Multifragmental fractures are

generally the result of greater violence than is the case with most simple fractures, and consequently there is an increased risk of damage to neighbouring muscle, blood vessels and skin (I). The fractures tend to he unstable, and delayed union and joint stiffness are common. Segmental fractures are often difficult to reduce by closed methods, anil direct exposure may threaten the precarious blixid supply to the central segment. Non-union at one level is not uncommon in these fractures (2).

31. Avulsion fractures (b): Avulsion fractures may also result from traction on a ligamentous or capsular attachment: these are often witness of momentary dislocation, e.g. (I) an abduction force may avulse the ligament attachment, with spontaneous reduction, lute subluxation (2) is common with this ('gamekeeper's thumb') and other injuries and is especially serious in the case of the spine.

fracture lies close to a joint, stiffness may also be a problem due to tethering of neighbouring muscles and tendons by spread of callus from the healing fracture, e.g. in fractures of the lemur close to the knee, the quadriceps may become bound down by the callus, resulting in difficulty with knee flexion.

32. Depressed fracture: Depressed fractures occur when a sharply localised blow depresses a segment of cortical bone below the level of the surrounding bone. Although common in skull fractures, this pattern is only rarely found in the limbs, where the tibia in the upper third is probably most frequently affected. Healing is rapid; complications are dependent on the site.

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