15 Orthopaedic surgery

Examination of the limbs and trunk 492

Fracture healing 494

Reduction and fixation of fractures 498

The skeletal radiograph 502

Injuries of the phalanges and metacarpals 504

Wrist injuries 508

Fractures of the distal radius and ulna 510

Fractures of the radius and ulnar shaft 512

Fractures and dislocations around the elbow in children 514

Fractures of the humeral shaft and elbow in adults 518

Dislocations and fracture dislocations of the elbow 522

Fractures around the shoulder 524

Dislocations of the shoulder region 526

Fractures of the ribs and sternum 530

Fractures of the pelvis 532

Femoral neck fractures 536

Femoral shaft fractures 538

Fractures of the tibial shaft 540

Fractures of the ankle 544

Fractures of the tarsus and foot 546

Injuries and the spinal radiograph 550

Spinal injuries 554

Acute haematogenous osteomyelitis 558

Chronic osteomyelitis 560

Septic arthritis 562

Peripheral nerve injuries 564

Brachial plexus injuries 566

Osteoarthrosis (osteoarthritis) 568

Carpal tunnel syndrome 570

Ganglion 572

Bone tumours 574

Low back pain 578

Paget's disease (osteitis deformans) 582

The great toe 584

Arthroplasty 586

Useful reading 588

Always begin with a history, followed by examination.

The classical orthopaedic triad of ‘look, feel, and move’ applies.¹

Remember to examine the patient as a whole, not just the joint!

Is there a specific area of tenderness?

Does the pain radiate?

Is the joint swollen?

Can the joint be moved actively?

Has there been an injury to the joint?

Is there any swelling? If so, is it an effusion, synovitis, or bony deformity?

Are there any colour changes? Bruising or erythema?

Is there any skin involvement, i.e. rheumatoid nodules at elbow, psoriatic plaques?

Are there any scars? If so, are they traumatic, surgical, or infective?

Look for muscle wasting, generally around the joint and specifically in the whole limb.

Examine the patient as a whole for clues to the disease process at the joint.

Examine the unaffected or least painful side prior to examining the affected side.

Is the joint hot, cold, or moist?

Is there any local tenderness? Look at the patient's face, not the joint.

Is the joint swollen? An effusion can occur after trauma (haemarthrosis) or with infection (septic arthritis). Does the fluid shift with sweeping? Is synovitis present (non-movable fluid feel), or is it a bony swelling?

Test active movements first before passive. This gives an idea of the patient's pain and reduces further discomfort.

Ask the patient to move the joint through a full range of movement.

Look for pain (patient's face) and limitation of movement.

Is the limitation mechanical (blocked by loose body, meniscal tear, contracture) or restrictive (resisted by the patient due to pain)?

Shoulder. Flexion, extension, abduction, internal and external rotation.

Elbow. Flexion, extension, pronation, and supination (ensure humerus at patient's side).

Wrist. Flexion, extension, radial and ulnar deviation, pronation, and supination.

Metacarpophalangeal joint (MCPJ). Flexion, extension, abduction, and adduction.

Proximal interphalangeal joint (PIPJ) and distal interphalangeal joint (DIPJ). Flexion and extension.

Thumb. Flexion, extension, abduction, adduction, and opposition.

Hip. Flexion, extension, internal and external rotation.

Knee. Flexion and extension.

Ankle. Plantar and dorsiflexion, eversion and inversion.

Cervical spine. Flexion, extension, and lateral rotation and flexion.

Lumbar spine. Flexion, extension, and lateral rotation and flexion.

Muscle power is graded via the MRC system (see  p. 492).

Always get the patient to walk to test gait if the problem is lower limb.

Or provocation tests that aim to locate the cause of intra-articular pain, for example:

Is the limb tone normal, reduced (flaccid or floppy), or increased (rigidity)? Is there any spasm? Are there any joint contractures?

Is the rigidity through whole movement or only initially (spasticity)?

Is the alteration in movement from a neuromuscular disorder, a mechanical block, or pain from the joint?

Grade 1, flicker of movement only.

Grade 2, movement with gravity eliminated.

Grade 3, movement against gravity.

Grade 4, movement against resistance.

Grade 5, normal power.

Alternatively, ask the patient to put their right heel on to their left knee and run it down their shin and vice versa. Note whether these movements are smooth or jerky.

Romberg's test. Stand with feet together and eyes shut. Positive result will cause the patient to become unstable or fall; be prepared!

Abdominal, T8–T12.

Triceps jerk, C6/7.

Knee jerk, L2/3/4.

Brachioradialis, C5/6.

Ankle jerk, S1/2.

Plantar response. Normal flexor, abnormal extensor (Babinski's sign).

Clonus at ankle (normal two beats or less).

1, hypoactive.

2, normal.

3, hyperactive, no clonus.

4, hyperactive with clonus.

Vibration sense tested with a 128MHz low-pitched tuning fork on a bony prominence. Start distal and if abnormal, move from proximal.

Proprioception (joint position sense) tested by moving the metatarsophalangeal joint (MTPJ) of the hallux, up and down; the patient confirms the correct movement.

Primary bone healing does not produce callus. It occurs when fracture fragments are reduced ‘anatomically’ and ‘interfragmentary compression’ is achieved with ‘absolute stability’. There is no motion between fracture surfaces (e.g. compression plating techniques or lag screw fixation).

The size of the haematoma depends upon the blood supply to the bone and the violence of the injury; it can continue to expand during the first 36h.

Injured tissue and platelet activation causes an inflammatory cascade via the release of growth factors and various cytokines.

Inflammatory cell migration to the haematoma occurs (macrophages, fibroblasts, osteoclasts, chondroblasts).

Fibroblasts and chondroblasts organize the haematoma into collagen and granulation tissue, with new capillary ingrowth (angiogenesis).

Osteoclasts and macrophages remove dead bone and tissue, respectively.

This stage usually lasts up to 1 week.

Intramembranous (or periosteal) hard callus forms peripherally, with endochondral (fibrocartilagenous/bridging) soft callus forming alongside. A third type ‘medullary callus’ forms later if the above fails.

The amount and type of callus produced is dependent upon local factors such as the type of fracture, proximity of the bone ends, amount of haematoma, and is inversely proportional to the amount of movement present.

Soft callus is calcified by chondroblasts and subsequently resorbed by chondroclasts.

New blood vessels invasion into the callus brings osteoblastic type cells, resulting in ossification into woven bone.

By this point, the fracture will have united and be pain-free.

This stage lasts 1 week to 4 months.

Final remodelling occurs when swelling around the fracture site decreases; trabeculae can be seen crossing the fracture site on radiographs and the medullary canal is recreated.

Remodelling is most marked in children and follows the mechanical forces applied to the bone in a physiological environment.

This process is identical in both primary and secondary bone healing and can last for several years.

Areas of direct contact undergo some activity.

Any gaps are invaded with blood vessels and cells differentiate into osteoblasts, laying down woven and lamellar bone (gap healing).

Osteoclasts acting as ‘cutting cones’ pass directly across the fracture site, leaving channels that are filled with blood vessels and allowing osteoblasts to fill them with lamellar bone.

No callus is formed and union takes much longer to achieve, with the strength of the healing process being borne by the mechanical properties of the fixation device.

Remodelling occurs as above.

Inadequate reduction and immobilization.

Infection.

Location of fracture. Which bone and where on bone i.e. metaphysis versus diaphysis (see below)?

Disturbances of ossification, e.g. metabolic bone disease, osteoporosis, local pathological tumour.

Age, poor nutrition, smoking, drugs (especially NSAIDs), diabetes.

Fractures of cortical (diaphyseal) bone (e.g. shafts of long bones) will take 12 weeks to unite.

Fractures of the tibia (because of poor blood supply) will take 24 weeks to unite.

Time to union for children equals the age of the child in years plus 1, e.g. tibial fracture in a 2y-old child will unite in 3 weeks. Common sense needs to be applied when applying the rule to fractures of cancellous bone in older children.

Atrophic non-union. Due to poor blood supply resulting from initial injury or surgical intervention. There is poor healing potential. Usually require stabilization and biological augmentation to heal.

Stability by fixation or splintage as the personality of the fracture and the injury dictates.

Preservation of the blood supply to the soft tissue and bone by careful handling and gentle reduction techniques.

Early and safe mobilization of the part and patient.

Typically involves splinting of joints either side of a long bone fracture to provide additional rotational stability.

Simplest and cheapest to apply.

Lowest risk of septic complications.

It will provide pain relief.

‘Half casts’ or ‘backslabs’ can be utilized to immobilize a fracture prior to definitive management.

Complications include problems with cast (pressure areas, loosening and breakdown of cast), thromboembolic events, coverage of wounds.

It is a very involved process, requiring regular follow-up to ensure maintenance of reduction.

Has the advantage of allowing early movement of the joint without the use of weight bearing, e.g. tibial shaft fractures.

Unstable fracture patterns.

Neurovascular damage. Fracture stability must be achieved before the delicate repair of vessels or nerves takes place. If not, these repairs may be damaged.

Polytrauma. Multiple injuries are better managed by fixation to facilitate nursing care and to allow early mobilization.

Elderly patients tolerate immobilization and prolonged bed rest poorly (fractured neck of femur).

Fractures of long bones (e.g. forearm, femur, tibia). Rehabilitation is facilitated more quickly with internal fixation after anatomical reduction.

Failure of conservative therapy (loss of acceptable alignment).

Pathological fractures.

Nerve and vessel injury.

Non-union (increased with iatrogenic soft tissue and periosteal injury).

Implant failure and subsequent fracture through a bony defect if the implant is removed.

Highly comminuted or unstable fractures and fracture dislocations.

Life-saving splintage procedure in pelvic fractures.

Initial stabilizing device for any fracture where ‘damage limitation’ surgery may be appropriate in the multiply injured patient (damage control orthopaedics).

Definitive treatment of periarticular fractures (pilon and tibial plateau).

As a salvage option in the face of mal-union, non-union, or significant bone loss.

Modern systems incorporate ring fixators with pins and rods (hybrid).

Circular fixators (Ilizarov) can be used for definitive fracture fixation or as a salvage option.

Nerve, vessel, ligament, and tendon injury (good understanding of cross-sectional anatomy required).

Over-distraction, resulting in non-union.

These act as ‘internal, external fixators’ where forces are transmitted from bone to screw to plate.

The locking plate provides angular stability and is much stronger than a normal plate as all screws act in unison.

Advantages are:

Accurate history and clear requests to be documented on X-ray forms. Always write the side in full, e.g. ‘right’.

Always take two views at 90° to each other (orthogonal).

Examine the film carefully.

Most hospitals use computer-based X-ray viewing systems but if using a viewing box, have a bright spotlight and magnifying glass available.

When describing the lesion, think of side, anatomical site, nature, displacement, and soft tissue components.

Keep it simple.

Look for cortical/medullary changes, periosteal reactions, deformity, soft tissue swelling, and cortical breach (definition of a fracture).

Supplement radiological findings with further biochemical investigations, bone scanning, and biopsy if indicated.

Characterized by low bone mass and deterioration of the microarchitecture of bone tissue with consequent increase in bone fragility and susceptibility to low trauma fractures.

Affects middle-aged and elderly women, predisposing them to fractures of the distal radius, femoral neck, and vertebral bodies.

Localized osteoporosis follows disease, e.g. after joint fusion.

The cortices are thin with reduced medullary trabeculae, i.e. the bone is essentially normal; there is just too little of it.

Symmetrical transverse or oblique cortical defects appear (Looser's zones, pseudofractures).

In children, changes are most marked at the metaphysis (rickets).

Ensure the appropriate X-ray is taken with two views at 90° to each other (e.g. an X-ray of an ankle, rather than the whole lower leg).

Which bone is fractured?

Where is the fracture in the bone? Joint (intra-articular), proximal, middle, or distal third, or metaphysis (flares at end of bones), diaphysis (shaft), physis (growth plate), and epiphysis (end part of bone) in children.

What is the pattern? Transverse, oblique, spiral, comminuted or multifragmentary, segmental.

Is there displacement? Quantify this (e.g. 50% of bone width or completely ‘off ended’ >100%).

Is there any angulation? Which direction (varus, valgus, recuvartum)?

If a joint is involved, comment on whether it is ‘in joint’ or dislocated.

Other things to look for are gas in soft tissues (suggests open fracture or gas-forming infection), foreign bodies (metal, glass, grit), fluid in joints (e.g. lipohaemarthrosis in knee suggests fracture), fat pad signs in the elbow (suggest fracture and are prominent due to blood in joint).

A ring-like structure (e.g. the bony pelvis) rarely fractures in only one place; if you find one fracture, look hard for another one!

Comment on implants if present and the proximity and involvement of this to fracture (periprosthetic fractures of a total hip replacement (THR) or total knee replacement (TKR)).

Pitfalls. Is it a fracture? Structures that may be mistaken for fractures include suture lines between bones, vascular channels, and physes in immature skeletons. Anatomic structures are more likely to be symmetrical, if not midline.

Metacarpal base fractures. Often displaced or angulated due to deforming forces of the tendon attachments. If fractures undisplaced, can manage with closed reduction and immobilization in cast. For displaced/significantly angulated fractures, closed reduction with K wire fixation or open reduction with internal fixation (ORIF) is required.

Rolando fractures. Multifragmentary fracture, at least three parts in a ‘T’ or ‘Y’ pattern ± dislocation. Treatment depends on degree of fragmentation. Reduction and K wire fixation or external fixation should be considered. ORIF only if large fragments.

Tear of the UCL can be partial or complete, with adductor aponeurosis stuck in the joint (Stener lesion), preventing reduction.

Partial tears (stable) are immobilized in cast for 6 weeks.

Complete tears (unstable or Stener Lesion) require surgical repair.

Chronic tears are treated with tendon reconstruction of UCL or MCPJ fusion.

Small fragments or purely tendinous types are treated in ‘mallet splint’ (extension) for 8 weeks continuously, followed by 2–4 weeks just at night. If large fragment, fixation can be undertaken if unable to maintain in splint.

Undisplaced stable fractures are treated with neighbour strapping for 2–3 weeks with early mobilization.

If unstable, rotated, severely angulated, or involving the joint, consider closed reduction and K wire fixation or ORIF with mini-fragment screws ± plate. Stable fixation to allow early mobilization is the goal.

Dislocations require reduction under ring block.

If stable, they can be treated with extension blocking splint with PIPJ flexed for 4–6 weeks.

If unstable or associated with significant fracture, they require either manipulation under anaesthesia (MUA) and K wiring, ORIF, or volar plate arthroplasty.

Tenderness on the volar surface of the scaphoid, i.e. the tubercle, is more predictive than snuffbox tenderness (dorsal) which is unreliable.

Wrist movement, particularly pronation followed by ulnar deviation, may be painful.

Pain on compression of the thumb longitudinally or on gripping may be present.

However, clinical examination is highly variable and skill-dependent.

If initial X-rays negative, but clinical suspicion persists, cast the wrist and repeat films in 2 weeks.

Displacement of >1mm or angulation requires ORIF with compression screw.

Proximal pole fractures are relative indication for fixation as high chance of non-union.

Avascular necrosis. ↑ with proximal and displaced fractures (see above). Treatment is by internal fixation and bone grafting which may need to be a ‘vascularized’ graft.

Degenerative change. May occur after non- or mal-union. Treated by limited wrist fusion (four corner fusion, scaphoidectomy, and radial styloidectomy).

Treatment is usually excision, but internal fixation may be attempted if the fragment is large.

If left untreated, they can cause long-term disability.

The proximal row of carpal bones forms an intercalated segment, i.e. they are connected and work together as a unit. Injury may occur to the ligaments connecting the bones.

On rarer occasions, the scapholunate ligament remains intact and the scaphoid fractures, resulting in a trans-scaphoid perilunate dislocation.

Commonly missed due to poor history and examination.

Indicated by tenderness at the carpometacarpal base.

Diagnosed with a true lateral (not the standard lateral oblique) X-ray (shows subluxation or dislocation at the carpometacarpal joint).

Very common. Approximately 1 in 6 of all fractures treated.

Bimodal incidence. Peaks in childhood (6–10y) and early old age (60–70y).

Scaphoid and ligamentous wrist injuries may also be present.

Historical eponymous terms (‘Colles’, ‘Smith's’) are still used.

To avoid confusion, stick to describing the fracture by anatomical methods, e.g. dorsally displaced fracture of the distal radius with shortening and ulnar deviation.

In children, the fracture usually involves the epiphyseal region and these fractures are classified by the Salter–Harris system.³ Salter–Harris type II is easily the most common injury of the distal radius.

Dorsal cortex comminution.

Intra-articular extension (radiocarpal and distal radioulnar joint (DRUJ)).

Ulnar styloid fracture (suggests a TFCC injury which is a strong DRUJ stabilizer).

Loss of radial inclination (normally approximately 22°).

Loss of palmar tilt or dorsal angulation (normal tilt approximately 11°).

Loss of radial height (approximately 11mm from distal ulna to tip of radial styloid).

If very unstable in theatre (radial and ulnar complete fractures, displaced) or if the fracture has slipped position in plaster after manipulation, then internal fixation with percutaneous K wires or more rarely, open fixation with plates and screws may be used.

Displaced + stable. Closed reduction and plaster immobilization for 6 weeks.

Displaced + unstable. Closed reduction and either percutaneous K wire fixation (two wires), external fixation, or ORIF with plates and screws.

Complex intra-articular fractures or highly unstable patterns can now be successfully treated with modern anatomic pre-contoured distal radius locking plates.

Dorsal comminution is a common problem and must be taken into account in the method chosen.

Bone structural substitutes, e.g. Biobon, lack RCT data to back up their use and considerable expense.

High energy may be involved, therefore look closely for neurovascular status and compartment syndrome.

As displaced or angulated fractures affect the proximal (Monteggia) and distal (Galeazzi) radioulnar joints, it is essential to get orthogonal X-rays of the wrist and elbow.

May be angulated only with one of the cortices still intact (‘greenstick fracture’).

Be aware of plastic deformation (no obvious fracture, but bowing of one or both bones).

May sustain a fracture dislocation as in adults.

Isolated ulna shaft fractures (‘nightstick fractures’ named after mechanism of defending direct blow from a policeman's nightstick or truncheon).

Displacement and significant angulation are indications for fixation.

Remember, the forearm is a ‘force parallelogram’ and that a fracture of only one bone will usually result in a dislocation of the other bone at the proximal or distal joints. These fracture dislocations are:

Plastic deformation needs to be corrected.

Displaced fractures are often unstable and can be treated by ORIF with plates and screws, or flexible intramedullary nail fixation.

Fracture dislocations (Monteggia and Galeazzi). Closed manipulation and cast immobilization (failed reduction may require open reduction).

Undisplaced fractures can be managed in an above elbow cast.

Displaced fractures are treated with open reduction and compression plate fixation.

‘Nightstick fractures’ of the ulna are splinted by the intact radius so if undisplaced, then early protected motion with an elbow cast-brace is indicated.

If the fracture is displaced (>50% displacement or >10°), open reduction and compression plate fixation should be used.

Fracture dislocations. Treated with open reduction and internal fixation to accurately reduce and hold the associated dislocations.

Non-union is normally treated by open reduction, debridement of the non-union site, and compression plate fixation with or without bone grafting.

It is not usually necessary to remove metalwork from the radius and ulna unless they cause significant problems after the fracture has healed. Radial plate removal has been associated with a significant risk of neurovascular complications.

Cause is usually a fall on to the outstretched hand. The result is related to age:

Salter–Harris injuries of the elbow occur through the lateral condyle and radial neck.

Classified using the modified Gartland system:²

Reduce under GA by straight arm traction (up to 5min may be required).

Then manipulate to correct rotation, varus/valgus tilt, and finally any extension deformity.

Try to flex the elbow up past 90° with the forearm pronated (may be difficult due to anterior soft tissue swelling; the reduction technique itself can cause loss of the pulse in the flexed position).

Displaced (type III/IV) fractures should be reduced and stabilized with K wires. Some advocate the same for type II injuries.

Common configuration is two crossed condylar K wires, one medial (beware of ulnar nerve), and one lateral used to fix the fracture.

An above elbow cast is then used to supplement fixations and wires are removed at 4 weeks.

Long arm traction may be used as definitive treatment, but involves a long inpatient stay until the bone has united (usually 3 weeks).

Examination is the key. An absent pulse with a well perfused hand does not require any immediate vascular management; however, a pulseless cold hand or a pulse that is lost post-reduction and pinning does!

True loss of the radial pulse may be due to:

Contracture. Untreated vascular injury will result in fibrosis and contracture of the forearm (‘Volkman's ischaemic contracture’). This is a devastating and debilitating condition and should be avoidable with early (<12h) exploration and/or repair or vascular damage.

Recurvatum common following cast management of type II/III; remodels poorly.

Type II. Fracture medial to growth centre and can involve trochlea (Salter–Harris type II).

The fragment is always considerably larger than expected from the X-ray due to the condyle being not fully ossified.

If not reduced and fixed, the fragment will displace. This is due to the pull of the wrist extensors, arising from the lateral epicondyle. This will lead to a cubitus valgus deformity and can present in later life with an ulnar nerve palsy as it has been chronically stretched (‘tardy’ ulnar nerve palsy).

These fracture occur in a similar pattern to the lateral condyle (type I and II).

Treatment is essentially as described for lateral condyle fractures.

The key is recognition of this injury as it is intra-articular and if missed, can be associated with valgus instability of the elbow and subluxation.

Fractures of the neck are often angulated, displaced, or both.

Head fractures are of the Salter–Harris type.

Fractures associated with dislocation happen at the time of injury or as a result of reduction (radial head pushed into ulno-humeral joint).

30–60°. Reduction should be attempted, but ongoing debate.

>60°. Reduction is required under GA, usually stable; once reduced, do not require any further fixation.

Occasionally open reduction is required.

Intra-articular fractures that are displaced may require fixation with K wires or screws.

Displaced fractures require ORIF with tension band wiring.

Can be low energy (osteoporotic) or high energy (younger age group).

X-rays of joints (above and below) important to rule out intra-articular extension. High energy injuries, especially to rule out floating elbow or shoulder.

Remember to evaluate neurovascular status (radial nerve at risk).

Distal third fractures associated with radial nerve palsy, known as Holstein–Lewis fracture.

Can accept 20° anterior/posterior angulation, 30° varus/valgus angulation, 15° rotations, and 1–3cm of shortening.

Remember to mobilize elbow and shoulder or will stiffen!

ORIF with plate and screws is commonly used. Locking plates can be utilized if poor bone quality.

Intramedullary nailing is an alternative, good for pathological or segmental fractures, or medically labile patients due to small exposure. It is associated with shoulder pain and rotator cuff dysfunction.

Supracondylar.

Isolated medial or lateral condyle fracture.

Isolated capitellum fracture.

Can be difficult to treat if heavily comminuted and the bone quality is poor.

ORIF if displaced. 90/90 plating was the classical method (medial and posterolateral), but now utilize pre-contoured, bicolumnar locking plates. Again stable fixation with early mobilization is the goal.

Management follows same principles as of supracondylar type.

Treatment. Type I requires ORIF. A common technique is headless compression screws from a posterior to anterior direction. Type II is usually not amenable to fixation and is excised, as are the loose components of type II injuries.

Kocher's approach (interval between anconeus and extensor carpi ulnaris) often used.

Type II. Displaced (subtypes—IIA, avulsion; IIB, oblique/transverse; IIC, comminuted; IID, fracture-dislocation).

Displaced. ORIF with tension band wire technique.

Comminuted. Plate and screw ± bone graft. Newer pre-contoured locking plate available.

Type 2. Displaced.

Type 3. Comminuted and displaced.

Type 2 (displaced, mechanical block to motion or part of more complex injury pattern). ORIF with compression screw and/or mini-plate.

Type 3 (too comminuted to allow ORIF). Radial head replacement indicated. Excision considered at a later stage and contraindicated if other destabilizing ligamentous injuries.

Degenerative joint disease (osteoarthritis).

Heterotopic ossification.

Neurovascular injury and its sequelae.

Complex. Associated bony injury.

Posterior and posterolateral. Most common type; fall on to an outstretched hand with the elbow in extension or slight flexion (with supination and valgus forces).

Anterior (rare). Fall on to a flexed elbow or as a direct blow from behind (‘side swipe injury’).

Divergent (rare). Radius and ulna separated proximally.

Coronoid fractures. Occur as distal humerus is driven against it during subluxation, dislocation, or instability. Any injury to coronoid suggests an episode of instability.

Regan and Morrey classification.

In-line traction. Supinate forearm (clears coronoid); flex elbow from an extended position whilst pulling olecranon in an anterior direction.

Check elbow stability once reduced and X-ray to confirm.

If stable, collar and cuff at 90° for 7–10 days with early motion.

If unstable (redislocates), place forearm in pronation if lateral collateral ligament disrupted or supination if medial collateral ligament disrupted, and immobilize in above elbow cast for 2–3 weeks.

If there are associated injuries, then most fractures will require ORIF to aid the stability and allow early mobilization. This may include radial head prosthetic replacement.

The elbow will require surgical stabilization via ORIF of coronoid and anterior capsular repair, ORIF or replacement of radial head, lateral collateral ligament repair.

Compartment syndrome.

Chronic elbow instability.

Articular cartilage damage.

Heterotopic calcification.

Stiffness (especially extension). Early motion at 1 week to try to prevent this.

The pattern of lateral third fractures depends on relationship and integrity of the coracoclavicular ligaments, and involvement of the acromioclavicular joint.

Medial third fractures are assessed with displacement and involvement of sternoclavicular joint in mind.

Lateral third. Undisplaced can be treated non-surgically; however, the presence of displacement suggestive of coracoclavicular ligament disruption will require fixation with either plate and screw constructs, hook plate, or ligament reconstruction (Weaver–Dunn procedure).

Medial third. Most are undisplaced and treated conservatively in a sling. Displacement, especially posterior, into the root of the neck may warrant surgery.

Non-union. Associated with displacement and shortening.

Acute complications. Neurovascular injury (including brachial plexus injury), neurovascular compression (costoclavicular syndrome), pneumothorax from bony penetration of the pleura.

Complex (involving the glenoid and glenoid neck). May need ORIF after further imaging such as CT/MRI scanning.

Floating shoulder will require ORIF of clavicle.

Displaced. Usually requires ORIF by ‘locking’ plate, proximal humeral intramedullary nails or cannulated screws, and K wires with or without tension band wiring.

Severely comminuted fractures (4-part), especially including fracture dislocations, have a high rate of avascular necrosis; usually treated with hemiarthroplasty and soft tissue reconstruction of the rotator cuff to the prosthesis.

May be indicative of a non-accidental injury.

Most require no treatment apart from collar and cuff with mobilization as for adults. Remodelling potential is good in this area.

Mechanism. Indirect force to lateral shoulder or direct impact on medial end of clavicle.

Types. Usually dislocates anteriorly; posterior dislocation is rare. The deformity is at the medial clavicle.

Complications. Tracheal and oesophageal compression may occur with posterior dislocation. Careful assessment is required.

Posterior dislocation with tracheal compression. Requires closed reduction or open if this fails (with cardiothoracic surgical help).

Mechanism. Fall or direct impact on to the point of the shoulder.

Rockwood classification.¹ Six types with increasing numbers relating to increasing severity of ligamentous disruption (acromioclavicular and coracoclavicular) and displacement.

Type III and above. Acute repair indicated. Soft tissue reconstruction better than hook plate.

Rotator cuff tears. Approximately 30% of those >40y and 80% of those >60y will have a tear.

Greater tuberosity fractures. Common over the age of 50y.

The shoulder looks ‘square’ as the deltoid is flat and a sulcus can be visible where the humeral head may be.

The patient supports the arm which is abducted and very painful.

Assess neurovascular status (axillary nerve).

X-rays (AP and axillary or scapular ‘Y’ lateral views) show the humeral head anterior and inferior to the glenoid. Used to exclude a fracture of the humerus or glenoid.

Give IV morphine 5–10mg + inhaled N₂O (IV midazolam 5mg is usually unnecessary).

Alternative technique is patient prone on the trolley, arm hanging freely down and weighted (e.g. 3L bag of saline) (‘Stimson's technique’).

If there is an associated humeral neck fracture, then the reduction should be done under GA.

Place the arm in a collar and cuff sling under the clothes. Repeat the X-ray to confirm reduction and that there has been no iatrogenic fracture.

Always document the neurological status (axillary nerve) before and after reduction.

Follow-up in clinic mandatory to assess for associated injuries.

The humeral head should be palpable posteriorly.

AP X-rays may show the humeral head as a ‘light bulb’ shape (internally rotated), but this is not diagnostic of posterior dislocation.

Lateral X-ray shows the dislocation.

May be very unstable; occasionally the ‘broomstick’ plaster may be used.

Commonest in young age of first dislocation (90% recurrence if <20y, 60% if 20–40y, <10% if older than 40y).

May be done open or arthroscopically.

Capsular laxity is treated by capsular shift, an overlapping ‘pants-over-vest’ procedure to improve proprioceptive joint sensation.

Fractures of the lower ribs can occur with coughing.

Sternal fractures occur with direct injury, e.g. contact with steering wheel or by restraint by a seat belt.

High velocity (RTA) or large crush injuries can result in a ‘stove-in’ chest with a flail segment, i.e. multiple rib fractures, each fractured at two sites.

Multiple rib fracture. If ≥3 ribs involved, should admit for observation overnight, but treatment symptomatic with analgesia and chest physiotherapy.

Sternal fracture. Symptomatic treatment, but observe for associated injuries (see below).

Flail chest or extensive multiple rib fractures. Potentially life-threatening injury and may present with severe respiratory distress.

First, second, or third ribs.

Sternum.

Scapula.

Diagnosis is by high clinical suspicion, muffled heart sounds, raised JVP, and no signs of a tension pneumothorax.

Treat by immediate pericardiocentesis with transfer to cardiothoracic unit for repair of the defect.

Often associated with haemothorax.

Signs are respiratory distress, absent breath sounds, hyperresonant percussion note (pneumothorax), or shock.

Tension pneumothorax is life-threatening and requires immediate decompression via a 16G needle placed into the second anterior intercostal space, followed by definitive chest drain placement.

If in any doubt, always treat first on clinical grounds rather than wait for investigations (X-rays, etc.).

Age >60y. Low energy (insufficiency fracture)—fall from standing height.

Anteriorly are the ligaments of the symphysis pubis and posteriorly, the ligaments to the sacrum (sacrospinous, sacrotuberous, and sacroiliac).

An isolated break at any part is generally stable (the ring will not separate).

Two breaks in the ring make it unstable (able to displace or open). Remember this can be due to a fracture or ligament disruption!

Young and Burgess classification (descriptive):¹

Mechanism of injury important as gives insight into degree of injury.

Assessment and documentation of other injuries is mandatory.

Look for neurological, gastrointestinal, and genitourinal injury.

Fractures of both superior and inferior pubic rami on the same side are a single break in terms of ring stability.

Other stable patterns include ilium fractures into sciatic notch or sacrum.

Remember that if a significant single break in the ring is present, there is a chance that concurrent ligamentous injury exists. Thus, a CT scan is often required prior to mobilization to confirm stability.

Isolated fractures of the ilium, ischium, or pubis are normally treated with bed rest, analgesia, and early mobilization as soon as the pain allows.

Fractures that extend to the acetabulum (joint) require further investigation to plan treatment, but are usually stable if isolated.

Simple pubic rami fractures in the elderly (osteoporotic) can be treated conservatively with bed rest and early rehabilitation.

Haemorrhage is leading cause of death with pelvic injuries.

Tachycardia and hypotension suggest bleeding.

Establish at least two large calibre IV infusions and commence resuscitation with warm crystalloid 2000mL, and then reassess.

Send blood for urgent cross-match of 4–6U. O –ve blood is given if no response to initial fluid challenge.

Continued bleeding must be controlled by reducing the pelvic volume. This may be achieved by:

Laparotomy is contraindicated unless there are life-threatening intra-abdominal injuries that must be treated since this effectively ‘decompresses’ the pelvis again superiorly.

Urethral injury occurs, especially with anterior compression bony injuries. If there is blood at the urethral meatus, perineal bruising, haematuria, or a high riding prostate on rectal examination, then catheterization should only be performed by an experienced urologist (very often suprapubically). Investigation for injury is with a retrograde urethrogram or IVU once the patient is stable.

Once ATLS stabilization is complete, CT scanning is required to define the fracture and plan treatment.

External fixation is excellent to temporarily control unstable fractures and manage definitively. It can help to control haemorrhage in a haemodynamically unstable patient.

Once stable, liaise with local pelvic fixation centres to arrange definitive fixation if required.

ORIF with screws and plates for the symphysis pubis of ilium fractures. Posterior pelvic instability involving the sacrum require screw fixation.

Open fractures carry a 50% mortality and need to be treated aggressively by both orthopaedic and general surgical teams.

Urogenital injury.

Thromboembolism (35–50% develop DVT and 10% PE).

Neurological injury.

Paralytic ileus.

Mal-union may lead to difficulty with pregnancy.

Osteoarthritis.

Assess as per all pelvic fractures (i.e. ATLS).

X-rays required include AP pelvic views plus Judet views (45° internal and external views); CT is routine.

Letournel–Judet classification. Fractures as posterior wall, posterior column, anterior wall, anterior column, or transverse.

Non-surgical management is reserved for fractures that are undisplaced (except posterior wall as hip unstable) and do not involve the ‘dome’, the superior acetabular roof (weight bearing area).

Surgical management, ORIF, in displaced dome fractures, fractures resulting in joint instability, or trapped intra-articular fragments.

Assess as per all pelvic fractures (i.e. ATLS). Must assess for sacral nerve root injury.

X-rays include AP pelvic (inlet and outlet) views; CT is required as difficult to fully appreciate on X-ray.

Denis classification. Alar lateral to foramen, involving the foramen, or central portion medial to foramen.

Non-surgical management is reserved for fractures that are undisplaced or impacted.

Surgical management if displaced or loose fragments impinging on nerve roots.

The risk increases with decreasing bone mass (osteoporosis).

In the elderly, usually result from a trip/fall onto side (low energy).

Fractures in the young are usually a result of high energy trauma.

Extracapsular fractures. Occur distal to the joint capsule (involving or distal to intertrochanteric line).

It is then important to describe fractures as displaced or undisplaced.

The relationship to the blood supply is key:

Other classification systems are not generally required.

Subtrochanteric fractures. Occur below the level of the lesser trochanter. May be through an area of pathological bone (metastasis) or high energy in young.

Consider medical cause of fall (stroke, MI, etc.).

Other comorbidities essential to ascertain.

Pre-injury level of function and home circumstances important.

If the fracture is displaced (common), the leg will be shortened and externally rotated. Straight leg raise and hip movements are globally inhibited by pain. Neurological state important.

Most fractures do not require any temporary stabilization; however, subtrochanteric fractures may benefit from a Thomas splint for pain relief.

X-rays. AP pelvis and lateral of affected hip (long leg views if history of malignancy to look for metastases).