Distal tibial metaphyseal fractures
The soft metaphyseal bone is susceptible to buckle or greenstick fractures, similar to the proximal end. There is less tendency to coronal angulation, but anterior collapse and recurvatum may occur, which is overcome by casting the foot in plantar flexion. 15 saggital angulation and 30 translocation will remodel. The 'bicycle spoke' distal tibial fracture is a specific injury occurring in young children. The foot is caught in the spokes and forced internal rotation results in an open,...
Tarsometatarsal joint disruption Lisfrancs dislocation
Tarso-metatarsal joint injuries are rare. Intrinsic stability is by bony architecture with the base of the second metatarsal recessed in between the medial and lateral cuneiform bones. There are strong ligamentous connections between the bases of the lateral four metatarsals. Lisfranc's ligament runs between the medial cuneiform and the base of the second metatarsal. There is no ligament attachment between the first and second metatarsals, representing a relatively weak portion in the...
Polytrauma Fat Embolism And Respiratory Distress
Fat embolism is the systemic release of bone marrow fat, or other fat, into the circulation. As the peripheral arterial circulation is affected, the term 'embolism' is a misnomer. Fat embolism syndrome FES is the systemic response to this phenomenon. Although FES is an infrequently recognized complication of trauma, the effects can be dramatic, a major cause of mortality, and an important cause of adult respiratory distress syndrome ARDS . FES is really part of the spectrum of trauma-related...
Olecranon
Olecranon fractures are most commonly caused by the pull of the triceps, or a fall onto the olecranon. 1. Classification. Numerous systems exist and that described by Colton is popular Type 1. Non-displaced and stable. 2. Non-displaced fractures. These are treated in a cast for 3 weeks, after which supervised mobilization is commenced. 3. Displaced fractures. Many techniques are described for displaced fractures, but tension band wiring, plating and olecranon excision are the principal options....
MCPJ injury
Dorsal, volar and lateral dislocations of the MCPJ occur. Dorsal is the most common. 1. Dislocation can be 'simple' or 'complex' irreducible and differentiating the two is important, to avoid making a simple injury complex. The simple dislocation appears more dramatic, with the finger in 60 or more of hyperextension, compared to a few degrees with the complex. In complex dislocation, the metacarpal head is buttonholed through the capsule, often with puckering of the palmar skin. The simple...
Thoracolumbar spine fractures
7. Holdsworth classification. Holdsworth divided the spine into two columns. Anterior body and posterior elements. The spine is unstable if both columns are injured. 2. Denis classification. This describes fractures as four types compression, burst, flexion distraction Chance and fracture-dislocation. Denis divided the spine into three columns Figure 1 Anterior anterior longitudinal ligament and the anterior half of the vertebral body and disc. Middle posterior half of the vertebral body and...
Myositis Ossificans
Myositis ossificans MO is a process of extraskeletal ossification in muscle and soft tissues, which most commonly follows elbow fractures, elbow dislocations and injuries with large haematomas, especially soft tissue injuries of the thigh. Haematoma formation is followed by an invasion of fibroblasts, which undergo metaplasia to osteoblasts and chondroblasts. The term really refers to the formation of bone in striated muscle, but is synonymous with heterotopic bone formation around a capsule or...
Imaging Fzr
An AP pelvis X-ray will confirm clinical suspicion of an injury. More detailed assessment, including Judet views AP views with the pelvis tilted 45 internally and 45 externally Figure I , pelvic inlet and pelvic outlet views, is required to demonstrate the injury pattern and plan surgical reconstruction. The use of CT to delineate the intra-articular extent of the fracture is essential and the increasing availability of spiral CT with three-dimensional 3D reconstruction will improve the...
Special plain radiograph views
1. Additional plain views are often of benefit, to demonstrate the characteristics and extent of an injury, and to plan the surgical approach to management. Examples include X-rays such as axial views of the glenohumeral joint, a tunnel view of the wrist for hamate fractures, a tunnel view of the knee for condylar fractures and loose bodies, 15 oblique views of the tibial plateau, 60 pelvic inlet and outlet views for pelvic fractures and 45 Judet views for acetabular fractures. 2. Tomograms may...
Midtarsal injury
The mid-tarsal region is a relatively stable area injuries are rare, but range in severity from a sprain, through subluxation, to the occasional dislocation. The acute diagnosis is difficult, but the consequence of missing the diagnosis is severe for the patient. Diagnosis is based upon careful initial clinical assessment and evaluation of the radiographs. 1. Classification. Main and Jowett 1975 identified five patterns of injury, based on the mechanism of injury Medial stress. Inversion of the...
Fracture patterns and treatment
1. Lateral condylar fractures typically occur in the 6-year-old child Figure 1 . Milch type I are uncommon and Milch type II more common. The fractures are further divided into non- or minimally displaced lt 2 mm , moderately displaced Figure 1. The Milch classification of lateral condylar fractures of the humerus. Note that type I is a Salter-Harris type IV injury, and that type II is a Salter-Harris type II injury. Figure 1. The Milch classification of lateral condylar fractures of the...
Spinal shock
Spinal shock is a transient condition, shortly after cord trauma, whereby cord function below and often above the level of injury is totally suspended. It is characterized by generalized flaccidity and the absence of local spinal reflexes, such as the bulbo-cavernosus reflex S3 4 . This is tested by looking for anal contracture after squeezing the glans penis or clitoris, or pulling on a catheter. Spinal shock may prevent accurate assessment of the extent of a cord injury complete or incomplete...
Proximal tibial epiphyseal fractures
These are rare injuries, as the collateral ligaments insert below the epiphysis, but may follow a direct valgus blow in adolescents. This is occasionally 'mis-diagnosed' as collateral ligament sprain. Vascular injury occurs in 10 , and peroneal palsy in 1. Classification. Salter-Harris II is the most common 43 , but S-H III 22 and S-H IV 27 also occur. 2. Management. Immobilization following reduction in an above knee cast for 6 weeks. Operative fixation is required for the unstable S-H II and...
Pathophysiological response to injury
1. Neurapraxia. Temporary ischaemia is reversed and function recovers. Focal demyelination is followed by remyelination over a period of 2 to 6 weeks. 2. Axonotmesis and neurotmesis. Axonal Wallerian degeneration occurs in the whole distal axon and the proximal stump up to the nearest node. Wallerian degeneration consists of enzymatic degradation and ingestion of the axon and myelin by macrophages and Schwann cells. This takes 1 to 3 months, leaving an empty neural tube, continuous or divided....
Polytrauma Outcome Scores
Scoring systems generate a measure of the severity of a patient's, or a group of patients' trauma, and provide a prediction of survivorship or mortality. Scoring systems can be applied to develop preventative measures, audit a region's trauma load, plan service delivery, audit the level of care and compare outcomes in different regions or countries. These latter functions are important as trauma is the leading cause of mortality and morbidity during the first four decades of life. Scoring...
Metatarsophalangeal joint dislocation
Metatarso-phalangeal joint dislocation may affect the hallux, or lesser toes. 1. The hallux. Dislocation of the first MTPJ is rare and associated with high-energy trauma. Most dislocations are dorsal and simple reducible . If stable, the toe is immobilized in a below-knee cast with a toe extension for 4 weeks. If unstable, a K-wire is placed across the reduced joint. Complex irreducible dislocation occurs when the metatarsal head becomes entrapped on the plantar side of the sesamoid complex....
Unilateral facet dislocation
Classical presentation is with the chin turned to the opposite side and the neck laterally flexed to the injured side. Seventy per cent have a radiculopathy, 20 are normal and 10 have spinal cord injury. The vertebral body is anteriorly subluxed 25 on plain lateral X-ray. The injury is often missed and is more easily demonstrated on oblique views. Reduction is by traction often unsuccessful , or open reduction. Stabilization is either with a halo, or preferably posterior cervical fusion due to...
Further reading Uye
Arciero RA, Wheeler JH, Ryan JB etal. Arthroscopic Bankart repair versus non-operative treatment for acute, initial anterior shoulder dislocation. American Journal of Sports Medicine, 1994 22 589-594. Hovelius J, Augustini BG, Fredin H et al. Primary anterior dislocation of the shoulder in young patients. A ten-year prospective study. Journal of Bone and Joint Surgery, 1996 78B 1677-1684. Neviaser RJ, Neviaser TJ, Neviaser JS. Concurrent rupture of the rotator cuff and anterior dislocation of...
Replantation
'Replantation' is the reattachment of a part that has been completely separated, as opposed to 'revascularization' of a partially amputated limb or digit. Generally, revascularization is easier and more successful, as some of the venous and lymphatic drainage remains in continuity. Table 1. The Mangled Extremity Severity Score MESS Low energy closed fracture, stab, low-velocity gunshot 1 Medium energy open, multiple fractures, dislocation 2 High energy close-range gunshot, high-velocity...
Tibial eminence fractures
Avulsion of the ACL tibial insertion is more common than cruciate rupture in the immature skeleton and not infrequent in adolescents playing sport. Haemarthrosis is the usual presentation with a fracture on X-ray. 1. Classification. 'Meyers and McKeever' lateral X-ray . Type I minimal displacement. Type II hinged anteriorly, attached posteriorly. Type III detached - rotated. 2. Management. Type I and II may be treated in a knee extension cast for 6 weeks. A check X-ray should be obtained to...
Classification Wto
The Milch classification refers to medial and lateral condylar fractures of the humerus, with type I passing through the capitellum or medial condyle, fracturing off the condyle, leaving the trochlear ridge intact. Type II fractures pass close to the trochlear sulcus and include the trochlear ridge, allowing the elbow joint to sublux. Milch type I are Salter-Harris type IV fractures and type II behave as Salter-Harris type II fractures, although some authors classify them as Salter-Harris type...
Subtalar dislocation
Simultaneous dislocation of the talo-calcaneal and talo-navicular joints has been termed a 'sub-talar' or 'peri-talar' dislocation. The ankle and calcaneo-cuboid joints remain enlocated. The injury is classified according to the direction of displacement of the foot. Medial dislocation, with the talar head prominent dorsolateral , accounts for 75-85 of cases. Lateral dislocation, with the talar head prominent medially, accounts for almost all the remaining cases, with occasional reports of...
Management of nonunion
Treatment of non-union depends upon the modality of primary treatment and the aetiology of the non-union. In broad terms, the fracture should be exposed, rigidly stabilized and bone grafted with morsellized iliac crest cancellous graft. Interposed soft tissue should be removed. Stripping of periosteum alone may stimulate callus formation and fracture healing. Infection must be eradicated and treatment may therefore be a staged procedure. Extensive bone loss or infection, sometimes combined with...
Classification Poe
Hohl and Luck's classification of the 1950s has been superseded by Schatzker's classification Figure 1 with six fracture patterns Type 2 - vertical shear and compression. Type 3 - local compression. Type 4 - medial condyle fracture a fracture subluxation of the knee . Type 6 - tibial plateau and segmental fracture separating metaphysis and diaphysis . AO classify the fractures as 41-B or41-C. Figure 1. Schatzker classification of tibial plateau fractures. Modified from Schatzker, J., McBroom,...
Treatment Kaf
The aim of treatment is early mobilization, avoiding the attendant complications of bed rest, either by mobilization alone, internal fixation or arthroplasty. Rehydration and urgent medical assessment of all patients is vital. Surgery should be performed within 48 hours of the fracture as confusion, pneumonia, the incidence of pressure sores and the duration of hospital stay all increase significantly with further delay. 1. Impacted fractures can be mobilized early when the head is tilted into...
Proximal tibiofibular joint dislocation
This rare injury may occur in isolation or in association with major trauma. Classically known as 'horseback rider's knee', the injury more often follows parachute jumping. The mechanism is axial force on a knee flexed beyond 80 . Hyperlax individuals Ehlers-Danlos are more susceptible. The four types include subluxation, postero-medial, antero-lateral and superior dislocation. Closed reduction is usually successful and most are stable, allowing early mobilization. Complications include a...
Principles of radiation protection
Radiation protection is based on three principles Justification - a proposed intervention should do more good than harm. Optimization - the magnitude of the dose should be kept as low as reasonably achievable abbreviated as 'ALARA' . Limitation - exposure of individuals should be subject to a dose limit. 1. Staff safety. Adequate training and local rules are paramount. New members of staff should be trained and copies of the rules should be available. There are three physical factors involved...
Classification
The AO classification is widely accepted 31-A1 or 31-A2 for pertrochanteric fractures and 31-A3 for intertrochanteric fractures, with subtypes to describe the morphological pattern. Classification and stability depend upon the degree of comminution and trochanteric involvement. The Boyd and Griffin classification 1949 , based on the ease of obtaining and maintaining reduction of the fracture, is often quoted, as is the Evans classification 1949 , dividing fractures into stable and unstable...
Vascular anatomy of muscle and skin
Skin blood flow is from a deep dermal plexus of vessels running parallel to the skin in the superficial fascia. This plexus is principally supplied from musculocutaneous perforators. These vessels are derived from the muscular pedicular vessels. The perforating vessels supply limited areas of overlying skin and form the basis of the 'random pattern' flap Figure la . Muscular blood supply is from one or more pedicular arteries. The muscle can be rotated on its pedicle, or the pedicle divided...
Metacarpal fractures
There are three regions of the thumb metacarpal - the head, shaft and base. Green and O'Brien classified four types of base fractures Type 1 an avulsion of the volar lip and subluxation of the carpo-metacarpal joint, equivalent to the Bennett's fracture. Type 2 a comminuted fracture of the base of the metacarpal, involving the joint surface Rolando fracture . Type 3 extra-articular fractures of the metacarpal base. Type 4 epiphyseal injuries. 1. Head fractures are rare. If the fragments are...
Treatment Qks
The aim of treatment is to achieve early mobilization of the patient, avoiding the attendant complications of prolonged bed rest. Young patients should be treated in the same manner. Rehydration and urgent medical assessment of all patients is vital. Surgery should be performed within 48 hours of the fracture, as confusion, pneumonia, the incidence of pressure sores and the duration of hospital stay all increase significantly after this period if surgery is further delayed. 1. Closed treatment,...
Mechanism and classifications
Mechanisms of injury include both high-energy injuries e.g. road traffic accidents RTA , falls from a height and sports injuries , and low-energy injuries e.g. falls, twists or slips . The most common age groups are young sportsmen and late-middle-age obese females. Simple descriptive Henderson, 1932 . Weber, 1972 expanded by AO, 1979 . 1. Descriptive classification. This is based on the number of malleoli involved bi tri-malleolar and the displacement. 2. Lauge-Hansen classification. This is...
Biological fixation
With massive comminution it may not be possible to reduce a fracture anatomically and compress the fragments. Healing therefore relies on soft tissue viability and callus formation. The emphasis with comminuted fractures is to maintain the 'biological milieu' around the fracture to enhance healing. This can be achieved using a number of techniques Indirect reduction methods, with traction and a guide wire. Using implants that minimize fracture exposure, including IM nails, external fixators,...
Knee Extensor Mechanism Disruption
The extensor mechanism of the knee comprises the quadriceps tendon, the patella, the medial and lateral retinacular fibres, the patellar tendon and the tibial tubercle. Injuries can occur at any age, but quadriceps tendon avulsion or rupture is more common in mature adults and patellar tendon injuries are more common in younger adults. Disruption of the extensor mechanism is six times more frequent in males than females. Direct injuries to the anterior aspect of the knee can result in damage to...
Distal radioulnar joint
The DRUJ is formed between the ulna and the sigmoid notch of the radius. The flat distal end of the ulna is covered by the triangular fibrocartilage complex TFCC attaching to the fovea at the base of the styloid process. DRUJ injury can be isolated rare , or associated with other fractures. The classic is the Galeazzi fracture dislocation, but DRUJ injuries occur in association with fractures of both forearm bones and distal radial fractures. The most helpful radiograph is a true lateral of the...
Thoracolumbar spine implants posterior devices
Posterior 'tension band' stabilization may be achieved with sublaminar wires, screws and hooks, secured to posterior metal rods or rectangles. Hook-and-rod constructs are best suited to the thoracic spine, whereas pedicle screw-and-rod systems are favoured in the lower thoracic and lumbar spine. Rod systems may be classified as distraction, segmental or pedicle screw systems. 1. Distraction systems Harrington . This system relies on three-point bending for mechanical fixation. Hooks secure the...
Odontoid peg fractures
Peg fractures have been classified by Anderson and D'Alonzo Figure 1 . Type 1 fractures are at the tip, above the transverse ligament, and are caused by alar ligament avulsion. These fractures are stable and treated in a collar or brace. Type 2 fractures are level with the body of the axis, which is a watershed for the blood supply. Non-union rates of 67 have been reported. The risk of nonunion increases with displacement of gt 4 mm, angulation of gt 10 , in patients who smoke and those over 40...
Amputation
Traumatic amputation accounts for 11 of all amputations, and in the under 50s the figure approaches 50 . The decision to amputate is difficult. The limb must be considered both in the context of the patient's acute condition and long-term health. Economic, social and psychological factors should be assessed, ideally involving the patient in the decision-making process. Independent orthopaedic and plastic surgical opinions on the feasibility of limb salvage are helpful. Prognostic factors...
ATLS concept
ATLS started in Nebraska, North America, after an orthopaedic surgeon crashed his plane, injuring his family. He found the delivery of emergency care to be inadequate. The aim of ATLS and resuscitation is to treat reversible, potentially life-threatening injuries, which become evident during the first 'golden' hour after trauma. ATLS provides a simple, structured system for the rapid assessment, treatment, re-evaluation, stabilization and possible transfer of the critically injured, enabling a...
Traumatic spondylolisthesis of the axis
This injury is caused by hyperextension and axial loading. Typically these injuries widen the spinal canal and therefore rarely produce neurological damage. The traditional 'Hangman's fracture' extension in association with distraction is seldom seen today. Spondylolisthesis of the axis was classified by Effendi and later modified by Levine Type I a stable injury with lt 3 mm displacement, treated in a collar for 6 weeks. Type II an unstable injury, with gt 3 mm C2 3 displacement and...
Avulsion injuries and rupture
Avulsion injuries can occur at the attachment of the Quadriceps tendon to the superior pole of the patella. Patellar tendon to the inferior pole of the patella. Patellar tendon to the tibial tubercle. 1. Quadriceps tendon avulsion is three times as common as patellar tendon avulsion. These injuries result from forced contraction of the extensor mechanism, with the foot planted on the floor. Injuries to the quadriceps tendon are more common in elderly patients, sometimes with chronic illnesses,...
Primary survey
1. Airway and cervical spine protection means rapidly assessing and securing a patent airway, while stabilizing a presumed cervical spine injury. The airway may respond to removal of debris, vomit and secretions alone, or elevation of the soft tissues of the palate with a chin lift or jaw thrust. A nasopharyngeal or oropharyngeal airway, or establishment of a definitive airway by endotracheal intubation, may be required. Oxygen should be delivered with a flow of 10-121 min. Protection of the...
Fracture classifications
1. AO classification. This is alphanumeric, ascribing a code specific to every fracture with increasing complexity, which identifies the anatomical location Figure 1 , type, group and subgroup of the fracture. Fracture location is identified by the first two numbers. The first number refers to the bone involved 1, humerus 2, radius and ulna 3, femur 4, tibia and fibula 5, spine 6, pelvis 7, wrist and hand 8, foot. The second number refers to the bone segment 1, proximal metaphyseal 2,...
Further reading Agl
Ingman AM, Waters DA. Locked intramedullary nailing of humeral shaft fractures. Implant design, surgical technique and clinical results. Journal of Bone and Joint Surgery, 1994 76B 23-29. Rosen H. The treatment of non-unions and pseudarthroses of the humeral shaft. Orthopedic Clinics of North America, 1990 21 725-742. Sarmiento A, Horowitch A, Aboulafia A et al. Functional bracing for comminuted extra-articular fractures of the distal-third of the humerus. Journal of Bone and Joint Surgery,...
Rockwood Classification
Tossy classified injury of the ACJ into three types. This has been increased to six by Rockwood Figure 1 . Of these six types, 98 are type I, II or III Table 1 . Controversies regarding operative or non-operative management centre around type III which make up 40 of all ACJ injuries. Conjoined tendon of Biceps and Coracobrachial Figure 1. Rockwood's classification of acromioclavicular joint injuries. Reprinted from Rockwood C.A., Williams G.R., Young D.C. Injuries to the acromioclavicular...
Leffert Classification
Brachial plexus injuries are classified according to the aetiology and level of the lesion. The Leffert classification Table 1 considers brachial plexus lesions in four types. Iatrogenic and tumour-related lesions can be added to this classification. Closed traction injuries account for gt 75 of lesions. Lesions may be at more than one level. Table 1. Leffert classification of brachial plexus injuries Preganglionic - nerve root avulsion Postganglionic - traction injuries IIB Infraclavicular...
Peripheral Nerve Injuries And Repair
Each peripheral nerve contains many nerve fascicles. The fascicles and intervening connective tissue are bound by a sheath of epineurium. Fascicles contain many individual nerve fibres surrounded by perineurium. A nerve fibre consists of an axon with a Schwann cell covering, bound by endoneurium. Nerve fibres may be myelinated A and B or unmyelinated C . The myelin sheath is produced by the Schwann cell. Sequential' Schwann cells surround myelinated fibres, separated at the nodes of Ranvier....
PIPJ injury
Dorsal, volar, rotatory and lateral dislocations of the PIPJ occur. 1. Dorsal dislocation is caused by hyperextension, typically in a sporting accident. The major structure injured is the volar plate, which may be avulsed with a fragment of bone visible on a lateral X-ray. Treatment is mobilization with neighbour strapping for 3 to 6 weeks. Neighbour strapping prevents hyperextension. Left untreated, the PIPJ can hyperextend and a swan-neck deformity develops. Rarely the volar plate or flexor...
Shoulder Scapular Fractures
Scapular fractures are in themselves a rarity lt 1 of all fractures , but are often associated with other bony or soft tissue injuries to the shoulder girdle, neck or thoracic cage. The mean patient age is 35 to 45 years motor car accidents account for 50 of all scapular fractures and motor cycle accidents 20 . Major trauma is required to fracture the scapula, so other injuries and complications are common 50 to 90 of cases . Desault 1805 , was most probably one of the first surgeons to...
Lunate
Acute lunate fractures are a rarer cause of presentation than Kienbock's disease, but the relationship between the two is unclear. The blood supply is from both the dorsal and palmar aspects. Fractures can be of the dorsal horn, volar horn, or body. Fractures of the body are most frequently transverse. Diagnosis and treatment Acute diagnosis can be difficult, as the fracture may not be visible on plain X-ray. Bone scintigraphy, tomography, MRI or CT can confirm the diagnosis, if the clinical...