Fractures

26/11/12 30/11/12

Skeletal System

Function: allow movement, carry loads, protect the neural

structures
Disorder causes: PAIN, neurological deficit and physical
deformity
Lumbar spine moves the most so most commonly
affected L1/L2 in particular. 5cm extension in Schobers
test is normal
Spine exam LOOK. FEEL. MOVE.

Skin, shape and posture, walking

Palpitation of muscles and spinous processes
Flexion, extension, lateral flexion, schobers test.
Neurological examination for any nerve compression etc

Spina bifida hairy patch, dimples/sinus, blue patch.

Nerve tension signs:
Straight leg raise sciatic stretch
Crossed straight leg raise
Femoral stretch test (Lasegue)

Spine

Investigations:
CRP
Plain x-ray: AP&LATERAL
30% loss of bone mass for OP to show
50% destruction of interior bone for tumour to show

CT/MRI are over sensitive for causes of nerve root compression

Simple low back pain

20-55
Mechanical in nature increased by activity/posture
Pain fluctuates, sleep disturbed.
Rx: analgesia, KEEP MOBILE

Chronic low back pain

Pain persists after 3months
<5% LBP patients. Multiple factors: disc, facet joints, ligaments
Psychosocial factors, surgery rarely helpful

Acute disc prolapse:

bed rest, NSAIDS, nerve root injection 90% relief rate.
Surgical Rx 10-15% need it, more rapid relief but same end point.
If leg pain the worst will have Sx

RED FLAGS!!!

20-55
Non-mechanical pain
Thoracic pain
PHx carcinoma, steroids, HIV
Systemic symptoms: weight loss
Saddle anaesthesia, incontinence (urinary or faecal)
Widespread neurology
Structural deformity

Causes:
cauda equina,
MET
spinal tumour

Orthopaedic Trauma

Initial assessment: detailed Hx, mechanism of injury,

patterns of injury, signs of trauma, complications of
injury
BONDS

Bones involved?
Open or closed?
Neurovascular intact?
Deformity of length, alignment or rotation
Soft tissue compartment tight?

Fracture location:

Epiphysis, metaphysis, diaphysis,apophysis (not length)

Vertebral
Proximal, distal, middle
Head, neck, body
Intra-trochanteric
Supracondylar

Fracture Patterns

Fracture Patterns:

Transverse
Oblique
Butterfly fragment (triangle chip)
Spiral
Multi-fragmental comminuted - >2parts of bone
Segmental (2 parts)
Axial loading: impacted/crushed giving wedge #

Deformity
Displacement:

Angulation: valgus/varus (distal end of bone is Va to the proximal end)

Translation full or partial, one end sitting beside/slightly on the other
shortening
Rotation cortical line doesnt match up

Fractures

Clavicle #
Most common childhood #, majority heal without
intervention
Common in cyclists, jockeys, skiers
AP view clavicle
Coraco-clavicular ligs important!!!
Mainly conservative Mx, surgery if more than 2cm
shortening due to angle of break, if skin compromised or
unlikely to heal.
Hx & Ex neurovascular, skin integrity and feel bump!

Osteoporosis in the young

Alcohol abuse
Steroids
Chronic underlying condition e.g. DM

Fractures

Proximal Humeral #
Humeral head, greater and lesser tuberosities and humeral
shaft
FRAGILITY #
Osteoporosis

Radius and Ulna #

Children associated with greenstick (one side)
Adults more often displaced
Children remodel much more so leave it!

Distal Radius

Colles

Distal 2cm radius

Over 65 years old
Dorsally displaced
Radially displaced
Dorsally tilted
Radially tilted
Impaction
Supinated
(Comminuted fracture)
30-40 deg angulation
FRAGILITY #

Fractures

Scaphoid #

Young men, difficult diagnosis

High clinical suspicion with Anatomical SnuffBox tenderness
Repeat Xray in 10days
Bone scan, CT, MRI useful
RETROGRADE blood supply distal to proximal so risk of
avascular necrosis

Retrograde blood supply

Scaphoid
Navicular
Proximal humerus
Femur
talus

Fractures

Pelvic #

Young adults in RTA or elderly with simple fall

AP pelvis inlet, outlet view, Judet views
CT scan
Contents include bowel: faecal peritonitis risk, 50% mortality

Neck of Femur intracapsular #

OP and simple fall
Garden classification: Garden stage I : undisplaced
incomplete, including valgus impacted fractures. Garden
stage II : undisplaced complete. Garden stage III : complete
fracture, incompletely displaced. Garden stage IV : complete
fracture, completely displaced.
Above trochanteric line

Neck of Femur extracapsular

OP and simple fall
Intertrochanteric, sub-trochanteric

 When femoral neck # occurs, intraosseous

cervical vessels are disrupted;
- incidence of AVN in undisplaced
fractures is 11%;
- only 1/3 of patients with AVN will
require additional surgery where as 3/4
patients with non union will require
reoperation;
-risk of AVNgenerally corresponds to
degree of displacement of the fracture of
the femoral neck on the initial
radiographs;
-minimally displaced femoral-neck
#:
is at low risk (< 10%) for osteonecrosis
if displacement of the fracture remains
unchanged;
-displaced frx:
- incidence AVN > 80% in displaced #;
- most of retinacular vessels are
disrupted;
- femoral head nutrition is then
dependent on remaining retinacular
vessels and those functioning vessels in
the ligamentum teres;

Fractures

Tibial plateau #
Life changing injury: intra-articular #
Cartilage is worn away with the damage.
Cannot regrow so permanent problems with the joint.

Ankle #

Injoint
Subluxed
Dislocated
Not much soft tissue around ankle so tissue may be
compromised!

Calcaneal
Associated with spinal #

Compartment syndrome

Painful condition that occurs when pressure within the muscles builds to
dangerous levels.
Pressure decreases blood flow, preventing nourishment and O2 reaching cells.
Can be acute or chronic.
Acute medical emergency. It is usually caused by a severe injury. Without
treatment, it can lead to permanent muscle damage.
Chronic compartment syndrome (exertional compartment syndrome), is usually
not a medical emergency. It is most often caused by athletic exertion.
Compartments are groupings of muscles, nerves, and blood vessels in your arms
and legs. Covering these tissues is a tough membrane called a fascia. The role
of the fascia is to keep the tissues in place, and, therefore, the fascia does not
stretch or expand easily.
Compartment syndrome develops when swelling or bleeding occurs within a
compartment. Because the fascia does not stretch, this can cause increased
pressure on the capillaries, nerves, and muscles in the compartment. Blood flow
to muscle and nerve cells is disrupted. Without a steady supply of oxygen and
nutrients, nerve and muscle cells can be damaged.
ACUTE - unless pressure is relieved quickly, premanent disability and tissue
death can occur.
Most often occurs in the anterior (front) compartment of the lower leg (calf). It
can also occur in other compartments in the leg, as well as in the arms, hands,
feet, and buttocks.
TEST: passive stretch of toe

Compartment syndrome

Pain out of proportion to apparent injury

History
Pain unresponsive to analgesia, increasing
Usually a closed #
Examination
Pain increases with passive movement stretching muscle group
transversing compartment (2nd toe)
Investigation
Compartment measurement:
Isolated or continuous
>30mmHg or within 30mmHg of diastolic BP
Treatment
Surgical release of compartment by fasciotomy

PAIN PAIN PAIN PAIN PAIN PAIN PAIN

Abduction Pillow

Abduction pillow: prevents adduction and internal

rotation which could cause dislocation of the hip
prosthesis. Should be used when patient is sleeping
and lying in bed. Typically worn for 6-12 weeks, this
allows a pseudo-capsule to form around the joint and
muscle strengthening. Patients who have had
previous hip surgery are more likely to dislocate the
hip prosthesis and are therefore always given the
abduction pillow.

Management of common #

Principles of treatment
Reduction
Immobilisation
Rehabilitation

Fracture = loss of continuity in the substance of the

bone
Dislocation = complete loss of congruity between
articulating surfaces
Subluxation = partial loss of congruity
Causes of #

Direct trauma: high impact

Fatigue #: repetitive stress to a bone
Pathological #: bony MET
Osteoporotic

Defining fractures
Angulation: varus/valgus or dorsal/volar

Common #

Defining #
Age of pt: skeletal maturity (presence of growth plate, bone
elasticity by greenstick # or buckle # - one side of bone
affected)
Salter harris classification

Diagnosis of #

History

Nature of activity
Nature of incident
Point of impact and direction of force
Site of pain
Loss of function: weight bearing
Significant co-morbidities: cause of fall/affect on Rx

Examination
LOOK: asymmetry, swelling, discoloration, skin damage
FEEL: site of tenderness, crepitus, pulses (distal to #)
MOVE: pain or tenderness, reduced ROM

Investigation

Bloods
X-ray
US
Maybe MRI/CT

Treatment of #

Want to attain sound bony union without deformity

Want to restore function to as close to previous as possible
Want to prevent complications
Want quickest fixing and recovery possible
Management
Multiple injuries: fracture fixed after soft tissues
Analgesia
Manipulation of limb: overlying skin threatened, obvious #
dislocation, NV compromise
Compound # (OPEN): IV abx, NV status, remove contaminants,
photo, sterile saline soaked gauze, splint, 1o Sx- debridement, #
stabilise
Isolated #: relocation by
1)manipulation
2)traction
3)external fixation
4)open reduction (surgery)

Immobilisation

Plaster
Continuous traction
External skeletal fixation
Internal fixation:
Plates
Wires
Intramedullary nails

Complications

Haemorrhage
Infection: of wound or pneumonia from lying flat
Visceral damage
Metabolic response to trauma
Pressure sores
DVT/PE
Muscle wasting
Joint stiffness
Nonunion/malunion/unsuccessful treatment

Complications

Factors influencing bone healing

Biological: type of bone, age, infection, disturbance of blood
supply
Mechanical: type of injury, separation of bone ends (level of
displacement), type of fixation

Complication
Malunion:
Clinical deformity: varus/valgus deformity, axial, shortening
Osteoarthritis
Avascular necrosis: neck of femur, talus, scaphoid
Osteoarthritis: intraarticular # or malunion
Growth arrest
Joint stiffness
Complex regional pain
Neurological compromise: early/late, e.g. carpal tunnel
Tendon rupture
Implant complications
Fat embolism (Adult Respiratory Distress Syndrome): long bones like femur and
pelvis, fat escapes into circulation causing an unexplained deterioration in
clinical condition.
Compartment syndrome

Fragility Fractures

Osteoporosis
Skeletal disease characterised by low bone mass and deterioration
of bone tissue, leading to bone fragility and low trauma fractures
Bone density measured relative the that of 25-30year olds of same
gender
T score given for the amount of standard deviations you are away
from that 25-30 year old
Z score is for how many SDs you are away from your own age
group
Normal bone mineral density is above 1 SD below average
Osteopenia BMD 1-2.5 below average
Osteoporosis is <2.5 below average
RFs: early menopause, smoking, alcohol, sedentary lifestyle, diet,
malabsorption
Common # - neck of femur, L3, wrist
1/3 women, 1/12 men get OP
70% of 70yo women have OP
Investigations: rule out other cause e.g. tumour or infection.
Hx&Ex. X-ray requires 30% bone loss to show up. DEXA. bloods

Osteoporosis

DEXA scan
Dual emission x-ray absorptiometry
2 x-ray beams passed through the body, low radiation
Can be performed on hip, spine and wrist

Prevention

Exercise YOUNG, especially women

Stop smoking, reduce alcohol, and drugs
Monitor at risk groups those on steroids for e.g. COPD
Measures to prevent falls: OT
HRT best prevention method
Calcium: normal requirement 750mg/day adult, 1000 child,
1500 pregnant

Treatment
Depends on presentation: fix fracture etc if necessary
Calcium, vitamin D, calcitonin, calcitriol
HRT, Bisphosphonates, selective oestrogen receptor
modulators

Fragility #

Hip #

Annually 10/1000 population

33% die within one year post #
5% male and 15% female lifetime risk
Usually following a fall at home, elderly patient who then
cannot walk
May have pain in hip prior to fall OA or METs
Lower limb may be shortened and externally rotated.

Assessment

Hx, Ex, MMSE

Bloods, ECG, CXR, ECHO look for cause of fall
X-rays: AP and lateral
CT, MRI or isotope bone scan if in doubt

Intra or Extracapsular
Intra is treated with hemiarthroplasty
Extra given dynamic hip screw

 Intracapsular:
Displaced:
Young: screw, allow to heal itself
Old: replace hemiarthroplasty

Undisplaced: fix in situ screw

Intertrochanteric/Extracapsular
Reduced non-displaced: DHS
Reduced and displaced: IM Nail

Performing surgery
Operate on patients with the aim to allow them to fully weight bear
(without restriction) in the immediate postoperative period.
Perform replacement arthroplasty in patients with a displaced
intracapsular fracture.
Offer total hip replacements to patients with a displaced intracapsular
fracturewho:
were able to walk independently and
are not cognitively impaired and
are medically fit for anaesthesia and the procedure.

Use a proven femoral stem design rather than Austin Moore or Thompson
stems for arthroplasties.
Use cemented implants in patients undergoing surgery with arthroplasty.
Consider an anterolateral approach in favour of a posterior approach when
inserting a hemiarthroplasty.
Use extramedullary implants such as a sliding hip screw in preference to
an intramedullary nail in patients withtrochanteric fractures above and
including the lesser trochanter (AO classification types A1 and A2).
Use an intramedullary nail to treat patients with asubtrochanteric
fracture.

Fragility #

5 branches of medial circumflex femoral artery

Superficial, ascending, acetabular, descending and deep branch

Blood supply to femur

MCFA
LCFA
Intramedullary
Ligamentum teres (children only)

Management

Orthogeriatric support for management of co-morbidities

Analgesia and rehydration
VTE thromboprophylaxis
Theatre within 36hours

Surgical Mx

Intracapsular displaced : hemiarthroplasty if over 65

Intracapsular undisplaced : internal fixation with DHS/CHS
Extracapsular: internal fixation with DHS or intramedullary device
Young intracapsular # pt is a high energy injury. Can be left to heal as
replacement will cause lifelong problems and is always an option if they fail to
heal themselves
Intramedullary metal pin
Extramedullary metal plate
Fixation: NAIL (intracapsular) or DHS (extracapsular)

Surgery Hip #

Hemiarthroplasty

Blood supply to femoral head is at risk this negates the risk

Usually cemented
Indication for THR: active independent patient
Only replace femoral head

DHS intracapsular #
Internal fixation indicated for undisplaced in all age droups
and displaced in >65
Non-union 20-30%, AVN 10-20%, deep infection 0.4%
20% need further Sx within a year
25-30% converted to THR
Lower early mortality for internal fixation than arthroplasty

Mortality

Near 100% if not treated

Limited indications for conservative Mx
9% mortality at 30days, 20% at 90days, 30% at 12months
Mortality rate increases if Sx >4days after

OP Vertebral #

Reduction in anterior vertebral height

Chronic pain, increasing kyphosis, limited mobility
and Fx
Decreased lung capacity
Possibly neurological compromise
Commonly at thoracolumbar junction
Treatment

Conservative: bed rest, analgesia, physio

Bracing: >30% collapse
Sx if neuro unstable or unstable #
Medical treatment to prevent further collapse
Percutaneous vertebroblasty: needle inside to broken bone,
acts as a jack and fill with cement

OP wrist #

Common 1/6 of all #

Bimodal distribution: young high energy and old females
Colles: dorsal displacement/tilt, radial shortening, ulnar
deviation dinner fork deformity
Smiths: volar displacement
Barton: volar or dorsal # and dislocation of radiocarpal
joint
Wrist #

Fall on outstretched hand

AP and lateral x-rays
In undisplaced and stable: SA POP
If displaced then MUA and SA POP
If displaced and unstable then MUA and K-wiring, ORIF or
external fixation

Fixation in OP bone
OP shell thin and weak, will take longer to heal so fixation needs
to last longer. Screws often fail so metal plates best

Fragility #

Improving Fixation
Increase number of screws
Augment bones with bone cement, calcium phosphate
cement
New techniques: locking/fixed angle plates, new nails and
Ilizarov frames

Soft tissues
Care of soft tissues vital in elderly to prevent infection,
pressure sores and wound breakdown.

The Limping Child

Limp means abnormal gait

Gait cycle:
Heel strike, stance, toe off and swing

Required for gait cycle:

Control centre: brain and spinal cord
Bony alignment, architecture, stability
Muscle control

Types of gait

Antalgic painful, less time in stance

Trendelberg weak abductors, waddling
Spastic
Short leg
Normal variant in toeing, genu varum/valgrum
Shuffling: PD wide stance, difficult to start and stop
Ataxic: neurological deficit, wide stance

Limping child

RED symptoms

Asymmetric
Progressive
Painful
Reduced ROM
Falls, trips, late development

Assessment

Birth Hx
Developmental Hx walking by 2years
Family Hx: DDH, Perthes, SUFE
Hx of limp
Duration, pain, trauma, night pain (TUMOUR), swelling, weight
bearing, systemically unwell
Joint involvement

Investigations
Examine: LOOK FEEL MOVE, observe Gait
X-rays, USS, MRI
Bloods: CRP, ESR, CK (duchennes), FBP

Limping child

Infection

Can be bone or joint

Unwell child with raised temperature, refusing to weight bear
Red, swollen, tender area
Investigations: temp, bloods, culture, X-ray, USS, joint
aspiration
Brodies abscess round, symmetrical lesion in bone on x-ray

Irritable hip
Transient synovitis diagnosis of exclusion
Inflammation associated with viral illness presenting with limp
and loss of motion
Investigations: normal temp, bloods normal, USS +/- aspiration
Rx: pain management and rest

Muscular weakness (proximal myopathy)

Hx of tripping and losing balance, inability to climb stairs
Family history
Investigations: CK level, Gowers sign climb up legs to stand

Limping child

0-5
DDH

Family history, breech baby

Limited hip abduction
dipping painless hip
Skin creases, ortlani and barlows test
Diagnosed on x-ray once over 4months

Toddlers fracture
Hx of fall, point tenderness, refusal to weight bear, x-ray can be normal
initially
LL POP (long leg plaster of paris) the re x-ray 7-10days later

Neurological
Walks with limp, possible upper limb involvement, walks on tiptoes
Thinner leg, weak/spastic muscles, brisk reflexes
Do neuro assessment and MRI brain/spine

Limping child

5-10
Perthes disease

Idiopathic avascular necrosis of capital epiphysis of femur

Presents with painful limp, can be hip pain OR KNEE PAIN!!!
Long history, 4-6wks increasing limp
Boys > girls, the younger the age on onset, the better the prognosis as bone
has longer to remodel and heal
Boys do better than girls, 75-80% do well regardless of treatment
EXAMINATION: decrease in internal rotation, abduction and flexion
INVESTIGATION: x-ray: AP and Lauenstein (lateral with legs abducted). Loss
of spherical shape of femoral head due to AN
Rx: containment achieved by regaining motion

Trauma: #
Infection
Inflammation
Osteochondritis
Kohlers disease or navicular: Rx rest
Severs disease: os calcis
Osgood schlatters disease tibial tuberosity pain (GP!!!)

Limping child

10-15
SUFE

Boy, 10-15, heavy with sore hip!!! Overweight and sexually under developed
Presents with groin pain and KNEE pain
Exam: in flexion hip goes into abduction or lateral rotation
INVESTIGATIONS: x-ray 2views (AP and frog lateral)
Rx: internal fixation with NO attempted reduction screw in situ
Degree of slip: 1,2 or 3 or complete. Stable or unstable. Acute, chronic or
acute on chronic.
Risk of same on other side so may prophylactically fix it with screw too (2533% chance if over 12, 50% chance if <12)
Under age of 10 consider hypothyroidism and fix other side

Trauma
Infection
inflammation

Clinic

Open #

Benodine soak
Check neurovascular status
Give antibiotics
Check they are up to date with tetanus

# proximal femur
Intra/extra capsular
Intratrochanteric: along trochanteric line
THR / DHS

Radial #

<2cm from radial head short arm cast

>2cm from radial head long arm cast to prevent ligaments moving
Colles: dorsally angulated. Cast flexed and ulnarly deviated
Smiths: volarly angulated.
Bartons: intra-articular
Frykman classification

Lisfranc #
2nd metatarsal
Holds foot together so can be catastrophic

Frykman Classification

Frykman classification of distal radial fractures

Based on the AP appearance and encompasses a the eponymous entities
ofColles fracture,Smith fracture,Barton fracture, chauffeur fractureetc
Assesses the pattern offractures, involvement of the radio-ulnar joint
and presence of distal ulnar fracture.
Although it appears complicated, it is actually only a 4 type classification
(odd numbered types) with each type having a subtype which
includesulnar styloid fracture(these are the even numbered types).
type I: transverse metaphyseal fracture
this includes both aCollesandSmith fractureas angulation is not a feature

type II: type I + ulnar styloid fracture

type III: fracture involves the radiocarpal joint
this includes both aBartonandreverse Barton fractures

type IV :type III + ulnar styloid fracture

type V: transverse fracture involves distal radioulnar joint
type VI: type V + ulnar styloid fracture
type VII: comminuted fracture with involvement of both the radiocarpal
and radioulnar joints
type VIII: type VII + + ulnar styloid fracture

Principles of Management

REDUCE
Manipulation
surgical repositioning and pinning

IMMOBILISE
Cast/sling
External fixation device
Plates and screws

REHABILITATION
physiotherapy

Ankle #

Most common weight bearing #

(70%) hip, wrist not weight bearing
Fragility #
Increased weight puts more
pressure on joint so increases
likelihood of #
2 peaks: young, active men and
women >60
NOT RELATED TO OP
Complicated joint, made up of
bones, ligaments and held in place
by muscles
Thin soft tissue envelope, much
thicker in children : periosteal
envelope. This provides all
nutrition to the bone. In childrens
ankle # this tissue flips over and
often needs surgically reduced
before healing can occur

Lateral Ligaments

Medial (deltoid) Ligament

 Syndesmosis

Ankle #

Distal tiobiofibular joint

Bones overlap
Hard to see on x-ray: just look for pattern
Ankle has a syndesmosis joint between the tibia and fibula, held
together by interosseous membrane, anterior inferior
tibiofibular ligament and posterior inferior tibiofibular ligaments
Injury can cause dislocation of the joint
If there is a # of fibula need to check for syndesmosis injury

Ankle #

Can get tri-maleolar # where MM, LM and posterior

malleolus (on posterior aspect of talus) are all #
Tauls is prone to AN due to retrograde blood supply
Sign of # is bony tenderness, soft tissue pain is more likely
ligament damage. MRI good to differentiate
MRI will find #, CT will define it
Ankle ROM is
20 degrees extension
40 degrees flexion
If ankles need fused for arthritis/# the patient will not notice much of
a change

To visualise the ankle you need 2 x-rays perpendicular to

eachother
At least 10 degrees of dorsiflexion is needed for normal gait
1 mm of lateral talar shift decreases tibiotalar surface
contact up to 40%
Can do stress view X-rays: force joint apart. Too sore.

Ankle #

Looking at the x-ray:

Tibiofibular overlap: <10mm
implies syndesmotic injury
Tibial clear space: >5mm
implies syndesmotic injury
Talar tilt: >2mm is abnormal

Mortise view:
15deg INT ROT
AP view
Abnormal findings:
Medial joint space widening
TIBFIB overlap <1mm

Ankle #

Examination

Note obvious deformities

Neurovascular exam
Pain to palpation of malleoli and ligaments
Palpate along the entire fibula
Pain at the ankle with compression (shouldnt really do, too painful)
syndesmotic injury
Examine the hindfoot and forefoot for associated injuries

WEBER CLASSIFICATION - Based on location and appearance

of fibula fracture
Type A
Below syndesmosis
Internal rotation and adduction

Type B
At level of syndesmosis
External rotation leads to oblique fracture

Type C
Above syndesmosis
Syndesmotic injury

Medial and posterior malleolar fractures, deltoid ruptures

may occur with any of these

Ankle #

Duputrens/Maisonneuve #
Higher fibula #
Technically a Weber C

Management of Webers #
Type A: weight bearing cast/bandage
Type B: not displaced: cast. Displaced: ORIF (MM affected too)
TypeC: implies syndesmosis injury so surgery!!!

Mx

 MM #

Management Ankle #

Nondisplaced fractures may be treated nonoperatively

Displaced fractures require anatomic reduction and fixation
High nonunion rate
Open reduction, Remove interposed soft tissue and intraarticular
fragment, Anti-glide plate for vertical fractures

LM #

Nonoperative managmement
2-3 mm displacement
NO medial widening or syndesmotic injury
Patient in extremis
Cast or boot immobilization 6 wks
Follow closely!

Ix Sx

Bimalleolar / trimalleolar fractures

Syndesmotic disruption
Talar subluxation
Joint incongruity / articular stepoff

Management Ankle #

Posterior malleolus

Repair if >25% of articular surface

Reduce by ankle dorsiflexion
Clamp through fibular incision
Anterior lag screws

Maisonneuve #

Fracture of proximal 1/3 of fibula

+/- medial malleolar fracture
Pronation-external rotation mechanism
Requires reduction and stabilization of syndesmosis

Post-Op
Well padded splint/cast immobilization, Ice and elevation, Non
weight bearing for 6 weeks but Early weight bearing is possible

Consent/Risks
Infection, neurovascular injury, DVT/PE, ongoing pain and
stiffness, Non/Mal union, failure of procedure, further procedure,
anaesthetic risk-MI/CVA/renal dysfx

Prevention of Infection

Pre-Op

Screened for infection: FBC and swabs

Prophylactive Abx
Separate room on ward
Nice clean room

Intra-Op

Abx before any wound made

Anti-septic to skin- excessively
Double gloving and frequent glove changes
Minimal staff in theatres
Double drapes
Masks
Laminar air flow
Cleaned between surgeries

Post-Op
Antibiotics for 24hours, single rooms, barrier nursing for MRSA

Wrist #

Hx&Ex

ATLS
Isolated injury?
Open or closed? (any tenting of the skin?)
Neurovascular status
Age/Handedness/Profession

Usually both bones are involved so check each from

joint to joint
Need AP and lateral views on x-ray
General treatment
Child greenstick # - MUA (manipulation)
Adults: ORIF shaft fractures (open reduction, internal fixation)

Colles

Colles fracture

Distal 2cm radius

Over 65 years old
Dorsally displaced
Radially displaced
Dorsally tilted
Radially tilted
Impaction OP BONE
Supinated ALWAYS
FOOSH
IMPACTS!

!!!!!!!!!

Colles cast:
Flexed
Ulnar deviation

Any dorsally displaced # in someone <65 is colles like

Smiths

Opposite of Colles
Volar displacement
Volar Tilt
UNSTABLE
Fall when holding something volar tilt to wrist
Can use cast. Rarely. Supinates and extends.
Often Tx with ORIF

Bartons
Intra-articular fracture/subluxation
Volar displacement
UNSTABLE
Split up onto articular surface
Carpus falls off radius (subluxating)
Fix with plates

Radial Styloid #

Intra-articular fracture
Minimally displaced
Treat in plaster 6/52
Check X ray at 1&2 weeks

Displaced
Fix

Look out for ulna styloid/scaphoid fracture

May indicate perilunate injury/ligament damage
Will need further imaging/aggressive Tx

Young adult wrist #

High energy
Risk of NV damage median nerve. Test by touching index finger
pulp and lifting thumb off the table (lateral lumbricals, opponens
pollicus, abductor pollicus brevis)
Risk of compartment syndrome
Reduction must be perfect
Often unstable if comminuted/intra-articular
K-wire
ORIF
Ex-Fix

Children Wrist #

Childrens:

Buckle fracture: not a full cortical breach. Large periosteal

border contains # to one side
Cast for 3 weeks, take off and leave it
Torus/Buckle fractures
Stable
Splint/bandage 2-4 weeks

Green stick
MUA if clinically deformed

Salter Harris
MUA if displaced

Parameters to assess

Radial height: normal 11mm, 8 acceptable. Tip ulnar

styloid to tip radial styloid

Radial Inclination: 22degrees. Line drawn from

radial tip to lateral ulna in gradient of radius

Volar Tilt: 11degrees.

Management aims are to restore these angles and

lengths!!!

Extent of dorsal comminution

Status of articular surface: ,1mm congruity acceptable
Status of distal radio-ulna joint

Treatment wrist #

MUA
K-wire
ORIF
Ex-Fix

Scaphoid #

Blood supply retrograde

Risk of non-union/avascular necrosis
AVN: Proximal pole becomes sclerotic
Non-union: # line becomes sclerotic
Wrist instability/OA

Treatment

Minimally displaced:
POP for 6-12 weeks
90% heal
Displaced:
Percutaneous Herbert screw
ORIF

Notes

Any joint # will get arthritis in joint unless fixed within

1mm of articular step QUICKLY
Principles of Rx:
Reduce
Immobilise
Rehabilitate

99% colles treated with cast. Must x-ray within 3 weeks

of cast placement. After 3 weeks cannot change
healing.
External fixator: helps maintain radial height,
alternative to a cast
Wiring: percutaneous, good in non OP bone. Use if not
happy with how it will heal and aged 30-60.
Thumb is always positioned more volar. Use it as a
marker.

 DRUJ dislocation
(distal radio-ulnar joint)
Monteggia
# Ulna + dislocated radial head
(at elbow!)
Galeazzi
# Radius + dislocated ulna head
(at wrist!)

Mx- surgery

If you break the ulna or radius and the other does not # - must
give in some way. Here by dislocating out of joint

Bennetts #
# base of the first MCP
Extends into the carpometacarpal
joint
Most common type of fracture of
the thumb
Nearly always accompanied by
some degree of subluxation or
frank dislocation of the
carpometacarpal joint.

Hangmans #
Extension injury
Bilateral
fractures of C2
pedicles (white
arrow)
Anterior
dislocation of C2
vertebral body
secondary to
ALL tear (red
arrow)
Unstable

Boxers #

Swelling over
dorsal aspect of
hand, most
pronounced
below the small
finger.
# of fifth MCP
Usually
associated with
striking an object
with a closed fist.

 Flexion Teardrop
fracture
Flexion injury
causing a
fracture of the
anteroinferior
portion of the
vertebral body
Unstable
because usually
associated with
ligamentous
injury