bio- inert ) .
48
Fig.2.49 - Variations plates with screws
success depends on an internal osteosynthesis Two categories of factors :

true indication ( with appropriate choice of implant fractures each category
separately , depending on the biomechanical characteristics of the fracture ) ;
perfectly aseptic surgical technique , with maximum sparing the bone
vasculature .
from the point of view of the implant used to distinguish 5 categories of internal
osteosynthesis :
wire fixation cerlaj - Used peroneal malleolus fractures oblique diaphyseal
fractures and some long or spiroide;
fixation with screws - Oblique fractures or spiroide;
fixation principle Hoban - Applied olecranon fractures , patella , internal
malleolus;
screwed plate fixation ;
intramedullary rod fixation .
most used in practice are osteosintezele screwed plate (fig . 2.50 ) and osteosintezele
intramedullary rod ( Fig . 2.51 and 2.52 );
Fig . 2.50 - plate

fixation
screwed
Fig.2.51- elastic
fixation rods
49
Fig . 2.52 - latch rod

fixation femur
screwed plate fixation has evolved as a concept, in recent decades, as impulses

biomechanical studies conducted by school AO ; conventional plates 'classic' had the
disadvantage of extensive cortical contact , leadingto to impaired bone movement of the plate ; to
eliminate these drawbacks , improved versions have been developed plates of type :
cortical limited contact dynamic plate (LC- DCP \"limited contact dynamic
compression plate , \" );
internal fixatoarelor ( angular stable plate with screws unicorticale , locked
plate) ;
also applying a classical conventional plates required a surgical approach widely ,
leading to a further devascularisation removing periosteum and bone fragments ; to eliminate this
inconvenience , were designed mini - invasive osteosynthesis techniques (using LC- DCP or
internal fixators ) type MIPO ( minimally invasive plate - Osteosynthesis - Fig . 2.53 ) or LISS
(less - invasive stabilizing system - fig. 2.54 )
Fig . 2.53 - MIPO technique for

distal femur fracture 1/3
Fig . 2.54 - LISS technique for distal

femur fracture 1/3
osteosynthesis purpose of any intervention is to achieve a solid fixing the fracture ,

allowing early mobilization joint ( thus avoiding the installation of joint stiffness , muscle
hypotrophy and the algo - neurodystrophic syndrome .
C.Treatment recovery functionalA - is carried out early and continuously .
cuprinde stages of sleep , antalgic purpose followede progressive mobilization of the
affected segment and then a series of processes that medical gymnastics , massage ,
Physiotherapy, to a better recovery of the function as Membership segment affected by
trauma;
efficient and fair treatment led allow faster social and professional reintegration of the
patient.
50
III . Spinal cord trauma ( TCV )

TCV are polymorphic, having a component osteo-joint and one nevraxial;
scomplex butter, comprising: fractures;
sprains;
dislocations.
The structure of the spine:
Bone: 24 + sacred + coccigele individual vertebrae (Fig . 3.1) ;
Soft Parts: represented by mobile spinal segment ( SMR )
Fig.3.1 - bone structure of the spine

I. vertebrae consist of a previous arc and posterior arch (Figure 3.2 ).
Arch previously ( vertebral body )
has two sides ( top and bottom ) and
posterior wall ( Rieunau ) ;
structure is a cancellous bone with a network
trabecular beams made up of two oblique
oriented posterior wall; fragile area is
located above.
Arch posterior ( neural )
is semicircular , with anterior concavity ;
is particularly resistant to the pedicles ,
joint and vertebral apophyses blades .
1
5
2
1
6
2
7
3
3
7
4
Fig . 3.2 - Structure of the spine :

1- vertebral body ; 2- pedicle ; 3- transverse
apophysis ;
4 spinous processes ; 5- spinal canal ; 6- articular apophyses ; 7- blade spine
51
II . Mobile spinal segment ( SMR ) is the ( fig . 3.3 ):

posterior ligamentous complex ( Holdsworth ):
supraspinous ligament ( 1);
interspinous ( 2);
yellow ( flavum ) -3 ;
capsular ligaments (4 ) ;
ligament posterior vertebral joint ( LVCP ) -5 ;
common vertebral anterior ligament ( LVCA ) -6 ;
intervertebral disc - 7
Fig . 3.3 - Ligaments Spine
4
5
2
6
1
The functions of the spine:
support ( static );
mobilization ( dynamic );
protection ( restraining neuraxis )- Fig . 3.4
Fig . 3.4 - cervical spinal cord
and lumbar roots
nerve
etiopathogeny:
- Frequency is 1 % of all fractures , affecting the preponderance of active adults and the
elderly;
- causes are traffic accidents , work and sports;
- There Is locations in the preferred C1 - C2 , C5 - C6 and T11 - L2 , Mobile transition zone,
considered ,, trauma centers\"; TCV prevail in dorsal region-The lumbar ( 75 % ) .
The mechanism and pathology

I. mechanisms andndirecte:
1. Hiperflexia:
fall of a heavy body falling on the head or the head resulting in a spinal tap ( cuneiformizare ) ;
buffering front producing a previous acceleration of the head ( Fig . 3.5) ;
begin posterior lesions , posterior ligament complex rupture and spreads
, giving rise to : simple settlement ;
intervertebral dislocation ;
fracture - dislocation .
52
Fig . 3.5 - vertebral fracture by hiperflexie
2. hyperextension:
tamponarea rear vehicle, determandtaining a brutal acceleration back of head;
theSports ccidentele ( uppercut , diving );
lStart eziunile ( LVCA , intervertebral disc ) and propagates back, resulting in sprains or
fracture - dislocations (when failure occurs articular apophyses ) - Fig . 3.6 ;
hiperextensia associated with rotation can cause a massive articular fracture - separation ,
we can meet medullary lesions .
Fig . 3.6 - vertebral

fracture - dislocation by
hyperextension
3. axial compression ( telescoping ) - is rare ;

sit meets or falls with support ischioane standing with rachis in extension or falls
on the head;
lare determined eziunile comminuted fracture, with subsidence severee; ex. :
separation fracture of the atlas ( Jefferson fracture ) comminuted fractures of the vertebral
body ( ,, burst fracture\") - Fig . 3.7
53
Fig . 3.7 - Fracture - compaction

comminuting compression - \"burst
fracture \" ( aspect radiographic and CT)
4. horizontal shear
is common in auto accidents, being determined by the sequence proceselor
acceleration - deceleration ;
leziunile predate, then back, from sprain to dislocation and fracture - dislocations
complex - fig.3.8
Fig . 3.8 - fracture dislocation

vertebral shearing
5. rachis torsion - is commonly combined other mechanisms, posterior ligament
complex leading to rupture or fracture apophysistheir articulation, with sprains or
dislocations serious - Figure. 3.9
Fig . 3.9 - Dislocation

intervertebral
torsionally
II . mechanism dIRECTIVE: rarely met with hard objects or projectile hits .
54
Classifications
anatomical - pathological ( Bohler ):
1. Fractures of the anterior arch , posterior and combined;
2. Anterior- posterior dislocations (cervical ) and side ( back );
3. Fracture - dislocations, most common in the neck .
After prognosis ( Nicoll ):
1. Stabile - when osteoligamentar posterior complex ( COLP ) is
integral; tocups are settling cuneiform fractures and comminuted lots;
2. unstable - COLP is degraded dislocations and fracture - dislocations .
Dfter prognosis ( Denis ) - Denis divides bone structures and capsulo - vertebral
ligament in 3 columns : anterior , middle and posterior ; a fracture is considered
unstable
when
two
or
all three
affected
spine
(Fig .
3.10).
Fig . 3.10 classificationnis

After nerve injury - BCn Depending on the Involvement of neuraxis, meet :
fracturi Amiel - 65 %;
fractures lamb - 35 %
clinical examination
is preceded by anamnesisWhich establishes the mechanism of production ,
recording the reasons for hospitalization ( pain andmfunctional potency );
Inspection highlights bruising , hematoma , deformation ( gibusuri );
palpation headquarters reveals increased pain and facet space;
fScores important neurological examination, who notes:
skin sensitivity
( dermatomes - Fig . 3.11);
limb mobility
( miotoame Fig . 3.12) ;
tendon reflexes
(anal , penile , soles);
sphincter function.
Fig . 3.11 - dermatomes
body
55
Fig . 3.12 Miotoamele

limb
Bithe patient with neurological chain TCV is after standardized examination protocols
such as Protocol ASIA (American Spine Injury Association) - Fig . 3.13
Fig . 3.13 - Protocol Neurological examination I WOULDIA of patients with

PCC
imaging examinations
radiologia : is performed face and profile radiographs, and oblique
radiographs (3/4 ), for the study region and holes facet conjugation;
myelography ( pneumatic or with contrast ) - Spinal cord compressions for
evidence ;
selective angiography of the vertebral arteries;
56
computed tomography (CT ) , with or

reconstruction CT is useful for evaluating the exact
vertebral compression medulla root;
nuclear magnetic resonance ( NMR ) - Highlights
degree etnature medullary lesions , edemany and
disc injuries and ligament associated , etc. - fig.3.14
without three-dimensional
configuration and complex
precisely fracture pattern ,
hemorrhage TraumaticUm,
Fig . 3.14 - Fracture T - compaction11 ( Skin Rx ) with

compression
spinal cord ( as evidenced on MRI )
A. Immediate complications:
nerve complications ( 40 % ) - patologia can :
vascular : + contusion spinal elongation, compression of the spinal vessels ,
causing ischemia, edema,
Local inflammatory reaction , followed by
myelomatocie ;
mechanical : fractured bone fragments produced concussion or nerve section (
Figure.3.15)
Fig . 3.15 - Medullary

vessels
Anatomical varieties - pathologic nerve damage:
spinal contusion - Manifested by flaccid paralysis , lack of sensitivity and paralysis
viscera in medullary lesion ; prognosis ( under specific care ) is good, and is often full
neurological recovery;
section marrow ( partial or complete ) - Is manifested initially identical marrow
contusion , but nerve damage is irreversible ; after a while, Spinal reflex resumes and
57
penile reflexes reappear ( bulbocavernos ) , anal and planting ; after several weeks of
evolution, paralysis becomes ( in flaccid ) spastic; regeneration is incomplete (
incomplete spinal sections ) or absent ( complete sections severe) ;
nerve root section - Manifested by motor paralysis ( which remains flaccid in
development ), Numbness and paralysis visceral root distribution in the territory of the
injured ; regeneration is theoretically possible .
clinical forms ( Fig . 3.16):
tetraplegia - cervical fractures;
paraplegia - in the lower back;
central medullary cord syndrome ;
spinal cord syndrome before;
posterior spinal cord syndrome ;
syndrome hemisection marrow- Brown syndrome - Sequard;
syndrome \" Ponytail\" - fracture below the L2 .
Fig . 3.16 - Driving

Routes medullary
Developments nerve injury ( complete or incomplete ) is in three phases:
spinal shock (7-21 days) - Characterized by flaccid paralysis ,
areflexia ( bulbo - cavernous reflex absent), hypotension ,
bradycardiahyperthermia ;
medullary automatism - improves general well being, bulbo cavernous reflex returns and anal ( with micturition and defecation
automatic but insufficient ) involuntary muscle contractions occur
, quadriplegia or paraplegia spastic; sphincter reflexes after the
non-occurrence of spinal shock translates the presence of a
complete spinal section irreversible ;
areflexia terminal - Complete sections severe bone marrow;
overall condition worsens , gradually disappear reflexes and
sphincter function , urinary superinfection occurs , pressure sores
and patient death.
B. Late Complications - include:
pseudartoza (especially for fractures of the odontoid and
transverse apophyses ) ;
cifoscolioza;
discartroza;
sneurological echelele.
58
evolution :
TCV amiethemthey perform well under treatment;
TCV lambandhaving a development serious .
Diagnosis:
positive : is based on subjective symptoms , clinical signs and laboratory
examinations;
diferenial : is osteoporosis , primary or metastatic neoplasms , sequels morb Pott
, vertebral osteochondrosis , kyphoscoliosis, and so on
traumaetheir cervical spine

\" trauma centers \" : upper cervical rachis ( C 1 - C2 ) ;
cervical rachis inferior ( C3 - C7 ) .
Clinical aspects :
pain in the neck, shoulders and arms sometimes irradiated, Sometimes
accompanied by dysphagia ;
injuries associated with the forehead and face - Abrasions , bruises (which suggests
the mechanism of hyper -extension ) ;
attitudes killers ( \" head resting on hands\" ) and torticollis ;
headquarters palpation reveals pain ( vertebral bodies and can feel the spinous
processes ) and paravertebral muscle contraction ; palpation of the vertebral body
with high office ( C 1 - C3 ) Is possible by touch trans - mouth ; palpation of space
increased inter- apofizar suggestive of ruptureand ligament ( sprain )And the
presence of kyphosis suggest a fracture - dislocations ;
radiographic aspects :
radiography examfic is done with great care and gentleness;
required to radiographic incidence and profile , sometimes supplemented with
special oblique incidence ( for holes conjugation );
viewing C 1 - C2 Radiography present will be trans - mouth (to avoid duplication
mandible );
within the correct profile includes vertebra T1 and therefore it is with \" shoulders
down\" ( by traction arms );
without bone lesionsWe will search for radiographic criteria of severe sprains :
extending over 3 mm distance between the odontoid and cortical
posterior arch of the atlas above;
posterior vertebral wall gap over 3.5 mm (fig 3.17- A);
removing abnormal spinous ;
angulation over 110 posterior wall (Fig . 3.17 - B ) ;
59
apophyses joint subluxation .
T
B
h
e
Fig . 3.17 - Radiographic criteria for severe cervical sprains
I.
Additional imaging examinations (CT , MRI ) are often recommended to

determine the seriousness of injuries ( precise configuration of the fractureUm,
ruptures ligamente, Perilesional edema and hematoma , associated disc disease ,
spinal cord Involvement and nerve roots ) .
fractures C1 - C2
are very serious and can result in quadriplegia with cardiorespiratory disorders
( due to possible impairment of cardiopulmonary centers in medulla oblongata
);
cervical anatomy . cervical C 1 - C4 is shown in FIG . 3.18
Fig . 3.18 - Structure of the

cervical spine bone C 1 - C4
1.
atlas ( C1 )
BC'll meet five types lesionand ( after Levine ) - Fig . 3.19:
-A transverse process fracture isolated ;
-B posterior arch fracture ;
anterior arch fracture - C ;
break - separation of the lateral ( Jefferson ) - D;
comminuting fracture \"burst fracture \" - E
60
Fig . 3.19 - Fractures of the atlas

one encounters Anterior dislocation of the atlas (with respect to axis) , which can be (
fig . 3 .20):
isolated - lig rupture . transverse when it is accompanied by serious neurological
disorders;
associated with odontoid fracture , which has the savior .
Fig.3 .20 - Dislocation atlas
2. Axis ( C2 )
pll be interested in :
odontoid - at the tip , femoral or its base; fracture can be caused by
hyperextension mechanism or hiperflexie and may be associated with
anterior displacement or rear of C 1 to C2 ( fig . 3 .21);
Fig . 3 .21 - Fractures of the

odontoid
posterior arch ( fracture ,, Hanged\") - Hangman fracture Wood

Jones ; one ofstfel fractureUm peRMIT anterior displacement of the
odontoid , with atlas and processetheir superior articular ( anterior
spondylolisthesis )While the inferior articular processes , blades and
61
spine spinous process of C2 remain in place ; depending on the degree

spondylolisthesis , can produce severe neurological damage - fig. 3 .22
II . C3 - C7
The lesions are found mainly at the junction C5 - C6 where we meet sprains
facet which may be accompanied by previous subluxations and neurological damage.
Treatment:
- fracture without displacement :
- Schanz collar or ,
- Minerva gypsum , for 21-90 days
- fracture displacement :
- cranial traction using horseshoe or halo for 21-30 days
- in case of reduction : Minerva plaster immobilization year for 3-6
months;
- in the case of failure of surgical therapy is used : posterior
arthrodesis followed by Minerva plaster for 3-6 months.
Trauma dorso - lumbar

- Are common in the T12 - L2
- Fractures can be stable (affecting only the vertebral body - the whole posterior wall ) or
unstable the spring back is damaged .
- Evolution is favorable .
Treatment :
A. Stable fractures (85% )
- stable fractures compaction under 1/3 the height of the vertebral body (
more common in the elderly and bran ) is practiced early functional
recovery ( Magnus ) .
- In the compaction over 1/3 ( young athletes ) is practiced fracture
reduction by reclinaie ventral extension Bohler or frame , followed by
immobilization in plaster corset 2-3 months.
B. In unstable fractures (15%) treatment consists of bed rest 30 days followed by
plaster corset 2-3 months. Modern therapeutic approach to chirurgicalizat: be practical to reduce
bleeding , posterior arthrodesis + fixation .
Treatment myelin TVC :
First aid is very important . Mobilizing the patient from the scene is ,, block\" and
transport against a solid , supine . At the hospital treatment is complex : antibiotic , antiinflammatory , vasculotrop , protein and electrolyte rebalancing and a good local care . Surgery
is performed reduce decompression and internal fixation plates or fixer .
62
IV. pelvic trauma

- Frequency is increasing as a result of car accidents and work.
- Active predominantly affects men .
- High gravity have to meet in the polytrauma and accompanied by shock and mortality of over
10% .
architectural basin
The pool has a morphofunctional structure that would ensure a Statico - dynamic role and
content of the viscera . Basin must be firm , smooth and easy. Presents areas increased
resistance ( middle portion of the hip and sacrum ) and areas low resistance ( obturatory holes ,
holes sacral and iliac wing acetabular bottom ) . Power transmission lines that give strength basin
is done by three trabecular beams systems :
- The sacroiliocotiloidian with an upper beam which continues to support the femoral
head fan opposing compressive forces and a lower beam extended
arciform system of the femoral head , which opposes the forces of
tension.
- The sacroischiatic
- The sacropubian
Pathogenesis
I. Indirect Mechanisms
1. Anterior-posterior compression causing a double fracture hemibazinului Voillemier :
obturatory fracture area ( above ) and sacral fracture ( rear ) ; lateral and posterior segment
rotates externally .
2. Transverse compression , producing double fracture type hemibazin Malgaigne :
fracture zone and fracture obturatory iliac bone (posterior ) . Hemibazin clog the external
segment .
3. vertical compression ( by dropping the pin bone ) fracture resulting in the rise Voillemier
type basin.
4. oblique compression Atypical fractures occur .
5. Violent muscle contractions determining uprooting or epiphyseal offs .
II . Direct mechanisms . Are rare , due to bruises , missiles , etc.
Anatomopathological classification :
A. isolated fractures ( rare ) Ilion , ischium , bins, sacred or coccyx .
B. Fractures of the pelvic girdle (common) :
1. Anterior pelvic fracture arc single sacroiliac sprain + .
2. Double fracture anterior and posterior pelvic arch (common )
3. Anterior arch fracture bilateral sacroiliac sprain + .
4. Fracture and bilateral double ( quadruple ) : rare.
5. Atypical Fractures : cross , comminuted , passing etc.
63
C. articular fractures : acetabular fracture with or without dislocation of the femoral

head . They are produced by the fall of the trochanter or traffic accidents ( injuries ,, board\") .
Acetabular fractures are:
1. Previous fractures ( ilio - pubic column )
2. Transverse fractures ( bottom acetabular )
3. Posterior fractures common:
- acetabular wall fracture with posterior dislocation of the femoral head
- postero - superior fracture ( fracture brow acetabulum )
- fracture ilio - ischial spine complex .
D. disjunctions occur in the symphysis pubis , sacroiliac joint and sacro - coccigiene .
E. Take-offs ( detachments of bone epiphyseal nucleus ) seen in the iliac crest , anteriorsuperior iliac spine and the ischium .
clinical examination
subjective: Functional ipoten total malaise .
objective:
- Inspection - vicious attitude ( shortening + external rotation )
- palpation - compression maneuvers or removal wake iliac crest pain but
should be executed gently.
- general exam - pulse, blood pressure , abdominal exam , rectal or vaginal,
neurological , urological examination .
radiology radiographs made herein profile and oblique incidence ( 3/4) Alar and obturatory .
complications :
Visceral I.
1. Uretrovezicale : Rupture of the posterior urethra or bladder intraperitoneal or
exceptional .
2. vascular : vascular rupture - retroperitoneal hematoma - hypovolemic shock
3. nerve : may be injured sciatic nerve , obturator nerve or ponytail ,,\".
4. Vaginal and uterine
II . osteoarticular
1. vicious callus resulted in lower limb shortening and / or deformation of the basin.
2. Osteoarthritis and sacroiliac osteoarthritis
3. Necrosis of femoral head secondary dislocation
4. chronic sprains of the symphysis pubis or sacroiliac
Treatment is elective . First Aid begins by extracting block ,,\" the patient at the scene.
Transportation is hard stretcher lying down. TREATMENT initial shock addresses .
The treatment of displaced fractures of the pelvic girdle :
1. Sway : pool hammock suspension in 45-60 days followed by functional rehabilitation and
lumbar belt drive .
2. Sway and skull : + hammock suspension continues skeletal extension supracondylar 4560 days followed by functional rehabilitation support being resumed after 3 months.
3. Go skull : continuous extension + contraextensie healthy limb .
64
III . Treatment of fracture of cotiloid cavity:

Without travel : continuous extension 30 days followed by progressive functional recovery
1.
.
2. Shift + dislocation of the femoral head :
a) Transacetabular ( pelvic ) : 45-60 days continuous extension
b) rear : dislocation reduction is carried out in an emergency. For small acetabular
fragments : continuous extension 30 days followed by functional rehabilitation .
For large displaced fragments reduction and internal fixation is required plate and
screws. Postoperatively 30 days bed rest , early functional recovery at 3 months
and heel support .
IV. Treatment pubic disjunction
1. Small Displacements : functional treatment
2. 2-3cm larger displacements : reduction and internal fixation with plate .
V. Treatment of complications :
1. Urology : rupture of the urethra and bladder requires specialized urological treatment .
2. Vascular : intensive resuscitation and surgery for hemostasis .
3. Neurological : the sciatic paralysis is practiced neurolysis or crooked foot arthrodesis sequel .
4. Musculoskeletal : necrosis of the femoral head osteotomy and osteoarthritis practiced or
replacements . For coccigodiniile waste - Physiotherapy treatment , infiltration anesthesia or
resection of the coccyx .
V. FRACTURES upper limb

1. Fractures of the shoulder girdle
1.a. Fracture of clavicle
incidence : 11% , thereby ranking the second in the economy fractures .
Favorable conditions :
- superficial position of the clavicle
- role ,, buffer\" between limb and trunk
The mechanism frequently is indirect. Fall on the shoulder or hand lead to greater curvatures
collarbone ( in ,, S\" italic ) , causing fracture . The mechanism is less direct .
Clinical forms:
I. Fracture 1/3 External : rare direct mechanism is more frequent .
a) Without travel : fracture path is through the ligaments coracoclaviculare .
b) Displacement : path is outside ligaments coracoclaviculare ; deformation occurs in step
scale ,, \" and reveals the existence sign ,, piano keys \" .
Treatment: compressive bandage as luxation acromio - collarbone , Type Robert - Jones.
II . Fracture 1/3 internal : is rare. Movements are variable depending on the position on the
sternocleidomastoid muscle (SCM )
65
III . Fracture 1/3 average is common. The course may be transverse , oblique - short or long .
The focus may be unique or comminution . The fragment can be single or comminution .
Intermediate fragment can be determined by tilting vascular injuries - nerve .
Movements encountered :
- nouse cranial fragment ( the action SCM)
- External caudal fragment ( deltoid and pectoral muscle in action )
Inspection:
- antalgic position ( ,, humble\" the patient's forearm held at 90 )
- shoulder down
- deformation region
- ecchymosis late
palpation :
- Fixed pain
- abnormal mobility
- bone crepitation
evolution : consolidation in 3-4 weeks. It is permissible shortening less than 1.5 cm .
Treatment: First aid consists of immobilizing the scarf or bandage Desault .
I. orthopedic :
a) Fracture without displacement :
- Bandage Desault
- Desault plaster - Gerdy
The duration of immobilization :
- child 7 -14 days
- Adults : 21 days
b) open fracture
1. Reduction orthopedic :
- shoulder thrust upward , backward, outward
- contraextensie knee between the shoulder blades
2. Immobilization
- cross- dressing ,, 8\" ( Watson -Jones ) - 21 to 28 days
- Desault plaster - Gerdy
- Couteau method : the polytrauma and bran
II . surgical :
indications:
- complicated fracture
- irreducible fractures
- shortening greater than 1.5 cm with large angular
Methods:
- cerclage wire in long oblique fractures
- Kirschner spindle screw or plate transverse and short oblique fractures
Immobilization :
- Desault bandage 14-21 zile
Postoperative complications :
66
pseudarthrosis
suppuration
adherent scars
complications :
I. Immediate
- open fracture
- vascular lesions : direct, indirect
- visceral lesions : pleural dome impaired
II . tardive
- vicious callus
- nonunion
- osteitis
- joint stiffness scapular- humeral periarthritis leading to
1.b. Fracture of scapula

Frequency is smaller than 1%.
Mechanism of production :
- direct : the polytrauma (common)
- indirectly: by violent muscle contractions (rare)
Clinical forms :
A. Fracture body
Traiect : horizontal , vertical displacement with or without
Clinic: swelling, bruising, pain , partial functional ipoten
evolution : towards consolidation in 30 - 60 days
Treatment: immobilization device Desault 10-20 days
complications : rare ( pseudartoz , vicious callus )
B. Fracture angles
- internal angle or lower ( rare ) . Treatment consists of immobilization device Desault 10-15
days.
- external angle :
a) Cervical fracture anatomically .
- This is intraarticular fractures with the possibility of association with
glenoid .
- The result of this combination is the scapular- humeral recurrent
dislocation .
- Consolidation is early .
- Treatment consists of device Desault 10-14 days.
- Evolution : to scapulohumeral periarthritis ( PSH ) , scapulohumeral
arthrosis .
67
b) Cervical Fracture Surgery

1. Fractures without displacement :
- Progress toward consolidation
- Treatment consists of device Desault 10 days
2. Displaced fractures :
- Deformation ,, the epaulet \" shoulder requires differential diagnosis of scapular- humeral
dislocation where we mobilize passive shoulder , unable lifting arm and lifting arm
disappearance subacromial scorer .
- Concomitant displacement arm movements coracoid is a pathognomonic sign .
- Evolution is favorable towards consolidation in 1-2 months
- Brachial plexus injuries are complications , circumflex nerve and axillary vessels .
- Treatment : reducing travel by traction arm in abduction 80 , 40 anteducie with the elbow
flexed 90 . Immobilization in a cast thoraco- brachial 4-5 weeks .
C. Fractures apofizare
Are rare , directly or shock caused by muscle contractions .
1. Fracture of the coracoid is characterized by pain , abnormal mobility and crepitation
bone .
2. Fracture of the acromion :
symptoms:
- pain on palpation and arm movements
- tumefaction
- ipoten functional shoulder .
For positive diagnosis is performed radiographs in two planes , face and profile .
evolution : consolidation in 30-45 days may be for PSH
Treatment:
- Orthopedic : 14-21 days Desault device
- Surgery : rare
2. Fracture of humerus
2.A Fracture of the proximal
limits proximal end of the humerus are interleaved scapulohumeral joint and the lower
edge of the great pectoral insertion . Fractures are common in the elderly and women.
The mechanism : direct (rarely ) by direct blows , indirect (common) falls or torsion .
Classification anatomopathological
1. Humeral head fracture patchy : rare
2. Anatomical cervical fracture ( subcapitata ) :
Classification: - Without traveling
- with inferiority deplasare- overturning 180
- expulsion ( fracture - dislocation )
symptoms: swelling, pain , bruising and functional ipoten
68
Developments is towards consolidation in 3-4 weeks

Treatment:
- First aid consists of immobilization bandage scarf or provisional
- orthopedic treatment is done Desault or scarf bandage for two weeks.
- Surgical treatment consists of osteosynthesis or prosthesis Neer .
3. Fracture of trohiter : rare
Mechanism of production : by ,, pull \" caused by rotator muscle contracture (
supraspinatus , subspinos , small round ) .
The fracture may be associated with cervical fracture dislocation scapulohumeral or
surgery.
Symptoms: subacromiale pain , limitation of adduction and external rotation .
Developments is towards consolidation
complication PSH is possible
Treatment:
-
the fracture without displacement : machine Desault 10 days

in small fracture displacement : thoraco- brachial plaster in 90 abduction
.
The high fracture displacement : + reduction transacromial bleeding
screw fixing .
4. Fracture of trochin : rare

- Mechanism : subcapular muscle contracture ( internal rotation and abduction ) .
- Can be associated with posterior scapulohumeral luxation
- Treatment: device Desault 10 days
5. Cervical Fracture Surgery (common )
The causes are decreased bone strength at the junction of the upper humeral epiphysis to
metaphysis .
1. Fractures involved :
a) Adduction fractures ( young people ) : open angle cervicodiafizar internal and
posterior .
b) Abduction fractures (the elderly ) is open cervicodiafizar external angle and
posterior .
II . Fracture with large displacement : distal fragment is displaced toward the upper and
medial subcoracoidian under the action of the pectoralis and deltoid .
symptoms:
- Fracture without displacement engaged : reduced symptoms
- Displaced fracture , dezangrenat : specific symptoms
- swollen shoulder , globose , immobilized analgesic
- subdeltoidian external depression ( ,, ax blow \" )
69
abduction or adduction arm

brahio - chest bruise Hennequin
pain on palpation at 5-6cm below the acromion
bone crepitation
distance acromio low - epicondilian
functional ipoten
positive diagnosis is on the basis of historical data , clinical and radiological examneului
( front and profile thoracic radiographs ) .
Differential diagnosis :
- bruise or sprain shoulder
- scapulohumeral dislocation
- col scapula fracture
- acromion fracture
evolution, favorable towards consolidation in 3-4 weeks
Treatment: first aid is by immobilization in makeshift bandage .
- fractures without displacement , involved in the movement in the elderly or those with
orthopedic treatment practiced by immobilization bandage Desault or scarf for two weeks .
- The fractures involved , the young ( with angulation \u003e 20 to 30 ) , is practiced in
immobilization bandage Desault with axillary pelota ( when the mechanism is abduction ) or
elbow in abduction ( when the mechanism is in adduction ) .
- In displaced fractures , dezangrenate :
a) Orthopedic : reduction orthopedic extemporaneous ( Bhler maneuver ) or continuous (
plaster of hanging Caldwell )
Conditions for success :
- sufficient traction ( 1-2kg )
- making the unit suitable plaster
- radiological control
- patient to take as much time standing or seated position
Disadvantages:
- joint stiffness
- distension capsuloligamentar scapular- humeral can determinasubluxaii
b ) Surgical :
- Screw osteosynthesis plate T , clips , brooches or intramedullary osteosynthesis with cluster
beam rods brooches or Rush ( process Hakental )
- Humeral head resection arthroplasty prosthesis and cephalic NEER
complications
I. Early :
-
open fracture
axillary lesions package
circumflex nerve injury
interposition fragmentary
stiffness of the shoulder joint

PSH
II . tardive :
70
vicious calluses
nonunion
Aseptic necrosis of the humeral head
6. Taking Off epiphyseal : rare in children and adolescents may be associated with fractures . In
cases without traveling , treatment consists of immobilization for 7 days . Where displacement is
practiced orthopedic fracture reduction and immobilization for 14 days or can practice surgical
treatment , which consists of Kirschner wires osteosynthesis type .
7. Fracture - dislocation of the femoral head :

- frequent in the elderly
- mechanism : intense trauma - dislocation - fracture
- differential diagnosis is made with simple dislocation
- Clinical : - low swelling
- Arm in abduction
- Bone crepitation
- Relative functional impotence
- radiology diagnosed certainty
Treatment:
1. orthopedic : dislocation reduction (\u003c 48 hours), Immobilization device Desault 3-4
weeks
2. surgical : - Reduction and internal fixation with screws or clips
- head resection and prosthesis type NEER
2.B. Humeral shaft fracture

The boundaries of the region : from the lower edge of the great pectoral insertion to 4 sides of
finger above the elbow
Frequency: fracture is more common in adults and less common in children ( obstetrical fracture
)
Mechanism : - direct (rare) , comminuted fractures open
- indirectly (common) or torsional failure
pathologist :
- The most common location is the headquarters of 1/3 average
- paths : transverse or short oblique , more common in the upper third and
long oblique ( or spiroid ) more common in 1/ 2 below .
- Travel: upper fragment moves above and abduction ( deltoid muscle and
the action of scapulohumeral ) lower fragment remains vertical and
internal rotation .
It produces angular low back off and overlapping fragments .
symptoms: functional impotence , swelling, change the normal axis of the arm , bruising,
shortening the distance acromio - epicondiliene . On palpation pain and spontaneous
mobilization, crepitation . On physical examination there is radial nerve condition .
71
Radiological examination : Face and profile is achieved .

evolution : towards consolidation in 6-8 weeks.
Treatment: First aid consists of immobilization with splints, scarf or Desault device .
1. Orthopedic - extemporaneous reduction followed by immobilization in a cast
toracobrahial with arm : abduction 60 , 30 and anteducie elbow flexed 90 . Duration asset is
3-8 weeks.
- Plaster of hanging Caldwell for 21 days or for 21 days Desault
device .
2. Surgical . Indications are irreducible fractures , orthopedic treatment failure and
treatment of complications . Is the reduction and internal fixation with plate compactors screwed
or bolted transverse fractures oblique fractures or spiroide . Postoperative immobilization is 3-4
weeks.
complications :
1. Early :
- open fracture
- vascular lesions
- nerve damage : the radial nerve is affected primary or secondary
2. Tardive :
- consolidation delays
- nonunion
- chronic osteitis Fistulising
- callus vicious tolerate 3cm shortening and angulation of 30 .
- Radial nerve injury late .
2.c. Fracture of distal humerus ( humerus )
The boundaries of the region : an area of 4 sides of the finger above the elbow to elbow
interlining .
The mechanism :
- direct (rarely ) by direct blow or fall with the elbow hiperflexie
- indirectly (common) by hyperextension . This mechanism causes fracture
dislocation in children and adults.
1. supracondylar fracture
2. fracture intercondilian
3. fracture epitrohlee
4. external condyle fracture
5. rare fractures : internal condyle , epicondyle , capital , bicondilian , etc.
A. supracondylar fracture
Pathological classification :
a. The mechanism is based on :
72
1. hyperextension fracture : mechanism is indirect ( falling on hand with the elbow

extended ) coronoid push fracturnd humeral trochlea and moves back palette .
The course is obliquely upward and dinainte- back .
2. fracture hiperflexie : mechanism is direct ( dropping the elbow flexed ) ,
olecranon fractures trochlea , moving above humerus . The course is oblique from
top to bottom and back before .
b . After moving fragments :

1. Antero -posterior ( sagittal ) - in hiperflexie
- in hyperextension
2. Side ( transverse plane ) : - valgus
- varum
3. Translation : lateral
4. Offset : around a vertical axis by twisting
5. Ascension : by overlapping fragments
Often they are combined.
Symptoms:
On inspection : - tumefaction
- linear bruise Kirmisson
- movement olecranon
- shortening the distance acromio - epicondilian
On palpation : - pain
- normal bone points ( nelaton 's triangle )
- reducible strain ( Cooper 's sign )
- radial pulse is investigated
- it is found the sensitivity and mobility of the fingers
Radiology : is performed face and profile radiographs .
Developments is good for building
functional prognosis is reserved
Treatment:
1. Orthopedic . Is carried out within 24 hours.
a. Reducing extemporaneous :
- elbow flexion and supination 90 (to go valgus ) or pronation (to go in
varus ) .
- Contraextensie the armpit by sheet or webbing
- Strong wheel shaft
- Pushing the distal fragment : anterior and posterior fractures in
hyperextension fractures by hiperflexie .
Immobilization is performed brahio - palmar plaster elbow at 90 for 4-6 weeks.
b. Reducing the continuous extension :
- transosseous children
73
with a cast of hanging type elders Caldwell
2. Surgical
Indications: - orthopedic treatment failure
- complications
The approach can be transtricipital , transolecranian or transcutaneous . Osteosynthesis materials
used are : Drawings Kirschner , screws and plates .
complications :
1. Immediate:
a. firebox opening
b. Nerve : radial nerve damage , median cubital
c. Vascular : humeral artery injury
2. Secondary:
a. infection after open fractures or operated
b. Volkman ischemia
3. Tardive :
a. callus vicious resulting gap may cause functional impairment in children can be
improved by increasing or may persist in adults , treatment consisting of corrective osteotomy .
Varus or Valguma result can cause cubital nerve elongation treatment is all corrective osteotomy
.
B. Fracture over and intercondilian
The fracture is more common in adults.
Pathology :
- fracture trajectory may take the form of letters T , Y , V .
- movement is important: shaft acts as a wedge dislocation intercondilian
producing fragments
symptoms is nonspecific : swelling, deformity , crepitation , abnormal mobility .
Treatment is made as early as possible and consists of:
- perfect reduction
- solid contention
- early recovery
a) orthopedic :
- extemporaneous reduction
- continuous reduction by extension transosseous traction zenith , followed by the
establishment of a plaster brahio - circular palmar 40 days
- plaster of hanging ( old )
b ) surgical :
- transtricipital or posterior approach transolecranian
- summary screws triangle , brooches, plates
Postoperative immobilization : 7-14 days and early recovery .
C. Fracture of epitrohlee
Extraarticul the trajectory is a vertical fracture .
74
The mechanism : is to pull through :

- internal collateral ligament strain ( pronounced valgus )
- violent contraction of the muscles epitrohleeni
1. The fracture without displacement or small displacement
Symptoms: pain , swelling , irritation cubital (sometimes )
Treatment: posterior plaster splint immobilization of 2-3 weeks at 90 elbow with the
forearm in pronation .
2. Fracture displacement sea:
Fragments can move into the joint ( between Troha and sigmoid cavity of the olecranon )
.
symptoms: Flexo - extension and supination blocking , increased valgus lateralitii with
irreducible dislocation of the elbow .
treatment:
a) Orthopedic : Extemporaneous reduction achieved by abduction + supination + extension ,
leading to the expulsion of the hinge fragment . Follow flexion to 90 and immobilization of 2-3
weeks.
b ) Surgical :
- Indications are previous treatment failure and cubital nerve injury .
- Methods: - removal ( small excerpt )
- osteosynthesis ( large fragment ) screw wire .
- exploration and practice is needed, cubital nerve transposition earlier .
- 2-3 weeks immobilization .
D. external condyle fracture
It is produced by indirect mechanism : olecranon hits trochlea or cupuoara radial column
head humeral heads turn .
The course is oblique to the trench trohleean displacement of the low back .
Is uncharacteristic symptoms . Correct diagnosis is made by radiographs front profile and
semi - profile .
Treatment:
a) fracture without displacement : plaster 4 weeks
b ) fracture displacement : - orthopedic reduction in elbow flexion + varus emphasized
- pressing fragment . Alabaster 6 weeks
- surgical treatment : screws , brooches .
75
3. forearm fractures
3.A. FRACTURE of the proximal ulna
a. olecranon fracture
It is most common in adults.
Mechanism of production : - Directly (via blow to the elbow )
- Indirectly (through fall on the elbow flexed )
By location:
- At the base or body olecranon (which are intra-articular fractures ) . - At the tip ( this is extradisplacement being given by the triceps muscle contraction inserted at this level )
After moving there :
- Incomplete fracture , rare
- Complete fractures , common
They may be without movement or displacement . The causes of displacement can be
contractions triceps , which determines ascension fragment , breaking complex capsulo ligamnetar and intraarticular effusion of blood .
symptoms:
- Without traveling : unspecific (pain, functional impotence elbow ) .
- Displacement : inspection (attitude , deformity , ecchymosis ) palpation ( sore point , ditch
interfragmentar ) .
Correct diagnosis is put front and profile radiographs .
differential diagnosis is the lack of bone ossification nucleus of the child and the olecranon
beak ,, patella cubits\" ( sesamoid cubital ) .
Treatment:
- Incomplete fractures , fractures with minimal displacement and fracture without displacement
complete treatment consists of plaster brahio - palmar ( elbow 90 ) for 3-4 weeks.
- Practiced in displaced fractures fixation . This can be : hemicerclaj wire ( framing ) hobanaj or
screw.
Conditions for success they are:
- Anatomic reduction of the fracture
- Compaction interfragmentar
- Restoring device fibrous tendon and ligament
- Postoperative immobilization in brahio - palmar splint for 1-3 weeks , continuing with an early
recovery .
I am against passive movements , massage , local heat can cause local congestion and
ossification paraarticulare .
evolution : favorable under appropriate treatment.
complications :
1. Early : - Open fractures require surgical treatment
- Vascular and nerve injury requires surgery
- Associated injuries , coronoid fracture and dislocation of the elbow
76
2. Tardive : - Post-traumatic osteoarthritis

- nonunion
b ) coronoid process fracture
Frequency: is rare.
The mechanism is indirectly through:
- Hyperextension ( coronoid tip is ripped muscle brachial )
- Hiperflexie ( humeral trochlea coronoid fractures based )
symptoms :
1. simple fractures :
- swelling , bruising
- emphasizing abduction arm ( biceps action date )
- limitation of elbow flexion (given by the interposition joint )
- pain on palpation in the plica elbow
2. fractures associated symptomatology is richer and more difficult diagnosis .
Correct diagnosis is determined using X-rays of face and profile .
differential diagnosis brachial osteoma is made previously.
Developments is favorable under treatment
Treatment:
1. In fractures without displacement immobilization in a cast - palmar brahio 90
elbow for two weeks .
2. In displaced fractures can perform orthopedic or surgical treatment . Orthopedic
treatment consists of: digital pressure reducing forearm supination and elbow immobilization for
4 weeks at 90 . The surgical treatment consists of osteosynthesis , which can be achieved by
Kirschner pin , wire or screw. Indications are that there is a large fragment , irreducible and
associated dislocation . In interpoziiile practiced articular fragment removal issue.
complications :
-
Paraarticulare osteomas ( brachial earlier) , requiring surgical treatment

Vicious calluses leading to flexion limitation , requiring surgery.
Nerve damage ( median cubital ) , requiring surgical treatment
77
3.B. RADIUS FRACTURE proximal end

a. Fracture of radial cupuoar :
Frequency: higher in adults and less for children.
The mechanism : direct and indirect rarely more frequently ( dropping hand with the elbow
extended and the forearm in abduction ) .
- incomplete fractures
- fractures lots
- comminuted fractures
symptoms:
- fractures without displacement relative encounter pain and functional
ipoten .
- in displaced fractures , the inspection we find : swelling, bruising,
ipoten specific functional in supination ( flexion and extension are kept
) . On palpation discern : integrity palette, pain on palpation end and
radial bone crepitation .
Correct diagnosis is set using the front and profile radiographs .
Treatment:
1. In fractures without displacement treatment consists of gypsum brahio - palmar splint for 3
weeks .
2. In displaced fractures Surgical treatment is practiced :
- For fragments less than 1/3 cupuoara practice radial removal of the fragments.
- For larger fragments 1/3 of cupuoar : the child practiced or screw osteosynthesis
(removal is proscribed because it can cause elbow in valgus deviation ) ; adult can practice or
screw osteosynthesis ( results are weaker due to the emergence vicious callus and secondary
osteoarthritis ) . We may use the radial head resection ( preferable with good functional results ),
followed by postoperative immobilization 10 days after starting the recovery . Intraoperative risk
is deep branch of radial nerve injury .
complications
1. Post- fixation : - arthrosis radio - cubital
- synostosis radio - cubital
2.Post- resection : - elbow valgus deviation
- cubital nerve elongation
- Rising radial bone
b . al radial fracture
Frequency: fracture is more common in children between 8-12 years
Mechanism of production : identical to the fracture of cupuoar .
evolution : cubitus valgus without treatment can occur due to disturbance of growth cartilage .
78
Treatment:
orthopedic , palmar plaster splint - brahio 3-4 weeks
surgical , discount + brooch summary Kirschner
3.C. Isolated diaphyseal fractures forearm bone
a. The fracture of radius

The mechanism : can be direct, indirect fractures and fractures transverse or oblique
spiroide ( by pronation and torsion ).
Location: is commonly seen in level 1/3 medium and lower and less at level 1/3 higher .
symptoms: is reduced ( swelling, pain , crepitation , functional impotence ) .
Correct diagnosis is placed on the face and profile radiographs which must necessarily
include the elbow and wrist joints .
Treatment:
- Fractures without displacement plaster immobilization is performed brahio - palmar for 6
weeks .
- In stable displaced fractures ( cross ) is practiced reduction and cast immobilisation for 6-8
weeks. Failure determines surgery.
- In unstable displaced fractures ( oblique spiroide , comminuted ) is practical to reduce
bleeding , screw osteosynthesis plate or rod Rush cast immobilisation followed by 6-8 weeks.
complications :
1. Early : - Open fracture
- Galeazzi fracture - dislocation
- radial nerve injuries ( fractures 1/3 top )
2. Tardive : - Vicious callus
- Limiting pronosupinaiei
- nonunion
b . The fracture of ulna
It's rare , recognizing the direct mechanism for producing it ( blow , fall) . The
headquarters of choice is one/3 Superior . The movement is generally low consisting of angular
rear .
symptoms is reduced pain, blockage , crepitation bone .
Radiology : face and profile radiographs show us the premises and type of fracture .
Treatment:
- Fractures without displacement was immobilized in a cast - palmar brahio for 4 weeks.
- in displaced fractures practiced reduction and cast immobilisation for 6-8 weeks or surgical
treatment and plate fixation screws, rod Rush . Postoperative immobilization is 6-8 weeks.
complications :
79
-pseudartroza
- Synostosis radio - cubital
c . diaphyseal fractures of both bones of the forearm

Mechanism of production :
- Direct ( blunt body shot )
- Indirectly ( dropping hand twists )
Location: variable
Movements muscle groups are given by :
- supinatorii ( biceps , supinator short ), 1/3 proximal .
- Pronatorii ( pronator round , square pronator ), 1/3 distal .
1. Fracture 1/3 average: The gap is given by supination , pronation and for higher fragment to
fragment below .
2. Fracture of lower 1/3: Displacements are small square pronator muscle that incorporates
fragments . There may travel with angular , overlapping ( ,, aspect of bayonet \" ) .
symptoms:
- fractures without displacement Meet pain , functional ipoten relative , crepitation ,
abnormal mobility ( investigated with caution ) .
- In displaced fractures to meet inspection swelling , shortness , ( Decal ,, bayonet \" ) and on
palpation find interrupting the continuity of bone , abnormal mobility and crepitation bone
outbreak ; functional impotence is total .
Correct diagnosis is determined using X-rays of face and profile that includes the elbow and
wrist .
Developments is towards consolidation in 8-10 weeks.
Treatment , objectives:
1. Restoring curvature radius : - upper = supinatorie
- lower = pronatorie
2. Maintain ratio of length radius / ulna
3. Keeping the antebrachial rotation axis ( between the center of the radial head and center head
cubital ) .
Orthopedic treatment :
- Fractures without displacement or minimum displacement establish brahio - palmar
plaster 6-8 weeks.
- In displaced fractures orthopedic traction is reduced by hand in supination ( for
fractures of the upper 1/3 ) , the intermediate position (location in average 1/3 ) and pronation
(1/3 below ) .
Immobilization in a cast is split brahio - palmar initially maintained for 10-12 weeks ,
with weekly during the first month radiological control .
80
Surgery :
indications thereof are unstable fractures ( oblique spiroide ) and orthopedic treatment
failure found by underwater gypsum .
osteosynthesis is performed with plate and screws on both bone plate and screws radius
and ulna at contramedular rod . Postoperative immobilization for 6-8 weeks followed by
functional recovery .
Prerequisites surgical act are:
- Limiting dilaceration muscle and circulatory disorders
- Removing periosteum limited
- Coaptare and perfect compaction
- Solid mounting ( plate with screws)
- Restoring the curvature radius
- Removing fragments rotation
complications :
- Immediate:
- open fracture
- vascular lesions - sided, light
- Bilateral severe
- Tardive :
- Volkmann syndrome
- nonunion , frequent , can be unilateral or bilateral
Causes:
- in orthopedic treatment :
- interpoziii muscle
- poor vascularity of muscle inserts
- persistence movement fragments
- defective cast immobilisation
- In the surgical treatment :
- indication and technical errors
- postoperative infections
- lack of protective plaster immobilization
- Early removal of osteosynthesis material
- muscle injury and periosteal blood supply to decrease
Diagnosis: deformation , hyperthermia , edema, abnormal movements . Radiographs of front and
profile highlights the lack callus as a clear band between bone fragments fused or atrophic ,
obstructed channel .
Treatment is difficult - fragments fiber finish
- Opening the medullary canal
- Fixing plate and screws
- Spongy grafts
Cast immobilisation is 10-12 weeks.
Vicious calluses : in ,, bayonet \"with angular shift . Treatment consists in correcting
offsetting , and graft fixation .
Synostosis radio - cubital ( encountered when movements occur as fracture fragments
letters K or X). Treatment consists of resection of bone bridge and interosseous membrane .
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3.D. FRACTURES - dislocation of forearm

a. The fracture - dislocation Galeazzi :
It is rare , and is the radius fracture in 1/3 distal and posterior dislocation of the head
cubital lower triangular ligament rupture . Orthopedic treatment is usually ineffective . Surgical
treatment consists in reduction and plate fixation on the radius and ulna dislocation reduction .
b . The fracture - dislocation MONTEGGIA- STNCIULESCU
It is common , consists of ulna fracture and dislocation of the femoral head .
Classification:
1. typical : ulna fracture in average 1/3 proximal posterior open angle ; radial head
is dislocated previous
2. atypical ,, Inverted \" fracture of the proximal ulna in average 1/3 with open angle
above; radial head is dislocated posterior ;
The mechanism is directly by blow ( agresionailor fracture ) or fall.
symptoms:
- To meet deformation inspection of semi-flexible elbow and pronation fixing and cubital
clogging .
- To touch , meet interruption of continuity of bone and anterior migration of the radial head .
positive diagnosis is based on clinical and radiological data . Mandatory is catching on
radiograph of the elbow and wrist ( ,, luxation is everything, there is nothing fracture\") .
differential diagnosis is the posterior dislocation of the elbow.
evolution : child friendly , reserved for adult ( limit Pronoia - supination )
Treatment can be orthopedic, when making traction reduction and re forearm supination
radial cupuoarei . Treatment can be surgical , consisting of the ulna fixation ( rod or plate) ,
reinstatement and fixation of the radial head resection brooch transcondilian or radial head
dislocations irreducible .
complications :
irreducibility radial head
vicious callus ulna
nonunion of ulna
periarticular ossification posttraumatic
radio - cubital synostosis top
stiffness and ankylosis of the elbow
nerve damage ( radial)
postoperative infections
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3.E.1 . FRACTURE OF distal ulna

It is rare. It may encounter styloid fractures , head or neck anatomic cubital . Treatment
consists of cast immobilisation for 2 weeks or resection of the distal ulna fractures of irreducible
.
3.E.2 FRACTURES distal radius
a. intraarticular fractures ( rare )
Pathological classification
- Fractures lots : - radial styloid
- Edge
- Marginal posterior
- Total fractures : appearance fractured fragments may take the form of letters V , Y , T.
Associated fractures may exist supraarticulare and carpal fractures
positive diagnosis is made based on anamnesis , clinical and radiological .
Treatment is the reduction and cast immobilisation 4-6 weeks .
Complications stiffness and ankylosis are encountered punch .
b . Fractures supraarticulare
Are the most common fractures of the human skeleton .
Classification:
1. Colles fracture type POUTEAU2. Fracture type GOYRAND- SMITH
1. Colles fracture type POUTEAUmechanism is indirectly by dropping the palm of your hand crank hyperextension or
kickback ( ,, fracture drivers\") .
Pathology : normally in the frontal plane , the angle between the articular surfaces of
radius and ulna ( bistiloidian line ) and horizontal is 30 . In the sagittal plane , the angle
between the horizontal and radial articular surface is normally above 10 open .
Travel :
1. Posterior ( about an axis transverse , sagittal ) ,, look inside the fork\"
2. proximal fragment penetration and engagement .
3. Lateral ( about an axis transverse sagittal plane ) , cubital deviation , ,, bayonet \" hand .
symptoms:
- At inspection : bruising and deformation in the back of fork ,, \" and ,, bayonet \" .
- On palpation : radial styloid and leveling ascension bistiloidiene line .
evolution : to strengthen early but with frequent functional sequelae
Treatment:
A. Orthopedic : are factors that influence the extent offsetting reduction ( in foreground
) and leveling ( sagittal ) lower radial surface . The existence of posterior cortical fragments is a
factor of instability.
83
Closed reduction is carried out under local anesthesia ( 1% lidocaine ) . The technique is
as follows:
- Is achieved by means of a strap contraextensia wall
- An extension done thumb ( the axis of the forearm ) and fingers II , III , IV . ( In the sense
cubital ) .
- Orthopedist performed by pressing disengagement digital and palmar and dorsal flexion
movements in the outbreak .
Plaster splint immobilization is achieved with wide , palm anterobrahio - circular plaster
or split.
Correct immobilization conditions are:
- Thin lining ( gauze )
- Bottom: to the metacarpal flexion crease - falangian
- Top: below the elbow or up above the elbow joint damage radiocubitale lower diaphyseal
fractures and fractures associated with unstable oblique .
- Duration of immobilization : - fracture without displacement or small displacement : 4 weeks
- Displaced fracture average : 5 weeks
- High fracture displacement , comminuting : 6 weeks
- Control of the reduction of X-ray : 24 hours , 7, 14 , 21 days
B. Surgical .
Indications are comminuted fractures redeplasrile under plaster and unstable . Perform
osteosynthesis , screws , plate with screws or external fixation .
complications :
1. Osteoporosis immobilization
2. joint stiffness
3. vicious callus
4. Nonunion
5. Osteoarthritis radiocarpian
6. Carpal Tunnel Syndrome
2. Fracture type GOYRAND- SMITH

It has a mechanism of indirect production falls on the back of hands ( hand in hiperflexie
) . Deformation in the sagittal plane is opposite to that encountered POUTEAU- Colles fracture ,
causing previously. Diagnosis , treatment and complications are similar fracture described above.
4. Fractures of the carpal

4.A. Fractures of the carpal scaphoid
The mechanism : fall hand in hyperextension occurs more frequently medium fracture
zone , which is less vascularized .
84
Pathology : scaphoid vasculature characteristic is that the lower is better vascularized

girl of the middle and upper .
Vascular pedicles are moving towards the dorsal side . The consequences are avascular
necrosis , more common in the proximal pole scaphoid . Dorsal approach is contraindicated due
to the risk of vascular injury .
Fracture path : Horizontal ( minimum shear forces focus) , vertical ( maximum shear
forces in focus) . So the risk of nonunion is all the greater as the path is closer to vertical .
The seat of fracture :
- in the proximal ( risk of nonunion is higher )
- in the distal ( nonunion risk is lower ) .
Bone necrosis are common and usually lead to osteoarthritis . Associated lesions worsen
prognosis.
Symptoms nonspecific : neck pain and limitation of motion of the hand.
The inspection edema and swelling meet .
On palpation , pain in cigarette anatomical feature .
Radiology : is necessary to perform face and profile radiographs of the wrist and an
oblique radiograph ,, writing position\". Repeat radiographs at an interval of 15 + 20 days,
because cracks may become visible through inapparent bone resorption that occurs during this
time.
Treatment:
a) orthopedic : antebrahiopalmar plaster II + V fingers free but catching the first phalanx of the
thumb ( 8 weeks ) . If you notice radiological control delayed union remains immobilization
another 4 weeks.
b) surgical : indications of treatment are high fracture displacement and dislocation
scafosemilunar . Perform cancellous screw fixation or Kirschner Brooch
complications :
1. Nonunion .
Clinically manifested by pain and limitation of grip strength and wrist mobility .
Radiological are seen clearly interfragmentar space .
Treatment consists of screw fixation and graft foam that may be associated radial styloid
resection .
2. necrosis of the proximal fragment
It also leads to osteoarthritis radiocarpian . Treatment consists of removal of the
proximal fragment ( inconclusive ) or carpal arthrodesis radio .
Metacarpals and phalanges 4. B. Fractures

The mechanism of fracture is directly associated soft tissue injuries ( skin and crushing
delabrri muscle ) .
A. Fractures metacarpals
Pathology . The most common location is diaphy and is spiroid or transverse path .
symptoms:
- Are characteristic pain and limitation of motion in fixed fingers .
85
- The inspection notice deformation and local hematoma

- To touch discern abnormal mobility , crepitation bone , angulation and pain.
Radiology : radiographs of the hand is performed face and profile
Treatment:
1. Orthopedic
- In immobilizing the fracture without traveling is performed on a roll of bandage for 10 days.
- In fracture displacement is achieved by reducing the tensile axis finger and metacarpal direct
pressure on affected
- Immobilization is performed in metal splint splint or plaster ; I phalanx asset position is 30-45
flexion , flexion 90 phalanx II and III phalanx 30-45 flexion .
2. Surgical : practiced in orthopedic treatment failure . It consists of osteosynthesis with
intramedullary Kirschner brooches or plate with screws.
complications
- Early : open fracture injuries vacsulo - nerve , tendon injuries
- Late : ischemia , vicious consolidation
Fracture - dislocation B. Bennett
definition: I metacarpal base fracture is the association with metacarpal dislocation trapezian .
The mechanism is directly represented by the blow with his fist and thumb hidden ( ,,
Boxer's fracture\") .
Pathology . It is an intraarticular fracture fragment by posting a triangular base of
metacarpal I accompanied metacarpal dislocation - trapezian .
Clinic. On inspection we see massive swelling and deformation region. On palpation
discern pain at the base of metacarpal I fixed and abnormal relief at this level. Pulling the police
lead to the disappearance of deformation which reappears at the termination of the maneuver .
Treatment:
1. Orthopedic : Bhler maneuver is performed consisting maximum traction in abduction thumb
pressure on metacarpal I. plaster immobilization is antebrahio - catching palmar proximal
phalanx of thumb for 4-6 weeks.
2. Surgical : indications are orthopedic treatment failure , open fracture and associated injuries .
Perform or plate osteosynthesis .
complication can be seen that due to osteoarthritis pain requiring surgical correction (
arthrodesis ) .
C. Fracture phalanges
We meet :
1. distal epiphyseal fracture (rare) . Plaster treatment for 3 weeks .
2. epiphyseal fracture proximale- edge or trailing edge . Orthopedic or surgical treatment is .
3. diafizelor fracture . Orthopaedic treatment - 3-4 weeks cast immobilisation .
These fractures can be opened when associated tendons and neurovascular injury .
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VI . LOWER LIMB FRACTURES

1. femoral fractures
1.A. Fractures of the proximal femur
A.1. Lots fractures of the femoral head
They are quite rare as frequency. As can be associated lesions coxo - femoral posterior
dislocations . Bone fragment may be:
- Infero - posterior internal or domestic .
- Free movement (rarely ) or displacement (common) .
symptoms is inconclusive , characterized by pain and functional limitation .
Correct diagnosis put using radiological examination .
differential diagnosis is made with : contusion , sprain , hip osteochondritis dissecans (
for higher cephalic fragment ) .
Treatment :
- fractures without displacement consists of bed rest 45 days and 90 days ban support .
- In displaced fractures fragment excision is practiced , whether it is less or fix it if is large with a
screw ,, lost\".
Complications osteoarthritis and may be delayed femoral head aseptic necrosis .
A.2 . Femoral neck fractures
The frequency is relatively high . Exceptionally encountered in children, rare in adults, is
common in the elderly. Girls are affected predominantly especially after menopause.
Background anatomical
Bone structure ( functional) . This bay is the bone that make up a system architecture of
resistance :
- Support system (which is resistant to compressive forces ) consists of fan support ( Delbet ) ,
Adams lug (located below ), and Merkel's lug ( located posterior ) .
- Support system ( voltage withstand forces ) consists of fan support ( Duhamel ) and thickening
Supracervical
- Trochanteric ogival system , located externally. Between trabecular systems there is an area of
low resistance ( trine Ward ) .
Bone resorption occurs between 45-60 years and affects trine Ward fractures often cause
mediocervicale . Bone resorption occurs after 60 years ,, affecting predominantly ogival system
determines pertrohanteriane fractures .
Vascularization
Femoral head vascularity sources are represented by four vascular pedicle from:
1. anterior circumflex
2. posterior circumflex
3. round ligament artery
4. inferior gluteal artery
87
There are two vascular rings extracapsular one another at the base of the neck and the
base intracapsular femoral head . Postero - superior vascular pedicle provides 4/5 of the head and
neck irrigation .
Classifications
A. Anatomical - topographic ( Dalbet )
1. fracture subcapitata
2. fracture mediocervical
3. fracture bazicervical
B. pathogens ( Bhler ) :
1. Adduction fractures : frequency, displacement , neangrenat in coxavara . Treatment is
difficult and the prognosis reserved .
2. Abduction fractures : rare , without traveling , engaged in coxalvalga . Treatment is easier
and more favorable prognosis .
C. Biomechanics ( Pauwels ) depending on the angle of the fracture with the horizontal path :
1. Type I : \u003c 30 ; compacting forces are increased in this case.
2. Type II : 30-50
3. Type III : 50-70 ; disengagement forces are predominantly in this case.
D. pathological and radiological ( Garden)
1. Grade I: incomplete fractures ( fractures abduction )
2. Complete fractures without displacement
3. Grade II: complete fracture with partial displacement
- cortical posteroinferioar is broken arch
- the femoral head is tilted in abduction
- distal fragment is rotated externally
- radiological bone spans horizontal and vertical head , the neck presents a
vaulted arch ( aspect ,, Gothic\") .
4. Grade IV: Complete fractures with total displacement
- synovium and muster pectineo - foveal are broken
- fragments are separated completely
- radiological bone bays are vertical to vertical head and also the cervix ,
which are parallel but offset each other.
symptoms:
- fractures involved , incomplete or is manifested by spontaneous pain on palpation and
functional ipoten relative .
- Neangrenate fractures with displacement presents ipoten subjective pain and total functional .
Objective:
- To discern inspection : lower limb shortening , have external rotation , adduction and Scarpa 's
triangle base bulge .
- To find signs of rising palpation of the greater trochanter . They are objectified using
Schoemaker 's line , Bryant 's triangle , line suprasimfizare (Peter ) .
positive diagnosis is based on anamnestic data , the subjective symptoms , objective
signs and radiological examination .
Radiography consists of front and profile radiographs , study important elements being
the place of departure and comminuted fracture path back .
differential diagnosis is made with :
88
- Simple hip contusion

- Dislocation anteriorsuperior and postero - superior
- Acetabular fracture
evolution : determinants of evolution are path fracture fragments and engagement
mechanism is . Usually strengthens fractures involved in 12 weeks. Fractures dezangrenate have
forecast reserved .
Treatment:
1. Fractures without displacement and engaged ( Garden I, II )
- orthopedic treatment can be dragged to the sick and elderly and consists of bed rest
for 6-8 weeks with support prohibition for 4-5 months.
- Surgical treatment is Wherever possible , realizing ,, security osteosynthesis\" to
allow early mobilization .
2. Displaced fractures ( Garden III , IV ) :
- treatment is surgical . By extension consists in reducing moderate internal rotation
and abduction accompanied by an orthopedic table . There are several types of
osteosynthesis : trilamelar pin ( left ) , parallel screws ( presently preferred ) or
triangulation screws , bolts and impaction plate bunch of brooches . Lately, the
elderly , it is preferred replacement with a prosthetic femoral head cephalic (A.
Moore or bipilar ) .
- Early functional treatment consists of immobilization of patients without further
treatment or surgical orthopedic and addresses elderly patients and bran .
complications :
A. Immediate:
1. Lung disease (pneumonia bronchopneumonia and cardiorespiratory failure )
2. Urinary complications : urinary retention urinary renal failure .
3. Bedsores ( sacral , calcaneal , trochanteric ) septicemia infectious complications
4. Embolic stroke ( thrombophlebitis )
B. Tardive :
1. Femoral head necrosis: Found in about 1/3 of cases
Predisposing factors :
- interception initial trauma or vascular network due to consecutive haemarthrosis
- evasive maneuvers to reduce
- surgical mistakes
Clinic: persistent pain , limp and hip mobility limitation
radiological:
- Alteration of normal appearance ( alternating with hypertransparency bone condensation )
- clogging necrotic area
- osteophytes and joint space pinched appearance (signs of osteoarthritis ) .
Treatment:
- Arthroplasty with cephalic prosthesis ( A. Moore or bipolar type ) or total prosthesis cemented (
in coxarthrosis )
2. nonunion : seen in 1/3 of the cases,
- abnormal vascularity
89
- headquarters and type of fracture

- land ( the elderly and bran )
- treatment mistakes
symptoms:
- pain
- limp
- curtailment
Radiology :
- clear zone interfragmentar
- marginal bone condensation
Treatment:
- intertrochanteric osteotomy of valgizare ( Pauwels )
- cephalic or total arthroplasty prosthesis
A. 3. Solid trochanteric fracture
a. The fracture of the greater trochanter is rare
The mechanism is :
- directly ( especially common in the elderly, consisting of fall on the hip )
- Indirect ( especially common in young muscle contraction pelvitrohanterieni ) .
symptoms:
- Leg in internal rotation and abduction
- Rise trochanter
- Total functional ipoten ( external rotation and abduction impossibility of ) .
Treatment:
- Fractures without displacement practiced 3-4 weeks immobilisation .
- For displaced fractures can be practiced : orthopedic treatment ( plaster pelvipodal in
abduction , flexion and external rotation for 4-6 weeks) surgery ( screw fixation or removal of
bulky pieces for small fragments ) .
b . the small trochanter fractures
The mechanism is indirectly through violent contraction of the muscle psoas - iliac .
symptoms is manifested by functional ipoten Relative unable thigh flexion in sitting
position ( Ludloff 's sign ) .
Treatment is orthopedic , consisting of bed rest for 3 weeks in flexion and internal
rotation position of the limb .
c . Fractures pertrohanteriene
There are frequent , with a maximum incidence in women after menopause, osteoporosis
appears .
The mechanism directly , by dropping the hip .
Pathological classifieds , Evans
1. stable fractures ( two pieces )
- cervico- trochanteric
- pertrohanteriene ( fracture path is from the small trochanter digital fossa )
2. unstable fractures :
90
pertrohanteriene complex (3-4 pieces )

intertrochanteric ( fracture path is transverse circumferential spiroid extended to
diaphyseal ) .
II . Decoulx and Lavardi
symptoms manifested by localized pain and subjective functional ipoten hip .
Objective: to discern inspection swelling, shortening and external rotation of the lower
leg. On palpation stands pain and hard prominence under the skin .
Treatment is exceptional orthopedic elderly patients and bran . It consists of extension
continued for 45-60 days.
The treatment of choice is surgery. Fixation can be achieved :
- Nail - plate Neufeld ,
- Compacting plate screw (DHS ) in young
- Ender type elastic rods ( intramedullary osteosynthesis ) in the elderly.
Advantages Ender fixation type are:
- Minimal incision , closed hearth , bleeding small , short duration of the operation, resume
support and early walking.
The disadvantages of this method are :
- Varus outbreak proximal or distal stem migration .
Complications are:
- Reinforcing vicious coxa - summer , with shorter leg .
1.B FRACTURE femoral shaft

limits region are: a horizontal line passing under the small trochanter and a horizontal
line 6 cm proximal to the knee joint .
Classification anatomopathological recognizes fractures :
- 1/3 proximal ( subtrochanteric )
- 1/ 3 average
- 1/3 distal
The last two are considered diaphyseal fractures themselves.
A. subtrochanteric fractures
The mechanism directly , through the fall and indirectly through violent twist .
Classification of pathological ( Seinsheimer )
1. unstable fractures ( 2 pieces )
- with cross paths
- with oblique trajectory ( down and inside)
2. Unstable Fractures
- the trajectory obliquely downwards and outwards (2 pieces )
- complex fracture fragments 3-5
Moving fragments :
1. moving the proximal fragment :
- in abduction ( under the action of small and medium gluteal )
- in external rotation ( large buttocks and psoas )
- flexion ( psoas - iliac )
91
2. moving the distal fragment :

- ascent
- adduction , both under the action hamstrings
It produces an angulation with antero- external convexity ( in ,, pistol grip '')
symptoms:
Subjective patient complain of pain in the proximal 1/3 and total functional ipoten .
Objective inspection notice deformation with shortening and external rotation . The probe tip
discern the fragment fractured bone under the skin , bone crepitation , abnormal mobility .
Correct diagnosis put radiographs using the front and profile .
Treatment is surgically using:
- nail plate
- Gamma nail
- DHS screw - plate
- Kntscher rod (+/- cerclage wire )
- Ender elastic rods ( arc secant )
Complications are immediate ( open fracture and neurovascular lesions ) or late (
nonunion and vicious calluses ) .
B. diaphyseal fractures themselves
The mechanism is :
- Direct , transverse and short oblique fractures
- Indirect , long oblique fractures or spiroide .
Fractures can be:
- 2 pieces
- 3 pieces ( an internal fragment ,, butterfly\")
- comminuted
there may be associated with significant damage to soft tissues and massive hemorrhage
symptoms
Subjectively , the patient complain of pain and total functional ipoten . Objectively, the
inspection discern external deformation and shortening convexity thigh with external rotation .
On palpation highlights abnormal mobility , crepitus bone and possible puncture of the
quadriceps . It investigates peripheral pulse , sensitivity and motility away.
Over 24 hours can detect the existence of effusion in the knee . Correct diagnosis is put
by means of face and profile radiographs .
treatment
1. Orthopedic . It comminuted fractures practice and when contraindicate surgery. It
consists of continuous extension for 4 weeks followed by plaster or femuropedios pelvipedios
high for 2 months.
2. Surgical . The treatment of choice . Fixation can be achieved :
- Intramedullary rod Kntscher open or closed hearth ( transverse or short oblique fractures in
1/3 proximal or average).
- Ender rods arc secant elastic type ( comminuted fractures in polytrauma and bran ) .
- Plate and screws ( for fractures of the lower 1/3 ) .
complications
1. Immediate:
92
a. local
-
neurovascular
open fracture
hemorrhagic shock
embolism Gras
b . General
2. Tardive :
a. knee stiffness
b. vicious callus ( tolerance to a shortening of 3 cm )
c. delayed union
d. septic complications
- latest :
- infected hematoma , superficial or deep
- Late :
- posttraumatic osteitis
- septic nonunion
1.C. Fracture of the distal femur
a. Fracture of the femoral condyles
Intra-articular fractures with functional prognosis are reserved . The mechanism is
indirect , falls on foot varus or valgus in the leg , causing fractures unicondiliene .
Intercondilian fossa fracture path is to the edge of supracondylar shaft . It produces ascension
deviation condyle with Valguma or varum . The mechanism may be direct , by falling on his
knees , when there are fractures unite or bicondiliene ( fracture path in the shape of the letters V
or T) .
Symptoms and treatment
in fracture without displacement subjective patient complain of pain , functional and
objective discern ipoten hemarthrosis . Treatment consists of immobilization in a cast for 6
weeks femuropodal banned support 3 months.
in displaced fractures unicondiliene Meet pain and functional ipoten subjective and
objective inspection partial swelling is present , varus or valgus deviation in and external rotation
. On palpation is objectified patellar shock , laterality of the knee movements , abnormal mobility
and crepitation . Treatment is surgical and orthopedic .
Orthopedic treatment consists of reduction ( bias corrected by direct pressure ) ,
immobilization in a cast for 6 podal femoral- week ban for 3 months support . Surgical reduction
and internal fixation is practiced with screws ..
in displaced fractures bicondiliene Meet subjective pain, functional ipoten total .
Objective inspection notice swelling massive limb shortening , varus or valgus deviation shank
and external rotation . On palpation meet patellar shock present outbreak abnormal mobility ,
crepitation .
It investigates the Pedi and posterior tibial pulse due popliteal artery injury risk in this
type of fracture . Radiological examination of front and profile is required.
93
Orthopedic treatment leads to knee stiffness and vicious calluses and is not used currently
.
Surgical treatment is to restore the articular surfaces thoroughly , fixation practicing the
blade - plate, nail - plate or plates with screws.
b . supracondylar fractures
Extraarticular fractures are sometimes secondary intraarticular opening up . The
mechanism is rarely directly . Indirect fractures occur through failure and torsion standing strong
.
Anatomico-pathological
The fracture is oblique upper and lower anterior and posterior . Moving the proximal
fragment is earlier and the distal is superior ( under the action of muscles ischio - Gambier ) and
rear ( under the action of muscles twins ) .
Lesions are:
- subcvad bag bottom damagericipital , making articular fracture . It produces a
double transfer : synovial fluid to the fracture , leading to delays in consolidation
and joint fracture hematoma causing haemarthrosis and joint stiffness .
- Injury to the popliteal neurovascular package ( compression, puncture , total rupture
) . Required pulse shape and sensitivity will distal limb and immobilization will be
flexed knee ( thus ensuring reduction in muscle relaxation tilt posterior inferior
fragment ) .
symptoms
Subjective patient complain of pain at level 1/3 lower thigh and knee .
Objectively, the inspection notice globular swollen knee . Viewed from the angle presents
an external tip and viewed in profile shows a deformation ,, bayonet\". On palpation feel the tip
of distal fragment fragment is prohibited palpation , abnormal mobility and crepitus search , with
the risk of major vascular injury . It investigates peripheral pulse , leg and foot sensitivity .
positive diagnosis BCdetermined using X-rays give him front and profile .
Treatment:
1. Orthopedic . In fractures without displacement or when surgery is contraindicated
establish immobilization the pelvic plaster - podal 6-8 weeks , with support ban for 3 months. In
displaced fractures , surgical contraindicated , is practice continuous extension plaster 3-4 weeks
followed by femoral- plantar 3-6 weeks , with support prohibition 3 months.
2. Surgical , practiced reduction and internal fixation with screws Pavement blade - plate
and screws, or rods elastic Ender ( arc secant ) .
complications :
1. Immediate - open fracture
- Sciatic nerve injury
- Popliteal artery injury
2. Tardive - knee stiffness
- Delayed union
- nonunion
- Septic complications
- Vicious callus
94
- Shortness of posttraumatic
2. patella fracture
production mechanism directly ( by dropping the knee ) or indirectly (through forced
flexion of the knee ) .
pathology
1. the fractureMost frequently , it is transverseLocated in any of thirds kneecap. Displacement
factors are:
a. Diastazisul intrefragmentar primary ( trauma , patient lifting ) or secondary (
hemarthrosis voluminous quadriceps contraction leading to higher tipping fragment ) .
b . Damage to the extensor apparatus kneecap , prerotuliene portion of the patella fins ,
leading to travel more than 1 cm.
c . interposition of fibrous fringes prepatellar at interfragmentar , leading to delayed
union .
2. the fracture can be vertical ( sagittal ) Without moving slowly.
3. comminuted fractures , by directly presenting and injury mechanism tegumnetare .
4. Fractures lots
symptoms
The pain and fractures without displacement have ipoten in displaced fractures relative
functional . Meet subjective pain and limiting knee function ipoten active extension .
Objectively, inspection, discern swelling with bruising, palpation , depression find cross ( ,, mark
pen\" = pathognomonic sign ) .
differential diagnosis is made with :
1. patella two-party ( regular edged fragments fused with a specific office , bilateral) .
2. osteochondritis dissecans of the patella ( simptomatologia is reduced and minimal or
no trauma ) .
Treatment
In fractures without displacement , treatment is orthopedic immobilization in a cast
femoral - ankle for 3-4 weeks.
In displaced fractures is surgical treatment .
1. cerclage is rarely used .
2. Hobanajul : Major indications are transverse fractures in 1/3 average. Provides transformation
tension forces in compaction forces . The conditions for success are joint resurfacing , rotuliene
fins .
Post-operative immobilization is minimal , 2-3 weeks. Recovery is early and sustained .
3. Patelectomia can be partial or complete , accompanied by restoration of extensor apparatus .
The indications are fractures of the lower pole( Patelectomie partial) and comminuted fractures
when making the total patelectomie . We practice three weeks in plaster immobilization of
femoral- ankle , followed by the recovering knee mobility .
complications
1. Immediate -fractura open
2. Tardive - nonunion
- Vicious callus
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- gonarthrosis
- Knee stiffness
3. LOWER fractures
A.
Plato tibial fracture
B.
diaphyseal fractures
C.
Tibial plafond fracture
D.
malleolar fractures
3.A. Tibial plateau fracture ( FPT )

Tibial plateau articular spacing is limited , and a horizontal line taken at 5 cm beneath.
Articular fracture is more common in adults and the elderly (due to osteoporosis ) .
The mechanism , standing leg in extension bituberozitar fracture .
pathology
1. External FTP ( 57%)
- Pure separation posting tuberosity
- With pure clogging associated with fracture of the fibula head
- Mixed ( separation + clogging ) - with marginal fragment separation
- By plugging the central part of the plateau
2. Internal FPT ( 8% )
- Pure separation (mostly )
- By plugging pure
3. Fracture bituberozitar ( 35%)
- Simple fracture separation ( tracks form the letters T , Y , V reversed )
- Complex fractures
- Comminuted fractures
symptoms
Subjective patient complain of pain spontaneous and functional ipoten knee .
Objectively, the inspection are seen swelling of the knee valgus or varus deviation , ecchymosis .
On palpation , patellar shock , abnormal mobility and crepitation bone side . Necessarily
examine peripheral pulse , sensitivity and distal mobility .
Correct diagnosis is set using the front and profile radiographs and sometimes three/4.
treatment
1. Orthopedic :
- Fractures without displacement is achieved femoral- plantar plaster immobilization for
3 weeks followed by active mobilization ban support for 3 months.
96
- In some fractures with separation can be achieved by reducing skeletal continuous

extension transcalcanean 30-40 days. This should ensure early mobilization with alternative
positions and correct lateral displacements . Follow immobilization with a cast of 30 days
intredicia support for 3 months.
2. Surgical :
It is indicated in all displaced fractures . Treatment consists of spongy grafts joint
resurfacing and fixation screws, bolt or plate ,, T\" with screws. Postoperative immobilization is
short in supporting early recovery and ban for 3 months.
complications
1. Immediate: - meniscal injuries
- Fracture fibula head
- External popliteal sciatic nerve injury (SPE )
- Popliteal artery lesions
2. Tardive - lax posttraumatic knee (determined by fracture supraligamentare )
- Consolidation vicious ( varum , Valguma in fractures intraligamentare )
3.B. diaphyseal fractures
a. diaphyseal fracture isolated peroneal
The mechanism directly or indirectly (through torsion )
symptoms is the external face pain leg .
Treatment consists of high -heeled boot drive plaster for 30 days or elastic bandage .
Fracture of upper end of fibula .
The mechanism directly or indirectly by forced varus or biceps contraction .
symptoms spontaneous pain is subjective in the palpation. Objective discern bruising and
crepitation . It is mandatory exploration knee ligament , nerve and ankle SPE ( Maisonneuve
fracture ) .
b . Fracture shafti tibial
limits diaphyseal region are 5 cm below the knee joint up to 5 cm of the upper ankle joint
.
The mechanism may be directly or indirectly by the torsion shot .
Location of choice is the union of one/3 the distal environments .
Contributing factors they are:
- Changing the shape of the bone at this level ( the triangular prismatic cylinder ) .
- lack of muscle insertions .
- Poor vascularization
A stable fractures :
- Transverse fractures ( by direct mechanism and location more frequently in 1/3 average
)
- Short oblique fractures
B. unstable fractures :
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- Long oblique fractures

- Spiroide fractures ( by indirect mechanism and localization in 1/3 average )
- Comminuted fractures
- Bifocal fractures
symptoms:
Subjective patient complain of pain on palpation and spontaneous and total functional
ipoten . Objectively, inspection , we see deformation , external rotation of the distal and
bruising . On palpation discern interrupting the continuity of bone , abnormal mobility ,
crepitation bone and failure to transmit movements in the distal segment . Examine the pulse and
distal sensitivity .
Treatment :
A. fractures without displacement . Orthopedic treatment is consisting of femoralpodal immobilization for 45 days without support , followed by immobilization in plaster boot
heel walking for 45 days , with progressive support .
B. displaced fractures
1. Stable . It can practice orthopedic or surgical treatment . Orthopedic treatment is to reduce the
mass orthopedic traction followed by immobilization in a cast 90-120 days. Repeated
radiological controls can detect any movement secunadre under plaster .
Surgery is performed in case of failure of orthopedic treatment . The methods used are:
fixation with intramedullary rod Kntscher , arc secant elastic rod or plate with screws ( rare) .
2. Unstable . For the small displacement is indicated by continuous extension or reduction
extemporaneous , followed by immobilization in a cast 90-120 days.
For medium movements mediated fracture fragment is achieved continuous extension ,
followed by immobilization in a cast femuroplantar 90-120 days.
For large displacements or fractures without intermediate fragment indicated screws and
plate fixation with screws.
The comminuted fractures , or in cases where surgery is not possible to indicate the
skeletal extension continued for 21 days , followed by a cast 90-120 days.
The conditions for fair treatment :
I. Cast immobilisation :
- above the knee minimum of 45 days
- 10 to 20 knee flexion
- perfect focus in the sagittal plane
- - Strict surveillance of distal circulation
- Prevention of bedsores calcaneal
- Repeated radiological controls
II. Extension continues:
- Strict aseptic introduction spindle
- 90 foot rotating indifferent
- splint adapted to the checkered
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3-4 kg traction , always adjust

clinical and radiological control repeatedly
III. surgery
Indications are:
- orthopedic treatment failure
- unstable fractures
- avoid prolonged bed
The methods are :
1. Fixation screwsAddresses the long oblique fractures and spiroide
The conditions for technical achievements are:
- support both cortical
- screws are perpendicular to the fracture path
- minimum 3-5 screws
- cast immobilisation 45-60 days
- support prohibition 3-4 months
2. Fixation plate and screwsFor unstable fractures , the union of one/3 proximal or distal
to the media .
Conditions for success :
- longboard , with minimum 3 screws on each side
- plate affixed to the external face
3. Kntscher rod fixation , transverse fracture in 1/3 medium and short oblique fractures
1/3 average.
Conditions:
- introduction prespinal
- with or without reaming channel
- with or without opening the outbreak
4. Elastic fixation rods , prespinal introduce or arc secant . The advantages are :
maintaining furnace closed fracture , minimal trauma , early mobilization of the patient .
5. Locked intramedullary rod fixation ( Gross- Kempf )
complications :
A. Immediate - open fracture
- musculo- aponeurotic damage
- arterial lesions ( tibio - peroneal triangle in 1/3 proximal ) causes
gangrene .
- nerve damage
- venous thromboembolism
B. Side - vascular disorders ( blistering , swelling , bruising , etc.)
C. Tardive - pseudarthrosis
- Vicious calluses (it tolerates a misalignment of 10 and a shortening of 3
cm )
- Joint stiffness
- algoneurodistrofii
3. C. Fracture of the tibial plafond
anatomical limits of the region are the ankle joint and a horizontal Lina 5 cm proximal .
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The particularity of the area is given by the spongy structure of the mast poor
vascularization and high functional consequences of fractures.
Classification:
A. fractures supramalleolar
B. marginal fractures
A. Fractures supramalleolar
The mechanism is indirect through torsion , when resulting comminuted fractures and
direct spiroide or when resulting transverse fractures .
Subjective symptoms consist of pain and functional ipoten ankle . Objective notice
swelling . It investigates distal pulse and sensitivity .
Correct diagnosis is put by means of face and profile radiographs .
Treatment :
orthopedic : Extemporaneous continuous reduction or extension followed by cast
immobilisation femuroplantar 3 months with support prohibition 1.5-3 months. Surgical
osteosynthesis plate with screws or bolts.
complications :
- Immediate : open fracture , neurovascular injury
- Secondary vicious attitude ( var , valgus , recurve )
- late : pseudarthrosis , vicious callus
B. marginal fractures
The mechanism is indirect , by falling from a height . Astragalus determine the impact
fracture tibial plafond .
Depending on the position of the leg during the fall fracture occurs following varieties :
- talus foot marginal fracture anteriotoMiss
- equinus footmarginal posterior fracture
- indifferent foot position comminuting fracture bimarginal
There are variety of internal and external sagittal fractures . Marginal fractures may be
associated with fractures bimaleolare .
symptoms the pain is subjective , functional ipoten ankle . Objective highlights equinus
foot with swelling and pain in the Achilles region ( the marginal posterior fracture ) or leg
swelling and pain stretching before ( the fracture edge ) .
Correct diagnosis set of radiographs profile , front and oblique incidence .
Treatment :
1. Orthopedic : the fracture edge is to reduce traction and immobilization in plaster in
equine boot for 2-3 months. The marginal posterior fracture reduction is achieved through
maneuver ,, boot out\" and immobilization in plaster in talus boot for 2-3 months.
2. Surgical : practiced fixation with screws. Indications are: the existence of larger
fragments 1/Pillar 3 of the tibial and orthopedic treatment failures . Postoperative immobilization
is variable depending on the strength and joint assembly lesion .
complications :
1. Immediate -fractura open
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- Subluxations or dislocations association with

- Vacsulo - nerve injury
2. Tardive - vicious callus
- Post-traumatic osteoarthritis ( which tibio - talar arthrodesis sometimes require )
3. D. malleolar fractures
They have a special importance because tibio - tarsal joint function disorders causes
severe osteoarthritis .
Anatomy region
- ,, Clamp\" ( Morteza ) tibio - peroneal malleolus is the tibia , tibial ceiling and peroneal
malleolus . ,, clamp\" is flexible , adapted talar sheave , previously bulky .
- Tibio - peroneal Sinartroza ligament is performed before, ligament and posterior interosseous
ligament .
- System is the collateral ligaments : external collateral ligament ( LCE ) and internal collateral
ligament ( LCI ) ( deltoid )
- Normal movements are allowed in the anterior- posterior direction ( flexie- extension) .
The mechanism consists in causing abnormal movements of the ankle :
- inversion = supination + adduction + internal rotation
- eversion = pronation external rotation + abduction +
inversion includes 3 phases:
a) Partial or total rupture elongation LCE ( sprain gr. I, II , III ) or external malleolus
fracture ( fracture unimaleolar )
b) If trauma continuous internal malleolus fracture occurs with or without subluxation of the
talus ( bimaleolar fracture ) .
c) If trauma continues marginal posterior fracture ( fracture trimaleolar ) .
eversion includes all 3 phases :
a) Partial or complete rupture elongation LCI ( sprain gr. I, II , III ) or internal malleolar
fracture ( unimaleolar ) .
b) If trauma continues external malleolus fracture occurs ( bimaleolar )
There are 3 varieties , depending on the fracture of the fibula :
- Dupuytren low , based on the peroneal malleolus
- Dupuytren high , 7-8 cm from the tip of the external malleolus
- Maisonneuve , the neck of fibula
c ) If continuous trauma fracture occurs posterior marginal ( trimaleolar ) with or without
posterior subluxation external .
symptoms subjective manifested by pain and functional and the objective ipoten by
moving the leg side and rear .
Developments is towards consolidation , complications with severe functional
consequences .
Treatment
1. Orthopedic . Orthopedic reduction is performed under anesthesia. The principle of
this reduction is printing movements opposite to those producing fracture and bleeding in
addition ,, forceps\". The inversion is performed eversion fractures , fractures by inversion and
101
eversion is performed trimaleolare fractures with posterior subluxation runs maneuver ,, eject
boot\".
Plaster immobilization is performed in boot:
- unimaleolare fractures - 30 days ( walk heel to 7 days )
- bimaleolare fractures - 45 days ( walk heel to 14 days)
- trimaleolare fractures - 90 days ( walk heel to 45 days )
radiological verification of the reduction is performed at 5, 10, 15 days with discount or
surgical treatment if redeplasri .
2. Surgical . Currently the trend is chirurgicalizare all displaced fractures .
Indications are orthopedic treatment failure and posterior marginal fractures greater than
1/Pillar 3 of the tibial surface .
Screw fixation can be achieved , brooches , wire ( the principle hobanajului )Plate with
screws , rods Rush .
The principles of fixation at this stage are :
- Fixing firmly peroneal malleolus ( plate with screws , rods , brooches )
- synthesis screw or hobanaj the internal malleolus
Postoperative immobilization is performed in boot gypsum 45-60 days (depending on
installation durability ) .
complications :
1. Immediate: - open fracture
- Neurovascular injuries
- irreducibility
2. Tardive - vicious callus
- nonunion
- Osteoarthritis ( tibio - talar arthrodesis treated )
Tibio - peroneal diastasis
Anatomically, tibio - peroneal lower joint is sinartroz showing a concave portion and a
convex tibial peroneal . Radiological bone overlap occurs at this level.
Diastasis ligament rupture is the tibio - peroneal leading to widening tibio - peroneal
staples , leading to joint incongruity with external displacement of the talus .
radiological there is a space between the tibia and fibula with space widening between
internal malleolus and talus .
symptoms is abnormal movements of laterality of the talus ( ,, runoff talar\") .
Treatment :
1. orthopedic : orthopedic reduction followed by immobilization in plaster boot 3 months.
2.
surgical : preferably ; external malleolus tibial fixation with a long screw cancellous
supraarticular introduced .
Screw extraction is performed 4-9 weeks to prevent a possible tibio - peroniene
synostosis .
4. FRACTURE talus
102
The mechanism is indirect through violent trauma ( road traffic accidents , falls from
height) .
Depending on the position of the foot can fracture :
- Marked dorsal flexion , neck or body of the talus
- Plantar flexion marked head ( hit the scaphoid )
Classifications :
I. pathologist :
1. Fractures lots - head of the talus
- Apofizare ( more frequent posterior apophyses )
2. Fractures total - body ( rare )
- The cervix ( common); associated with posterior dislocation of the foot.
II . Hawkins ( depending on the movement fragments )
1. Type I fractures Stationary
2. Type II displaced fractures with subtalar subluxation without tibio - talar joint changes
3. Type III displaced fractures with dislocation of the talar body subtalar and ankle joint (
posterior fragment enucleation )
symptoms
Fractures without displacement have nonspecific symptoms (pain , swelling ) . Displaced
fractures occur through :
- Subjectively , through pain, functional ipoten the ankle
- Objective by deleting relief Achilles ; is flattened elongated heel varus equine foot . Forced
flexion of the great toe is produced by pressing the big toe flexor tendon bone fragment .
Correct diagnosis is made by means of face and profile radiographs . Evolution is limited
due to poor blood supply that determine the risk of aseptic necrosis .
Treatment :
For type I: gypsum boot support 8-12 weeks to 6 weeks.
For type II : orthopedic reduction ( ,, technique of catching\" corporeal fragment ) or reduce
bleeding + fixation screws ( preferably ) .
For type III: Emergency surgery ( reduction + synthesis ) .
complications :
1. bone necrosis (common ) . Radiological changes occur bone structure evolves towards
settlement or seizure . Finally arthritis tibio - talar appears . Treatment consists of fusion .
2. vicious callus with significant misalignments and severe functional consequences .
Tibio - talar 3. Osteoarthritis (treatment : tibio - talar arthrodesis )
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5. FRACTURES calcaneus
There are frequent mechanism of production is falling from height ( found in 90% of
cases) or shear appears crushing and tearing ( rare ) by the action of the sea triceps tuberosities .
- thalamic fractures ( joints )
- extratalamice fractures ( extra-articular )
- complex fractures (associated with other fractures of the ankle )
symptoms :
1. calcaneal fractures body ipoten subjective patient complain of pain and total
functional . Lens , enlarging the region calvaneene deleting anatomic relief , flattening the arch
planting , bruising plantar peak decreasing the distance -ground malleolus . Flexion and
extension is keeping pathognomonic but agonizing pain in Pronoia - foot supination .
2. posterior tuberosity fractures subjective and objective meet retromaleolar pain relief
retroachilian change .
3. In previous extremity fractures are pain , swelling, ecchymosis ( on the back of the leg)
.
Correct diagnosis is established by using profile radiographs and axial ( retrotibial ) . On
radiographs are studied tubero - articular angle ) Bhler ) . It is given by the intersection of a line
connecting the upper edge of the posterior tuberosity with the highest point of the calcaneal
surface with another line joining the highest point of the surface to the top of the calcaneal
tuberosity earlier . Normally this angle is 30 and open back . Thalamic fractures are 3After
Bhler 's angle :
1. -degree angle decreases while preserving between 30 and 0
2. II degree angle is canceled her
3. III degree angle is reversed, less than 0
Thalamic fracture treatment :
Principles:
- Restoration of normal morphology
- Restoring parallelism articular surfaces
- normalization angle Bhler
- Varus or valgus absence of bias in
orthopedic treatment
Reduction and immobilization in plaster type Graffin boot with heel open 4-8 weeks.
Interdicia support is 3 months .
functional treatment
The practice especially for older platforms . It consists of bed rest with leg raised on a
splint , cold compresses , anti-inflammatory medication . Ankle mobilization is under the
protection of a diaper elastic early . The patient resumed walking with crutches . Support is
enabled in 60-90 days .
surgery
1. Reconstruction of the calcaneus : reduction and internal fixation with screw or plate
brooches .
Subtalar arthrodesis 2. Reconstrucia- by cortico- spongy grafts ( Stulz process ) .
104
complications
1. Immediate: - open fracture
- Neurovascular lesions associated
2. Tardive - posttraumatic flatfoot
- Valgus deformity of the foot
- Subtalar arthrosis
6. FRACTURES metatarsals
The mechanism is direct by the fall of a heavy body on foot or indirectly by plucking,
torsion .
Classification of pathological
- Head fractures ( rare )
- Neck fractures ( common in middle metatarsals )
- Diaphyseal fractures : isolated , with oblique trajectory
- Fractures bases : common in the metatarsals I ( by pulling the long lateral peroneal ) and
metatarsal V ( by pulling the short lateral peroneal )
symptoms the pain is subjective , functional ipoten falangian metatarsal joint .
Objective encounter abnormal mobility , crepitation , deformation
treatment
1. Orthopedic . Fractures of the metatarsals II , III , IV without traveling gypsum enjoy
walking boot two weeks . The displacement is immobilized for 3 weeks . In fractures of
metatarsals I, V , without traveling the duration gypsum is 3 weeks and displaced 4 weeks.
2. Surgical . Displaced fractures , osteosynthesis Kirschner .
FRACTURES phalanges
The mechanism is direct ( crushing ) . Angular displacement occurs by plantar proximal
phalanx subsequently causing the appearance of a clavus .
treatment
1. Orthopedic . For immobilization of fractures without displacement healthy finger
joined with adhesive for 2-3 weeks. For displaced fractures is similar reduction and
immobilization .
2. Surgical . Osteosynthesis thin
indications: - displaced fractures , unstable
- open fracture
- vicious calluses
105
VII. JOINT TRAUMA
Articulation : morpho differentiated system that ensures the union of two or more
neighboring bones .
The joint is exposed to direct or indirect trauma , most commonly by accidents, traffic
and sports.
injuries joints are:
1. Closed - contusion
- sprains
- dislocation
- Articular fractures
- Meniscal injuries
2. Open : - Joint wounds
I closed traumatic lesions
Determines vasomotor reflex and reaction with various anatomical lesions as a result
stiffness ( major sequel ) . The goal of treatment is to restore normal joint range of motion
amplitude .
I. 1. Contusions
They are the result of sending a low kinetic energy of the vulnerable agent tissues without
causing gross morphological changes .
Clinic: diffuse pain , functional ipoten partial inflammation , effusion . Radiology is
without modification.
Treatment: articular rest , ice pack . Healing occurs spontaneously in a few days .
Contusion articular cartilage degenerative cartilage lesions determined time .
I. 2. Sprains
Are injuries capsuloligamentare , ranging from simple and elongation to break , but
without permanent loss of contact between articular surfaces .
Etiology : higher frequency is early adulthood ( sports ) , very rare in children ( ligaments
supple , elastic ), Old (osteoporosis fractures causing production )
Location :
- Ankle , the most common
- Knee , medial tarsal , carpal radio
- Local : congenital or acquired joint laxity ( traumatic paralysis, muscular atrophy )
- General fatigue , lack of exercise, muscle hypotonia
Pathology :
- Grade I: ligament stretch which causes a distortion of the nerve endings
106
- second degree partial ligament tear

- Grade III ligament rupture or tearing total bone insertion
Lassociated eziuni at :
- capsule
- synovium (source haemarthrosis)
- menisci
- periarticular tissues ( vascular lesions that may cause bruising or swelling
in the superficial subcutaneous tissue )
- musculo
symptoms :
Pain : - living , syncope
- Attenuated ( patient continues work )
- Further intensifies
- Muscle contracture , joint locks
Clinic:
- Joint swelling : due to edema , hematoma or haemarthrosis
- Hyperthermia : the result vasomotor reaction
- The painful points : at the points of insertion ligament
- Abnormal movements : due to total rupture or ligament disinsertion
- amyotrophy
radiological:
- removes a subluxation , fracture
- Shows a ligament avulsion of bone pill ( sprain gr. III)
- Radiography maintained in position , stress ,,\" objectified by expanding unilateral abnormal
movements joint space ( gr. III) , is carried out with or without anesthesia .
evolution : is dependent on the location , age and degree of strain
- Gr. I , II 7-21 days , healing
- Gr. III treated early , fair, favorable evolution , neglected or improperly treated lead to
sequelae.
Early sequelae : - painful instability
- Vascular and trophic disorders : pain, functional ipoten , swelling, edema ,
effusion , cyanosis , stiffness , muscle atrophy .
Sequelae , late - painful osteoporosis , diffuse ( Leriche syndrome Sdeck- )
- Periarticular ossification
- Intraarticular free body
- Pulling lots bone
- Osteoarthritic changes
Treatment:
Objectives:
a) immediately block harmful vasomotor reactions by infiltration anesthesia. It also soothes
the pain .
b) Repair ligament injury, Orthopedic surgery
c) Fighting amiotrofiei by muscle reeducation well run
In emergency :
107
The local infiltration with lidocaine practice 1% for discontinuation nociceptive reflex
sympathetic point of departure to capsular and ligamentous nerve endings . The risk is
aggravated injuries ( by continuing )
In the first 24 hours :
Administer analgesics and anti-inflammatory leg was immobilized in position proclaim
and put ice pack .
Orthopaedic treatment
Joint immobilization in functional position ( with simple strips , elastic yincat glue ,
plaster , synthetic resin ) leads to pain relief , resorption of edema , scarring and blockage
vasomotor reaction ligaments.
surgery
It addresses the severe sprains , ligament injuries capsulo flat with joint instability
evident.
Recovery is achieved by:
- Isometric contractions in plaster machine
- Walking , maintain muscle tone , muscle atrophy combat
- Physiotherapy
- Physical therapy : ultrasound , ultra , diadinamice
- Anti-inflammatory dose rntgenterapie
indications treatment are based on the extent of injury
- Sprain gr. I: simple bud , elastic
- Sprain gr. II: plaster 14-21 days
- Third degree sprain : is surgical rehabilitation , ligament suture
knee sprain
Definition: capsulo - ligament injuries device over successive movements physiological
limits .
Etiology : second place after sprains are tibio - tarsal common in adulthood . The
mechanism is complex . Indirect and direct ( lateral impact to the knee in extension , frequent in
traffic accidents ) . Internal collateral ligament( LCI ) is forced by a combination of movements
of abduction , flexion and external rotation of the lower leg is common in sports : football , rugby
, skiing . External collateral ligament ( LCE ) gives the adduction , flexion and internal rotation .
Anterior cruciate ligament -external ( LXAE ) gives in the anterior- posterior shocks knee
hyperextension .
Anterior-posterior cruciate ligament ( LXAP ) is affected in shock anteroposterior knee
flexion .
Biomechanics :
1. anatomical structures :
108
- Port - bone ends

- Slip - menisci , synovial Scholarships serous
- Fixing ( passive stability ) - capsule and ligaments
- Motion ( Active Stability ) - muscle
2. The capsulo - ligament
- Central pivot ( LXAE , LXAP ) :
- Ensure rotation axis movements
- Maintain a degree of compression joints
- LCI - control valgus
- LCE - control varus
- Collateral ligaments control the rotations capsule +
Pathology :
Sprains most common internal ligament care unit . They are of various shapes , from
simple to more serious the meeting:
- Plucking higher or ligament insertion
- Complete break in the middle associated with musculo- fibrous lesions
- LCE lesions rarely meet
- Severe sprains interested in the following structures :
- A nefarious triad' Donoghue : - LCI ( both beams )
- LXAE
- Internal meniscus ( + capsule)
- Pentad harmful Trill : - Internal : - LCI
- LXAE and LXPI
- Internal capsule and meniscus
- Dezinseria tendons ,, paw goose\"
- External : - LCE
- LXAE and LXPI
- Capsule and external meniscus
- Dezinseria biceps
Symptoms:
Subjective pain, functional ipoten , walking instability . Objective: inspection, knee
swollen , distended bag bottoms , antalgic position of semi-flexible , bruising ( occurs early then
broadcast ) . On palpation : pain - along track ligament ; is investigating the presence of patellar
shock , research laterality movements in valgus = LCI injuryMovements of laterality in excessive
valgus = LCI + LXAE injury , laterality movements in var = lesion LCE .
These movements are performed by adduction or abduction of the leg with the knee
locked in extension. anterior drawer = LXAE lesion consists in previous mobility increased tibia
to the femur with the knee at 90 . sign Lachman = LXAE lesion : previous mobility on femur
tibia with the knee at 20 . posterior drawer = LXPI lesion : posterior increased mobility on
femur tibia with the knee at 90 .
Radiology :
Exclude existence of bone lesions radiography in fixed position maintained widening
unilateral joint spacing .
evolution :
109
based on fair treatment of reconstituting normal ligament length and tension . Healing
with feeling of instability stretching ligaments + repeated bouts of knee effusion . Instability
can be offset by thigh muscle recovery .
Treatment:
There are two objectives: to restore joint stability and suppression of pain and nociceptive
reflexes .
I. mild sprains . We do infiltration with novocaine , elastic bandage , quadriceps contractions .
Downpipe knee plaster with rectitude 21 days. Isometric quadriceps contractions .
II . Serious sprains : surgery : sutures , ligament rehabilitation
indications:
- plucking bone inserts
- lateral laxity \u003e 10 unilateral opening interlining \u003e 0.5 cm
- loading collateral ligament in the joint
- associated complex lesions ( triad O ' Donoghue , joint blockage ) .
For nefarious triad O ' Donoghue :
1. Internal meniscectomie
2. suture reintegration transosseous LXAE
3. suture posterior capsule reintegration LCI +
- Gypsum femuropodal with knee flexion 30, 6 weeks
- Recovery + elastic bandage 4-6 weeks
Ankle Sprains
Ankle sprains is a joint exposed (position 1 as frequency) . Etiology : youth, adults ,
accidents, traffic and sports. The causes are : landslides , falling on uneven ground .
Biomechanics :
- tibio - talar joint : flexion + extension ( transverse axis )
- subtalar joint : pronation supination + ( anteroposterior axis )
- medio- tarsal articulation : + abduction adduction ( vertical axis )
It is a complex movement , inversion ( internal torque ) , eversion ( external torsion ) .
Movement: indirect trauma , torsion forced over the mechanical strength of ligaments
causes joint sprain .
Pathology :
- benign sprain : ligament distension
- severe sprain : rupture , ligament dezinserie
- peroneo ligament - talar above ( ,, ligament sprain\")
- peroneo- calcaneal ligament
- tibio - peroneal ligaments lower
Pathophysiology :
Ligaments are innervated rich headquarters nociceptive stimuli that trigger vasomotor
reactions that result in significant sequelae : muscular atrophy , edema, laxity , painful
osteoporosis Sudeck - Leriche .
symptoms:
110
joint pain living

functional ipoten
local swelling , hematoma
hemarthrosis
Inversion sprains :
- clinical signs located on the external face of the ankle
- adduction movement or pain inversion
If the internal lateral ligament and anterior tibial - peroneal results are broken a severe
sprain that forced out on radiography ,,\". Mild sprain is stable, the grave is unstable .
evolution : stable sprain is a positive development in three weeks . Severe sprain treated
incorrectly lead to functional disability which consists of instability painful relapses .
Diagnosis : Clinical symptoms + signs + radiological signs . differential diagnosis is
made with ankle fractures .
Treatment:
1. Sprains stable - compression bandage , elastic ,, 8\"10-14 days
- Physical treatment inflammatory
2. Serious Sprains - gypsum -heeled walking boot for 3 weeks and functional recovery and
balneophysiotherapy .
- Surgery - ligament suture
- ligamentoplastie
3. tibio - peroneal Sprains with diastasis :
- Diastasis screw removed in 6-8 weeks.
Sprains Hand
There are rare , less serious than sprains leg .
Sprains radiocarpian
The mechanism is through forced hyperextension arm adducted . Clinic: external
posterior pain , swelling, limitation antalgic movements .
Radiological: exclusion, fr4actura distal radius, scaphoid fracture , osteonecrosis of the lunate .
Treatment: antebrahiopalmar splint 10-14 days.
Sprain metacarpophalangeal , interphalangeal

Clinic: Hot painful swelling . Treatment consists of immobilization digital beam affected.
I. 3. Sprains
Definition: permanently change the relationship bone extremity joints, leading to loss of
contact between them. May be complete or incomplete , subluxations ( still little contact ) .
Classification dislocation ( L ) :
- L. traumatic suddenly appears on a healthy joint
111
- L. pathological TB occurs slowly , tabes , polio

- L. congenital malformations after articular surfaces (eg . Congenital hip dislocation ) .
etiopathogeny
- Report L. traumatic /fractures is 1/8
- Report L. upper limbs/is below 4/1
- Rare in children, due to ligament laxity
- Rare in the elderly , fractures are more common ( bone yield )
- Common in men , athletes, 30-65 years.
The mechanism is indirect : the force is transmitted through the shaft .
I. Time I: relaxation capsular injury rupture extremity bone protruding through the
opening created.
II . Time II: secondary displacement , by L. fixing the weight member plus muscle
contraction .
Pathology :
- Capsular rupture , synovium , ligaments .
- Epiphysis : discrete lesions ( tearing , cracking osteochondral )
- Periarticular tendon injuries
- Nerve compression , vascular
- Skin lesions
symptoms:
- pain
- Functional ipoten
Clinic:
- Vicious attitude of the member : feature is shortened limb .
- Deformation region
- Is investigated vacsulo - nerve complications
radiological:
- Radiographs of the bud and Profile: highlights loss of contact articular surfaces
Treatment:
- Emergency
Three successive time :
1. reduction ( re )
2. maintenance of the reduction ( immobilization )
3. functional recovery
1. Reduce orthopedic
- Anesthesia
- Gentle maneuvers
- Epiphysis is forced to go through the reverse way during the production of L
- ,, Discern a click\" sensitive audio
- Followed by radiological control
- Failure reduce bleeding
2. Maintain reduction : specific assets
3. Functional recovery : muscle contraction , active mobilization
acromioclavicular dislocation
112
etiology :
- young
- falls on the shoulder + keystone violent contractions and sternocleidomastoid
Classification:
I. L. Incomplete ( subluxation ) , capsule - acromio collarbone broken , coraco- clavicular
ligament ( ligament ligament trapeze + Conoids ) = intact
II. L. complete and ligaments are torn away coraco - clavicular top of the clavicle to the
acromion ( sternocleidomastoid and trapezius muscles in action ).
symptoms:
- spontaneous pain in the shoulder , arm abduction grow at
- shoulder deformation in ,, step ladder\"
- sign ,, piano keys\"
Radiografie :
- radiograph of the shoulder to the hand-held weight
Diagnosis :
- is on the basis of clinical signs and symptoms of radiographs .
- is the external end clavicle fracture .
- and shoulder contusion
evolution :
- subluxations are well tolerated
- dislocations - articular incongruity decreased range of motion and strength
disability increased.
Treatment:
- subluxations : 2-3 weeks Jones bandage robert- dislocation : surgical procedure Barrington Dewar : top coracoid transfer (
+ inserts its MUSCUlar ) on the underside of Clavwedge . Weaver Dunn
method : using acromiocoracoidian ligament .
Scapular- humeral dislocation

definition: permanent loss of contact of the humeral head with the glenoid cavity of the
scapula .
etiopathogeny :
- 50-60% of the total dislocation
- Male , 20-50 years
Biomechanics :
- scapular- humeral arculaia = enartroz
- presents a very high mobility and joint involving interscapulotoracic ,
sternoclavicular joint , acromioclavicular joint .
- humeral head = 1/3 sphere with a radius of 30mm
- Glenoid cavity is less than the humeral head , surrounded by burelet .
- Ligaments, joint capsule is reinforced by periarticular muscles and
tendons .
113
movements :
-
flexion -extension
abducie- adduction
circumducie
rotation
muscles :
Movement: indirectly
subscapular
supraspinatus
subspinos
small round
, drop arm in abduction and external rotation of 90 .
Pathology :
1. L. anterointerne ( 95%)
- Varieties: - extracoracoidian : humeral head on the edge of the cavity glenoidiene .
- Subcoracoidian : coraco - humeral ligament integrity and external rotator
muscles fixed head position .
- Intercoracoidian : May anterior humeral head medial to the coracoid and
- Subclavian , humeral head lower edge of the clavicle
2. L. rear - humeral head under the acromion
as spina scapula
- Arm in internal rotation
3. L. anterior- inferior ( Erecta L. ) , ( L subglenoidian ) - 1%
- Under glen humeral head
- Abducie- aspect of mast arm .
symptoms:
- pain
- functional ipoten
- L. antero- internal:
Inspection: - forearm flexed , supported by his good hand
- Shoulder epaulet ,,\"
- Short arm abduction + external rotation +
Palpation : - forced adduction arm pain + return in abduction ( sign ,, adduction elastic
Berger )
- glenoid cavity missing head + palpation his armpit
- L. Rear :
- Irreducibility internal rotation
- Palpation of the humeral head under acromial angle
Radiology : X-rays of face and profile
Diagnosis : subjective symptoms + + radiography clinical signs
complications :
- Bone fracture of the upper extremity humerus
- Vascular ( rare ) : compression fractures
- nerve (common) : circumflex nerve injury ( truncal )
- tendon rupture long portion of biceps
evolution : L. down immediately and correctly rarely leads to complications .
114
Treatment: Emergency carried out with or without anesthesia,

Methods for discount:
1. Hippocrates :
- patient supine
- heel orthopedic patient armpit
- traction and easy adducted arm shaft snap
2. Von ArtLit :
- patient chair with the back in the armpit
- continuous traction in the axis of the arm , the forearm 90
- chest and arm angle between 30
- have external rotation 12 after a good muscle relaxation
3. Mothes :
- patient supine
- upper limb traction in abduction 90 + contraextensie
- simultaneously push the humeral head out from under the coracoid
- gradually increase the abduction + internal rotation + anteducia
5. Djanelidze
6. Kocher
After reduction is an immobilization bandage Desault 14 days. Irreducibility is surgery.
Dislocation of elbow
definition: Continuous movement of the upper end of the two bones of the forearm in
relation to the humerus .
Classification:
- L. rear - postero - external
- Postero - internal
- L. previous
- L. isolated radius and ulna
- L. divergent : - internal ulna
- External radius
Biomechanics :
At this level we find three joints :
- humero- cubital : makes flexia- extension 140
- humero - radial
- proximal radio - cubital
etiopathogeny :
-
second place after scapular- humeral L.

fall on the palm , forearm supination in extension and
young women- often
Pathology :
- Hyperextension : anterior capsule + collateral ligaments ( internal and external ) coronoid
process tear slid under the olecranon fossa trochlea in posterior displacement radius and ulna
115
symptoms:
1. Topic: - living pain
- Total functional ipoten
2. Inspection: - elbow deformity
- The patient 's forearm supports his hand healthy
- Semi-flexible 130 elbow
L. rear : - In profile appears shorter forearm
- Olecranon prominence under triceps
3. Palpation : - olecranon ascended ( nelaton 's triangle reversed )
- Abnormal movements of laterality
L. postero - external :
- forearm pronated
- trochlea + epitrohleea medial elbow
L. postero - internal :
- forearm supination
- Condyle + epicondyle side by side
L. previous :
- incomplete : - Elbow extension
- Elongated arm
- All - total elbow flexion
- Short arm above
- Humerus feels fossa goal olecraniene
- Cubital nerve may be injured
Radiography : The front and side profile .
Differential diagnosis : humeral supracondylar fracture , which remain normal relations
between bony landmarks .
complications :
1. Immediate: - bone fracture of the olecranon , coronoid process , epitrohlee , radial head
- Vascular humeral artery , compression or rupture ( due to previously displaced
humerus )
- Nerve or medial cubital nerve elongation
2. Tardive - osteoma posttraumatic brachial previous
- Post-traumatic osteoarthritis
- Volkmann ischemic syndrome
evolution : - Good , properly treated
- Complete recovery within 2-3 weeks
Treatment:
- urgent
- Reduction orthopedic
- In L. rear :
- Patient supine
- Traction in the axis of the forearm
- Contratraciune arm
116
- Gentle pressure with the thumb on the olecranon and flexion of the forearm
( distal before)
- In L. previous :
- Patient supine
- Help maintain flexion
- The doctor makes a top end of the forearm traction ( pulling down and
back )
- Brahio - palmar plaster immobilization ( 90 bend ) , 21 days
- Recovery active movements
sprains hand
1. L. radiocarpal , rare
2. L. carpo -metacarpal rare
3. L. carpal frequent
Pathological forms :
1. Previous L. crescent
2. L. retrolunar the wrist
3. L. transscafoperilunar
4. L. previous lunate , scaphoid fracture associated with .
5. L. retroscafolunar
Movement: indirectly fall on hand in hyperextension , more common in adults aged 20-50
years, especially in men.
symptoms:
- pain
- functional ipoten
- palpation sprained bone protrusion
- compression of the median nerve ( hypoesthesia, parestezi )
radiography Face and Profile
Treatment: Emergency under anesthesia.
1. Orthopedic - hand axis traction
- Antebrahio - palmar splint immobilization
2. Surgical : - irreducibility reduce bleeding .
finger sprains
Dislocation of the thumb metacarpal - falangian
Movement: hyperextension of the metacarpal phalanx falling on police + extension +
abduction .
Pathology :
- Anterior capsular rupture
117
- Phalanx and sesemoidele , adductor muscle inserts internal and external short flexor
movement back in the back of the hand.
Symptoms:
- Deformed thumb Z
- Head protrudes face palmar metacarpal
Treatment:
- Reduction by : hyperextension sprain phalanx and metacarpal shaft pushing progressive order
of the phalanx , distal to the dorsal .
Traumatic dislocation of the hip

Anatomy of the hip joint : This joint is a enartoz .
movements :
- Flexion -extension
- abduction - adduction
- internal rotation , external rotation
stabilityfactors bone
capsulo factors ligament
factors muscle
Femoral head is 2/3 sphere with a diameter of 40-50mm . ligaments :
- Ilio - femoral Bertin
- Pubo - neck
- Ischio - femoral
- ring
- Round ( intraarticular )
- The extension ligaments tensions
- Relaxes the ligaments in flexion
Muscles ripe :
- pelvitrohanterieni
- milociu buttocks and lower
Muscle trend dislocation :
- abductor
- flexors , iliac psoas
etiology :
- Violent trauma - traffic accidents
- Falls from height
- Young men , 20-45 years
Movement: indirect
- trauma act thigh shaft which is in flexion and adduction luxeze forces
to posterior femoral head
- Anterior dislocation hip in abduction ( hole plugs , pubic crest )
- if adductor fracture eyebrow cotiloid cavity is reduced
- if abduction is low central dislocation fracture acetabulum .
Pathology :
- femoral head - round ligament tear
- Creates a gap at the bottom of the capsule
118
- Bertin ligament remains upright ; it represents the axis of motion

- By muscle contraction - adduction , femoral head back
- Abduction , femoral head before
- L. Rear : - High ( iliac ) : external iliac fossa femoral head deals
- Low ( ischial ) femoral head comes into contact with spina sciatica
- L. previous : - High ( iliopubiene ) femoral head before reaching the horizontal branch Trash (
under the muscle psoasiliac ) .
- Low ( shutters ) femoral head comes before obturatory hole .
Associated injuries :
- Bone fractures eyebrow cotiloid cavity , femur ;
- Soft tissue : muscle crural square , twins ; internal obturator tendon
- sciatic nerve
symptoms:
- living pain hip , total functional ipoten
1. L. high back ( iliac ) :
- Leg - almost complete extension
- adduction
- Internal rotation
2. L. low back ( ischial ) :
- 90 flexion
- Internal rotation
- adduction
3. L previous high ( pubic ) :
- rectitude
- External rotation
- abduction
- External rotation
Diagnosis :
- symptoms
- clinic
- Radiology - to pool
- 3/ 4 postero - external
- 3/4 postero - internalUm
complications :
1. Immediate:
- Bone fractures - eyebrow
- acetabulum
- femur
- Nerve Compressor
- Obturator nerve
- Crural nerve
elongation greater sciatic
- Vascular - compression of the femoral vessels
2. Tardive :
- Femoral head necrosis
119
- coxarthrosis
- Traumatic ossification
- hip contusion
- hip sprain
- Movements are possible
- Trochanter can feel his place
- Fracture of the femoral neck , shortness pain, functional ipoten
Treatment: urgent
1. Reduction orthopedic anesthesia :
- Patient supine ;
- An anterior iliac spines immobilized pressing basin ;
- The thigh of the tank is 90 knee at 90 to the thigh ; axle traction noise resort thigh
2. Radiological Control
3. L. simple bed rest 3-4 weeks ( + skeletal extension )
4. L. fracture associated - 4-6 weeks skeletal extension bed plan
- Walking with support resume 6-10 weeks
5. L. irreducible fracture , bleeding reduction + osteosynthesis
sprains knee
etiology :
-
adult 2-3%
direct trauma
traffic accidents , work, sport
may be associated with other significant injuries
fractures , wounds , vascular rupture
Pathology :
1. L. simple : - Previous
- rear
- internal
- external
2. L. mixed : - antero- external
- Postero - external
L. previous :
- Rupture - posterior capsule
- Cruciate ligaments
- Muscle twins
- External popliteal sciatic nerve elongation
- Collateral ligaments intact
- tibial plateau before femoral condyles
Movement: leg fixed on the ground , the body in motion. Traumatic force acting on the
femoral condyle anterior-posterior direction , emphasizing recurvatum knee hyperextension .
L. rear :
120
- soft tissue injuries are the same

- tibial plateau behind the femoral condyles
- Force is applied to the upper end of the tibia. Risk of injury to the popliteal vessels .
L. internal, external :
- Rare , incomplete
- Rupture of cruciate ligaments and one or both collateral ligaments .
Mechanism: knee immobilized in extension . Force abduction or adduction leg to .
Symptoms: pain, ipoten fully functional . Objective We deformation knee ,, bayonet\".
radiography : variety of front and profile specifies clinic.
complications : - Vascular : common variety posterior
- Nerve : common in earlier L.
1. Fracture of the femoral condyle
2. Tibial plateau fractures
Treatment: Emergency under anesthesia.
1. L. previous - tibia on the femur traction slow
- Progressive flexion of the leg
- Direct manual pressure
2. L. rear :
- Bent leg on the thigh
- Traction shaft distal thigh
3. External L. :
- The patient supine
- Leg thigh flexion
- The pool thigh flexion
- Pressure on the external condyle and patella
- Abduction increased by passing the shank extension
4. Internal L. - ill positioned as above
- Pressure on internal condyle
- Adducted by passing the shank extension
Immobilization in a cast - plantar femur , knee semiflexible 15-20 2-3 weeks. Surgical
complications are resolved .
sprains foot
Tibio - talar 1. Dislocation
Astragalus is strongly maintained clamp tibio - peronir by : lig . tibio - calcaneal , lig .
peroneo - calcaneal , lig . tibio - talar , lig . peroneo - talar , lig . astragalo - calcaneal .
Simple L. todayrslowly ( the whole foot ) without associated fractures of the tibial
plafond ankles or marginal , is exceptional .
Pathologist :
- rear
121
- previous
complications : skin necrosis compression
Treatment: - reduction= urgency
- Anesthesia
- Immobilization in plaster boot 30 days
2. L. subtalar :
- Astragalus tibio - peroneal remains clamp
- Sprains are often instep internal
- Reduction is achieved by movement of the boot ,, desclare\"
- Immobilization in plaster boot 4-6 weeks.
3. L. total talus ( enucleation ) , exceptional .
4. L. mediotarsian
- In the interlining of Chopart
- Anterior tarsus moved - dorsal
- plantar
5. L. plantar total ( most common)
- Astragalus protrudes on the back of the leg
- Leg appears shortened fingers retracted ,, claw -shaped dorsal\" extensor tendons by
tensiuonarea .
Treatment:
- Reduction under anesthesia in emergency
- Antepicior traction to reduce overlapping + movement in the opposite movement
- Immobilization is 4-6 weeks
6. L. tarso -metatarsal
- Articulation Lisfranc
- Very rare
- Varieties: - external lateral spine
- Divergent - tarsal pure form
- Form columno - spatulation
- Isolated metatarsal
Treatment:
- reduction under general anesthesia or spinal anesthesia by extension +
pressure on the metatarsal metatarsal sprained
- immobilization in a cast 4-6 weeks
- Temporary fixation with Kirschner pin percussion
Meniscal lesions
menisci = formations fibrocartilaginoase mobile . The smell of grass = solution of
continuity occurs in the meniscus .
122
Anatomy :
- External meniscus shape is Q; internal meniscus shape is C (O C E I).
- The triangular shaped section
- Internal meniscus is less mobile to external more susceptible to breakage.
biomechanics :
- shock absorber
- flexion and extension protects synovial maximum
- achieved balance tibial plateau femoral condyles
- help the lubrication of the knee
etiology :
- 20-30 , men
- Sport ( forbal , rugby , skiing )
- Report internal meniscus/External broken is 5-6/ 1
Movement:
- association knee flexion movement with external rotation calf
Pathologist :
- fractures : longitudinal in ,, handle basket\" dislocation
intercondilian
- cross : in ,, parrot beak\"
- horizontal cleavage
- complex : vertical fringe
symptoms:
1. Jam - now in flexion
- Absent in extension
2. Knee Swelling
- Effusion ( adult : meniscus = avascular )
- Haemarthrosis ( child : meniscus = vascularized )
3. Pain
- Spontaneous - located on the front of the knee
- Strictly localized on interliniu
- The result of: - sign Bohler , pain laterality movement with the knee in extension lime
internally torn meniscus . Pain maneuver external valgizare torn meniscus .
- Oudard sign -Jean : thumb placed on interliniu , knee flexion and
extension we live sudden pain = meniscus tear .
- Appley sign : - sick prone
- The knee flexed to 90
- Pain in the press and external rotation = internally torn
meniscus .
- Pain when pressed and internal rotation = external
meniscus tear .
- Sign is addressed posterior horn lesions .
4. SMA quadriceps reflex .
radiology :
exclude : - Osteochondral fractures
- Osteochondritis dissecans
123
- gonarthrosis intra-articular free body

Diagnosis :
Put on the basis of anamnestic , clinical and radiological .
1. Simple and grade III sprain .
2. intra-articular free body
3. Pellegrini - Stieda calcification ( internal pararotuliene )
4. condropatii rotuliene
5. subluxations rotuliene
6. femoral- patellar arthrosis
7. meniscal cyst
8. synovitis
Evolution, forecast :
Without treatment does not heal ( meniscus is fibrous cartilage formation , no utensils ) .
If broken portion is excised osteoarthritis cartilage lesions .
Treatment:
-
partial meniscectomie
Suture ( the break is 0.5 cm from the outer edge = vascularized area ) .
total Meniscectomie
Modern arthroscopy is performed by
Open joint injuries

joint wounds
Definition: any break in the skin, underlying tissue and synovial joint cavity that allow
communication with the outside.
etiopathogeny :
- superficial joints may interest all
- opening is achieved by:
- puncture
- cutting
- concussion
- Open fractures joint
- Opening takes place from the outside, with the possibility of opening inside
the articular fractures .
Pathology :
Skin lesions , subcutaneous tissue , muscles necrosis infection = gravity .
Diverticular aspect of joint maintain infection .
Happens :
Synovial peritoneum has no power of defense against infection . Haemarthrosis and
synovial fluid = excellent environment for culture, infection may develop acute, subacute ,
chronic .
124
symptoms:
- evacuation synovial fluid wound .
evolution :
There is a risk of infection acute arthritis , manifested clinically by :
- pain
- Fever 39-40
- swelling
- Liquid discharge cloudy
- Malaise
Under antibiotic slow evolution ; 10-14 days after radiography reveals signs of
osteochondritis .
Diagnosis : historical data , clinical and radiological
Treatment:
1. Wound recent joint ( uninfected )
- Tetanus prophylaxis
- Antibiotic protection
- anesthesia
- Chemical toilet - hydrogen peroxide , bleach, saline
- Toilet surgery - excision wound edges fiber finish .
- suture situation
- Plaster
The complex wounds muscle flap plasty is performed . Subsequently functional treatment
is performed in order to recover mobility.
2. Wounds complicated joint arthritis
- artrotomie
- Surgical toilet periarticular tissues devitalized
- Antibiotic treatment according to the antibiogram : by local instillation general.
125
VIII. Open fractures (FD)
Definition: fracture outbreak communication with the outside through a wound of the soft
parts or less , with a hollow organ ( bladder) . It is the most serious complication of fractures .
The frequency is high, approximately 33% of all fractures of the leg .
The mechanism :
a) FD - nafar inside - primary
- Secondary ( mobilization imprudent )
- Is punctate wound , fracture being uninfected
b ) FD dinafar- inside the vulnerable agent pierces the skin and soft tissue in proportion to its
intensity . The wound is large , afractuoas fracture being infected . These are often accompanied
by traumatic shock .
Pathology :
I. bone lesions : comminuted fractures , unstable , with significant displacement .
II . Soft tissue lesions : significant alteration periosteal
- Skin lesions : bruising , take-offs, dilacerations dieback skin necrosis .
- Injuries aponeurotic : dilacerations , tears , tears .
- Muscle injury : section, concussion , crushing , hematoma ; if he is deeply hematoma can cause
compression of the elements in that box = compartment syndrome .
- Vascular lesions spasms , injuries parietal , elongation , tear , up to acute ischemic syndrome .
- Nerve damage
FD classifications :
Cauchoix - Duparc (1957 ) :
- Type I : wounds point , linear or remotely without the risk of exposing the skeleton generated
inside - out, as benign as evolution and treatment
- Type II : various skin lesions ( wounds concussion, Takeoffs , bruising ) with the risk of skin
necrosis secondary . Their evolution is serious ;
- Type . III : loss of skin substance in the furnace + delabrri perijacente maximum . Evolution is
very serious therapeutic problem difficult .
Gustillo -Anderson (1982 ) :
- Type . III . A: Soft tissue injuries limited ;
- Type III. B: extensive soft tissue injuries ( requiring reconstructive plastic procedures ) ;
- Type . III . C: major vascular injuries ( requiring reconstructive procedures or amputation ) .
symptoms:
This is evident , with signs of certainty for fracture . Examine carefully cutaneous wound
. Vascularization and innervation is important research limb .
Radiological examination :
The binding is performed face and profile radiographs catching neighboring joints .
evolution :
126
It is dominated by the imminence of infection ( 12-15% ) , which is an inhibiting factor in

the formation of callus .
The mechanism of infection interfering with the calogenez : toxins ( streptokinase )
causes fibrin clot liquefaction protein ; cell differentiation does not occur ; destruction of alkaline
phosphatase .
complications :
I. Immediate: bleeding shock
II . Secondary infection ( tetanus, gas gangrene , sepsis , septicemia ) .
III . Tardive : - osteitis
- pseudarthrosis
- Retractions , vicious positions , joint stiffness
Treatment:
Principles:
1. sterile dressing + immobilization to the accident ( ,, first dressing decide wounded\") .
2. Transport of urgency in a qualified surgical service .
3. Transformation of FD in aseptic surgical plate
4. Immobilization rigorous bone fragments
5. Cover the primary or secondary skin defects .
A. Assistance to the accident :
Quick WC , wash with diluted detergent , skin disinfection , reintegration bone fragments
( tensile axis ) , sterile dressing , immobilization . Avoid tourniquet ( pressure dressing is
preferred ) . Administer analgesics and cardiovascular analeptics . It ensures rapid transport to
the hospital.
B. Assistance in the hospital :
The optimal range is maximum 6-8 hours after the accident . Take measures against
shock ( transfusion ) . Preparing for surgery injured limb ( washing detergents, Shaving ,
disinfection ) .
Surgery :
Type . Q: stable osteosynthesis ( closed fracture ) .
Type . II . - Thorough surgical toilet :
- antiseptic lavage
- devitalized tissue excision
- opening enclosed spaces
- regularization torn areas
- Osteosynthesis :
- intramedullary ( Kntscher rods , Ender )
- External fixator
Type . III . :
- Surgical toilet
- External fixation
Wound closure :
Type . Q: primary
Type . II . : primary
secondary
127
Type . III . : secondary

In FD shank type II -III use mioplastic coating process ( by ,, curtain muscle\") , Which
provides a focus of fracture protection without closing tightly wound , thereby allowing removal
of secretions and avoiding the formation of an outbreak of infection. Secondary cutaneous
coverage is achieved by the application of skin grafts or epithelialization .
IX. Polytrauma (PT )

Definitions:
Polifractura = association of two , three or more fractures.
polytrauma = simultaneous injuries and polyvalent ( cranial , thoracic , abdominal ,
osteoarticular , etc. )
Frequency: 42 % of accidents are polytrauma
etiology :
1. traffic accidents - Pedestrian skull , leg
- Moto calf , spine
- Auto chest , skull spine , femur
2. Train Accidents , tranva :
- Serious injury frequent amputations
3. Accidents at work : - Construction (fall) polifracturi
- Mine spine , pelvis
- Industry fractures of limbs , crushing .
4. Natural disasters (earthquakes, floods) or human ( war )
Lesional Factors :
1. Mechanical ( falls, blows, etc )
2. Physics (effect of compression , vibration , etc. )
3. chemistry
4. Terme
5. thermonuclear
Pathogenesis :
Injury by : Impacts directly
- Indirect impact ( hiperflexie followed by hyperextension , projection viscera )
Lesions are determined axial organs ( dominant ) and limb (secondary) .
PT classic syndromes :
1 of dashboard : patella fracture , supracondylar femur , diaphy femur , femoral neck , hip
dislocation .
2. The steering wheel can cause contusions thoraco- abdominal
3. projection before the head trauma causes craniofacial
4. ejection can cause brain and cranial- spinal
Anatomic- clinical forms :
1. PT predominantly cranio- spinal :
128
- Syncope : mild , reversible

- Coma : Serious
2. PT predominantly chest :
- Damage to the airways
- Cardio - pericardial lesions
3. PT predominantly abdominal septic shock
4. PT predominantly osteoarticular traumatic shock
5. PT predominantly hemorrhagic hypovolemic shock
The various mechanisms are usually interferes traumatic shock
Diagnosis:
On physical examination to determine the state of severity (shock, respiratory failure ,
acute anemia ) . It takes stock of the damage quickly and prioritizing action lesions determine the
order of treatment. Clinical examination is minimized . Radiological examination will be
comprehensive , covering all damaged areas (note column and pelvis) .
Treatment:
1. First aid is very important because after Arnaud : ,, stands a damaged, is carrying a chronic
and hospitalized a dying\".
Clearing the victim : - gentle, without panic
- Avoid spinal flexion
- The axial thrust
Maintenance respiration :
- Clearing the airway
- Mouth to mouth
Haemostasis :
- Direct compression
- Pressure dressing
- . Garou (maximum 1.5 hours)
2. Control Centre :
Therapeutic measures :
a) The first emergency : up to 45 minutes
- haemostasis
- Restoring respiratory ( breathing assisted oxygen )
- Puncture and catheterization of vene- infusions of macromolecular solutions , trasfuzii
- Detection of abdominal or pleural puncture bleeding
- Assessment of head injuries brain
b ) The urgency of the second :
- Fixing rib flap
- extradural hematoma evacuation
- Exploratory laparotomy
- Catheterization
- Fixation of a fracture
- Reduction of dislocations
3. secondary phase of stabilization and re- injury :
- Is carried out within 5-7 days
129
- Is dominated by : traumatic shock ( organic reaction phase ) , injuries ( maintain and

worsen shock )
Classification:
Is based on the association with fractures and injuries dominant PT
A.1.PT. cranio - cerebral dominance with :
Priority: shock treatment of head and brain damage .
a) Coma serious (st . III -IV ) : therapeutic abstention ( temporary immobilization
splint or continuous extension ) ;
b) Easy Coma (st . I- II ) treated emergencies ( open fracture , fracture - dislocation
etc ) .
Definitive treatment of fractures is done by solving brain (note : in cranio-cerebral trauma
bone consolidation is faster therapeutic difficulties ) .
A.II. PT . thoraco -pulmonary predominantly :
a) simple trauma ( rib fractures ) without respiratory failure , priority treatment limb
fractures .
b ) serious trauma ( rib flap ) with respiratory failure , priority treatment thoraco pulmonary lesions , lesions resolve realizing limbs after a few days .
A.III.PT. predominantly abdominal :
+ Solving exploratory laparotomy is associated fractures in the same operative session .
A.IV.PT. with spinal cord injury :
predominant stabilization of vertebral lesions . In practice fracture of neck pain is
continuous traction ( Crutchfield ) , halo plaster or gypsum Minerva . In fractures of the lumbar
spine column practiced 45 days bed rest or plaster corset .
A. V. PT . with hip fractures with complications:
Factors Severity :
- Bleeding ( retroperitoneal hematoma , requiring laparotomy for achieving hemostasis in severe
cases )
- Visceral lesions digestive or urinary. Concurrent treatment associated lesions or later.
B. PT . dominant limb injuries or polifracturi :
a) measures and recovery deocare
b ) therapeutic program for solving fractures
Conduct current ideal is to solve all bone lesions in a single operative session (1-3 teams
operators )
Particular situations :
- vascular lesions
- open fractures
- tears in the States
- amputation of limb reimplantation opportunity .
130

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Course Orthopaedics Traumatology

Course Orthopaedics Traumatology

Fig . one.1- Simbolul orthopedics

Course Orthopaedics Traumatology

Course Orthopaedics Traumatology

Fig . 1.2 - osteocyte incorporated into the bone

Course Orthopaedics Traumatology

osteoporosisUm or pathologicalUm, osteocyte returns to form osteoblastUnder the influence of

Fig . 1.4 - osteoclastic bone resorption with a lacunar area

Course Orthopaedics Traumatology

Fig . 1.5- picture collagen fibers in bone structure (

B. bone structure as organ

Course Orthopaedics Traumatology

Fig.1.6 - Systemmany Haversian - Graphic and electron microscopic appearance

Fig . 1 .7 - Trabecular structure of the cancellous bone in the calcaneus

Course Orthopaedics Traumatology

Fig . 1.8 - vascularization of bone - after Meyer - Bone and cartilage

Course Orthopaedics Traumatology

Course Orthopaedics Traumatology

pattern of embryonic cartilage in two ways: osteogenesis surface ( realized by pericondrului )

Fig.1.9 - stages of bone formation

Onesteogeneza continues throughout intra- uterine life , transform pericondrulNDU into

Fig . 1.10 - cartilage growth in the

Course Orthopaedics Traumatology

(hydrated tricalcium phosphate , prepared as crystalstheir hexagonal hydroxyapatite Such

Course Orthopaedics Traumatology

Fig . 1 .11 - A) - accumulation fracture hematoma

Course Orthopaedics Traumatology

Fig . 1.13 - Morphological aspects of primitive callus

Course Orthopaedics Traumatology

Fig . 1.14 - Progression of bone

primitive callus is presented in four types morphological ( see Fig . 1.15):

Course Orthopaedics Traumatology

Fig . 1.15- callus morphological primitive

4. Calcification final phase and remodeling

Fig . 1.16 - remodeling phase , the morphological appearance of mature

Course Orthopaedics Traumatology

Fig . 1.17 - structural remodeling of callus ( callus callus grown primitive )

The evolution of fractures to strengthen - may occur in two ways:

Course Orthopaedics Traumatology

Fig 1.19 - histological aspects of primary ossification

Fig . 1.20 - bifocal fracture of the leg , healed by

Course Orthopaedics Traumatology

definition: FRACTURE is a lack of break in the bone, produced after of trauma .

Fig.2.1 - Types of fractures ( bone normal and pathological

Course Orthopaedics Traumatology

disruption occurs in the bone diaphysis as a

Fig . 2.3 - deflection

Course Orthopaedics Traumatology

by torsion ( twist ) are produced

Fig . 2.4 - Torsion

prin traction ( avulsion, avulsion):

Fig . 2.5 - Thrust

In some cases of fractures, traumatic mechanisms acting agent can be mixed ( +

Course Orthopaedics Traumatology

Fig . 2.6 - metaphyseal compression \" in

Fig . 2.8 - compression fractures in the external tibial

Course Orthopaedics Traumatology

fisura ( compression ) , resulting from

metaphyseal ( juxta -articular )

Usually , if a diaphyseal fractures with headquarters , to locate accurate as of the

Course Orthopaedics Traumatology

B. after TRAIECT may be: