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Orthopaedic and Hand
General principles of fracture management
Paediatric considerations in orthopaedics
i)
Salter-Harris classification
ii)
Injuries about the elbow
iii)
The child with a limp
iv)
Inflammatory arthritis
v)
Osgood/Schlatter disease
vi)
Perthe’s disease
vii)
Slipped capital femoral epiphysis
viii)
Transient synovitis
Casting techniques P Ex
i)
Short arm
ii)
Long arm
iii)
Short arm backslab
iv)
Scaphoid
v)
Bennett’s fracture
vi)
Volar splint
vii)
U Slab
viii)
Short leg
ix)
Long leg cylinder
d) Splintage techniques including splintage procedures
i)
Application of a broad arm sling
ii)
Application of a collar and cuff
iii)
Application of a figure-of-8 bandaging
iv)
Application of a knee immobiliser
v)
Application of a Donway/ Hare splint
vi)
Application of a Thomas splint
vii)
Pelvic stabilisation techniques
e) Fractures
i)
Clavicle
ii)
Scapula
iii)
Proximal humerus
iv)
Elbow
v)
Forearm bones
vi)
Wrist
vii)
Carpal bones
viii)
Spine
ix)
Pelvis and hip
i.
Pelvic fractures
ii.
Sacral fractures
iii.
Coccygeal fractures
iv.
Femoral neck fractures
x)
Hip and femur
i.
Femoral shaft fractures
ii.
Supracondylar fractures
iii.
Condylar fractures
iv.
Fractured patella
xi)
Tibia and fibula
xii)
Ankle
 Classification of ankle fractures
T Ex
TH
TH
DIS H
DIS H
DIS H
DIS H
DIS H
DIS H
DIS H
POP P Ex
POP P Ex
P Ex
POP P Ex
POP P Ex
P Ex
P Ex
POP P Ex
P Ex
P Ex
P Ex
P Ex
P Ex
P Ex
P Ex
P Ex
P Ex
DIS H
DIS H
DIS H
DIS H
DIS H
DIS H
DIS H
DIS H
DIS H
DIS H
DIS H
DIS H
DIS H
DIS H
DIS H
DIS H
DIS H
DIS H
DIS H
TH
xiii)
Foot
i.
Talar fractures
ii.
Calcaneal fractures
iii.
Tarsal bone fractures
iv.
Metatarsal fractures
v.
Phalangeal fractures
Dislocations
i)
Shoulder
ii)
Acromioclavicular joint
iii)
Elbow
iv)
Pulled elbow
v)
Carpal–metacarpal bones
vi)
Phalanges
vii)
Cervical spine
i.
Atlantoaxial
ii.
Facet joint
viii)
Hip
ix)
Knee
x)
Patella
xi)
Ankle
xii)
Foot
xiii)
Tarsal
xiv)
Metatarsal
xv)
Phalangeal
Soft tissues
i)
Shoulder
i.
Rotator cuff tears
ii.
Bursitis
iii.
Tendinitis
ii)
Elbow
i.
Bursitis
ii.
Tendinitis
iii)
Knee
i.
Bursitis
ii.
Ligament injury
iii.
Cruciate injury
iv.
Menisceal injury
v.
Bakers cyst
iv)
Ankle
i)
Ligament injury
v)
Foot
i.
Foot injury
Hand injuries
i)
Metacarpal fractures/dislocations
ii)
Phalangeal fractures/dislocations
iii)
Lacerations
iv)
Nail injuries
v)
Extensor tendon injuries
vi)
Mallet finger
vii)
Boutonniere deformity
viii)
Flexor tendon injuries
DIS H
DIS H
DIS H
DIS H
DIS H
DIS Ex
DIS H
DIS H
DIS Ex
DIS H
DIS H
DIS H
DIS H
DIS H
DIS H
DIS Ex
DIS H
DIS H
DIS H
DIS H
DIS H
DIS G
DIS G
DIS G
DIS H
DIS G
DIS H
DIS H
DIS H
DIS H
DIS H
DIS H
DIS H
DIS H
DIS H
DIS H
DIS H
DIS H
DIS H
DIS H
DIS H
ix)
x)
xi)
xii)
xiii)
xiv)
Overuse syndromes
Osteomyelitis
Septic arthritis
Infections
i.
Paronychia
ii.
Infective tenosynovitis
Foreign bodies
Amputations
Nerve injuries
High pressure injection injuries
Crush injury
DIS H
DIS H
DIS H
DIS H
DIS H
DIS H
DIS H
DIS H
DIS H
DIS H
Fractures of the Upper limb – ADULTS
Fractures of the Clavicle
 Account for 2.6-5% of all fractures, usually result from direct blow on the point of the shoulder or fall on
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outstretched hand
Most common site fracture of middle third of the clavicle – 69-82%
Varying degrees of displacement and overlapping may occur with shortening being common
Rare complications – pleural, axillary vessels/nerves , brachial plexus injuries
Non-displaced/ minimally displaced fractures –
 elbow supporting sling for 2-3 weeks,
 under the clothes for first few days, cease use once pain settles,
 early shoulder mobilization encouraged, non-union rare
Indications for surgical intervention
 Mid-shaft fractures with complete displacement in elderly patients – plate and screw
fixation
 Fractures of outer-third of clavicle with involvement of coracoclavicular ligaments
Late complications
 Shoulder stiffness
 Local lump of cosmetic significance
Figure 1 Clavicular Fractures
Fractures of the Scapula
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Uncommon, <1% of all fractures
Typically occur after high-energy impact with associated injuries in 90% of cases
Fractures of blade
 Usually direct impact
 Heal quickly despite comminution or displacement with excellent functional outcome
 Treatment non-operative with broad arm sling and early mobilization
Fractures of scapular neck
 Often comminuted and may involve glenoid
 Significant shoulder swelling and bruising likely
 X-rays to ensure shoulder head enlocation, CT scan to gauge extent of glenoid involvement
 Surgery often indicated for scapular neck or glenoid
Floating shoulder
 Ipsilateral fracture of clavicle and scapular neck
 Use of surgical techniques debatable – fixation of one or both fractures
Figure 2 Scapular fractures
Dislocation of the Shoulder
Dislocation of shoulder results in the humeral head lying anterior(95%), posterior(5%) or inferior to the
glenoid; anterior being most common.
Anterior dislocation
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Most often due to fall resulting in external rotation of shoulder
Most common in young adults and related to sports activity
Associated damage to shoulder capsule, subscapularis and greater trochanter part of injury.
Complications
 Damage to axillary nerve – inability to contract deltoid, numbness over insertion of deltoid
 Rarely affects axillary vessels and brachial plexus.
Clinical features
 Severe pain, reluctance to move shoulder, affected arm supported at elbow in slight abduction
 Flattening of shoulder contour with palpable gap under acromion
 Displace head palpable anteriorly in hollow behind pectoral muscles
Diagnosis
 Confirmed by x-ray
 Cannot be safely excluded on single views – axial lateral, translateral, tangential
Principles of management
 Adequate analgesia
 Reduction of dislocation
 Immobilization followed by
 Physiotherapy
Methods of reduction
 Over 20 types described in literature, 60-100% successful, most commonly used techniques include
 Spaso technique – supine, gentle vertical lifting of forearm, wrist + external rotation of shoulder
 Modified Kocher’s techniques – elbow traction, slow external rotation of shoulder to 90˚, elbow
adduction and internal rotation of shoulder
 Scapular rotation – medial displacement of tip of scapula using thumb in prone or sitting position
 Post-reduction x-rays to confirm relocation and recheck neurovascular status
Immobilization in sling under clothes for 2-3 weeks, no abduction or external rotation of arm
Duration of immobilization and timing of physiotherapy controversial
Indications for surgery
 Associated greater trochanter fracture which is still displaced after reduction of shoulder
 Recurrent dislocations with significant laxity
 Some first-time dislocations in young patients
Recurrences approaches 50% in young patients and rare in elderly
Figure 3 Infracoracoid (anterior) dislocation of shoulder
Posterior dislocation
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Frequently missed diagnosis with significant medicolegal burden, easy to miss in unconscious patients
Result of fall on outstretched or internally rotated hand or blow from the front
Close association with seizures and electrocution injuries – where uncommonly bilateral
Dislocation usually not apparent on AP film, additional views required
Reduction by traction on limb in 90˚ abduction + external rotation
After-care similar to anterior dislocation
Prone to recurrence
Poor prognostic factors
 Large anterior defect of humeral head
 Deformity or arthrosis of humeral head
 Associated fracture of humerus
 Need for arthroplasty
 Delay in diagnosis
Figure 4 AP view posterior dislocation showing ‘Trough Sign’.
Inferior dislocation
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Rare and usually obvious – arm held in abduction
High risk of neurovascular injury
Reduction by traction in abduction followed by swinging arm into adduction
After-care same as anterior dislocation
Figure 5 Infraglenoid dislocation with impacted Hill-Sacks fracture
Associated injuries with Shoulder dislocations
Hill-Sacks fracture
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Wedge shaped defect in posterolateral aspect of humeral head (figure 5)
Impaction fracture of humeral head (over the hill)
Seen as wedge or even just flattening of normal round contour and may occur at any site which impacts
the glenoid rim or coracoid process
Bankhart fracture
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Results from impaction from the humeral head and may be anterior or posterior depending on type of
dislocation (figure 6)
More common than Hill-Sacks, but radiologically less visible because may be purely cartilaginous (on the
Cart)
Figure 6 Bankhart fracture – noted post reduction
Fractures of the Humerus
Fractures of the humerus may be divided into proximal (neck), middle (shaft) and distal (supracondylar)
segments.
Fractures of Proximal humerus
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5% of all fractures presenting to ED and 25% of all humeral fractures
Typically indirect impact in elderly osteoporotic patients – fall on outstretched hand or extended elbow
Majority do not require surgical intervention and initially treated in ED
Figure 7 Neer’s classification of proximal humeral fracture
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Clinical assessment
 History and examination
 Present usually early after injury
 Pain, swelling and tenderness around shoulder and upper arm
 Crepitus and bruising may be present
 Bruising may be delayed and inferior to site of fracture due to gravity and blood tracking distally
 Neurovascular assessment of axillary nerve, brachial plexus and/or axillary artery needed
 Axillary nerve involvement most common with policeman’s badge sign and deltoid function loss
 Meticulous assessment for cause of fall to be made in elderly patients
 Investigations
 AP, lateral and axillary views of shoulder and upper arm usually suffice
 Fracture classification – Neer’s (figure 7)
 One-part – 80%, any number of fracture lines but none displaced
 Two-part – 10%, one part significantly displaced. May involve anatomical neck, surgical neck,
greater tuberosity or lesser tuberosity
 Three- and four-part – 10%, two or more significantly displaced fragments
 Anatomical neck and articular surface fractures – associated with any of above
Management
 One-part – collar and cuff, analgesia, follow-up and early mobilization with good prognosis
 Two-part – open or closed reduction depending on associated neurovascular injury, rotator cuff injury
or dislocations; early orthopaedic assessment recommended
 Three- or four-part – surgery superior to non-operative approach, viability of humeral head of prime
importance
 Anatomical neck and articular surface fractures – uncommon, high rate of compromised blood supply
and avascular necrosis, require humeral hemiarthroplasty
 Fracture dislocations – greater tuberosity usually associated with anterior and lesser with posterior
dislocations, usually displacements correct after reduction of joint but in c/o need for increased
shoulder function e.g. professional athletes; surgery may be considered early.
Fractures of Shaft of humerus
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Patterns of injury
 Usually 3rd and 7th decades of life
 Middle third commonest site (60%)
 Close proximity to radial nerve and brachial artery – high risk for injury
 Direct blows – transverse fractures
 Fall on outstretched hand – torsional forces – spiral fractures
 Combination of forces – butterfly segment
 Pathological fractures common – mostly due to metastatic breast carcinoma
Assessment features
 History about type of trauma
 Attention to elbow and shoulder for associated trauma
 Initial and post-reduction assessment of brachial artery and vein, ulnar, median and radial nerves
essential
 Commonest injury to radial nerve – wrist drop and altered sensation in 1st dorsal web space, occurs in
11% cases
 Investigations – AP and lateral x-rays
Management
 Uncomplicated closed – immobilization, analgesia, functional brace e.g. hanging or U-shaped cast
 Acceptable deformity – 20˚ AP angulation, 30˚ varus/valgus deformity
 Union rate > 90% with early specialist follow up recommended.
 Oblique/spiral fractures, open fracutres and complication (neurovascular) – surgical intervention
Fractures of distal humerus
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Patterns and classification
 Unlike pediatrics – uncommon in adults
 Many different classifications – AO/ASIF classification most common
 Classified into three categories – type A extra-articular, type B partial articular, and type C complete
articular (figure 8)
Figure 8 AO/ASIF classification of distal humeral fractures
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Mechanisms of injury usually involve direct blow to flexed or extended elbow
Assessment
 History – swollen tender elbow post injury
 Low suspicion for open injury
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Distal neurovascular injury common (12-20%) and need meticulous assessment
Investigations – AP and lateral of elbow and humerus, early CT scanning in c/o articular involvement
for planning surgery
 Subtle fractures may be missed – look for anterior and posterior fat pad signs
Management
 Undisplaced, uncomplicated fractures – immobilization in 90˚ above elbow cast and broad arm sling
for 3 weeks and active mobilization after that.
 Indications for surgery and early to urgent orthopaedic consultation
 Severe swelling
 Compound fractures
 Displaced fractures
 Neurovascular compromise
Dislocations of the Elbow
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Introduction
 Third common large joint dislocation
 Strong muscular and ligamentous supports and normally quite stable, rarely requiring operative
intervention
 Dislocations classified as either anterior or posterior. Posterior most common and can be either
posteromedial or posterolateral. Anterior may also be either anteromedial or anterolateral.
 Usually due to fall on to outstretched hand with some flexion or hyperextension of elbow
 Radius and ulna usually dislocate together and if a dislocation occurs in isolation, the other bone is
usually fractured. E.g. Monteggia fracture – radiohumeral dislocation with ulnar shaft fracture.
Assessment
 Swelling, tenderness and deformity of the elbow joint
 Three point anatomical triangle of olecranon, medial and lateral epicondyles to be checked and
compared with normal side
 Commonest neurovascular injury – ulnar nerve 10-15% of cases, less commonly radial, median nerves
and brachial artery may be involved.
 May be difficult to clinically differentiate from distal humeral fractures with significant swelling
requiring x-rays for confirmation
 Investigations
 AP and lateral x-ray views – check for associated fractures of coronoid process, radial head,
capitellum and olecranon.
 Doppler ultrasound may be needed to assess brachial artery anatomy or injury.
Management
 Simple dislocations – sedation, gentle traction and counter-traction, easy to relocate
 Due to severe associated injuries and risk of tissue swelling – closely observe for compartment
syndrome
 Check joint for full range of movement and/or crepitus for signs of associated fractures, capsular tears
or soft tissue interposition.
 Posterior plaster slab in 90˚ flexion (cylindrical cast C/I due to risk of swelling)
 Neurovascular compromise can occur both before and after relocation and should be checked for and
clearly documented
 Most patients discharged home in broad arm sling and early mobilization for simple dislocations
 Indications for admission and early/urgent orthopaedic consultation
 Failed relocations
 Neurovascular compromise
 Associated fractures and
 Open dislocations
Figure 9 Posterior elbow dislocation
Figure 10 Normal Elbow X-ray anatomy and anterior humeral and radiocapitellar lines
Figure 11 Anterior Elbow dislocation
Fractures of the Forearm
Radial head fractures
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Clinical features
o History – fall onto outstretched hand or direct blow on lateral side of elbow, pain and
restricted movement of elbow
o Examination – swelling, tenderness over radial head, tenderness over radial head while
rotating forearm in subtle cases. Elbow ROM limited
o Essex-Lopresti fracture-dislocation – proximal displacement of radius with associated
disruption of interosseous membrane and subluxation of distal radio-ulnar joint.
Figure 12 Essex-Lopresti fracture-dislocation
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Imaging
o AP and lateral elbow x-rays usually required with radio-capitellar view in subtle cases
o Anterior fat pad sign associated with radial fracture in 50% cases
o CT scan or follow up x-ray if clinical signs present despite normal x-rays
Classification
o Type I – hairline
o Type II – marginal (displaced and Undisplaced)
o Type III – comminuted
o Type IV – any of above with radial head dislocation
Management
o Type I and type II without mechanical block – bandage and sling
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Severe pain and swelling – aspiration of fracture hematoma, intra-articular bupivacaine +
backslab
o Early mobilization depending on symptoms with good prognosis with slight restriction of full
extension for months
o Type III or type II with mechanical block – surgical intervention, ORIF or excision of radial
head with/without prosthesis
o Radial neck fractures <20˚ tilts – managed conservatively, closed reduction for >20˚ tilts and
open reduction if fails
Complications
o Neurovascular complications and compartment syndrome uncommon
o Mechanical problems due to misalignment of radioulnar and radiocapitellar articular surfaces
– respond to radial head excision
Forearm Shaft fractures
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History – requires great force, typically from MVA, fall from height or direct blow; fractures commonly
open and nearly always displaced
Examination – forearm swollen, tender, angulated or rotated. Look for open wound, local
neurovascular compromise, compartment syndrome or musculotendinous injury. Look for other
injuries.
Imaging – AP and lateral x-rays of forearm including wrist and elbow joints usually needed
Signs to suggest torsion component –
o Radius and ulna are rectangular in cross-section, a change in bone width at fracture site
indicates rotation
o Radial and ulnar styloid processes normally point in opposite directions to bicipital tuberosity
and coronoid process – change in alignment suggests torsion.
Management
o Adult forearm fractures less stable than those of children
o Undisplaced fractures may be managed with an above-elbow cast, reviewed in 1 week for
displacement and angulation
o Most fractures displaced and require ORIF
Complications
o Wound infection and osteomyelitis
Monteggia fracture-dislocation
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Rare fracture of proximal ulna with dislocation of the radial head
Occurs through fall onto outstretched hand with hyperpronation or force applied on posterior aspect
of proximal ulna
Pain swelling and reduced elbow movement, forearm shortened with palpable radial head in
antecubital fossa. Associated posterior interosseous nerve injury common
X-ray – fracture easily seen but dislocation commonly missed – check radiocapitellum line and
anterior humeral lines. Dislocation anterior in 60% cases.
Management – all Monteggia fractures require ORIF
Complications – malunion and non-union of ulnar fracture and unstable radial head
Figure 13 Monteggia Fracture-dislocation
Galeazzi fracture-dislocation
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Fractures of distal third of radial shaft as a result of fall onto outstretched hand or direct blow
Associated subluxation/dislocation of distal radioulnar joint
Pain and swelling at radial fracture site with pain and swelling at distal radioulnar joint with
prominent ulnar head
X-rays show radial fracture, tilted anterolaterally with widening of distal RU joint and dorsal
displacement of ulnar head on lateral film
Ulnar styloid fracture in 60% of cases
Management – all Galeazzi fracutres require ORIF
Figure 14 Galeazzi fracture-dislocation
Fractures of distal Ulna and Radius
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Clinical features
o Common in children, young men and elderly
o History –
 fall onto outstretched hand or from direct blow
 pain, tenderness and variable degrees of swelling and deformity
 examine for associated injuries to carpals, radial and ulnar shafts, elbow/shoulder
joints, median nerve injury, vascular compromise and extensor tendon injury
Imaging
o AP and lateral x-rays of wrist demonstrate most injuries
Management
o Analgesia, splinting and elevation essential early before x-ray confirmation
o Reduction indicated for
 Visible deformity of wrist
 Loss of volar tilt of distal radial articular surface beyond neutral
 Loss of >5% of the radial inclination of distal radius ( N - 20˚)
 Intra-articular step of >2mm
 Radial shortening >2-3mm
 Greater deformity accepted in elderly patients
o Anesthetic options
 IV anesthesia with Bier’s block
 Hematoma block and
 Procedural sedation
o Reduction maintained with encircling plaster cast for 6 weeks. In case of significant swelling,
non-encircling casts placed.
o Weekly x-rays for 2-3 weeks with orthopaedic follow up recommended
o Stable Undisplaced, extra-articular fractures managed more conservatively with splinting,
review by LMO and early mobilization in 4 weeks
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Indications for operative management
 Comminuted, displaced, intra-articular fractures
 Open fractures
 Associated carpal fractures
 Associated neurovascular or tendon injury
 Failed conservative treatment
 Bilateral fractures or contralateral impaired extremity
Complications
o Median nerve injury – immediate or post-reduction or late due to plaster pressure, median
nerve function recorded pre- and post- reduction
o Delayed loss of reduction
o Malunion with chronic wrist pain, arthritis
o Secondary radiocarpal/radioulnar instability with intra-articular extension
o Delayed ruptures of extensor pollicis longus
Colles’ fracture
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First described in 1814 – metaphyseal bending fracture with a classic ‘dinner-fork’ wrist deformity
with significant soft tissue swelling
May have comminution dorsally with extensions to radiocarpal or radioulnar joints
Figure 15 Six classic deformities of Colles' fracture - anterior angulation, dorsal displacement and impaction, radial
displacement, ulnar angulation and ulnar styloid fractures
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Management
o Reduction to restore radial length, volar tilt and radial angulation
o Tilt of 0˚ is acceptable, reduction is successful in 87% cases and 2/3rd lose reduction in over 5
weeks, mostly during cast immobilization
o Cast immobilization in full ulnar deviation and pronation though other positions described
and acceptable
Smith’s fracture
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Metaphyseal bending fracture of distal radius due to direct blow or fall onto back of hand or fall
backward onto outstretched supinated hand.
AP and lateral x-rays show a ‘reverse Colles’ fracture
Closed reduction to achieve radial length attempted
Figure 16 Smith's fracture - reverse Colles' deformity
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Full above-elbow cast with wrist in supination, fully dorsiflexed to prevent loss of reduction
Barton’s fracture
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May be dorsal or volar intra-articular fractures of distal radial rim
Mechanisms similar to Colles’ and Smith’s fractures respectively
Significant soft-tissue injury and carpus usually dislocated or subluxed
Complicated by arthritis of the wrist
Most fractures unstable and requiring early operative management especially in younger patients
Early orthopaedic follow-up mandatory
Figure 17 Barton's fracture
Radial styloid (Hutchinson or Chauffer’s fracture)
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Oblique intra-articular fracture of radial styloid caused by direct blow or fall onto hand
Displacement associated with carpal instability and long-term arthritis
Most require anatomical reduction and fixation by orthopaedic team
Figure 18 Chauffer's fracture – mostly with carpal involvement
Ulnar styloid fracture
 Usually associated with radial fractures and rarely isolated
 Isolated fracture of the tip is clinically insignificant
 Displaced fractures usually associated with associated with ligamentous tears and can be associated
DRU joint instability
Figure 19 Ulnar styloid process - rarely isolated
Carpal fractures and dislocations
Scaphoid fracture
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Most commonly due to fall on outstretched hand, manifested by wrist pain and tenderness over the
scaphoid dorsally or in anatomical snuff box
Imaging via AP, lateral and scaphoid views will often identify fracture
CT indicated if clinical evidence with normal x-rays or significant distortion of anatomy
Classified by their location – proximal third, waist, distal third or tubercle and by stability
Stable fractures Undisplaced and minimally comminuted, unstable fractures – displaced and
comminuted
Management
o Stable fractures – below elbow scaphoid cast for 10-12 weeks
o Unstable fractures – surgical intervention
Complications – non-union and avascular necrosis of proximal segment
Dislocations of the wrist
 Usually result from high-energy falls on to the outstretched hand that result in hyperextension.
 Distal row of carpal bones commonly displaced dorsal to proximal row resultsing in scaphoid fracture,
scapho-lunate dislocation or a perilunate dislocation.
 Clinical features – wrist pain, swelling and tenderness with reduced grip strength
 Imaging requires PA and lateral x-rays
o Normal PA x-ray shows three smooth carpal arcs –
 The first arc is a smooth curve outlining the proximal convexities of the scaphoid,
lunate and triquetrum.
 The second arc traces the distal concave surfaces of the same bones, and
 the third arc follows the main proximal curvatures of the capitate and hamate.
o Lateral x-ray
 Longitudinal axis should align radius, lunate, capitate and third metacarpal bone
 The three common and clinically significant dislocations are
o Lunate dislocation
o Perilunate dislocation
o Scapholunate dislocation
Figure 20 PA radiograph of wrist. The three normal arcs
Lunate dislocation
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Usual PA image the lunate has a triangular shape rather than its usual trapezoidal shape(figure 20normal)
On the lateral film, the lunate has a ‘C’ or ‘half-moon’ shape. Other carpal bones in a normal anatomic
position in relation to radius
Figure 21Lunate dislocation - triangle PA 'C' in lateral
Perilunate dislocation
 Lateral film – lunate in normal anatomic position with respect to radius with rest of the carpal bones
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displaced dorsally
PA film – crowding evident between proximal and distal rows
Scapholunate dislocation
 PA film – scapholunate space >4mm – Terry-Thomas sign
 Scaphoid rotates producing classic signet-ring sign
All carpal fractures and wrist dislocations require orthopaedic consultation and prompt reduction
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Complications: for all carpal injuries median nerve injury, including carpal tunnel syndrome and long
term arthritis
Figure 22 Perilunate dislocation - note normal lunate alignment and position
Figure 23 Scapholunate dislocation showing increased scapho-lunate distance and signet ring sign
Hand injuries
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10% of ED attendances involve injury to the hand – wounds (35%), contusions (20%), fractures (20%),
sprains (10%) or infections (5%).
Clinical features
o History – most important aspect
 When
 Position of hand at time of injury
 Sharp versus blunt object or crush injury
 Brisk bleeding
 Hand numbness
 Contamination and foreign material
 Hand dominance
 Occupation and leisure activities
 Allergies and tetanus prophylaxis status
o Examination
 Suitable analgesia to allow full examination
 Local infiltration with local anaesthetic
 Digital nerve block
 Wrist block
 Wet dressings and elevation at triage
 Sensations – light touch or two-point discrimination
 Check for abnormal posturing of fingers
 Palpation – local tenderness of metacarpals and phalanges
 Functional testing of hand – individual flexion and extension at each MCP, PIP and
DIP
Figure 24 Cutaneous innervation of hand


Investigations
o X-ray indicated if obvious deformity or suspected mechanism likely to cause same or foreign
bodies suspected
o Dislocations should be always x-rayed before manipulation in ED
o X-rays can reveal metallic and some glass foreign bodies
o Ultrasound can detect organic foreign bodies and infections
o MRI may be needed for grading soft tissue injury but rarely in ED setting
Treatment
o Appropriate analgesia
o Remove rings from injured fingers early to prevent compromising circulation
o Elevation essential and helps reduce swelling
o Significant injuries require specialist repair
Fingertip Injuries


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
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Classification – fingertip avulsions classified as type A – oblique dorsal, type B – loss is transverse and
type C – oblique volar
Type A or B injuries < 50% of nailbed loss – conservative management with non-adherent occlusive
dressing
Other options – skin grafts, advancement flaps and cross-finger flaps
Major amputations of fingertip require terminalisation of finger.
All doubtful injuries and injuries with substantial tissue loss should be referred for specialist
intervention
Nailbed injuries
Figure 25 Anatomy of fingernail



Nailbed injuries always require some kind of repair and nail removal and subsequent use as a
biological dressing
Fractures distal to profundus tendon insertion are stable
Any involvement of the germinal matrix needs specialist referral
Distal interphalangeal joint injuries
Mallet finger






Acute flexion injuries on terminal phalange either ruptures the extensor tendon at level of DIP or
avulses its insertion from terminal phalanx producing acute flexion deformity of DIP joint – mallet
finger
X-ray joint – to rule out intra-articular fracture of >3rd of articular surface which needs surgical repair
Small avulsion fractures and tendon ruptures – mallet splint for 8 weeks
Persistent mallet deformity treated conservatively since finger functional
Avulsion fractures due to hyperextension require ORIF due to detachment of profundus tendon
Simple dislocations of DIP can be reduced safely with good outcomes after x-rays to rule out intraarticular fractures
Middle phalangeal injuries




Insertion of superficialis tendon slips through which passes the profundus tendon
Fractures need to be accurately reduced and may need ORIF
Usually unstable due to pull of the tendons and palmar wounds likely to involve profundus tendon or
digital nerves
Plastics /Hand surgeon referral needed for most injuries/fractures
Proximal interphalangeal injuries





Causes most long-term complications due to stiffness and contractures
PIP joint is supported dorsally by extensor apparatus and palmar aspect by strong fibrous volar plate.
Lateral stability provided by collateral ligaments
Rupture of either extensor or flexor support will lead to instability and long-term disability
Dislocations invariably causes damage to the support structures and so should be reduced and placed
in extensor splinting and early follow up
Boutonière deformity – flexion at PIP and hyperextension at DIP a long term complication of PIP injury
Proximal phalangeal injuries



Both flexor tendons pass close to palmar aspect of the phalanx and so fractures tend to be unstable
Open wounds may injure the tendons or nerves and examination should be directed towards
detecting them
Referral to hands specialist usually required
Metacarpophalangeal joint injuries




Subluxation can occur with trivial injuries in elderly and if not relocated promptly may result in
deformity with inability to fully extend joint
Injuries due to closed fist versus tooth are common and should be assumed as infected
If open injuries are present with fractures – treatment should include joint irrigation, splinting and
antibiotics
Gamekeeper’s of Skier’s thumb –
o due to ulnar collateral ligament rupture from and abduction injury of the thumb results in
MCP joint instability
o X-rays may show avulsion fractures of proximal phalanx, stress x-rays confirm joint instability
o Early repair gives superior results when complete rupture is diagnosed
Figure 26 Gamekeeper's or Skier's thumb
Metacarpal injuries





Caused by punching, crush injury or falls on closed fist
Commonest is fracture of neck of fifth metacarpal – usually best treated conservatively
Significant angulation corrected with ORIF
Spiral fractures result in shortening and loss of knuckle contour – conservative management with
splinting with MCP at 70˚, fingers straight and support at fingertips
Bennett’s fracture
o Abduction injury, intra-articular fracture of base of thumb metacarpal
o Most require referral and surgical correction
Figure 27 Types of intra-articular thumb metacarpal fractures
Dorsal hand injuries



Wounds on dorsum can easily involve extensor tendons due to superficial nature
Visualization of intact tendon during full range of motion only way to safely exclude injury
Repair usually necessary by specialist and followed by physiotherapy after immobilization
Figure 28 Intrinsic plus - recovery position
Palmar hand injuries


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Penetrating injuries could divide flexor tendons or digital nerves
Neurovascular injuries require early hand specialist referral
Foreign bodies difficult to find and exploration may increase damage and so must be conducted in
bloodless anesthetized field by surgeon
Nail-gun injuries need x-ray evaluation prior to removal to rule out anchoring of nail through bone or
barbs projecting laterally
High-pressure grease- or paint gun injuries result in extensive tissue penetration and require wide
exposure and decompression by hand surgeons
Management of pelvic fractures in trauma patients
Five potential sites of potentially fatal haemorrhage in trauma



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External
Long bones
Chest
Abdomen
Retroperitoneum
Approach to a patient with suspected pelvic injury



Primary survey
o Airway – assess and stabilise
o Breathing – O2 therapy and ventilatory parameters
o Circulation –
 2 X wide bore >18g IV access
 Initial crystalloid fluid boluses titrate
 To cerebral perfusion
 To maintain systolic BP >90mmhg
 Consider early call for un-crossmatched blood transfusions
 Early group hold and screen and pre-empt need for massive transfusion
protocol
 Control external sites of bleeding
 If obvious limb shortening and evidence of pelvic fractures with
hypotension consider placing pelvic binding with mechanical device or bed
sheet while log-rolling
o Disability – assess and record
o E-exposure – undress and assess, cover up and prevent heat loss
o Check LIMITS –
 Lines – ETT/IVC/NGT/SaO2/vitals/ETCO2
 Investigations – bloods/ABG/ECG/X-rays/FAST
 Check CXR for hemo-/pneumo-thorax
 Check Pelvic x-ray for unstable fractures, disruption of ring – apply pelvic
binding if obvious fractures and hemodynamically unstable
 Monitoring – SaO2/ETCO2/ECG/NBP/neuro/BSL
 Intravenous therapy – IV fluids and analgesia as required
 Teams – early referral to orthopaedic or radiology teams if persistently unstable
with no other obvious cause for hemorrhage
 Stabilise patient prior to beginning secondary survey
Secondary survey
o Only once primary survey complete and resuscitation complete
o Complete head to toe exam
o In 32% of pelvic fracture patients, significant abdominal injury will also be found – so primary
goal to rule out abdominal pathology
o DPA or FAST according to local protocol and availalbility
o Exclude all other sites of bleeding
Angiography facilities available
o If FAST negative and clinically unstable  transfer to angiography for embolisation
o Regular review of abdomen for free fluid
o If FAST positive and clinically stable  immediate laparotomy, damage control  pack
pelvis, fix intra-abdominal pathology  transfer to angiography facility for pelvic bleeding
control
o

If clinically very unstable <70mmhg systolic for urgent packing OT to stabilise patient even
before angiography
o If clinically mild instability  consider theatre before plan for operative or angiographic
intervention
Angiography services unavailable in hospital:
o Systolic BP >80  non invasive external stabilisation  100-200ml boluses to maintain BP
contact retrieval services for transfer to tertiary center
o Systolic BP<80  despite fluid resuscitation immediate laparotomy with surgical ligation
of bleeders  pack pelvis with large sponges  invasive external stabilisation of pelvis
Classification of pelvic fractures – Young and Burgess
APC III
Unstable
LC III
VS
Unstable
Young and Burgess classification is the most commonly used system for classification of pelvic fractures





Classifies pelvic fractures by vector of force
o Anteroposterior compression (APC)
o Lateral compression (LC) and
o Vertical shear (VS) types
APC and LC further classified into types I, II and III with increasing degrees of severity
Type I APC/LC are stable since posterior elements are intact
Type II APC/LC varying degress of instability
Type III APC/LC and VS all significantly unstable
Bladder rupture


Occurs in 9-16% of all pelvic fractures
Diagnosed by cystogram ± CT



Extraperitoneal or intraperitoneal
o Extraperitoneal due to shearing forces or laceration by bony spicules anteriorly
o Intraperitoneal due to severe pressure to a distended bladder
o Mixed rupture in 12% of case
Signs – suprapubic tenderness, low urine output and gross hematuria (>95%)
Treatment
o Intra-peritoneal – surgical repair
o Extra-peritoneal – conservative with IDC insertion
Urethral rupture





Occurs in 4-14% of pelvic fractures
Diagnosed by retrograde urethrography
May be partial or complete
Signs – meatal bleeding (98%), gross hematuria, perineal hematoma, vaginal laceration
Treatment
o Depends on location and severity
o Suprapubic or aligning urinary catheter
o Primary repair or
o Delayed urethroplasty/otomy
Hip Injuries





Large ball and socket articulation providing high degree of stability and mobility.
Head and intracapsular portion of femoral neck recives majority of their blood supply from
extracapsular arterial ring (trochanteric anastomosis) with minor blood supply from obturator artery
via the ligamentum teres (foveal artery). Retinacular arteries from extracapsular ring pass under
reflection of hip capsule to supply the femoral neck and head in retrograde manner.
Intracapsular fractures disrupt the ‘distal to proximal’ blood flow and so may result in avascular
necrosis of the femoral head.
Causes of femoral head avascular necrosis (AVN) –
o Intracapsular fractures of neck of femur
o Posterior hip dislocation
o Chronic pancreatitis
o Alcohol abuse
o Sickle cell anemia
o Vasculitis
o Irradiation
o Decompression illness
o Prolonged use of cortiocsteroids
Classification of hip fractures
Hip fractures
Intracapsular
Extracapsular
Type I to IV
Garden's classification
Intertrochanteric
Figure 29 Classification of hip fractures
Trochanteric
Subtrochanteric


Femoral head fractures
o IC femoral head fractures uncommon and usually associated with dislocation of hip and in
young patients (75% in MVA)
o May be single fragment (type I) or comminuted (type II), superior aspect involved in anterior
dislocations and inferior aspect involved in posterior dislocations
o May be missed in initial x-rays due to dislocation and may need CT scan to diagnose in case
of ongoing pain after relocation
o Urgent orthopaedic consultation to reduce dislocation and stabilization of fracture
o Risk of AVN dependent on initial severity of trauma, time to definitive reduction and number
of failed closed reduction attempts
o Complications – AVN 15-20%, post-traumatic arthritis 40% and myositis ossificans 2%
Femoral neck fractures
o Intracapsular fractures 4X more common in females than males
o Four main causes of this injury
1. Elderly, trivial trauma post fall onto greater trochanter – pathological
2. Elderly, with torsion or twisting injury prior to fall – pathological
3. Young persons involved in high-energy trauma – excessive loading
4. Repetitive stress or cyclical loading injuries – stress fracture
o Classification – Garden’s classification
 Type I – incomplete, impacted or stress fractures, trabeculae of inferior neck still
intact
 Type II – Undisplaced fracture across entire femoral neck, no displacement –
unstable
 Type III – complete fracture with partial displacement, associated rotation of
femoral neck
 Type IV – complete subcapital fracture with total displacement of fracture
fragments. Femoral head still in acetabulum
o
o
Management
 Stress fractures and Type I fractures – considered stable, conservatively treated with
close orthopaedic supervision
 Displaced fractures – markedly reduced hip movement, shortened lower limb,
abducted and externally rotated. X-ray usually diagnostic. Analgesia, femoral nerve
block and skin traction until definitive orthopaedic plans
 Young patients with severe energy impact fractures usually managed case per se
and have 35% risk of AVN and 57% risk of non-union
Complications
 Mortality – 14-36% in first year after injury, 3X more risk if patients institutionalized
prior to fracture
 Risk factors for increased mortality – male gender, increased age, malnutrition,
medical comorbidities and renal failure

 Morbidity – AVN, non-union, infection and osteomyelitis
Extracapsular fractures
o Intertrochanteric fractures
 Occur along a line between the greater and lesser trochanters, usually pathological
occurring in elderly with female preponderance
 Mechanism – trivial fall with direct force on greater trochanter, high speed MVA or
falls from heights in young adults
 Examination – pain, swelling due to hematoma, shortened, abducted and
significantly externally rotated lower limb
 X-ray diagnostic in most cases, lateral view to depict size, location and degree of
comminution of fracture fragments – stability
 Classification – Evan’s – little significance for ED
o Management
 Significant blood loss – addressing hemodynamic issues and comorbidities
 Systemic analgesia and fluid resuscitation
 Skin traction and immobilization
 Trauma analysis to rule out other injuries
 ORIF produces better anatomical alignment, reduces hospital stay and improved
function with reduced mortality
o Complications – mortality increased with comorbidities and associated multiple injuries
Figure 30 Evan's classification of intertrochanteric fractures



Greater trochanter fractures
o Isolated fractures of greater trochanter uncommon, usually in young patients (7-17 years)
involving true epiphyseal separation due to indirect trauma
o Forceful muscular contraction by gluteus medius causes avulsion of the apophysis
o Adult isolated greater trochanteric fractures rare
o Good prognosis, treated with bed rest 3 days, non-weight bearing crutches for 4 weeks
o ORIF needed for significant separation
Lesser trochanteric fractures
o Isolated fractures rare and usually in young 85% <20 years of age
o Avulsion fracture due to forceful contraction of iliopsoas
o Management with 10days bed rest and slow mobilization; surgery not indicated.
Subtrochanteric femoral fractures
o Fracture line below lesser trochanter up to 5cm distally
o 11% of hip fractures, usually pathological in elderly, osteoporosis, bone metastases or ESRF,
rarely young adults with high-energy impact
o Hemorrhage of up to 2L possible and attention to resuscitation essential
o Parenteral analgesia, splinting e.g. Donway or Hare.
o Orthopaedic referral for ORIF
o
20% mortality in elderly in first year. High rates of non-union and implant failure due to
cortical bone and less vascularity as compared to other fractures above
Hip dislocation



Inherently very stable joint requiring considerable force to dislocate and associated injuries always
sought for.
Anatomically classified into anterior and posterior. Non-prosthetic hip dislocations are orthopaedic
emergency due to increased risk of AVN and sciatic nerve injury/ischemia with delayed reduction
Posterior dislocation
o 85-90% of traumatic hip dislocations, due to direct distal force on flexed knee and hip of
varying degrees
o Usually hip and knee flexed to 90˚ and adducted – weakest position for hip stability e.g.
dashboard injury in MVA
o Clinically – shortening, adduction, internal rotation and some degrees of flexion
o AP x-ray film usually adequate to confirm diagnosis
o >50% associated with acetabular, femoral head or femoral fractures and further
investigations needed – Judet views, lateral views and CT scan
o Neurological examination important – for sciatic nerve and branches involvement – peroneal
nerve injury
o Associated other injuries – ipsilateral knee ligament disruption with PCL tear.
o Management – early urgent orthopaedic consult and full trauma survey to rule out other
injuries, reduction with procedural sedation or GA
o Complications
 AVN 15% increased with increased time to reduction
 Sciatic neuropraxia 15% - relieved by reduction, permanent damage 3%
 Missed knee injuries 15%
 Patellar/tibial plateau injuries
Figure 31 Posterior hip dislocation

Anterior dislocation
o 10-15% associated with femoral neurovascular injury and occult hip joint fractures
o Usually result from direct blow to abducted and externally rotated hip and usually associated
with tear of anterior capsule of hip and acetabulum
o Classification –
 Superior or iliac Type I
 Type II or inferior or obturator
o Clinically – extended, externally rotated and slightly abducted distal limb in superior type;
flexed, externally rotated and abducted in inferior type. Femoral head palpable in femoral
triangle or near ASIS.
o Injury to femoral artery, nerve and vein common with superior dislocation
o X-ray diagnostic but further imaging needed to rule out occult fractures
o
o
Full trauma assessment to rule out other injuries
Urgent consultation for early closed reduction and need for GA
Figure 32 Anterior inferior dislocation of hip
Femur injuries

Femoral shaft fractures
o Usually a result of considerable force e.g. MVA, falls from height or GSW unless pathological
o Classification broadly into open/closed, transverse/oblique/spiral/segmental and may occur
in proximal/middle/distal third.
o Clinically – usually straightforward diagnosis, thigh shortened, externally rotated and hip
held in flexion
o Neurovascular injuries rare but distal pulses, capillary refill and distal sensation must be
carefully examined, especially in open injuries
o Associated injuries – fractures of the pelvis, femoral head and neck, dislocation of the hip,
soft tissue and skeletal injuries around the knee and 1.5 – 2Lblood loss may thus occur
o Management – trauma care, analgesia, fluid resuscitation, femoral shaft fracture reduction
and immobilization prior to x-ray of the limb
o Femoral nerve block important adjunct in analgesia management
o Early reduction and immobilization reduces
 Overall mortality
 Pain
 Limits blood loss
 Reduces risk of fat embolism
o Donway and Hare traction splints have replaced Thomas splint in ED
o Early operative fixation within 8hrs usually indicated
o Complications –
 Immediate – fat embolus syndrome, hemorrhagic shock, ARDS
 Delayed – shortening, mal-alignment and non-union, post-traumatic arthritis
o Distal third fractures – consider arteriography for evaluation of arterial injury.
Figure 33 AO classification of femoral shaft fractures
Knee injuries

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
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




Largest joint in body, synovial, complex hinge joint comprising patellofemoral and tibiofemoral joints.
Most commonly injured joint in the body, mostly young patients involved in sport.
Mechanism of injury knowledge essential
Examination of hip and ankle joint essential.
Anterior cruciate injury associated with meniscal and collateral ligament injury in >50% of cases
Lateral tibial plateau fractures → Anterior cruciate and medial collateral injury, medial tibial plateau
fractures → PCL and lateral collateral ligament injury
Clinical assessment
o Mechanism of injury, degree of force, presence of immediate swelling and ability to weight
bear
o Direct/indirect trauma, varus/valgus stress
o Comprehensive knee examination – inspection, palpation, active/passive movements, SLR
test, anterior/posterior drawer tests, Lachman’s test, collateral laxity tests, McMurray’s test
and Apley’s test.
Radiology – check Ottawa/Pittsburgh knee imaging rules
o AP, lateral, tunnel views for acute knee skeletal injuries, hemarthrosis
o Oblique x-rays – elucidate tibial plateau fractures
o Skyline x-ray view – patella and patella-femoral joint assessment
o CT scanning – define tibial plateau fractures and complex injuries
o MRI knee – evaluation of complex soft tissue knee injuries
Fractures around the knee joint – distal femur
o Usually result of high force trauma – MVA/fall from height
o Classification – supracondylar/intercondylar and isolated condylar
o Clinically – swelling, deformity, rotation and shortening. Tender joint along joint lines and
acute haemarthrosis in articular fractures
o Rule out other injuries in the same limb e.g. hip dislocation, pelvic fractures, tibial plateau
fractures
o
o
o
Rule out injury to deep peroneal nerve – loss of sensation in web space between first and
second toes
AP, lateral knee x-rays to diagnose injury and pelvic x-ray to rule out associated injuries
Management
 Adequate analgesia and ED splinting
 Cast immobilization for Undisplaced/impacted fractures
 Fractures with joint involvement and incongruity need ORIF
 Early orthopaedic consultation required
Figure 34 AO/ OTA classification of distal femur fractures
Tibial plateau fracture










Superior articulating surfaces of the medial and lateral tibial condyles
Mechanism – valgus/varus deforming force apllied to weight bearing knee
Account for 1% of all fractures, lateral tibial plateau fractures twice as common with bilateral
involvement in 20-30% cases.
Anterior fractures occur when knee is in extension and posterior fractures when knee in flexion
Classification – Schatzker classification most commonly used
o Type I, II, III – lateral tibial plateau with increasing articular depression
o Type IV – medial plateau
o Type V and VI – both plateaus with increasing comminution and joint instability
o Segond fracture – tibial plateau avulsion fracture at site of lateral capsular ligament insertion
due to excessive internal rotation and varus stress to fixed knee. ACL disruption and rotatory
instability common.
Clinical assessment
o Inability to weight bear, painful swollen knee, limitation of movement with focal tenderness
at site of injury
o Distal circulatory compromise due to compression of popliteal artery by comminuted
fragments may occur
o Peroneal nerve neuropraxia may occur in lateral plateau injuries – foot drop
Associated knee soft tissue injuries
o Lateral tibial plateau → ACL and MCL disruptions
o Medial tibial plateau → PCL and LCL disruptions
Radiology – AP/ lateral views usually sufficient but oblique views may be required, CT scan to evaluate
non-displaced comminuted fractures, MRI for soft tissue damage quantification
Management – early orthopaedic consult and ORIF if significant comminution
Complications – missed neurovascular injuries, compartment syndrome and osteoarthritis
Figure 35 Schatzker classification of Tibial plateau fractures
Patellar fracture






Largest sesamoid bone in the body, lying within the quadriceps tendon, improves strength, stability
and mechanical advantage of the extensor mechanism.
1% of all skeletal injuries, commonly young adults between 20-50 years as a result of direct or indirect
trauma
Direct trauma to anterior aspect of patella → incomplete, stellate, comminuted or vertical fractures –
usually in MVA dashboard injuries
Indirect trauma – stumbling or falling forwards → powerful quadriceps contraction → transverse
fracture – 80% of patellar fractures mainly in central and lower third of patella
Clinical assessment
o Pain bruising and swelling over patella
o Ability to walk and active extension of knee dependent on type of fracture and separation
o Inability to extend knee actively – sign of significant separation of quadriceps tendon
Management
o Fragment displacement >3mm suggestive of extensor mechanism disruption requiring
orthopaedic consultation and review → ORIF with tension band wiring
o Non-displaced fractures with intact extensor mechanism → long leg cast immobilization in
full extension for 6weeks
Indications for Knee x-ray – Ottawa / Pittsburgh rules




Epidemiology
o Fractures occur in only 6% of knee trauma cases
Efficacy: Accuracy for Acute Knee XRay Indications
Pittsburgh Knee Rules (Pittsburgh Decision Rules)
o Test Sensitivity: 99%
o Test Specificity: 60%
o Reduced the use of Knee XRays by 52%
Ottawa Knee Rules
o Test Sensitivity: 97%
o Test Specificity: 27%
o Reduced the use of Knee XRays by 28%


Knee XRay Indications: Pittsburgh Knee Rules (acute)
1. Primary criteria (required)
1. Blunt trauma or fall type injury
2. Secondary criteria (one of the following present)
1. Age younger than 12 years or over 50 years
2. Inability to walk four weight bearing steps in ER
Knee XRay Indications: Ottawa Knee Rules (acute)
1. Age over 55 years
2. Isolated patella tenderness
3. Tenderness at head of fibula
4. Inability to flex knee to 90 degrees
5. Inability to bear weight (4 steps)
1. Immediately at site of accident
2. Emergency department
6. Rules efficacious down to age 5 years
1. Bulloch (2003) Ann Emerg Med 42:48-55
Dislocation of the knee






Rare and usually occur in males in third decade of life
Orthopaedic emergency associated with vascular damage that require urgent reduction
Mechanism
o Usually involves rupture of both cruciate ligaments and one collateral ligament
o Usually high velocity injuries e.g. MBA
Classified in respect to displacement of tibia in relation to femur – anterior dislocations most common
Assessment
o Gross distortion of the knee joint, easily visible and palpable
o Associated with high rate of peroneal nerve and popliteal artery injury – careful
neurovascular assessment essential
o Distal vascular compromise may be evident with reduced pulses but may be normal with
10% of popliteal artery injuries
o Peroneal nerve dysfunction present in 50% of cases causing foot drop and sensory
impairment over lateral border of foot.
Management
o Urgent orthopaedic and vascular teams consultation with early reduction under procedural
sedation in ED if necessary
o Risk of compartment syndrome and amputation significantly increased if dislocation >6hrs
o Failed reduction rarely occurs due to buttonholing of femoral condyle and requires urgent
ORIF under GA
o Angiography essential in every reduction to assess for any vascular injury.
Figure 37 Anterior knee
dislocation
Figure 36 Posterior knee
dislocation
Patellar dislocation







Common and may be recurrent, majority occur in the setting of patellofemoral dysplasia secondary to
hypoplastic vastus medialis, shallow trocheal groove or genu valgum
Lateral dislocation most common, usually caused by direct blow to the anterior or medial surface of
the patella
Clinical assessment
o c/o knee suddenly giving way with immediate pain and swelling
o inability to weight bear or extend knee
o palpation reveals central defect and laterally deviated patella, swelling anf medial joint line
tenderness
Standard AP and lateral x-rays confirm diagnosis and to rule out osteochondral fracture
X-rays can follow reduction or may be skipped in recurrent dislocation with absence of trauma
Management
o Spontaneous reduction prior to arrival in ED
o Closed reduction in ED done with analgesia ± sedation
o Immobilize knee in extension for 3-6 weeks for medial retinaculum healing to occur
Complications
o Recurrent dislocation in 15% requiring surgery
o 50% symptoms of instability or anterior knee pain
Figure 38 Lateral patellar dislocation
Lower leg fascial compartments

Divided into four compartments by bone and fascia. Each compartment contains a sensory nerve and
muscles with specific functions.
Figure 39 Fascial compartments of the leg
Anterior
compartment
Lateral
compartment
Superficial
posterior
compartment
Deep posterior
compartment
Muscles:
Muscles:
tibialis anterior
Peroneus longus
Muscles:
Tibialis posterior
extensor digitorum
longus
Peroneus Brevis
Gastrocnemius
Function:
Soleus
Flexor hallucis
longus
Eversion of the
foot
Function:
extensor hallucis
longus
peroneus tertius
Function:
dorsiflex ankle and
foot
Nerve supply:
Deep peroneal
nerve
First web space of
foot
Artery:
Anterior tibial
artery→ dorsalis
pedis artery
Nerve supply:
Plantarflex the
ankle
Muscles:
Flexor digitorum
longus
Popliteus
Superficial
peroneal nerve
Nerve supply:
Function:
Sural nerve
Plantarflex toes
Dorsum of the foot
Lateral side of the
foot and distal calf
Nerve:
Tibial nerve
Sole of the foot
Artery:
Posterior tibial and
peroneal arteries
Tibial shaft fractures




Most common long bone fracture and easily recognized with high risk for open injury due to
subcutaneous nature
Direct and indirect violence usually involving significant force e.g. MVA, pedestrian incidents
High risk for comminution and displacement with increasing energies and increased risk for
compartment syndrome with same
Classification
o Open/closed
o Proximal/middle/distal third
o Transverse/oblique/spiral/comminuted
o Angulation of distal fragment in relation to proximal fragment – anterior/posterior,
varus/valgus
o Degree of displacement and rotation
o Involvement of fibula
Figure 40 Tibial shaft fractures
Type
Type A
Grade
1
2
3
Type B (Multifrag wedge)
1
2
3
Type C (multifrag complex) 1
2
3
Characteristic
Spiral
Oblique >30˚ angle
Transverse <30˚ angle
Spiral wedge
Bending wedge
Fragmented wedge
Spiral wedge
Segmental
Irregular
Figure 41 AO classification Tibial shaft fractures

Clinical assessment
o Fracture site pain, inability to weight bear, swelling and deformity
o Check skin for integrity
o Check lower leg and foot for neurovascular status urgently – skin colour, capillary refill, distal
pulses
o Checking neurological function –
1.



Deep peroneal nerve → active ankle and toe dorsiflexion, sensation of first dorsal
web space
2. Superficial peroneal nerve → active foot eversion and sensation over dorsum of foot
o Assess ipsilateral limb for knee and femur injuries
Radiology – AP/lateral views including entire tibia/fibula from knee to ankle to assess joint
involvement
Management
o Analgesia, reduction of displaced and/or compound fractures under sedation
o Immobilization of lower leg
o Open wounds assessed for damage and dressings applied
o Tetanus immunisation and IV antibiotics
o Recheck neurovascular status after successful reduction and x-ray confirmation
o Surgical options – conservative/ closed reduction/ ORIF and intra-medullary rods
Compartment syndrome
o Documentation of neurovascular status essential to exclude acute neurovascular injury
o Occurs in up to 20% of closed injuries and may take up to 24hrs to develop
o Increasing pain early indicator, weakness of muscle action, pain on passive movement and
diminished sensation over the distal sensory component
o Pulses may be present until late in the presence of compartment syndrome and unreliable
sign
o Deep posterior compartment most commonly affected followed by anterior compartment
o Compartment pressures should be measured in all doubtful cases >30mmhg or within
30mmhg of MAP
Ankle injuries


Complex hinge joint between tibia, fibula and talus providing stable but mobile support for the body
Stability of joint relates to bony architecture, joint capsule and ligaments which form a ring centred
around the talus and is comprised of:
o Bones – tibial plafond, medial malleolus and lateral malleolus, calcaneus
o Ligaments – medial (deltoid) ligament, lateral collateral ligaments and syndesmotic ligaments
o Tibial plafond, medial and lateral malleolus form the bony mortise of the joint
Figure 42 lIgaments of ankle joints


Medial ligament – fans out from the tip of the medial malleolus to attach to
o Tuberosity of navicular
o Medial aspect of talus
o Sustentaculum tali of calcaneus
Lateral ligament – three discrete parts



o Anterior and posterior talofibular ligaments
o Calcaneofibular ligament
History
o Inability to weight bear, swelling immediately after injury imply significant injury
o Circumstances of injury, position of foot at time of injury
o Magnitude and direction of loading forces especially rotational
o Inversion injury – always assess the fifth metatarsal
Examination
o Analgesia, rest, ice and elevation while awaiting examination
o Examine entire leg and compare with opposite side
o Note integrity of skin, bruising, swelling and deformity
o Palpation for point tenderness to localize bone, tendon or ligament injury
o Examine entire length of tibia, fibula, fifth metatarsal, calcaneus and Achilles tendon
o Assess range of active and passive movement
o Check for motor/sensory impairment, capillary return, presence of dorsalis pedis and
posterior pedal pulses and injury to base of fifth metatarsal
o Stress tests – if clinical suspicion for fractures low – talar tilt test (calcaneofibular ligament)
and anterior/posterior drawer tests (anterior and posterior talofibular ligaments)
Radiology – Ottawa ankle rules and also foot rules
o 98% sensitive for detecting clinically relevant ankle fractures in competent adults and
children
Figure 43 Ottawa ankle radiology rules



Further imaging – CT scan to further evaluate complex fractures and MRI for difficult ligament injuries
and bone scans for suspected osteochondral or stress fractures
Ankle fracture classification
o Henderson or Pott’s classification – uni-/bi-/tri-malleolar fractures
o Weber classification – based on level at which fibula fractures, greater the proximity of fibula
fracture higher the risk of instability – Type A,B and C.
o AO classification – applies three subdivisions to each Weber type to account for medial or
posterior malleolar injuries
o Pilon fractures – distal tibial metaphyses with tibial plafond disruption - unstable
o Maisonneuve fracture – fracture of proximal end of fibula associated with medial malleolus
fracture, associated with disruption of interosseous membrane from tibiofibular
syndesomosis to proximal fibular head -unstable
Fracture management
o Minimally displaced fractures of distal fibula <3mm separation with no medial ligament
disruption – treated as sprains
o
o
o
o
Grossly displaced fractures – reduced and splinted in ED with analgesia or procedural sedation
prior to imaging if distal ischemia or skin integrity threatened
Extra-articular or non-displaced fractures with intact mortise – non-operative, below knee
POP cast in neutral position – ankle 90˚ no eversion/inversion, Orthopedic follow up.
Displaced and potentially unstable fractures – early orthopaedic consultation i.e. all bi-/trimalleolar fractures and unimalleolar fractures with contralateral ligamentous injury – ORIF.
Pilon fracture/ Maissoneuve fracture – unstable, reduce, splint and orthopaedic consult.
Figure 44 Weber Classification of Ankle fractures
Foot injuries

28 bones and 57 articular surfaces, divided into three anatomical zones –
o Hind foot – talus and calcaneum
o Mid foot – navicular, cuboid and cuneiforms
o Forefoot – metatarsals and phalanges
 Clinical assessment
o History – direct trauma –more serious swelling and injury, indirect trauma - avulsion fractures
o Record any pain, swelling, loss of function, reduced sensation and deformity or associated
ankle injuries
o Examination – inspection, palpation, active/passive movements at hind foot/ mid foot/
forefoot, walking and check posterior tibila and dorsalis pedis pulses, motor/sensory function
 Radiology –
o Ottawa foot and ankle rules – tenderness over navicular or fifth metarsal base and inability to
walk at least four steps – do not apply for hind foot or foot injuries
o AP. Lateral and 45˚ internal oblique projections , axial calcaneal view if injury to calcaneus
suspected
o Other – bone scan for stress fractures, CT for calcaneum, subtalar joint and lisfranc joint
complex
Hind foot injuries
 Calcaneus fractures
o Largest bone in foot and most commonly fractured tarsal bone
o Fractures result from direct axial compression during falls from height, 7% bilateral with lower
extremity injuries in 25% cases and vertebral compression fractures in 10% of cases
o Classification – 75% intra-articular, may be non-displaced, displaced or comminuted
o Clinical assessment –
 History of fall from height landing on heel, weight bearing impossible
 Examination – pain, swelling, bruising, tenderness over heel
 Associated fractures common – vertebral column, pelvis, affected lower extremity
and opposite calcaneus
o Radiology – AP, lateral and sometimes oblique views needed


Lateral view – Bohler’s salient angle <20˚ (normal 20-40) suggestive of compression
fracture, critical angle of Gissane (normal 95-130˚) reduced.
CT scan to define complex fractures and pre=operative planning
Figure 45 Rowe classification of Calcaneus fractures
Figure 46 Bohler's angle and Crucial angle of Gissane1
1
In determining the Bohler angle, a line is drawn between the posterior superior aspect of the calcaneus and
the highest point of the posterior subtalar articular surface; a second line, which intersects the first, is drawn
from the highest point of the anterior process to the posterior margin of the subtalar surface.
o

Management
 Difficult to manage with poor outcome
 50% - chronic pain and functional disability
 Intra-articular, displaced, comminuted fractures – risk of gross welling and compartment
syndrome – elevation, immobilization and ORIF in young patients
 Extra-articular fractures with minimal displacement – conservative, posterior non weight
bearing cast for 6 weeks
Talar fractures
o No muscular attachments and held in place by malleoli and ligaments, comprises a head, neck
and body.
o Head articulates with navicular and calcaneus, body articulates with tibia, fibula and calcaneus
and neck joins head and body, neck accounts for 50% of fractures
o Blood supply arises from anastomotic ring from the peroneal, posterior and anterior tibial
arteries – tenuous and easily disrupted → risk for AVN
o Mechanism –
 Second most common tarsal fracture – major or minor
 Minor – inversion injuries to plantar or dorsi-flexed foot
 Major – significant force (MVA) or axial loading (fall from height) associated with
calcaneal fracture
o Classification – Hawkin’s classification of talar neck fractures
 Type I – non-displaced, fracture line entering subtalar joint between middle and
posterior facets
 Type II – any degree of displacement or subtalar subluxation – AVN 30%
 Type III – displaced talar neck fractures with dislocation of both subtalar and ankle joints
– AVN 90%
o Commonly associated injuries – vertebral compression, calcaneal and medial malleolar fractures
Figure 47 Hawkin's classification of Talar neck fractures
Lisfranc’s Fracture




The Lisfranc joint, which represents the articulation between the midfoot and forefoot, is composed
of the 5 tarsometatarsal (TMT) joints. The Lisfranc ligament is attached to the lateral margin of the
medial cuneiform and medial and plantar surface of second metatarsal (MT) base. This is the only
ligamentous support between first and second ray at midfoot level.
A Lisfranc injury encompasses everything from a sprain to a complete disruption of normal anatomy
through the TMT joints.
Lisfranc injuries account for 0.2% of all fractures
Mechanism
o Low-energy, sports-related injuries - TMT injuries are caused by a direct blow to the joint or
by axial loading along the MT, either with medially or laterally directed rotational forces.
o





In high-energy injuries, the energy absorbed by the articulations results in significantly more
collateral damage to bony and soft-tissue structures, creating such injuries as MT fractures,
cuneiform instabilities, and cuboid fractures.
Clinical signs
o Swelling out of proportion with a normal radiograph
o Plantar midfoot ecchymosis
o Pain along the TMT joints with palpation, motion, and/or weight bearing
o Midfoot instability
Lisfranc’s injury can be potentially career-ending for elite sports professionals and carries significant
morbidity
Radiology
o AP view of foot - >2mm separation between first and second metatarsal increase suspicion
o Lateral view in standing position if possible – alignment of superior order of 1st metatarsal
with superior border of medial cuneiform
o Medial 30˚ oblique view – medial border of cuboid aligns with medial border of 4th
metatarsal base
o Weight bearing AP view if diagnosis in doubt
o ‘Fleck Sign’ – avulsion fracture from either 2nd MT or medial cuneiform present in 90% cases
of Lisfranc’s injury
o CT scan indicated in most cases to quantify injury
o MRI/bone scans for further ligament and bony injury delineation
Classifications – multiple available but no clinical significance except – stable/unstable
Management
o Stable injuries – well moulded non weight-bearing, short-leg cast for 6 weeks, weight-bearing
x-rays at 6 weeks → progressive weight-bearing over 6weeks
o Unstable injuries – virtually all need some form of ORIF as closed reduction can usually not
be maintained if ligament disruption has occurred
Figure 48 Lisfranc's fracture - AP view. Separation of 1st /2nd MT. Medial border of cuboid misaligned. White arrow –
Fleck sign.
Fractures of base of fifth Metatarsal


Most common metatarsal fracture of two types
o Fracture of tuberosity – sudden inversion of plantar flexed foot due to avulsion of lateral
band of plantar aponeurosis and usually extra-articular
o Jones’ fracture – transverse fracture through base of fifth metatarsal, 15-31mm from
proximal end of the bone, intra-articular involving articulation between 4th and 5th
metatarsals due to lateral load applied on un-inverted foot
Management
o Jones fracture - >2mm displacement of fragments or >30% involvement of articular surface
require surgical intervention
o Tuberosity fractures – conservative, compression bandage or weight bearing POP cast
Paediatric considerations in orthopaedics
i)
Salter-Harris classification
ii)
Injuries about the elbow
iii)
The child with a limp
iv)
Inflammatory arthritis
v)
Osgood/Schlatter disease
vi)
Perthe’s disease
vii)
Slipped capital femoral epiphysis
viii)
Transient synovitis
TH
TH
DIS H
DIS H
DIS H
DIS H
DIS H
DIS H
DIS H
Salter-Harris Classification for pediatric fractures
 Salter-Harris fractures are fractures through a growth plate; therefore, unique to pediatric patients.
 These fractures (radiographs of which are presented below) are categorized according to the



involvement of the physis, metaphysis, and epiphysis.
The classification of the injuries is important, because it affects patient treatment and provides clues
to possible long-term complications.
When all types of Salter-Harris fractures are considered, the rate of growth disturbance they cause is
approximately 30%. However, only 2% of Salter-Harris fractures result in a significant functional
disturbance.
The basic SH classification of fractures include the following
o Type I - transverse fracture through the hypertrophic zone of the physis. In this injury, the
width of the physis is increased. The growing zone of the physis usually is not injured, and
growth disturbance is uncommon.
Figure 49 Salter Harris type I
o
Type II - The most common type of Salter-Harris fracture occurs through the physis and
metaphysis; the epiphysis is not involved in the injury.
Figure 50 Salter Harris Type II
o
Type III - a fracture through the physis and epiphysis. This fracture passes through the
hypertrophic layer of the physis and extends to split the epiphysis, inevitably damaging the
reproductive layer of the physis. Relatively favourable prognosis. SH III fracture involving
lower end of tibia called Tillaux fracture and unstable needing operative intervention.
Figure 51 Salter Harris Type III
o
Type IV - Involves all 3 elements of the bone, passing through the epiphysis, physis, and
metaphysis. It is an intra-articular fracture; thus, it can result in chronic disability.
Figure 52 Salter Harris Type IV
o
Type V - is a compression or crush injury of the epiphyseal plate, with no associated
epiphyseal or metaphyseal fracture. This fracture is associated with growth disturbances at
the physis. Initially, diagnosis may be difficult, and it often is made retrospectively after
premature closure of the physis is observed. Typical history of axial load type of injury with
poor functional prognosis.
Figure 53 Salter Harris Type V

CT scanning or MRI indicated only if diagnosis or severity of injury in doubt and not indicated initially
though may be required preoperatively.
Pediatric elbow Injuries






Diagnostic difficulties stem both from the complex developmental anatomy of the elbow and from
significant differences between children and adults in the patterns of injury after elbow trauma.
Anatomy – the elbow is composed of 3 articulations.
o The ulna articulates with the humerus at the trochlea, which is the grooved and rounded
medial articular portion of the distal humerus. The articular portion of the ulna is formed by
the olecranon process proximally and by the coronoid process more distally.
o This humeroulnar or trochleoulnar joint is a hinged articulation that essentially permits
motion in a single plane, allowing flexion and extension.
o The concave head of the radius articulates with the capitellum, which is the convex lateral
articular surface of the distal humerus. This humeroradial or radiocapitellar joint permits the
radius to rotate to any degree of flexion or extension of the trochleoulnar joint; this rotation
allows supination and pronation of the forearm.
Developmental anatomy - complex but essential in analysing the impact of elbow trauma in children
o The distal humerus has 4 secondary ossification centers: those for the capitellum and
trochlea (which form the articular surfaces) and those for the medial and lateral epicondyles.
o the average age at which the humeral ossification centers are seen first in 50% of children
 3 months of age for the capitellum,
 5 years for the medial epicondyle,
 8 years for the trochlea, and
 10 years for the lateral epicondyle.
o The corresponding ages at which the forearm ossification centers appear are
 4.5 years for the radial head and 9 years for the olecranon.
o The acronym CRMTOL is used to describe the usual order of appearance of all 6 elbow
centers: capitellum, radial head, medial epicondyle, trochlea, olecranon, and lateral
epicondyle.
Normal x-ray findings that may appear as fractures
o Radial tuberosity and olecranon process may appear as large lytic lesions due to differential
ossification. Notch like deformity in metaphysic of radial head commonly normal
o Slight anterior and radial angulation to neck of radius with respect to its body is normal
X-ray evaluation
o AP and lateral view often suffice for most fractures
o Oblique views for lateral condyle fractures, Radiocapitellar view for capitellum and radial
head
X-ray findings
o Soft tissue findings – posterior fat pad sign always pathologic, anterior fat pad sign sometime
normal but angulation and degree may be significant in lateral views only
o Posterior fat pad present in 30-70% of cases and absence does not signify absence of
fracture. 70-90% cases of posterior fat pad sign, acute fracture usually noted though in
absence of trauma other causes for joint effusion should be sought.
Figure 54 Anterior and posterior fat pad signs
o

Anatomical lines – two lines used commonly
 Anterior humeral line - a line drawn along the anterior aspect of the distal humeral
metaphysis should pass through the middle third of the capitellum, which is also
part of the humerus. Mostly disrupted in supraondylar fractures.
 Radiocapitellar line - The radiocapitellar line is drawn through the radial neck and
should pass through the capitellum. This relation should be examined on a frontal
view as well. Failure of the radiocapitellar line to pass through the capitellum
indicates radiocapitellar dislocation.
Fracture frequency
o Adults – 50% radial head and neck, 20% olecranon, 10% supracondylar
o Children – 60% supracondylar, 15% lateral condylar, 10% medial condylar
Figure 55 Anterior humeral line and Radiocapitellar line
Supracondylar fractures








Most common pediatric elbow fracture (60%) occurring in children from 3-10 yrs of age, peak
incidence 5-8yrs
Most commonly involving humeral metaphyses where it flares out and thins to develop into the
condyles
Most commonly secondarily to a fall onto outstretched hand involving posterior displacement or
angulation of distal fragment and some medial displacement as force is transmitted from ulna to
humerus.
Less commonly from direct blow to back of elbow resulting in anterior displacement of distal
fragment
X-ray findings
o Fat pad signs in 70-90% cases
o Anterior humeral line passes anterior to middle third of capitellum in 94% cases
o Fracture line seen in most cases except in case of greenstick fractures and plastic bowing
fractures
Classification – Gartland-Wilkins define extension supracondylar fractures into:
o Type I – no or minimal distal fragment displacement – anterior humeral line still passes
through part of capitellum
o Type II – posterior displacement with intact posterior cortex
o Type III – fractures with displacement and complete cortical disruption
Fracture may be further described as transverse or oblique – oblique signifying rotation at fracture
site → risk for valgus/varus deformity.
Complications
o
o
o
Cubitus Varus – relatively common with varying degrees, rarely causing morbidity unless
severe requiring valgus osteotomy
Vascular injury – with severe displacement of fragments may injure brachial artery resulting
in Volkmann’s ischemic contracture of limb with long term functional morbidity. Doppler US,
angiography and arteriography may be indicated in selected cases.
Nerve injuries – occurring in 5% of fractures and usually involves anterior interosseous
branch of median nerve
Figure 56 Supracondylar fracture Type I
Lateral condylar fractures






Second most common elbow fracture (15%) in children. Findings may be subtle and often missed.
Two primary mechanisms of injury
o Frequently – acute varus stress on extended elbow resulting in traction on extensor muscles
and tendon attachment
o Fall on outstretched hand with elbow extended and forearm abducted
Currently considered Salter-Harris Type IV – humeral fracture usually involves cartilage and thus not
seen on x-ray
Classification and staging – Milch
o Stage I – incomplete fracture with no displacement and intact hinge – stable
o Stage II – complete fractures with minimal displacement of distal fragment
o Stage III – distal fragment significantly displaced laterally and proximally with rotation due to
traction from common extensor tendon – unstable and risk for malunion
Radiology
o When subtle findings may be missed and include – soft tissue swelling and joint swelling,
subtle subcortical fracture line along lateral aspect of metaphyses
o Internal oblique views may be helpful
o Cortical breaks usually seen in lateral views
o Key finding – lateral epicondyle last to ossify so if ossification seen usually represents
fracture rather than ossification centre
o MRI and ultrasound may be useful to further evaluate injury
o Always look for associated elbow dislocation as a result of fracture
Complications
o Instability
o Malunion
o Non-union – varus abnormality long term
Figure 57 Lateral condylar fractures
Medial epicondyle fractures




10% of elbow fractures in children, ages 7-15 years, peak incidence 10-12years
50% associated with dislocation
avulsion injuries caused by traction from the ulnar collateral ligament or the forearm flexor muscles
that arise from the medial epicondyle.
Radiology
o separation of the entire medial epicondyle from the metaphysis,
o avulsion of only part of the medial epicondyle or
o avulsion of the epicondyle together with a small portion of the adjacent metaphysis.
o Comparison with opposite elbow x-ray may be helpful
Figure 58 Medial epicondyle fracture



Owing to traction from the forearm flexors, the medial epicondyle is displaced distally and medially.
Mostly extra-articular and so joint effusion is absent
Complications
o Entrapment of fractured medial epicondyle fracture in elbow joint – may be mistaken for
trochlea but trochlea ossifies after medial epicondyle.
Figure 59 Medial epicondyle fracture with fragment entrapment
The limping child




Limp is defined by a deviation from the normal gait pattern expected for a child's age
The possibility of serious pathology underlying an acute presentation of limp makes accurate
assessment, diagnostic evaluation, treatment, and appropriate follow-up essential.
Age related predisposing aetiologies
o Toddler 1-3 years – immature gaits prone to falls, developing bony cortex cannot resist
infections well.
 Infectious/inflammatory (eg, transient synovitis, septic arthritis, osteomyelitis),
 Trauma (eg, toddler's fracture, stress fractures, puncture wounds, lacerations),
 Neoplasm,
 Developmental dysplasia of the hips,
 Neuromuscular disease, cerebral palsy, and congenital hypotonia.
o Children 4-10 years – high risk for trauma and microtrauma to vascular supply as in LCP
disease
 Fractures
 Legg-Calvé-Perthes
 Infections
 Juvenile rheumatoid disease
 Neoplasia – leukaemia and Ewing’s sarcoma
o Adolescent >11years – bones more resilient
 Slipped femoral epiphyses
 Arthritides – inflammatory and infectious
 STIs
 Neoplasms – osteosarcoma
Clinical assessment
o History
 Trauma and inciting events, though many cases of trauma may have non-traumatic
diagnosis
 Private interview in case of suspicion of NAI
 Fever, chills and constitutional symptoms – malignancies, infections, febrile illnesses
 Timing of day – morning stiffness (RA), night time pain only (growing pains),
worsening at night (bone neoplasms)
 Recent infections/URTI – transient synovitis
 Family history
 Growth patterns and milestones
 Immunizations
o Gait assessment
 9mths – infants pull up to stand and walk by holding onto furniture
 >1 year – walk unassisted but with wide based gait, short stance and smaller strides
due to weaker hip abductors
 >3 year – assume adult gait charecteristics
o Abnormal gaits
 Antalgic gait – shortened stance phase of painful limb and shortened swing phase
of normal side
 Abductor or trendelenburg gait – hip disease
 Steppage gait – foot drop due to injury to peroneal nerve or weakness of tibialis
anterior
 Toe-walking gait – real or apparent leg length discrepancy, sometimes no cause
 Vaulting gait – due knee pain and reluctance to bending knee or avoiding hip flexion
with psoas inflammation
o Orthopaedic assessment
 Feet and shoes for abnormal features, wear and tear
 Asymmetry of gluteal skin folds – congenital hip dysplasias
 Inspect and palpate spine and lower extremities for bony pathology
 Joints: warmth, effusion and range of motion



Leg lengths – from ASIS to medial malleolus, >0.5 inch abnormal – due to
developmental dysplasia of hip, growth plate injury, LCP disease
 Galeazzi test – hips, knees in full flexion in supine position on bed – unequal knee
height
 FABER test (Flexion, Abduction, External rotation) – pain on downward pressure –
sacroiliac joint pathology
 Trendelenburg test: standing on affected leg causes pelvic tilt toward ipsilateral side
– developmental hip dysplasia, LCP disease, slipped capital femoral epiphysis and
neurologic conditions causing weakness of gluteus medius
 Prone internal rotation – most sensitive for hip joint pathology – transient synovitis
or septic arthritis
o Neurologic examination
 Motor, sensation and coordination through direct observation
 Deep tendon reflexes to differentiate UMN/LMN lesions
 Muscular asymmetry between limbs
o Medical examination
 Jaundice – sickle cell disease, iritis/keratitis – JRA, blue sclera – osteogenesis
imperfect
 New murmur – rheumatic disease
 Back examination – tufts of hair – spina bifida
 Pupuric lesions – HSP, endocarditis, sepsis
 Abdominal examination – peritonism
 Scrotal examination testicular lesions
 Urethral discharge – infectious/inflammatory arthritis
Laboratory investigations
o CBC – WBC, platelets counts – malignancy or sepsis
o ESR – raised in rheumatoid condition in absence of infection
o Raised WCC >12000/mm, ESR >40mm/hr, h/o fever and inability to weight bear –
differentiate septic arthritis from transient synovitis.
o Blood culture – fever
o Serum chemistry and LFT – rarely diagnostic value
o Urinalysis – hematuria – endocarditis, HSP, AGN and SLE
Imaging studies
o Plain films – include full limb when possible and weight bearing views, x-rays of joints above
and below if patient signs poorly localized. Consider x-ray of unaffected side for comparison
o Bone scan with IV technetium-99m –
 Detects LCP, osteomyelitis(84-100% sensitive, 70-96% specific), discitis, stress
fracture and osteoid osteomas.
 High dose of radiation, consider US and plain films first
 May not be positive until 48-72hrs of disease process
o Ultrasonography
 Useful in younger children with unossified skeleton
 Can make diagnosis of DDH in infants
 Confirm presence of joint effusion and guide diagnostic/therapeutic aspiration
o CT scanning
 In case of suspiciaon of intra-abdominal, GUT or psoas abscess
 Cam identify periosteal abscesses and delineate pyomyositis
 Not used to diagnose joint effusion due dose of radiation
 Tarsal and foot conditions may require CT imaging
o MRI
 Excellent imaging modality to evaluate bony and soft tissue pathology with
multiplanar capability without radiation risk
 Modality of choice for evaluating internal joint derangement, soft tissue or bony
infection, tumors or osteonecrosis
 Also helpful for imaging brain and spinal cord
 Disadvantages – cost, poor availability and long duration – motion artefacts, need
for sedation in younger children and contraindications due to metallic implants etc.



Synovial fluid analysis – criterion standard for diagnosis of septic arthritis
Other special investigations – not necessary in ED
o Sickling tests, SLE, lupus antibodies, autoantibodies and specific serologies
Emergency department care
o Relief of acute pain
o Identification of cause
o Initiation of therapy for source and
o Referral to appropriate specialists for follow up care
Synovial fluid examination






Indications for aspiration
o Diagnostic indications
 Unexplained arthritis with synovial effusion
 Suggestion of an infected joint
 Suspicion of crystal-induced arthritis
 Evaluation of therapeutic response in septic arthritis
o Therapeutic indications
 Drainage of septic joint
 Relief of elevated intra-articular pressure
 Injection of medications
 Evacuation of a painful hemarthrosis
Potential complications of aspiration
o Iatrogenic infection: The risk of inducing joint infection is low when sterile technique is used.
o Tendon injury, rupture, nerve and blood vessel injury, which can result from improper needle
insertion
Contraindications to aspiration
o Severe coagulopathy
o Severe thrombocytopenia
o Overlying cellulitis
Evaluation for
o Gross – color, clarity, viscosity and mucin clot formation
o Microscopy – leucocyte count and differential, wet smear inspection by polarised light, gram
staining
o Cultures – bacteria, fungi and tubercle bacilli if indicated
Differential diagnosis
o Gout/ pseudogout
o Spondyloarthropathy/ RA
o Rheumatic fever
o Sarcoidosis
o Septic arthritis
o Hemarthrosis
Reference ranges
Feature
Volume
Viscosity
Color
Clarity
WBC
PMN %
Culture
Mucin clot
Glucose
Reference range
< 3.5ml
High
Clear
Transparent
<200
<25
Negative
Firm
≈ blood
Non-inflammatory
>3.5ml
High
Straw-yellow
Transparent
200-2000
<25
Negative
Firm
≈blood
Inflammatory
> 3.5ml
Low
Yellow
Transclucent
2000-75000
>50
Negative
Friable
Decreased
Septic
>3.5 ml
Variable
Variable
Opaque
Often >100000
>75
Often positive
Friable
Very decreased