Health Articles

Symptoms, Signs, and Classification
These fractures usually result from a fall, often on level ground. Physical examination of a displaced fracture shows the leg to be shortened and externally rotated from the pull of the leg muscles and gravity Hemorrhage from multiple bone fragments and associated soft tissue injuries can be extensive and may cause hypovolemic shock.
Intertrochanteric hip fractures are classified by the number of bony fragments and by the inherent stability (the ability to maintain continuity of the weight-bearing medial femoral cortex). Typically with two-part fractures, a single break slopes obliquely between the greater and lesser trochanters on the anteroposterior x-ray view (see FIG. 8-5). Three-part fractures also have a lesser trochanteric fragment, and four part fractures have a greater trochanteric fragment. As a rule, three-and four-part fractures are inherently unstable because of comminution of the medial femoral cortex. Fractures in the intertrochanteric region of the proximal femur usually allow adequate blood supply to all fragments; thus, osteonecrosis and nonunion rarely occur.
Treatment and Prognosis
Intertrochanteric hip fractures are treated by surgical stabilization unless an absolute medical contraindication exists or the patient is nonambulatory and demented, with limited pain perception. Traction does produce healing, but it usually takes 4 to 8 wk and introduces the risks of prolonged bed rest. Also, traction may not adequately control the deforming muscle forces around the hip, so that the bone may heal in a shortened and externally rotated position, producing a poor functional result.
The most common fixation device is the sliding compression hip screw, which provides rigid stabilization while impacting the fracture fragments, thus ensuring healing (see FIG. 8-6). Postoperatively, most patients can immediately begin full weight-bearing ambulation with a walker. Usually, they are able to use a cane in 6 to 12 wk.

Symptoms, Signs, and Classification
These fractures can be classified as occult, impacted, displaced, or nondisplaced. Occult fractures may occur in the elderly after little or no apparent trauma. The patient complains of persistent groin pain on weight bearing. A crack, initially undetectable on x-ray, can continue to propagate across the femoral neck with the cyclic stresses of walking. Weight bearing must be avoided, or eventually, complete displacement can occur. Bone scans or magnetic resonance imaging reveals the fracture before x-rays.
Patients with impacted and nondisplaced femoral neck fractures also present with groin pain and no deformity on physical examination. The Garden classification system describes the extent of impaction and displacement of hip fractures. X-rays of impacted fractures (Garden I) show the femoral head slightly tilted inward (valgus deformity) with an incomplete fracture line, leaving the medial cortex intact. Nondisplaced fractures extending across both cortices of the femoral neck (Garden II) are more unstable. Patients with displaced femoral neck fractures (Garden III and IV) present with groin pain and a shortened, externally rotated leg that is too painful to move (see FIG. 8-1).
The Garden classification reflects the degree of disruption of the blood supply to the femoral head and has crucial implications for treatment and prognosis. Because the femoral head is intra-articular, its sole
blood supply comes from vessels traversing three structures: the bone of the femoral neck, the surrounding hip capsule, and the ligamentum teres (see FIG. 8-2). A displaced fracture completely disrupts the blood vessels of the femoral neck and can tear those of the hip capsule. The vessels in the ligamentum teres do not function in % of adults. Thus, a displaced fracture often completely devascularizes the femoral head. Although a devascularized femoral head can heal if securely stabilized, poor healing is common. Nonunion occurs in 15% to 20% of patients, and osteonecrosis of the femoral head occurs in another 15% to 30%.
Treatment and Prognosis
Occult, impacted, and nondisplaced femoral neck fractures are usually treated by internal fixation with multiple pins (see FIG. 8-3). This stabilization permits immediate full weight-bearing ambulation and prevents later displacement. Since the blood supply to the femoral head is not significantly disrupted, these fractures usually heal well. Nonambulatory, demented patients who have limited pain perception can be treated with bed rest followed by transfer from bed to chair.
Displaced fractures have two main treatment options—operative stabilization and prosthetic replacement. Each has advantages and disadvantages. Open reduction and internal fixation is usually reserved for vigorous patients < 70 yr of age who are able to comply with a postoperative regimen of limited weight bearing using crutches. The procedure preserves the femoral head, and with successful healing, the hip is nearly normal. However, if osteonecrosis or nonunion occurs, the result is a painful, nonfunctional joint that requires total hip replacement. For this reason, less active elderly patients with displaced fractures often undergo primary prosthetic replacement of the femoral head (hemiarthroplasty). This permits immediate, full weight bearing and a faster return to independent functioning with a minimum chance of needing a second procedure.
The simplest prosthesis (the Moore prosthesis) consists of a smooth metal sphere attached to a stem that is wedged into the medullary canal of the femur (see FIG. 8-4). Drawbacks include a tendency to wear away the acetabular articular surface and pain from a loose fit of the stem in the femoral medullary canal. A loose fit can be remedied by a prosthesis designed to be stabilized inside the femur with either acrylic cement or a special coating of hydroxyapatite or porous metal that facilitates direct bone fixation. A bipolar prosthesis with an internal metal-polyethylene bearing can reduce acetabular wear. Patients who develop acetabular arthritis may require total hip replacement. Primary total hip replacement in acute femoral neck fractures is reserved for patients with severe preexisting arthritis because this more extensive operation has a higher morbidity than either hemiarthroplasty or internal fixation with pins.

Symptoms, Signs, and Diagnosis
The usual mechanism of injury is a fall on level ground. Patients present with pain and are unable to walk. Physical examination reveals localized tenderness in the groin and pain on leg movement. The clinical appearance mimics a proximal femoral fracture; diagnosis is made by x-ray. Usually, only a single ramus is fractured, with the pubic ramus breaking twice as often as the ischiatic ramus. Less commonly, two or more rami fracture, either on the same or on opposite sides of the symphysis pubis.
Normally, the pelvis bears weight mainly on the strong bony arches in the ilium, with the pubic and ischiatic rami acting as secondary tie arches. When the pelvis suffers trauma, the rami tend to fracture first, weakening the secondary tie arches but leaving the main iliac weight-bearing arches intact.
Treatment and Prognosis
Hospitalization is usually required because most patients are initially unable to stand or sit without considerable pain. Analgesics and nonsteroidal anti-inflammatory drugs help. To avoid the complications associated with bed confinement, patients should be encouraged to begin full weight-bearing ambulation as soon as possible. Most are able to walk with a walker by 1 wk. Pubic ramus fractures typically heal without causing permanent functional disabilities.

In 1814, Abraham Colles first described the classic silver fork deformity of the wrist. A Colles fracture occurs when the dorsal trabecular bone of the distal radius impacts into itself, resulting in angulation and shortening. Patients present with pain, tenderness, and swelling of the wrist. The mechanism of injury is usually a fall on an outstretched hand.
Treatment and Prognosis
The severity of the fracture and need for reduction are assessed ra-diographically. Ideally, on the anteroposterior view, shortening of the radial styloid should be < 0.5 cm compared with the ulna. On the lateral view, dorsal tilting of the distal radius articular surface should not go beyond neutral. Patients with minimally displaced fractures or low functional demands are treated with a short arm cast or splint. When a fracture requires closed reduction, anesthesia is necessary. A local lidocaine injection with hematoma aspiration may be sufficient, but regional or IV general anesthesia is superior for relaxation and analgesia. Fractures with severe shortening or intra-articular comminution may require external fixation. In the operating room, pins are inserted through the skin into the metacarpals and proximal radius or ulna. Next, a metal external frame or plaster cast is applied to the pins to maintain the fracture reduction.
The most frequent complication of distal radius fractures is finger and shoulder stiffness. Thus, active motion of the fingers, elbow, and shoulder should be strongly encouraged. Elevating the hand above the level of the heart minimizes swelling. Cast immobilization is usually maintained for 3 to 8 wk, depending on the fracture’s stability. Patients can expect pain to gradually diminish and wrist weakness to remain for 6 to 12 mo after the injury. Physical therapy may help speed recovery. Most patients eventually regain satisfactory pain-free function.

Symptoms, Signs, and Diagnosis
The most common mechanism of injury is a fall on an outstretched hand. Patients present with shoulder pain and an inability to move the arm. On x-ray, the proximal humerus may show as many as four separate fragments: eg, an articular fragment containing the humeral head, a greater tuberosity fragment, a lesser tuberosity fragment, and a distal fragment including the humeral shaft. These fragments are prone to displacement because of the pull of the supraspinous, subscapular, and pectoral muscles. Displaced fractures are classified according to increasing order of severity into two-, three-, and four-part patterns. Fortunately, about 80% of proximal humerus fractures are minimally displaced, with < 45° angulation and < 1 cm displacement of any fragment. When displaced, the articular fragment may not lie in a satisfactory posture above the humeral shaft, as shown on anteroposterior and lateral x-rays. Fractures associated with a glenohumeral dislocation usually result from major trauma and constitute the most severe injuries.
Treatment and Prognosis
Treatment and prognosis depend on the number of fragments and the extent of displacement. Patients should be told to expect considerable swelling and discoloration that will spread to the lower arm and hand. If the alignment and position of the fragments are satisfactory, the arm may simply be immobilized in a sling. Otherwise, an orthopedist may attempt closed reduction. If satisfactory alignment cannot be achieved by manipulation, open reduction with internal fixation or insertion of a prosthetic replacement may be indicated.
Beginning range-of-motion exercises as soon as possible is essential (see Ch. 29). The most common complication after a shoulder fracture is adhesive capsulitis, which results from approximation of the inflamed surfaces of the joint capsule. Capsulitis can cause chronic pain and functional disability because of restricted motion.
For a stable two-part fracture, active motion and use of the hand and wrist should be encouraged immediately. A physical therapist should give instructions and monitor exercises. At 1 wk, pendulum exercises in the sling should begin. The patient leans forward and, using the noninjured arm to assist, swings the injured arm like a pendulum, making circles with the elbow. The sling may be removed daily to allow bathing and elbow motion. By 2 wk, the patient should begin active and passive arm elevation. Regaining the ability to perform overhead activities, such as combing hair, may take several months.

Fractures of the proximal humerus, distal radius, pelvic ramus, proximal femur, proximal tibia, and thoracic and lumbar vertebral bodies occur more commonly in the elderly. These sites consist of predominantly trabecular bone, often seriously weakened by osteoporosis.
Most of these fractures, except those involving the hip, are treated nonoperatively. Nonetheless, rehabilitation is often prolonged, and recovery is incomplete (see also Ch. 29). Usually, several months to a year passes before patients regain their preinjury capabilities.

Although microscopic fat emboli accompany most femoral fractures, overt symptoms and signs develop in only about 2%. Usually occurring 2 to 3 days after fracture, fat embolism syndrome includes at least one of these major signs: respiratory insufficiency, drowsiness and confusion, petechial rash. Minor signs include pyrexia, tachycardia, retinal changes, jaundice, renal changes, thrombocytopenia, and an elevated erythrocyte sedimentation rate. Chest x-ray shows variable streaks and infiltrates associated with overt pulmonary edema in 33% of patients. Prothrombin time and activated partial thromboplastin time are also mildly elevated. In some patients, adult respiratory distress syndrome with noncardiac pulmonary edema and clinically significant disseminated intravascular coagulation occur. A hyperacute syndrome may result in death secondary to emboli of the coronary arteries and brain.
Treatment of fat embolism syndrome is aimed at respiratory support. Corticosteroids are often used, although their efficacy is unproved. Fortunately, the mortality rate is only about 8%, compared with that of 50% for most other causes of adult respiratory distress syndrome.

Pulmonary embolism is the most frequent fatal complication following leg trauma. Autopsies have shown that 38% of patients who die after hip fracture die of pulmonary embolism. Among patients with hip fractures who are not given anticoagulant therapy, about 50% develop deep venous thrombosis; about 10%, pulmonary emboli; and about 2%, fatal pulmonary emboli. The major predisposing factors for deep venous thrombosis are advanced age, leg trauma or surgery, history of deep venous thrombosis, immobilization, malignancy, and obesity. The associated clinical findings—pain, swelling, tenderness, Homans’ sign (pain on forced dorsiflexion of the foot), fever, and leukocytosis—are unreliable criteria for making a diagnosis. Venography remains the standard test, while ultrasonography has become the most effective noninvasive study for detecting deep venous thrombosis.
Ideally, patients with a femoral or pelvic fracture should begin prophylactic anticoagulant therapy for thromboembolic disease on admission and continue therapy until they are ambulatory. For orthopedic patients at high risk for deep venous thrombosis (eg, those with hip fractures), warfarin and dextran have traditionally been considered the most effective prophylactic agents. Neither aspirin, low-dose heparin, nor external pneumatic boot compression provides as much protection. If warfarin is used, the initial dose should be between 2.5 and 10 mg, depending on the patient’s age and weight. Subsequent daily doses are given to maintain prothrombin time at about 1.2 to 1.4 times control. A history of recent gastrointestinal bleeding, malignancy, bleeding tendencies, or stroke is a relative contraindication to anticoagulation. Newer agents such as low-molecular-weight heparin and heparinoids may be as effective as warfarin with a lower incidence of bleeding.

Compartmental, or closed-space, syndrome is the most frequent limb-threatening complication associated with extremity trauma. Swelling of injured muscle within a compartment surrounded by an unyielding envelope, such as fascia or a cast, leads to elevated tissue pressures that block normal perfusion. The resulting ischemia leads to further muscle injury and swelling and higher tissue pressures. The only solution to this ever-intensifying cycle is to remove all confining envelopes around the swollen muscular compartment. Thus, whenever patients complain of increasing pain or distal numbness in an immobilized, injured extremity, their casts, splints, and dressings must be thoroughly loosened immediately. If the muscle swelling has increased to the point that the surrounding fascia has become a constricting envelope, an emergency fasciotomy must be performed. Even a few hours of muscle ischemia can lead to irreversible injury and necrosis.
The most reliable clinical signs of impending compartmental syndrome are progressively increasing pain in an immobilized extremity, pain with passive flexion or extension of the toes or fingers, and numbness in a specific peripheral nerve distribution. The presence of distal pulses in a limb does not exclude compartmental syndrome; muscle necrosis and irreversible nerve damage occur at tissue pressures much lower than those required to obliterate arterial inflow. A definitive diagnosis of compartmental syndrome can be made using a device that percutaneously measures intramuscular pressures.

Initial immobilization of injured extremities prevents further damage before definitive stabilization can be achieved. Movement of sharp fracture ends can cause serious soft tissue trauma and even skin puncture, converting a closed injury to an open one. Immobilization also facilitates transport of patients and relieves pain, thus decreasing the need for narcotic analgesics.
Injuries located about or distal to the knee or elbow can usually be immobilized initially with splints. A wide variety of splints are available, including those made of preformed aluminum or plastic, those made of inflatable clear plastic, and those that are easily adjustable with Velcro closures. Plaster of Paris (calcium sulfate hemihydrate) splints molded individually for patients provide the best support. All splints are best applied by an assistant while the injured extremity is held with gentle longitudinal traction.
Most injuries of the shoulder, upper arm, and elbow can be immobilized effectively with a sling. If needed, the arm can be kept close to the body with an elastic wrap or swath. Hip fractures can be immobilized by careful positioning with pillows or by light skin traction.
Casts are used to control the alignment of a fracture while it heals. Traditionally, casts are made of rolls of stiff muslin impregnated with plaster of Paris. Inexpensive and easy to mold, plaster is often used for initial casts and for those that need frequent changing. Plaster casts are relatively heavy, deteriorate with excessive or prolonged use, and weaken when wet. Cast materials made of polymeric resins and fiberglass are stronger, stiffer, and half as heavy as plaster casts. Water will not weaken the cast itself, but if the underlying padding becomes wet, the cast must be changed to prevent skin maceration.
To provide complete immobilization, the cast must extend across one joint above and one joint below the fracture site. Thus for a distal radial fracture, the cast should extend from above the elbow to just proximal to the metatarsal joint; however, because joint stiffness is a major problem in the elderly, the cast is often made to end below the elbow, allowing joint motion.
Patients with casts must be given detailed instructions. For the first 24 to 48 h after the injury, the extremity should be elevated to prevent swelling. Rhythmic flexion and extension of the fingers or wiggling of the toes should be encouraged to facilitate venous return. The patient should immediately report progressive or unrelenting pain, pressure, or numbness in the affected extremity because swelling within an unyielding circular cast can cause enough pressure to stop tissue perfusion, creating compartmental syndrome (see below).
Traction is used in the elderly only when no satisfactory alternative exists, eg, if the fracture is too fragmented for a cast or surgical stabilization or if the patient’s medical condition will not permit surgery. Complications of traction include pressure sores, deep venous thrombosis, pulmonary embolism, depression, disorientation, loss of appetite, deconditioning, atelectasis, and pulmonary infection. Meticulous, aggressive nursing care is required during traction.
Skin traction is particularly hazardous in the elderly. Its only indication is to provide temporary, gentle restraint of the extremity for comfort. Such traction is applied using foam boots or carefully wrapped moleskin strips, a sash cord, and a pulley with a 5-lb weight. A weight > 5 lb should never be used. Vigilant monitoring is required. The strong, prolonged traction needed to maintain bone alignment must not be applied with skin traction but rather with the use of skeletal pins. The proximal tibia is the most common traction pin site for femoral and acetabular fractures.
Operative stabilization of fractures can offer dramatic benefits in elderly patients. Those with hip fractures, for instance, can usually begin walking within days after surgery. The risks of surgery are small compared with those of prolonged traction, especially for leg fractures.
Despite these advantages, surgical treatment of most fractures should be postponed until acute medical problems can be corrected. Only fractures associated with such limb-threatening conditions as impending compartmental syndrome, neurovascular compromise, or open wounds require urgent treatment. Furthermore, some conditions are relative contraindications to surgery. Sepsis could lead to infection of the operative site and prohibits the use of metallic implants. Severely osteoporotic bone has poor mechanical properties, and the hardware used in operative stabilization will become displaced if it does not have a secure hold in the bone.
A deep postoperative wound infection, a serious complication, frequently requires removal of all implanted hardware, prolonged daily dressing changes, and weeks of IV antibiotics. Prophylactic antibiotics can reduce the incidence of postoperative infections in hip fracture patients to about 1%. A cephalosporin is the agent of choice; an appropriate regimen is cefazolin 1 gm given IV during the hour before surgery, followed by 1 gm q 8 h for the next 24 h.