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Australian College of Rural & Remote Medicine
Rural Clinical Guidelines
ORTHOPAEDICS
Australian College of Rural and Remote Medicine
Rural Clinical Guidelines
ACRRM – July 2012
Note: As these guidelines have been specifically designed to be used on a mobile/smartphone device
or as an online activity on https://www.rrmeo.com you will find that there are numerous hyperlinks that
you will not be able to access in this .pdf document.
To further enhance the usability of the guidelines this .pdf version now has hyperlinks ‘from and back
to’ the ‘Table of Contents’ and is suitable to download onto your computer or any of the smaller iPad,
Tablet, Notebook etc. using your e-reader.
As each discipline is a separate file it is suggested that you also download the ‘Alphabetical List’ of
the guidelines to enable easy cross reference to guidelines in other disciplines.
For a list of all the abbreviations used in these guidelines download the ‘Abbreviations List’.
Table of Contents
End-user licence agreement for ACRRM Mobile Device Clinical Guidelines ............................................................................ 3
List of amendments in this update ............................................................................................................................................. 4
RRMEO Modules ...................................................................................................................................................................... 5
ACKNOWLEDGEMENTS ......................................................................................................................................................... 9
ANKLE FRACTURES .............................................................................................................................................................. 10
CLAVICLE FRACTURES ........................................................................................................................................................ 13
COLLES FRACTURE .............................................................................................................................................................. 14
DISLOCATIONS - OTHER ...................................................................................................................................................... 16
FEMORAL FRACTURES ........................................................................................................................................................ 20
FINGER FRACTURES ............................................................................................................................................................ 22
FRACTURES .......................................................................................................................................................................... 23
FRACTURES - GENERAL PRINCIPLES ................................................................................................................................ 24
HUMERAL FRACTURES ........................................................................................................................................................ 26
LIGAMENT INJURIES ............................................................................................................................................................. 28
PLASTERING TECHNIQUES ................................................................................................................................................. 37
SCAPHOID FRACTURES ....................................................................................................................................................... 38
SHOULDER DISLOCATION ................................................................................................................................................... 40
SHOULDER - FROZEN (Adhesive Capsulitis) ........................................................................................................................ 44
SUPRACONDYLAR FRACTURE ........................................................................................................................................... 46
TENDON INJURIES ................................................................................................................................................................ 48
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End-user licence agreement for ACRRM Mobile Device Clinical Guidelines
1. Introduction
(i) The terms and conditions stated here are in addition to the terms and conditions of the End-User
Licence Agreement for licensees of ACRRM software (Software Licence Agreement) which also apply
to your use of these Mobile Device Rural Clinical Guidelines (Guidelines).
2. Acknowledgement
(i) The Guidelines were developed by the Australian College of Rural and Remote Medicine (ACRRM).
3. Intellectual property rights
(i) The Software Licence Agreement is a legal agreement between the customer and ACRRM which
sets out the terms and conditions of this legal agreement. By clicking on 'Accept' and downloading the
Guidelines you have agreed to be bound by the terms and conditions of the Software Licence
Agreement.
4. Permitted users
(i) The Guidelines are for use only by health professionals who are currently enrolled in the ACRRM
Clinical Guidelines for PDA User Group on ACRRM's www.rrmeo.com website (Permitted Users). The
Guidelines may not be transmitted to or distributed to or used by other persons.
5. Permitted uses
(i) A Permitted User may download, store in a cache, display, print and copy the material in unaltered
form only. The Guidelines may not be transmitted, distributed or used by any other person, or
commercialised without the prior written permission of ACRRM.
6. Updating of Mobile Device Clinical Guidelines
(i) The Guidelines may be updated from time to time. We may advise you by email from time to time if
new versions of the Guidelines become available however you are responsible for checking whether
you have the most recent version. The most recent version of the Guidelines is available on the
ACRRM Clinical Guidelines for PDA User Group webpage on www.rrmeo.com. We disclaim all liability
arising from your failure to download updates of the Guidelines.
7. Seek independent advice
(i) The Guidelines are intended to aid Permitted Users in the management of their patients but do not
provide explanations as to the conditions or treatments outlined. There may be clinical or other
reasons for using different therapy. In all cases, users should understand the individual situation and
exercise independent professional judgment when assessing therapy based on these Guidelines.
Users should seek independent advice.
(ii) The Guidelines do not include comprehensive drug information. Drug usage and doses should
always be checked prior to administering drugs to patients.
(iii) Every effort has been made to ensure the validity and accuracy of the information in this
adaptation of the Guidelines however Permitted Users should at all times exercise good clinical
judgment and seek professional advice where necessary. Treatment must be altered if not clinically
appropriate.
(iv) This adaptation of the Guidelines is presented as an information source only and provided solely
on the basis that users will be responsible for making their own assessment of the matters presented
herein. Users are advised to formally verify all relevant representations, statements and information
from appropriate advisers as it does not constitute professional advice and should not be relied upon
as such.
(v) To the extent permitted by law, ACRRM expressly disclaims any responsibility and all warranties,
express or implied, and excludes liability for all loss (including consequential loss) whatsoever that
may result in any way, directly or indirectly, from the use or reliance upon the Guidelines.
Process: For detailed referencing of the guideline sources, please see the acknowledgements page in
the individual guidelines.
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ORTHOPAEDICS
List of amendments in this update
Amended:
Shoulder Dislocation
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ORTHOPAEDICS
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RRMEO Modules
Note: This section of the 'ACRRM Clinical Guidelines' is for the sole purpose of assisting users to locate other
educational resources relevant to the ACRRM Curricula statements and to use them as a reference tool only.
You are again reminded that your knowledge acquisition must still be via the directives set out in each of the
ACRRM curricula statements.
This list of modules can be accessed via RRMEO
- to enrol go to RRMEO: https://www.rrmeo.com - Educational Inventory/RRMEO Modules
Note: Abbreviations used:
ATSI = Aboriginal and Torres Strait Islander Health
AIM = Adult Internal Medicine
Anaes = Anaesthesia (JCCA, advanced rural skills)
EM = Emergency Medicine
GEM = Generalist Emergency Medicine (GEM) (Post-Fellowship program)
MH = Mental Health
Obs = Obstetrics and Gynaecology (DRANZCOG Advanced)
Paeds = Paediatrics
Pop = Population Health
RM = Remote Medicine
Surg = Rural Generalist Surgery
Module Name
Suggested Curricula relevance
An Introduction to Digital Photography and Videography
ATSI
AIM
Anaes
EM
GEM
MH
Obs
Paeds
Pop
RM
Surg
Antenatal Care
ATSI
MH
Obs
RM
Best Care Guide to Stroke Management in General Practice:
Module 1
- Transient Ischaemic Attack (TIA) and Early Assessment
Module 2
- Antiplatelet Therapy for Secondary Stroke Prevention
Module 3
- Preventing Fatal and Disabling Stroke in Patients with Atrial Fibrillation
ATSI
AIM
EM
GEM
MH
RM
Breast Cancer
- How not to miss a breast cancer / the triple test in practice
Breast cancer diagnosis
- What now?
Breast cancer treatment
- Managing the impact
Breast cancer treatment is over
- What's next?
ATSI
AIM
EM
GEM
MH
Obs
RM
Surg
Education Program in Cancer Care
(EPICC)
Module 1A
- General Principles of Cancer Care
Module 1B
- Types of Cancer Treatment
ATSI
AIM
Anaes
EM
GEM
MH
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Module 1C
- Cancer Diagnosis
Module 1D
- Multidisciplinary Care Teams
Module 2
- Side Effects of Treatment and Symptom Management
Module 3
- Oncological Emergencies
Module 4
- Psychosocial Care
Module 5
- Follow Up
Obs
Paeds
RM
Surg
General Practitioners Guide to Parkinson's Disease
ATSI
AIM
EM
GEM
MH
Obs
Paeds
RM
Introduction to
Cultural Awareness
ATSI
Pop
RM
Introduction to
Dental Emergencies
ATSI
Anaes
EM
GEM
Paeds
RM
Surg
Introduction to
Population Health
ATSI
EM
GEM
MH
Obs
Paeds
Pop
RM
Mx of Autism Spectrum Disorders in Childhood and Adolescence
Module 1
- Clinical Aspects and Diagnosis
Module 2
- Treatment and Ongoing Management
Module 3
- Special Challenges
ATSI
Paeds
RM
Mx of
Secondary Lymphoedema
ATSI
AIM
Paeds
RM
Surg
Non-Directive Pregnancy Support Counselling Training
ATSI
Obs
RM
Opioid Medication in Palliative Care
ATSI
AIM
Anaes
EM
GEM
MH
Paeds
RM
Surg
Palliative Care
- Choose Your Own Adventure
ATSI
AIM
MH
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Paeds
RM
Palliative Care in
Aged Care Homes
- Palliative Care Australia
ATSI
AIM
MH
RM
Radiology Online
ATSI
AIM
Anaes
EM
GEM
Obs
Paeds
RM
Surg
RANZCP - IMG Orientation
Module 01
- Components of Australian health care
Module 02
- Subspecialties of psychiatry
Module 03
- Professional expectations, your responsibilities & rights
Module 04
- Patient & community expectations
Module 05
- Mental health care in a multicultural community
Module 06
- Aboriginal & Torres Strait Islander mental health care
Module 07
- Gender & sexuality
Module 08
- Mental health in rural & remote Australia
Module 09
- Funding & payments
Module 10
- Mental health legislation & regulation
Module 11
- Psychiatric treatment in Australia
Module 12
- Current issues in mental health policy & Australian psychiatry
ATSI
AIM
EM
GEM
MH
Paeds
Pop
RM
Renal Failure
ATSI
AIM
Anaes
EM
GEM
Paeds
RM
Surg
Retrieval Medicine
- Advanced
- Basic
ATSI
AIM
Anaes
EM
GEM
MH
Obs
Paeds
Pop
RM
Surg
RVTS
Mental Health Disorders Package
for
Rural Practice Core
ATSI
AIM
EM
GEM
MH
Paeds
Pop
RM
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Sexual Health
- taking a sexual history and managing STI's
ATSI
AIM
EM
GEM
MH
Obs
RM
Tele-Derm National
ATSI
Anaes
EM
GEM
Obs
Paeds
Pop
RM
Surg
Tele-Tox
ATSI
AIM
Anaes
EM
GEM
Obs
Paeds
Pop
RM
Surg
The Beginnings of
Practice Management
RM
Women's Health
- Contraceptive Options in the Bush
ATSI
Obs
RM
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ORTHOPAEDICS
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ACKNOWLEDGEMENTS
Our thanks to Dr Andrew Whittle MBBS FRACS(Orth) FaOrthA, Orthopaedic Surgeon, St Vincent's Medical
Centre, Toowoomba who has generously agreed for ACRRM to adapt his presentations "Orthopaedic Trauma Tips and Traps" for use on a Mobile Device.
ACRRM would also like to thank Dr Warren Todd, Orthopaedic Surgeon, Cairns Base Hospital for his reviews of
these guidelines.
Reviewers:
Dr Warren Todd - Orthopaedic Surgeon, Atherton Hospital
Dr Robin Leven - GP, Atherton
Dr Peter Hickey - GP, Malanda
Dr Raj Tomar - Atherton Hospital
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ORTHOPAEDICS
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ANKLE FRACTURES
Talus held between medial and lateral malleoli
Powerful ligament complexes provide support
- lateral ligament (3 components)
- medial ligament (deltoid)
- tibiofibular ligaments (interosseous)
Lateral malleolar fracture
- most common in adults
Medial malleolar fracture
- most common in children
POTTS classification - 'historical'
First degree
- unimalleolar
Second degree
- bimalleolar
Third degree
- trimalleolar with fracture posterior part of inferior tibial articular surface
(essential to establish presence or absence of diastasis of inferior tibiofibular joint)
Webber classification
- most widely used and accepted
- based primarily on level of fibular fracture
Associated fracture patterns & ligament injuries
Ankle joint best considered as a circular complex of osseous and ligamentous structures
- if the circle breaks at one point, should look for where else it has broken
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Common recognizable patterns of injury
Fracture patterns vary between skeletally mature and skeletally immature patients
Children:
- strong ankle ligaments attached to the epiphysis account for epiphyseal separation being more frequent than
epiphyseal fractures
Xray Assessment:
- both malleoli to be viewed in same coronal plane on A-P
- in normal ankle on A-P, tibia and fibula overlap
- assess distance between medial malleolus and talus
- look for incongruity in joint line and joint space
- lateral view should show midfoot and base of 5th MT
- don’t forget to consider X-ray of proximal fibula
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Tx:
- aim of treatment is anatomical reduction which hopefully will result in a return of optimal function
Tx Principles:
Stable unimalleolar #’s treated by BK POP
- ensure no talar shift
- medial malleolar #’s only if undisplaced
- posterior malleolar #’s if <20% articular surface involved
Bimalleolar and Trimalleolar #’s are UNSTABLE
Usually require operative treatment
? conservative management in frail/elderly
Intraarticular distal tibial #’s have a very poor prognosis
- management controversial and specialised
Maisonneuve Fracture
- ruptured deltoid ligament with a high fibular #
- always X-ray tibia and fibula if
--> clinical suspicion
--> mortise widened with no # evident in ankle
- usually requires surgical repair
(Do not miss the high fibular fracture)
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ORTHOPAEDICS
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CLAVICLE FRACTURES
Aims
Tx
General
AIMS
Common fracture
Immobilization is difficult
May be very uncomfortable initially
Treatment is generally conservative
Patient concerns relate primarily to cosmesis
TX:
MEDIAL 1/3 #
- non union more likely
- refer at 6/52 if non union
LATERAL 1/3 #
- if lateral end elevated
-->ruptured ligaments from coracoid process
-->early orthopedic referral
MIDDLE 1/3 #
- usually heal well
BUT
- beware back-pack (lump may impede use)
- if shortens can affect shoulder muscles
GENERAL
Prefer use of clavicle brace +/- sling
- rarely use figure of eight bandage
Surgery rarely indicated
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ORTHOPAEDICS
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COLLES FRACTURE
Assessment:
- fracture of distal radius within 2.5cm of wrist
- common in patients with weakened osteoporotic bones
- usually due to fall on outstretched hand with dorsiflexed wrist
- often associated with a fracture of the ulnar styloid
- 5% have associated scaphoid fracture
- posterior (dorsal) displacement
- radial displacement
- distal fragment tilted posteriorly
- distal fragment tilted radially
- rotation
- impaction
Characteristic 'Dinner Fork' deformity
Tx:
Reduction is indicated if:
- there is a visible deformity on examination
- there is greater than 10 degrees of tilt of joint line
Reduction is accomplished by:
- GA/IV regional block/regional block
- traction-countertraction to disimpact #
- reproduce and exaggerate deformity
- pressure anteriorly on distal fragment
- correct radial displacement
- POP in pronation/flexion of wrist/ulna deviation
--> ensure adequate moulding of POP
- check X-Rays
(Impaction is the most critical feature to recognise)
NB - Elderly
Function and mobility (not XR reduction) is most important
Tx:
- At 4 weeks
--> remove plaster and clinically R/V (test union)
If OK --> physio
If too much pain -->1 wk more plaster and R/V
Common mistakes:
- POP with no ulna deviation
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- POP with full wrist flexion
- failure to split POP post manipulation
- failure to look after the fingers
- failure to consider social implications
- failure to ask 'why did patient fall'
(do not confuse with a Smith’s Fracture)
Complications:
- malunion
- Sudeck’s atrophy
- carpal tunnel syndrome
- rupture of the extensor pollicis longus
- persistent pain and stiffness of wrist
- persistent restriction of movement of fingers
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ORTHOPAEDICS
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DISLOCATIONS - OTHER
1. Acromio-clavicular joint dislocation
2. Dislocated elbow
3. Dislocated lunate
4. Dislocated fingers and toes
5. Carpometacarpal joint dislocation
6. Dislocated hip
7. Dislocated patella
1. ACROMIO-CLAVICULAR JOINT DISLOCATION
Common after football
- fall onto point of shoulder
Grade I:
- A-C sprain
- 7-10 days rest and immobilization in sling
Grade II:
- A-C capsular tear, C-C ligament sprain
- treated conservatively in sling till able to commence shoulder movement at 2 weeks.
Grade III:
- A-C and C-C tear
- normally treated conservatively initially. May need ORIF if athlete/ labourer.
ACROMIO-CLAVICULAR JOINT DISLOCATION
ACROMIO-CLAVICULAR JOINT DISLOCATION
Grade IV:
- clavicle through trapezius posteriorly
- closed reduction, then treat as III
Grade V:
- clavicle 100 - 300% Elevated
- may need ORIF or excision outer end clavicle
Grade VI:
- clavicle beneath coracoid process
- closed reduction, then treat like III
2. DISLOCATED ELBOW
Commonly due to fall on outstretched hand
Usually posterolateral
Can be confused with supracondylar fracture
Always test neurovascular status of affected limb
Look for associated fracture of coronoid process
Reduction very easy - analgesia / sedation as required
Usually reduction by traction with slight flexion
Post reduction treatment options
N.B.
- always xray
- apply back slab & elevate to 90o
- early mobilization with compression, ice etc.
Always check the position of the medial epicondyle
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SUPRACONDYLAR FRACTURE
Vs
ELBOW DISLOCATION
In the presence of dislocation the normal equilateral triangle formed by the lateral and medial epicondyles and
olecranon is lost. This is preserved with a supracondylar fracture.
DISLOCATED ELBOW
Anterior dislocation rare
- often associated with olecranon #
- usually requires reduction / internal fixation
3. DISLOCATED LUNATE
Most common carpal dislocation
Easy to miss clinically and radiologically
Median nerve may be involved
Reduction may be easy
- wrist extension and traction
- local pressure on lunate
- pop for 4/52
Avascular necrosis can be late complication
Perilunate dislocation treated similarly
Failure of reduction = open reduction +/- I.F.
DISLOCATED LUNATE
4. DISLOCATED FINGERS AND TOES
Can occur at MCPJ/MTPJ or IPJ
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Can be difficult to differentiate from fracture
- always xray
Usually posterior dislocations, due to hyperextension
Reduction by longitudinal traction
- follow with buddy strapping for 2/52
Volar dislocations usually result in button holing
- usually require open reduction
Thumb MCPJ - most common site
- reduction easy but potentially unstable
- immobilise as per Bennett’s #
Always think of rupture of ulnar collateral ligament
ULNAR COLLATERAL LIGAMENT INJURY
(GAMEKEEPER’S THUMB)
5. CARPOMETACARPAL JOINT DISLOCATION
Usually the thumb or 5th MC
Thumb CMC
- due to forced abduction
- reduce and hold in Bennett’s cast
5th CMC
- often a blow to a clenched fist
- reduce, but are unstable and often require K wire fixation
6. DISLOCATED HIP
Two common situations
- traumatic dislocation of normal hip
- dislocation of prosthetic replacement
Usually posterior dislocation
- leg shortened, hip flexed, adducted and internally rotated
Usually due to severe longitudinal forces
Central dislocation requires massive force
Pain can be severe
Assess the sciatic nerve
Reduction asap usually with GA +/- N/M blockade
- increased risk of A.V.N. If delay > 6 hours
Maintain in traction for 3/52
If associated #, will usually require open reduction
Treatment of associated injuries may take priority
7. DISLOCATED PATELLA
Lateral dislocation - traumatic or recurrent
Recurrent dislocation usually in adolescent girls
- positive apprehension test
- anatomical predisposition
- genu valgum, ligamentous laxity etc.
Reduction - usually easy using direct pressure
Always xray to exclude osteochondral #
Treatment - splintage with protected mobilization and strengthening with physiotherapist
If first episode, 6/52 in richards knee immobiliser
If recurrent, 2/52 in richards knee immobiliser
May require operative treatment in long term
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DISLOCATED PATELLA
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ORTHOPAEDICS
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FEMORAL FRACTURES
Classifications:
Proximal femur
- subcapital
- transcervical
- intertrochanteric
- pertrochanteric
- subtrochanteric
Shaft of femur
Supracondylar fractures
Intercondylar fractures
Proximal Femoral Fractures
- commoner in men < 60 / women > 60
- shortening and external rotation not always present
- impacted fractures are easily missed
- pain not always a feature / bruising rare acutely
- tomography (plain/CT) +/- bone scan can be useful
- if pain persists, repeat films
- intracapsular fractures at risk of avascular necrosis
- ? apply skin traction until operative repair
--> less common as no proven benefit
- surgical treatment - almost universal
--> internal fixation or arthroplasty
- femoral nerve blocks un-useful
Mortality Rate:
- 20 % for first year
- 13 % for second year
- after one year, returns to that for age and sex matched controls
Functional Recovery:
- not complete until at least 6 months post fracture
- only 20-30 % regain prefracture level of independence
- 15-40% functionally independent patients living at home require institutionalised care for >1year post #
- only 60 % regain prefracture ambulatory status within 1 year
- 50-80 % regain independent ambulation with assistive devices
Assessment:
- usually a result of severe trauma
- blood loss can be significant (> 1 litre in soft tissues)
- diagnosis usually straightforward
- always X-Ray hip and knee
- always look for signs of associated injury
- apply traction early (Thomas or Donway)
--> restore length/decrease dead space & blood loss
- femoral Nerve Blocks are extremely useful
Common Pitfalls:
- >30% risk of severe assoc injury
- failure to appreciate potential hidden blood loss
- failure to recognize assoc femoral neck #
- failure to adequately assess distal circulation
- failure to consider possibility of assoc knee injury
- failure to think of fat embolism
Tx:
= surgical fixation/replacement unless otherwise indicated
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ORTHOPAEDICS
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FINGER FRACTURES
General Principles
Avoid splinting MCPJ in extension
If splintage required use position of function
- wrist extended 20o
- MCPJ's at 90o flexion
- IPJ's at 15-20o flexion
- thumb abducted
- tips of fingers aligned
Consider buddy strapping in single digit injury
Minimise Swelling:
- elevate aggressively
- consider OT (compression gloves)
- early ROM exercises
- start at 3-4 wks ie clinical union
(XR union may not be evident for 3/12)
Thumb Fractures
Bennett’s #
- base of thumb involving trapeziometacarpal joint
- tenderness distal to ASB
- reduction easy but slipping common
- frequent early F/U and re X-Ray
# Base of thumb metacarpal
- treat as per Bennett’s #
# Proximal phalanx
- reduce if angulated and splint
NB.
Always think of rupture of ulnar collateral ligament (Gamekeeper's thumb)
- IF v lax and not v tender
--> Gd 3 tear (ligt can be trapped in aponeurosis and won't heal)
--> REFER for surgery
Finger Fractures
Neck 5th metacarpal
- usually punch injury
- be suspicious of any adjacent grazes/puncture wounds
- treat compound injuries aggressively esp 2o teeth
- controversy as to need for reduction
- dorsal slab with finger extension for 2 wks then mobilise
Shaft 5th metacarpal
- reduction and short arm POP
- occasionally may require ORIF
Other metacarpals
- as above
- increasing indication for surgery in radial metacarpals
Proximal & middle phalanges
- reduce and splint
- remember rotation as well as angulation
- fixation often considered
- dynamic splinting preferred - early ROM
Distal phalanges
- priority is treatment of assoc. soft tissue trauma
- avoid compression of soft tissues
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ORTHOPAEDICS
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FRACTURES
Topics:
1. General Principles
2. Supracondylar Fracture
3. Colles Fracture
4. Femoral Fractures
5. Ankle Fractures
6. Scaphoid Fractures
7. Clavicle Fractures
8. Finger Fractures
9. Humeral Fractures
Reference:
Dr Andrew Whittle MBBS FRACS(Orth) FaOrthA, Orthopaedic Surgeon, St Vincent's Medical Centre,
Toowoomba - QRMSA Emergency Medicine Workshop presentation.
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ORTHOPAEDICS
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FRACTURES - GENERAL PRINCIPLES
Initial assessment: (see Notes 1)
Neurovascular status
History
Inspection
Palpation
Associated injuries
Radiographic examination
- A-P/ lateral (standard)
- obliques (as required)
- comparisons (rarely)
Description:
Anatomical location
Complete vs incomplete
Closed vs open - simple vs compound
Direction of fracture line
Number of fragments
Type of deformity
- displacement
- angulation
- rotation
- impaction
(always consider the mechanism of injury)
Dorsal displacement; and
Dorsal angulation (see Notes 2)
X-ray Assessment:
Always examine the patient first
- then x -ray
If you see one fracture
- look for another
- always look at the soft tissues before the bone
NOTES:
(1) Need to emphasis:
- importance of assessment of neurovascular status
- ABC's always take priority
- good history (esp concerning the mechanism of injury) in combination with precise physical examination and
accurate documentation
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(2) Displacement is described relative to the movement of the distal fragment.
Angulation is best described by the direction of tilt of the distal fragment.
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HUMERAL FRACTURES
CLASSIFICATION
1. Proximal
2. Midshaft
3. Distal
1. PROXIMAL HUMERAL FRACTURES
- majority can be treated conservatively
- fractures of anatomic neck can disrupt blood supply and result in avascular neurosis (rare)
- beware nerve (brachial plexus, radical nerve) injuries
- most caused by fall on outstretched hand
(incidence increased with age)
Assessment
- mechanism of injury
- cause of fall (esp Ix of blackout)
- neurovascular
- arm usually held adducted against side (consider dislocation if abducted)
Xray:
AP, lateral films
Auxiliary or scapula and view to exclude dislocation
IF trauma series non diagnostic --> consider CT
Indications for Orthopaedic Referral
(i) significant displacement ( >1cm or angulated > 45 o )
(ii) # anatomic neck
(iii) fracture dislocations
(iv) joint instability
(v) neurovascular injury
(vi) open #
(vii) comminuted #
Tx:
(i) Immobilisation
- standard sling for impacted #
- collar & cuff if minimally displaced
- swathes may be useful for pain control
(ii) Analgesia
(iii) Advice
- sleep more comfortable semi recumbent
(iv) Review
1 week
- XR + clinical review
(esp skin/bruising/neurovascular)
Then 2 weekly
- mobilisation
(v) Mobilisation
-->ESSENTIAL FOR FUNCTIONAL RECOVERY
(aim is to touch back of head = 120 deg movt)
- as soon as pain allows (1-2weeks)
- feel the # and if firm to gentle rocking
--> exercise program & physio
Twice daily:
a) Pendulum Exercises
- lean forward, supported by good arm
- hang affected arm downwards and rotate in increasing circles
b) Wall Climbs
ie. moving straight arm up and down a wall with palm to wall
Abduction - stand side to wall
Flexion - face wall
c) Physiotherapy
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Prognosis
Non displaced / minimally displaced #
- 90% of function / mobility of normal shoulder
- most in 12 weeks
Complications
Adhesive capsulitis (frozen shoulder)
Avascular neurosis
Non union
Instability (assoc dislocation or rotator cuff tear)
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ORTHOPAEDICS
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LIGAMENT INJURIES
1. Knee Ligament Injuries
2. Ankle Ligament Injuries
1. KNEE LIGAMENT INJURIES
(i) Knee Ligament Sprains:
3 grades
- grade 1....no laxity
- grade 2....partial tear
- grade 3....complete disruption
May need EUA to fully assess injury
Treatment depends on injury complex
Beware physeal injuries in children
- may mimic ligament injury
KNEE LIGAMENT SPRAINS
(ii) Medial Collateral Ligament
Valgus strain
Tenderness
Swelling
Bruising
Limp, holds knee flexed
May feel unstable
Be wary of painless instability
Test with knee flexed at 30 deg
Also test in full extension
Look for an end point
Gauge the degree of opening
Check joint line
Look for other injuries
Usually no surgery
Brace with motion 30-120
Early wt bearing
Quad drill
Good prognosis if isolated
(iii) Lateral Collateral Ligament
Varus strain +/- rotation
Often ACL tear
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Also posterolateral corner
Usually need an EUA
Look for fracture
Surgery required
(iv) Anterior Cruciate Ligament
Very commonly injured
Often no contact
70% related to sport
Twist of hyperextended knee
Changing direction
70% of haemarthrosis = ACL
50% have meniscal injuries
Natural history varies
May not be “isolated” lesion
May “get by” without surgery
Need to reduce sport
Key is hamstring rehab
Debate - early or late surgery
Surgery for giving way
Repair universally fails
Need autograft
Middle third patella lig
Hamstring tendons
- synthetics disappointing
- ?Allograft in future
Stability generally restored
LACHMAN TEST
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AP drawer with knee at 30 degree flexion
PIVOT SHIFT TEST
Valgus and upward
Force applied to knee
Extended with foot
Internally rotated
Tibia subluxes on femur
Then flex knee, producing
Reduction of tibia
(v) Posterior Cruciate Ligament
Not as common
Hyperextension
Direct blow
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POSTERIOR CRUCIATE LIGAMENT
Assoc with chondral injury
Modest impairment
Surgery inconsistent
May be able to play sport
Degenerative arthritis likely
If bony avulsion....repair
PCL AVULSIONS
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(vi) Multi-ligament Injury (Knee Dislocation)
Vascular injuries common
May need arteriogram
Urgent referral
Early reconstruction
May be bony avulsions
Early aggressive rehab
Disruption or thrombosis of posterior tibial vessels
Lesion of lateral popliteal nerve
(vii) Knee Dislocation
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Requires immediate reduction, splinting
Immediate assessment of vascular status
Early surgery
High amputation rate
2. ANKLE LIGAMENT INJURIES
Most common ligamentous injury of the human body
15% of all athletic injuries
One ankle inversion injury per day per 10,000 people
Management is controversial
Tendency towards under-treatment
Anatomy:
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Anatomy:
Lateral
- ATFL is the most commonly injured ligament in the human body
- CFL is stronger - crosses two joints
- PTFL is the strongest of the lateral ligaments - least often injured
Medial ankle or deltoid ligament - fan shaped
- deep and superficial layers
Distal tibiofibular interosseous ligaments
- AITFL
- PITFL
- interosseous ligament
MECHANISM OF INJURY
Occurs with partial loading without full osseous stability
Muscles do not respond rapidly enough to maintain joint integrity, leading to disruption of ligament, capsule and
bone
Commonly assoc. with jumping sports
- relaxed foot adopts plantarflexed and inverted posture
- results in high incidence of ATFL tears
PATHOLOGY
Usually mid-substance tears - avulsion injuries approx. 14%
Incidences
- isolated ATFL - 60-70%
- combined ATFL/CFL - 20%
- syndesmotic ligaments - 1-10%
- deltoid ligament - 2.5%
- isolated CFL or PTFL - rare
EXAMINATION
Careful history
Careful fingertip evaluation of all structures potentially involved in injury
Anterior drawer test
- varus / valgus stress
N.B. Effect of swelling and protective muscle spasm
ANTERIOR DRAWER TEST
? State of ATFL
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(The anterior draw sign test to evaluate the intactness of the anterior talofibular ligament)
VALGUS STRESS TEST
Talar Tilt Test
(The ankle is unstable if the anterior talofibular and calcaneofibular are torn)
Classification Of Lateral Ankle Ligament Sprains:
Grade I
- mild injury
- minimal swelling & tenderness
- stable ankle with negative drawer and talar tilt tests
Grade II
- moderate injury with diffuse tenderness and swelling
- mildly positive anterior drawer & negative talar tilt test
- complete tear of ATFL and partial tear of CFL
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Grade III
- severe injury with significant functional loss and severe swelling, tenderness & pain
- positive drawer and talar tilt tests
- complete rupture of ATFL and CFL
Tx of Acute Ankle Injuries:
Grade I & II injuries
- non-surgical treatment aimed at limitation of tissue damage, restoration of motion & restoration of agility and
endurance
Grade III injuries
- controversial
- surgical vs. nonsurgical
- depends on surgeon and patient
- ? Early repair in elite athlete
- most favour 4-6 weeks in cast, followed by appropriate rehab. program
- possible role for functional bracing
- similar results to plaster treatment
Chronic Instability:
? Incidence of 20-40% after lateral ligament injury
Most respond to rehab. program (proprioceptive training & peroneal strengthening)
Variety of reconstructive procedures available with good results
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ORTHOPAEDICS
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PLASTERING TECHNIQUES
See - Ortho Plastering Techniques
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SCAPHOID FRACTURES
Common fracture
Commonly missed
Commonly complicated
- usually fall on to outstretched hand
- variable degree of force
- less common in elderly & skeletally immature
- high index of suspicion
--> A.S.B. tenderness & swelling
--> ‘Normal’ X-rays
Tx:
Definite fracture (clinical & x-ray)
- Spica cast for six weeks
Probable fracture (clinical - ‘normal’ x-ray)
- Spica cast
- repeat examination & x-ray at two weeks
- consider bone scan if still in doubt
- Spica cast for further four weeks
At six weeks
Remove cast, repeat examination and x-ray
- fracture united - mobilize - advise to return if any persisting or recurrent symptoms
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- union not definite - further six weeks in thumb spica
At twelve weeks
Remove cast, repeat examination and x-ray
- if not definitely united, refer for consideration of surgical treatment
Controversies:
Is there a case for immediate internal fixation ?
How long should internal fixation be delayed if union is delayed ?
Optimal management of late diagnosis of non-union with or without complicating factors (A.V.N., O.A., Carpal
collapse) ?
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SHOULDER DISLOCATION
Aims
Dx
Anterior Dislocation
Posterior Dislocation
Inferior Dislocation - Luxatio Erecta
Anterior (95%)
- fall on outstretched externally rotated arm
- arm slightly abducted & externally rotated
Posterior
- fall on outstretched internally rotated arm
Or post seizure / electrocution
- arm held in adduction & internal rotation
Luxatio erecta
- forceful hyperabduction (esp. grasping object above head while falling)
- arm held in abduction (above head), unable to adduct
Intrathoracic
- secondary to major trauma
AIMS
Beware subacute (7-10 days) presentation
- increased vascular injury / fractures with reduction
- seek orthopedic advice
Document neurological / vascular exam
- axillary nerve injury commonest neurological sequelae (deltoid numbness)
Test power (internal / external rotation)
- rotator cuff tears common (esp. elderly)
XR Indications (humeral neck fracture in 25%)
- every first time dislocation
- traumatic mechanism
- age over 40
- any clinical doubt of Dx
Post reduction films recommended
Dx:
Sx: (usually obvious)
- pain / deformity usually obvious
Subluxation:
Sx: (less severe)
- 'dead arm' or brachial plexus 'shooting'
X-Ray INTERPRETATION
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NORMAL LATERAL VIEW OF SHOULDER JOINT
INTERPRETATION OF THE LATERAL X-RAY
NORMAL AXILLARY VIEW OF THE SHOULDER JOINT
ANTERIOR DISLOCATION
O/E:
- Arm slightly abducted & externally rotated
- Prominent acromion, rounded appearance of shoulder
X-Ray:
- diagnosis usually obvious on A-P view
- loss of continuity between humeral head and glenoid
- axillary and lateral views may be required
Look for associated #’s of greater tuberosity,(humeral head, glenoid (Bankart lesion)
Hill-sachs deformity is cortical depression in humeral head due to glenoid rim compression
Tx:
Adequate muscle relaxation / sedation required
(i) Intra-articular local anaesthetic (strict sterile technique)
esp. few resources, multiple co-morbidities
i.e.
- into empty socket below acromion via posterior or lateral approach
- 20 mls 1% lignocaine
- USS guidance can be helpful
(ii) IV Procedural sedation --> (see Pain IV Opiate infusions, Pain Suggested Techniques)
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(iii) Interscalene nerve block +/- USS guided
- ensure neurological exam documented first
Multiple reduction methods exist
--> traction techniques preferred to leverage
Ability to place affected hand on opposite shoulder confirms reduction
- gravitational (Stimson) technique
(patient lies prone with dislocated arm holding 2.5-5kg weight for 15 mins)
- scapular rotation
- external rotation
(patient supine - flex elbow to 90 deg, SLOWLY externally rotate, stop with any spasm until subsides, usually
relocates at 70-110 degrees)
(i) Milch technique
- add to external rotation
(Patient lies supine. Perform external rotation above. Slowly abduct arm into overhead position with traction. To
assist reduction maintain external rotation and humeral head lifted with auxiliary pressure via clinicians thumb)
(ii) Kocher's technique
- requires greater force --> increased risk Cx
(Patient supine. Flex elbow to 90 degrees. Traction with abduction. External rotation. Adduction then internal
rotation across chest)
(iii) Hippocratic Method
- requires more force, muscle relaxation
(Patient supine. Counter-traction - sheet around chest better than stockinged foot in axilla. Traction applied with
arm in 45 degree abduction)
(iv) Self-Reduction Method (Anterior Dislocation)
(Position: Sit on floor with knees flexed. Wrap both arms around ipsilateral knee . Interlace fingers of each hand
with one another. Traction: lean backward, extend arm at elbow)
Post reduction:
Initially immobilise for 2-3/52, then physiotherapy
- mobilise the elderly early
Recurrence common in the young
--> REFER to orthopedic surgeon
Stiffness common in the old
POSTERIOR DISLOCATION
Dx:
Sx:
Arm in adduction / internal rotation (unable to externally rotate)
Prominence of post shoulder, coracoid process
X-Ray:
Posterior dislocation can be extremely hard to diagnose on x-ray
- ? history of seizure or electrocution
- AP often appears normal
- high index of suspicion required
High incidence assoc # humerus, acromion, scapula, glenoid
CT scan may be required for Dx / full assessment
Tx:
Consult Orthopedic surgeon
Associated injuries affect Mx
INFERIOR DISLOCATION - LUXATIO ERECTA
Dx:
Sx:
- hold arm above head (unable to adduct)
- forearm pronated, resting on head
High incidence
- neurologic injury
- rotator cuff injuries
- greater tuberosity #
Arterial injury 3% (no pulse)
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Tx:
Consult Orthopedic surgeon
Reduction
Traction: countertraction in line with abducted humerus then gentle adduction to reduce dislocation
May require open reduction if humeral head 'buttonholed' in inferior capsule
NORMAL AXILLARY VIEW OF THE SHOULDER JOINT
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SHOULDER - FROZEN (Adhesive Capsulitis)
Aims
Dx
Ix
Tx
AIMS
Early Dx may improve Tx
Spontaneous resolution 6/12 - 2yrs
Dx:
N.B. - clinical Dx
Classically
- from age 45 - 60 yrs, F>M
- non dominant arm
- associated with diabetes, AI disorders
- may be precipitated by trauma
Phases:
(i) initial hot, painful phase
(ii) less painful stiff phase
(iii) resolution
Sx:
Pain
- often night pain
Reduced range of movement
- almost NO glenohumeral movt
(scapulothoracic component unaffected)
- that is not due to glenohumeral arthritis or painful periarticular process
( eg. tendinopathy)
Ix:
XR
- excludes osteoarthritis
USS
- doesn’t aid Dx and can cause confusion
- more useful if tendon pathology
Tx:
Analgesics
- simple
- NSAID's
Hydrodilation
(under fluoroscopy/USS guidance)
- best within first few weeks
(if done later can prolong pain phase)
- hot acute phase
- LA + steroid + 10-20ml N-Saline injected into joint
- may improve pain 50% in 2 weeks (variable)
- may be repeated 6-8 weeks later
Exercises
- shoulder motion
- scapular stability
NB.
Must not stretch range of movement past comfort
--> reignites inflammatory cascade & prolongs resolution
Good Rule of Thumb
--> when patient sleeping through night with minimal analgesia
--> good time to start physio
Prior to this may prolong pain phase
Orthopaedic Referral - best EARLY
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- arthroscopic adhesion division
- manipulation under anaesthesia
Reference:
- Therapy Update
- Australian Doctor 14/5/10
- Up To Date
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SUPRACONDYLAR FRACTURE
Assessment:
- usually secondary to fall on outstretched hand
- capsule and collaterals stronger than bone
- often minimal swelling at time of presentation
- pain and local tenderness = high index of suspicion
- immediate assessment of neuro-vascular status
- brachial artery and median nerve predominantly
- can occur in absence of significant displacement
- assess for ipsilateral fractures of forearm
DDx - Posterior Elbow Dislocation
In the presence of dislocation the normal equilateral triangle formed by the lateral and medial epicondyles and
olecranon is lost.
This is preserved with a supracondylar fracture.
Xray - Assessment
Maintain high index of suspicion for undisplaced supracondylar fracture
Suspect an occult fracture
IF
- anterior/posterior fad pat sign
- displaced anterior humeral line
The anterior humeral line normally passes through the middle of the capitellum. With extension supracondylar
fractures this line passes anterior to this point.
- carrying angle > 12 degrees
Mx:
If reduction not required
- flex elbow till pulse disappears then extend until pulse reappears
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- ideally greater than 90 degrees flexion should be obtained
- if medial displacement (varus deformity)
--> pronate forearm
- if lateral displacement (valgus deformity)
--> supinate forearm
Two options:
(i) collar & cuff sling (favoured option)
- maintain elbow flexion ALWAYS
- should not be removed
(ie. worn under clothes)
(ii) long arm backslab
- axilla to just proximal of metacarpal heads
- POP should be 2/3rds circumference of arm
- never apply a complete plaster
Apply ice frequently
Consider overnight observation
Indications for reduction
- vascular compromise
- off ending of fracture
- <50% bony contact
- >20 degrees posterior tilt of distal fragment
- >10 degrees medial or lateral tilt of distal fragment
Pure displacement of <50 % bony surface will usually remodel
Reduction
- regional or general anaesthesia
- traction with countertraction to disimpact #
- slight hyperextension to unlock fragments
- pressure anteriorly on distal segment
- correction of lateral/medial angulation
- flex elbow to point before pulse diminishes
- ? percutaneous K wire fixation
- sling or POP/elevate/check x-rays/admission
NB:
The dilemma in immobilization of supracondylar fractures
- flex it more for stability
- flex it less for circulation
Failure of reduction
(ie. circulation cannot be maintained in a flexed, reduced position)
- usually treated with traction, unless exploration of brachial artery is indicated
NOTES:
- recovery of movement is often prolonged and unpredictable
- post fracture stiffness is normal
- remember to warn the parents of this initially and reinforce the message subsequently
- in general, a complete return of motion can be expected
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TENDON INJURIES
1. Achilles Tendon rupture
2. Flexor Tendon injury
3. Extensor Tendon injury
4. Mallet Finger
1. ACHILLES TENDON RUPTURE
Acute ruptures often assoc. with sharp tearing sensation
Often palpable defect present
Unable to do single heel raise
Positive Thompson (Simmonds) test
20-25% rate of misdiagnosis
No definite evidence to support surgical over non-surgical care
Favoured option is surgical repair in combination with early active protected mobilization in splint
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2. FLEXOR TENDON INJURY
Lacerations more common than rupture
Diagnosis of tendon (F.D.P.) rupture is often delayed
Often associated with digital nerve injury
Maintain high index of suspicion with any hand laceration
Management is early repair by surgeon familiar with anatomy, techniques and rehabilitation
Prognosis is variable and secondary surgery is not uncommon
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3. EXTENSOR TENDON INJURY
Very common injuries
Usually detected early, as tendons are superficial
Management is early exploration and repair, followed by appropriate splintage and rehabilitation
Generally have good prognosis
4. MALLET FINGER
Very common injury
Usually refers to closed rupture of the extensor tendon, but may be associated with bony avulsion from distal
phalanx, therefore always take an xray
Management depends on age, time of diagnosis and size of fracture fragment if present
- consider surgery if >25% joint involvement
Most common scenario is closed rupture of tendon with no fracture in middle-aged or elderly patient
Usual management is splintage of DIPJ in hyperextension, with stack splint or similar device for 6-8 weeks
N.B. It does no good to immobilize the P.I.P. Joint, as movement of this joint will relax the extensor mechanism,
assisting with repair and recovery
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