Femur Posterior Angulation

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40. Describing the deformity: If there is no deformity, i.e. il'lhe violence which has produced the fracture has been insufficient to cause any movement of the bone ends relative to one another, then the fracture is said to be in anatomical position. Similarly, if a perfect position has been achieved after manipulation of a fracture, it may be described as being in anatomical position.

41. Displacement (a): Displacement (or translation) is present if the bone ends have shifted relative to one another. The direction of displacement is described in terms of movement of the distal fragment. For example, in these fractures of the femoral shaft at the junction of the middle and distal thirds, there is (I) no displacement. (2) lateral displacement. (3) posterior displacement. (4) both lateral and posterior displacement.

42. Displacement (b): Apart from the direction of displacement, the degree must be considered. A rough estimate is usually made of the percentage of the fracture surfaces in contact, e.g. ( I ) 50% bony apposition. (2) 25% bony apposition. Good bony apposition encourages stability and union.

Delay Union Fracture

43. Displacement (c): When- none of the fracture surfaces is in contact, the fracture is described as having 'no bony apposition' or being 'completely off-ended'. Off-ended fractures are: I. Potentially unstable; 2. Liable to progressive shortening: 3. Liable to delay or difficulty in union: 4. Often hard to reduce, sometimes due to trapping of soft tissue between the bone ends.

46. Angulation (b): Equally acceptable, and perhaps less liable to error, would be to describe these fractures in the following way: (I) a fracture of the middle third of the femur with the distal fragment tilted laterally, (2) a fracture of the tibia and fibula in the middle thirds, with the distal fragment tilled anteriorly.

44. Displacement (d): (I) Displacement of a spiral or oblique fracture will result in shortening. Displacement of transverse fractures (2) will result in shortening only after loss of bony contact. The amount of shortening may be assessed from the radiographs (if an allowance is made for magnification). Speaking generally, displacement, whilst undesirable, is of much less significance than angulation.

Dorsal Angulation

47. Angulation (c): Significant angulation must always be corrected for several reasons. Deformity of the limb will be conspicuous (I) and regarded (often correctly) by the patient as a sign of poor trealmenl. Deformity from displacement (2) is seldom very obvious. In the upper limb, function may be seriously impaired, especially in forearm fractures where pronation/supination may be badly affected (3).

45. Angulation (a): The accepted method of describing angulation is in terms of the position of the point of the angle, e.g. (I) fracture of the femur with medial angulation, (2) fracture of the tibia and fibula with posterior angulation (both arc midshaft fractures). This method can on occasion give rise to confusion, especially as deformity is described in terms of the distal fragment.

Distal Femur Fracture Protocol

48. Angulation (d): In the lower limb, alteration of the plane of movements of the hip, knee or ankle may lead to abnormal joint stresses, leading to the rapid onset of secondary osteoarthritis.

Chinese Arm DeformatiesPosterior Angulated Femoral StemSecondary Fracture Prevention

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