Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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 ACRRM Rural Clinical Guidelines – Orthopaedics – Version July 2012Page 2 of 50 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. Back to TABLE OF CONTENTS / Orthopaedics ACRRM Rural Clinical Guidelines – Orthopaedics – Version July 2012Page 3 of 50 ORTHOPAEDICS List of amendments in this update Amended: Shoulder Dislocation Back to TABLE OF CONTENTS / Orthopaedics ACRRM Rural Clinical Guidelines – Orthopaedics – Version July 2012Page 4 of 50 ORTHOPAEDICS Back to TABLE OF CONTENTS / Orthopaedics 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 ACRRM Rural Clinical Guidelines – Orthopaedics – Version July 2012Page 5 of 50 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 ACRRM Rural Clinical Guidelines – Orthopaedics – Version July 2012Page 6 of 50 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 ACRRM Rural Clinical Guidelines – Orthopaedics – Version July 2012Page 7 of 50 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 (Back to Top) Back to TABLE OF CONTENTS / Orthopaedics ACRRM Clinical Guidelines Version July 2012 (*Expires July 2013 - check RRMEO for latest version) ACRRM Rural Clinical Guidelines – Orthopaedics – Version July 2012Page 8 of 50 ORTHOPAEDICS Back to TABLE OF CONTENTS / Orthopaedics 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 Back to TABLE OF CONTENTS / Orthopaedics ACRRM Clinical Guidelines Version July 2012 (*Expires July 2013 - check RRMEO for latest version) ACRRM Rural Clinical Guidelines – Orthopaedics – Version July 2012Page 9 of 50 ORTHOPAEDICS Back to TABLE OF CONTENTS / Orthopaedics 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 ACRRM Rural Clinical Guidelines – Orthopaedics – Version July 2012Page 10 of 50 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 ACRRM Rural Clinical Guidelines – Orthopaedics – Version July 2012Page 11 of 50 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) Back to TABLE OF CONTENTS / Orthopaedics ACRRM Clinical Guidelines Version July 2012 (*Expires July 2013 - check RRMEO for latest version) ACRRM Rural Clinical Guidelines – Orthopaedics – Version July 2012Page 12 of 50 ORTHOPAEDICS Back to TABLE OF CONTENTS / Orthopaedics 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 Back to TABLE OF CONTENTS / Orthopaedics ACRRM Clinical Guidelines Version July 2012 (*Expires July 2013 - check RRMEO for latest version) ACRRM Rural Clinical Guidelines – Orthopaedics – Version July 2012Page 13 of 50 ORTHOPAEDICS Back to TABLE OF CONTENTS / Orthopaedics 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 ACRRM Rural Clinical Guidelines – Orthopaedics – Version July 2012Page 14 of 50 - 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 Back to TABLE OF CONTENTS / Orthopaedics ACRRM Clinical Guidelines Version July 2012 (*Expires July 2013 - check RRMEO for latest version) ACRRM Rural Clinical Guidelines – Orthopaedics – Version July 2012Page 15 of 50 ORTHOPAEDICS Back to TABLE OF CONTENTS / Orthopaedics 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 ACRRM Rural Clinical Guidelines – Orthopaedics – Version July 2012Page 16 of 50 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 ACRRM Rural Clinical Guidelines – Orthopaedics – Version July 2012Page 17 of 50 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 ACRRM Rural Clinical Guidelines – Orthopaedics – Version July 2012Page 18 of 50 DISLOCATED PATELLA Back to TABLE OF CONTENTS / Orthopaedics ACRRM Clinical Guidelines Version July 2012 (*Expires July 2013 - check RRMEO for latest version) ACRRM Rural Clinical Guidelines – Orthopaedics – Version July 2012Page 19 of 50 ORTHOPAEDICS Back to TABLE OF CONTENTS / Orthopaedics 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 Back to TABLE OF CONTENTS / Orthopaedics ACRRM Rural Clinical Guidelines – Orthopaedics – Version July 2012Page 20 of 50 ACRRM Clinical Guidelines Version July 2012 (*Expires July 2013 - check RRMEO for latest version) ACRRM Rural Clinical Guidelines – Orthopaedics – Version July 2012Page 21 of 50 ORTHOPAEDICS Back to TABLE OF CONTENTS / Orthopaedics 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 Back to TABLE OF CONTENTS / Orthopaedics ACRRM Clinical Guidelines Version July 2012 (*Expires July 2013 - check RRMEO for latest version) ACRRM Rural Clinical Guidelines – Orthopaedics – Version July 2012Page 22 of 50 ORTHOPAEDICS Back to TABLE OF CONTENTS / Orthopaedics 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. Back to TABLE OF CONTENTS / Orthopaedics ACRRM Clinical Guidelines Version July 2012 (*Expires July 2013 - check RRMEO for latest version) ACRRM Rural Clinical Guidelines – Orthopaedics – Version July 2012Page 23 of 50 ORTHOPAEDICS Back to TABLE OF CONTENTS / Orthopaedics 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 ACRRM Rural Clinical Guidelines – Orthopaedics – Version July 2012Page 24 of 50 (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. Back to TABLE OF CONTENTS / Orthopaedics ACRRM Clinical Guidelines Version July 2012 (*Expires July 2013 - check RRMEO for latest version) ACRRM Rural Clinical Guidelines – Orthopaedics – Version July 2012Page 25 of 50 ORTHOPAEDICS Back to TABLE OF CONTENTS / Orthopaedics 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 ACRRM Rural Clinical Guidelines – Orthopaedics – Version July 2012Page 26 of 50 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) Back to TABLE OF CONTENTS / Orthopaedics ACRRM Clinical Guidelines Version July 2012 (*Expires July 2013 - check RRMEO for latest version) ACRRM Rural Clinical Guidelines – Orthopaedics – Version July 2012Page 27 of 50 ORTHOPAEDICS Back to TABLE OF CONTENTS / Orthopaedics 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 ACRRM Rural Clinical Guidelines – Orthopaedics – Version July 2012Page 28 of 50 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 ACRRM Rural Clinical Guidelines – Orthopaedics – Version July 2012Page 29 of 50 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 ACRRM Rural Clinical Guidelines – Orthopaedics – Version July 2012Page 30 of 50 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 ACRRM Rural Clinical Guidelines – Orthopaedics – Version July 2012Page 31 of 50 (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 ACRRM Rural Clinical Guidelines – Orthopaedics – Version July 2012Page 32 of 50 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: ACRRM Rural Clinical Guidelines – Orthopaedics – Version July 2012Page 33 of 50 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 ACRRM Rural Clinical Guidelines – Orthopaedics – Version July 2012Page 34 of 50 (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 ACRRM Rural Clinical Guidelines – Orthopaedics – Version July 2012Page 35 of 50 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 Back to TABLE OF CONTENTS / Orthopaedics ACRRM Clinical Guidelines Version July 2012 (*Expires July 2013 - check RRMEO for latest version) ACRRM Rural Clinical Guidelines – Orthopaedics – Version July 2012Page 36 of 50 ORTHOPAEDICS Back to TABLE OF CONTENTS / Orthopaedics PLASTERING TECHNIQUES See - Ortho Plastering Techniques Back to TABLE OF CONTENTS / Orthopaedics ACRRM Clinical Guidelines Version July 2012 (*Expires July 2013 - check RRMEO for latest version) ACRRM Rural Clinical Guidelines – Orthopaedics – Version July 2012Page 37 of 50 ORTHOPAEDICS Back to TABLE OF CONTENTS / Orthopaedics 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 ACRRM Rural Clinical Guidelines – Orthopaedics – Version July 2012Page 38 of 50 - 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) ? Back to TABLE OF CONTENTS / Orthopaedics ACRRM Clinical Guidelines Version July 2012 (*Expires July 2013 - check RRMEO for latest version) ACRRM Rural Clinical Guidelines – Orthopaedics – Version July 2012Page 39 of 50 ORTHOPAEDICS Back to TABLE OF CONTENTS / Orthopaedics 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 ACRRM Rural Clinical Guidelines – Orthopaedics – Version July 2012Page 40 of 50 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) ACRRM Rural Clinical Guidelines – Orthopaedics – Version July 2012Page 41 of 50 (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) ACRRM Rural Clinical Guidelines – Orthopaedics – Version July 2012Page 42 of 50 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 Back to TABLE OF CONTENTS / Orthopaedics ACRRM Clinical Guidelines Version July 2012 (*Expires July 2013 - check RRMEO for latest version) ACRRM Rural Clinical Guidelines – Orthopaedics – Version July 2012Page 43 of 50 ORTHOPAEDICS Back to TABLE OF CONTENTS / Orthopaedics 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 ACRRM Rural Clinical Guidelines – Orthopaedics – Version July 2012Page 44 of 50 - arthroscopic adhesion division - manipulation under anaesthesia Reference: - Therapy Update - Australian Doctor 14/5/10 - Up To Date Back to TABLE OF CONTENTS / Orthopaedics ACRRM Clinical Guidelines Version July 2012 (*Expires July 2013 - check RRMEO for latest version) ACRRM Rural Clinical Guidelines – Orthopaedics – Version July 2012Page 45 of 50 ORTHOPAEDICS Back to TABLE OF CONTENTS / Orthopaedics 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 ACRRM Rural Clinical Guidelines – Orthopaedics – Version July 2012Page 46 of 50 - 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 Back to TABLE OF CONTENTS / Orthopaedics ACRRM Clinical Guidelines Version July 2012 (*Expires July 2013 - check RRMEO for latest version) ACRRM Rural Clinical Guidelines – Orthopaedics – Version July 2012Page 47 of 50 ORTHOPAEDICS Back to TABLE OF CONTENTS / Orthopaedics 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 ACRRM Rural Clinical Guidelines – Orthopaedics – Version July 2012Page 48 of 50 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 ACRRM Rural Clinical Guidelines – Orthopaedics – Version July 2012Page 49 of 50 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 Back to TABLE OF CONTENTS / Orthopaedics ACRRM Clinical Guidelines Version July 2012 (*Expires July 2013 - check RRMEO for latest version) ACRRM Rural Clinical Guidelines – Orthopaedics – Version July 2012Page 50 of 50