Chapter

1
Fractures and dislocations are as old as mankind.
Hippocrates, in his corpus Hippocratus (300 BC) has talked
about the diagnosis and treatment of fractures and
dislocations. Even then, first aid was a priority, and it was
recognized that many complications could be averted with
emergent primary management. Dislocations are slightly
different from fractures, and despite us knowing about them
for many millennia, (Kochers method for reduction of
dislocated shoulder is 3000 years old and still popular), these
are often left unreduced too long. The problem often is a
delay in diagnosis!
An understanding of the basics of orthopedic injuries is
essential for appropriate first aid. By definition, a fracture is
a structural break in the normal continuity of bone whereas
dislocation is total disruption of a joint with no remaining
contact between the articular surfaces. In the 21st century,
advances in automation, better highways, faster cars and
overcrowding, etc. have multiplied the incidence of trauma
manifold. This is one of the most serious public health
hazards of modern civilization, and newly developing
economies, with poor infrastructure, but more and more
automobiles and machines, are especially at risk.
Patients disabled with fractures or dislocations, or their
complications are unable to earn a livelihood; we all know
that the most effective management of orthopedic trauma
starts when the medical personnel initially come in contact
with the trauma victim. Early recognition of the extent,
nature and potential problems of orthopedic injuries, as well
as the early appropriate treatment of fractures or dislocations

Introduction to Fractures
and Dislocations

MS Dhillon, Sarvdeep S Dhatt

will not only stabilize the patient, but will make all
subsequent management protocols easier.
Susruta, the father of surgery described 12 types of
fractures and 6 types of dislocations, 2500 years ago, when
he practiced and taught surgery in Varanasi, India. Etiology
of fractures and dislocations as described by Susruta in his
treatise Susruta Samhita are falls, compression, blows and
throwing. His book (written in Sanskrit) describes 12 types
of fractures:
1. KarkatakaFracture with hematoma
2. AsvakarnaOblique fracture
3. CurnitaComminuted fracture
4. PiccitaCompression fracture
5. Asthichalita Subperiosteal hematoma
6. KandabhagnaTransverse fracture
7. MajjanugataImpacted fracture
8. AtipatitaComplete fracture
9. VakraGreenstick fracture
10. Chinna Incomplete fracture
11. PatitaCrack fracture
12. SphutitaFissured fracture.
He also described six types of dislocations with direction
of their displacements. In a broader sense, the pattern of
fractures he described years ago remains the same, even today.
However, now in addition to the above described types, we
have the peri-implant and periprosthetic fractures.

First Aid and Emergency Management in Orthopedic Injuries

For the Emergency Medical Officer, a basic

understanding of fractures is essential to be able to pick
them up, to be able to understand their nature and potential
expected problems during their course of treatment, as well
as to be able to apply first aid measures.
Basically, fractures can be classified according to:
A. Etiology
B. Pattern of fracture
C. Nature of fracture.

CLASSIFICATION BASED ON ETIOLOGY

Based on etiology, fractures may be of three types:
1. Trauma or injury: A fracture sustained due to trauma is
called a traumatic fracture. It can be caused by a direct
injury as in a road traffic accident or a blow, etc. Indirect
injury can cause fracture by a force transmitted along
the bone, e.g. a fall on outstretched hand can cause
fracture of head of the radius.
2. Fatigue fracture: These fractures occur from repetitive
stress. This is similar to the fatigue fractures that occur in
metals. These fractures are mostly confined to the bones
of lower limb and ascribed to prolonged walking, running
or athletic activities. Some of the common fatigue fractures
are fractures of 2nd metatarsal, fibula, tibia or of neck of
femur. These occur mostly in sportsmen, but should be a
diagnosis that comes to mind in elderly people also.
Fracture of 2nd metatarsal is also known as March fracture
as it is found in fresh army recruits who march excessively
without being properly trained.
3. Pathological fracture: This term is applied to a fracture
through a bone already weakened by disease. Often the
bone gets fractured spontaneously or from a trivial
trauma. In contrast to the traumatic fractures, these
fractures are minimally displaced and often go into nonunion. The various pathological conditions responsible
for pathological fractures may be osteoporosis,
osteomalacia, osteopenia, Pagets disease, osteogenesis
imperfecta, fibrous dysplasia, primary benign or
malignant bone tumors or secondaries of a carcinoma.

CLASSIFICATION BASED ON
OF FRACTURE

THE

PATTERN

Fracture can be classified according to the shape or pattern

of the fractured fragments or surfaces. The fracture may

have a combination of two or more of the patterns. This

classification indicates the nature of the causative violence
and also gives an indication of the likely stability of the
fragments. This helps the surgeon in making decision
about the various forms of fixation methods (Figs 1.1 to
1.9). These may be:
1. Transverse fracture: It is caused by angulation or bending
force. The fracture line is perpendicular to the long axis
of the bone.
2. Oblique fracture: The fracture is caused by a bending
force, which in addition has a component along the long
axis and as the name suggests, the fracture line is oblique
or slanting.
3. Spiral fracture: It is caused by a twisting or torsional force
and the fracture line runs spirally in more than one plane.
4. Comminuted fracture: It is caused by a severe direct force
and the fractured bone has multiple fragments.
5. Compression or crush fracture: Fracture occurs in spongy
bones, which get compressed and cannot be restored fully
to its original form, e.g. vertebra, calcaneum.
6. Segmental fracture: In this type, there are two or more
fractures in one bone, but at different levels.
7. Greenstick fracture: In this type, the bones do not break
completely; the inner cortex bends while the outer breaks.
These fractures are peculiar to children as their bones
are more resilient and springy and can withstand greater
deformation without fracture. This can be likened to
the pole used in pole vaulting. Also, the bone of this
type can be crumpled like a concertina by a longitudinal
compression force and such a fracture is termed as Torus
fracture.
8. Avulsion fracture: This can occur when a piece of bone
detaches from the main bone usually because of being
torn by the tendon attaching muscle to bone. For
example, the avulsion of peroneus brevis tendon from
the base of 5th metatarsal.
9. Peri-implant or periprosthetic fracture: The fractures
which occur at one end of an implant, whether an
intramedullary nail or plate are known as peri-implant
fractures. As the name implies, fractures that occur near
the end of prosthesis, whether hip or knee prosthesis are
known as periprosthetic fractures. With more number
of joint replacements and implant surgeries taking place,
periprosthetic fractures have thrown a new challenge to
the orthopedic surgeon.

Introduction to Fractures and Dislocations

Fig. 1.1: Transverse fracture.

Fig. 1.4: Comminuted distal femur fracture.

Fig. 1.2: Oblique fracture.

Fig. 1.5: Compressioncrush fracture.

Fig. 1.3: Spiral fracture.

Fig. 1.6: Segmental humerus fracture.

First Aid and Emergency Management in Orthopedic Injuries

Fig. 1.7: Greenstick fracture.

Fig. 1.8: Avulsion fracture tibial spine.

CLASSIFICATION BASED
OF FRACTURE

ON THE

NATURE

They can be of two types:

1. Simple or closed fractures: Fracture is simple or closed
when there is no communication between the site of
fracture and the exterior of the body, i.e. the overlying
skin and soft tissues are intact. Importantly, a badly
comminuted fracture without any break in the skin will
still be called a simple fracture. For most closed fractures,

Fig. 1.9: Periprosthetic fracture.

treatment with casts or surgery can be delayed till the

patient is fit for anesthesia.
2. Open (compound) fracture: A fracture is open or
compound when there is a wound communicating to
the fracture. It is not merely the presence of the wound
but direct communication between the wound and
fracture that is important for it to be termed as open
fracture. If the sharp fracture-end pierces the skin from
within, resulting in an open fracture, then it is termed as
internal compounding (Fig. 1.10). If the object causing
the fracture lacerates the skin and soft tissues over the
bone as it breaks the bone, resulting in an open fracture,
it is termed as external compounding. The risk of
infection (Fig. 1.11) is more in the external compound
fractures. Open fractures need to be treated immediately
with surgery to carefully clean and close the wound.
Massive open fractures with great losses of the skin,
muscle, and blood supply to the bone are the most serious
and difficult to treat. Nowadays, the term compound
fractures has been largely replaced by open fractures.

JOINT DISLOCATIONS
A joint is dislocated when its articular surfaces are wholly
displaced, one from the other so that all apposition in
between them is lost. A joint is subluxated when its articular
surfaces are partly displaced but retain some contact between

Introduction to Fractures and Dislocations

Fig. 1.10: Grade I open wound.

(For color version, see Plate 1)

Fig. 1.12: Shoulder dislocation.

Fig. 1.11: Grade 3 open femur fracture.

(For color version, see Plate 1)

them. Dislocations and subluxations may be classified on

the basis of etiology into following types:
1. Congenital dislocation: It is a condition where a joint is
dislocated from birth, e.g. congenital dislocations of hip
or knee.
2. Traumatic dislocation: Injury is by far the most common
cause of dislocation and subluxation of the joints.
Common joint dislocations involve the shoulder, hip,
elbow, ankle and interphalangeal joints. In many cases,
dislocation or subluxation is associated with a fracture.
When this occurs, the injury is termed as fracturedislocation or fracture-subluxation. In some joints, the
supporting structures like the capsule and ligaments do
not heal properly after the primary dislocation if there is
inadequate initial care, leading to subsequent instability;
this causes repeated subluxations or instability, or even a
recurrence of dislocation, many times after trivial trauma

Fig. 1.13: Pathological dislocation hip with resorption of

head and neck.

or even after certain movements within the normal range.

This is termed as recurrent dislocation, and the shoulder
joint is the most common site for the development of
this problem (Fig. 1.12).
3. Pathological dislocation: The articulating surfaces
forming a joint may be destroyed by an infective or a
neoplastic process, or the ligaments may be damaged
due to some disease. This results in dislocation or
subluxation of the joint without any trauma. In
underdeveloped countries, tuberculosis is the leading
cause of such pathological dislocations, e.g. dislocation
of the hip joint (Fig. 1.13).

First Aid and Emergency Management in Orthopedic Injuries

4. Voluntary dislocation: Some individuals have hyperlax

joints by birth or some may have connective tissue
disorders such as Ehlers-Danlos syndrome, and they can
subluxate or dislocate some of their joints at will. Such
individuals are labeled as voluntary dislocators. However,
these individuals may be thought to be psychic cases,
and hence the term used nowadays for such a dislocation
is demonstrable dislocation.
This generalized and rather simplistic overview gives us
a fair idea about the diversity, severity, and nature of fractures
and dislocations. Management concepts are based on this,
and emergency treatment starts when the doctor first
evaluates the patient. We must realize that fractures can range
from a small, easily missed crack as a greenstick fracture to
a massive, life-threatening break of the pelvis. Emergency
Medical personnel should understand that serious injuries,

including injuries to the skin, nerves, blood vessels, muscles,

and organs, may occur at the same time as the fracture;
these injuries in addition to being life threatening can
complicate fracture treatment. All breaks in bone are
associated with internal bleeding, as blood vessels and tissues
are damaged internally. The bigger the bone, more the blood
loss, and the saying in most emergency rooms is that when
we see a fracture of the femoral shaft with displacement,
give 2 liters of fluid and a minimum of one pint of blood!
Fracture associated blood loss often leads to shock, and pelvic
fracture cases could bleed to death.
A suspected fracture should never be ignored since it
may lead to permanent disfigurement. Details will be
discussed in the following chapters. We end this chapter by
saying, If you are not sure whether a bone is fractured,
treat the injury as a fracture.