++
To properly reduce any displaced fracture, the following steps must be taken (see FIG. 133.6A).6
++
++
Disimpact the fragments, usually by increasing the deformity.
Re-establish the correct length of the bone.
Re-establish the correct alignment by proper reduction of the fracture.
Stabilise the bone in an acceptable position for as long as it takes to heal.
++
The above steps will only be achieved with adequate anaesthesia, analgesia and relaxation. Maintenance of the reduction depends upon the moulding, which utilises the intact periosteal bridge to hold the fracture fragments in a reduced position. FIGURE 133.6B illustrates the principle of moulding to maintain reduction.6
++
Orthopaedic problems that cause difficulties in diagnosis and management are outlined in TABLE 133.1.
++
+++
Fractures of the clavicle
++
This fracture typically follows a history of a fall onto the outstretched hand or elbow, although it may also occur with a direct blow to the clavicle or the point of the shoulder. The patient has pain aggravated by shoulder movement and usually supports the arm at the elbow and clasped to the chest. The most common fracture site is at the junction of the outer and middle thirds, or in the middle third. Consider the possibility of neurovascular injury.
++
St John’s elevated sling to support arm—for 3 weeks
Figure-of-eight bandage (used mainly for severe discomfort)
Early active exercises to elbow, wrist and fingers
Active shoulder movements as early as possible
++
Type II fracture at the lateral end of the clavicle that is displaced: this fracture, which usually occurs in elderly patients following low energy injuries,8 is often subject to delayed or non-union. The line of fracture passes through the conoid and trapezoid ligaments. Consider referral for open reduction.
++
Healing time is 4–8 weeks.
++
The appropriate use of slings for fracture-dislocations is presented in TABLE 133.2.
++
+++
Fractures of the scapula
++
Fractures of the scapula may include:
++
body of scapula: due to a crushing force, considerable blood loss, may be rib fractures
neck of scapula (may involve joint)
acromion process (due to a blow or fall on the shoulder)
coracoid process (due to a blow or fall on the shoulder)
++
Broad-based triangular sling for comfort
Early active exercises for shoulder, elbow and fingers as soon as tolerable
A large glenoid fragment usually requires surgical reduction because of potential glenohumeral joint instability
++
Healing takes several weeks to months.
+++
DISLOCATIONS OF THE SHOULDER AND CLAVICLE
++
+++
Acromioclavicular joint dislocation/subluxation
++
A fall on the shoulder, elbow or outstretched arm can cause varying degrees of separation of the acromioclavicular (AC) joint, causing the lateral end of the clavicle to be displaced upwards (see FIG. 133.7).
++
++
Grades I, II: partial separation, involving tearing of the AC capsule and ligaments
Grade III: complete tearing, also affecting the coracoclavicular ligaments
++
Analgesics
St John’s high sling (suitable for all injuries)
Mobilisation exercises as soon as possible
For Grade III, a compression bandage (or long straps of adhesive low-stretch strapping) with padding at pressure points—elbows, clavicle and coracoid. The clavicle should be manipulated into its correct position and the forearm elevated: applying pressure from above (clavicle) and below (elbow) to achieve compression, apply a bandage over the outer end of the clavicle and round the elbow joint, which is flexed to 90°. The bandage or strapping is worn for 2–3 weeks.8 Many patients are unable to tolerate this method of treatment. Skin irritation or blisters are common. This occurs particularly with adhesive strapping and the deformity commonly requires correction after the removal of the bandage or strapping. The same effect may be achieved with an orthotic device known as a Kenny-Howard sling or brace.
The issue of internal fixation versus conservative treatment for a complete dislocation is controversial in that the bulk of patients treated conservatively have minimal residual symptoms. However, a significant minority have residual symptoms in the form of AC joint pain and traction effects on the brachial plexus due to loss of scapular suspension. The patients most likely to have these symptoms are those with high grades of separation, involvement of the dominant shoulder and participation in employment or sports that place heavy physical demands on the shoulder girdle. If there is disruption of the suspensory ligaments of the clavicle, surgical reduction and stabilisation is the preferred option.8 If in doubt, refer within the first few weeks of injury for consideration of the pros and cons of conservative versus surgical treatment.
+++
Sternoclavicular joint dislocation/subluxation
++
This uncommon injury is caused by a fall or very heavy impact on the shoulder, causing the medial end of the clavicle to move forwards or anterior (making it prominent) or backwards.9 Plain X-rays are difficult to interpret and a CT scan is the ideal diagnostic method.
++
A special problem is backward (inward) displacement of the clavicular end with danger to major blood vessels and the trachea. This is one of the few potentially life-threatening orthopaedic injuries. Urgent referral for reduction is essential, especially if stridor or venous obstruction is present. A first aid measure is to place a sandbag between the shoulders with the patient supine and to extend the abducted arm on the affected side.10 Closed reduction can usually be achieved under anaesthesia. The reduction is nearly always stable.
++
Forward subluxation or dislocation, unlike posterior dislocation, is nearly always unstable and resists attempts at maintaining closed reduction. Despite the persistence of a medial clavicular swelling, most patients need a sling for only 1–2 weeks and the bulk of their pain settles over the following months. Surgery is generally indicated only for an unusually painful and chronic anterior sternoclavicular dislocation.
+++
Dislocation of the shoulder
++
Dislocations of the shoulder joint can be caused by an impact on the arm by falling directly on the outer aspect of the shoulder, or by a direct violent impact, or by a forceful wrenching of the arm outwards and backwards.
++
Anterior (forward and downward)—95% of dislocations
Posterior (backward)—diagnosis often overlooked
Recurrent anterior dislocation (recurrent posterior dislocation extremely rare)
+++
Anterior dislocation of the shoulder
++
AP and lateral X-rays should be undertaken to check the position and exclude an associated fracture. The arm should be assessed for the presence of neurological injury before reduction. Reduction can be achieved under general anaesthesia (easier and more comfortable) or with intravenous morphine ± diazepam/midazolam. A variety of methods can be used for anterior dislocation; two are described below. Satisfactory analgesia and patient relaxation are vital to the success of any of the methods.
++
++
++
Elbow flexed to 90° and held close to the body
Slowly rotate arm laterally (externally)
Adduct humerus across the body by carrying point of elbow while simultaneously applying longitudinal traction along the line of the humerus
Rotate arm medially (internally)
++
Apply traction to the outstretched arm by a hold on the hand with countertraction from stockinged foot in the medial wall of the axilla. This levers the head of the humerus back. It is a good method if there is an associated avulsion fracture of the greater tuberosity.
++
Reduction is complete if the hand can rest comfortably on the opposite shoulder.
Confirm reduction by X-ray in two planes and again assess for unsuspected fractures (e.g. glenoid rim or greater tuberosity fractures).
Keep the arm in a sling for 2 weeks.
Apply a swathe bandage to the chest wall.
After immobilisation, begin pendulum and circumduction exercises.
Combined abduction and lateral rotation should be avoided for 3 weeks.
+++
Posterior dislocation of the shoulder
++
This is the most commonly misdiagnosed major joint dislocation.7 Posterior dislocation most often follows an epileptic seizure or electrical shock. The postictal patient with a painful shoulder has a posterior dislocation of the shoulder until proven otherwise. Less often this injury is caused by a fall onto the outstretched hand with the arm internally rotated or by a direct blow to the front of the shoulder. If any doubt persists about the diagnosis, a CT scan is appropriate.
++
The shoulder contour may look normal, but the major clinical sign is painful restriction of external rotation, which is usually completely blocked. Beware of the problem of pain in the shoulder after a convulsion. An ‘axillary shoot through’ X-ray view should be routinely ordered following shoulder trauma.
+++
Reduction of posterior dislocation
++
Using appropriate analgesia or anaesthesia, apply traction to the shoulder in 90° of abduction (with the elbow at right angles) and laterally (externally) rotate the limb. Referral for reduction is advisable.
+++
Recurrent anterior dislocation
++
Acute anterior shoulder dislocation may tear or stretch the anterior capsular ligaments from their bony origin. This may predispose to recurrent anterior dislocation or subluxation. (Recurrent posterior instability is rare.)
++
A simple procedure for reducing recurrent anterior dislocation is as follows.
++
Get the patient to sit comfortably on a chair with legs crossed.
The patient then interlocks hands and elevates the upper knee so that the hands grip the knee.
The knee is gradually lowered until its full weight is taken by the hands. At the same time the patient has to concentrate on relaxing the muscles of the shoulder girdle. This method usually effects reduction without the use of force.
++
Recurrent dislocation often requires definitive surgery, depending on the frequency of dislocations and the degree of apprehension between episodes.
++
Teenagers and young adults who sustain a traumatic dislocation of the shoulders tend to have the Bankart lesion, which is avulsion of the anteroinferior capsulolabral complex, leading to a high rate of recurrent dislocation. This should be considered for an arthroscopic anterior stabilisation.
++
Nerve injury, especially axillary (circumflex) nerve
A fractured neck of the humerus, especially in the elderly, may mimic a dislocation
Associated fractures (greater tuberosity, head of radius, glenoid) may require internal fixation
Great difficulty with some reductions (this is often related to inadequate analgesia; the use of excessive force may result in fracture)
Failing to X-ray all suspected dislocations before and after reduction; failing to obtain an axillary view to show posterior displacement or fractures of the humerus or glenoid
+++
FRACTURES OF THE HUMERUS
++
+++
Fractured greater tuberosity of humerus
++
Treat with a combination of immediate mobilisation and rest in a sling unless grossly displaced, when surgical reduction is advisable. Shoulder stiffness can be a disabling problem, so early movement is encouraged, with review in 7 days. This fracture should be monitored by X-ray within 2 weeks after injury. Undetected displacement may lead to mechanical impingement against the acromion. This fracture may also be an indication of the patient having had a transient glenohumeral dislocation.
+++
Fractured surgical neck of humerus
++
This usually occurs in the elderly due to a fall onto the outstretched hand. The fragments may be impacted. The greater tuberosity may also be fractured. Watch out for associated dislocation. In adolescents, fracture–separation of the upper humeral epiphysis occurs.
+++
Treatment (no displacement or impaction)
++
Triangular sling
When pain subsides (10–14 days), encourage pendulum exercises in the sling
Aim for full activity within 8–12 weeks post-injury
++
Displaced fractures may require internal fixation. Severely comminuted fractures may predispose to post-traumatic osteoarthritis or humeral head avascular necrosis. Consider referral with a view to prosthetic hemiarthroplasty.
++
Union usually occurs in 4 weeks and consolidation at 6 weeks.
+++
Pitfalls with fractures of the surgical neck
++
Minimally displaced fractures of the surgical neck of the humerus are usually managed conservatively, but overzealous early mobilisation can lead to non-union.10 If there is a communication of this fracture with joint fluid, movement washes away the fracture haematoma and leads to the development of true pseudoarthrosis. Judicious early immobilisation will avert this complication.
++
The cardinal fracture management rule is: ‘First ensure that stability of the fracture is sufficient to allow healing before prescribing rehabilitation exercises or early use of the extremity’.7 However, prolonged immobility can cause its own problems. Hand and elbow exercises should commence early, and gentle shoulder ‘pot stirring’ at around 2–3 weeks.
++
The management of various humeral fractures is summarised in FIGURE 133.9.
++
+++
Fracture of shaft of humerus
++
Humeral shaft fractures may be:
++
spiral—due to a fall on the hand
transverse or slightly oblique—fall on elbow with arm abducted
comminuted—heavy blow
Caution: watch for radial nerve palsy.
++
Perfect bony opposition is not necessary; some overriding is acceptable but distraction of the fragments is not.
Undisplaced fracture: collar and cuff with elbow flexed to 110–120°.
Significantly displaced humeral shaft fractures may require manipulation under anaesthetic. However, the vast majority of shaft fractures realign to a satisfactory extent under gravitational effects in a sling once muscle spasm and oedema have subsided. A U-shaped hanging cast or slab enhances the gravitational effect and assists splintage.
+++
Intercondylar fractures in adults
++
Intercondylar fractures, which may be T-shaped or Y-shaped, are usually caused by a fall on the point of the elbow, which drives the olecranon process upwards, splitting the condyles apart. Fractures involving the joint can cause long-term problems of post-traumatic osteoarthritis and joint stiffness. Referral for reduction (closed or open) is appropriate.
+++
INJURIES OF THE ELBOW AND FOREARM
++
+++
Fractures and avulsion injuries around the elbow joint in children
++
Potentially severe deforming injuries include:
++
supracondylar fractures
fracture of the lateral humeral condyle
fracture of medial humeral epicondyle (see FIG. 133.10)
fracture of neck of radius
++
++
Fractures around the elbow in children require referral to consultants experienced in radiology and fracture management.
+++
Supracondylar fractures with forearm ischaemia
++
Supracondylar fractures represent about half of all elbow fractures in children and most are extension fractures following falls onto the outstretched arm.
++
Pressure of the displaced bony fragments causes impingement on the brachial artery, which can lead to impending forearm flexor compartment ischaemia and muscle death. Severe forearm pain is the most significant and important sign of ischaemia. Neuropraxia of the median, radial or ulnar nerves is common. These injuries almost invariably recover.
++
This diagnosis must always be assumed in displaced supracondylar fractures in children. Thus, it is the GP’s responsibility to ensure treatment is expedited. The brachial and radial pulses should be assessed carefully.
++
The fracture is reduced by hyperflexion of the elbow during traction (after lateral displacement has been corrected), and then immobilisation in collar and cuff and stockinet vest. The fully flexed elbow with the usually intact posterior periosteal hinge provides fracture stability. Plaster casting is unnecessary and some would suggest contraindicated because of the significant risk of ischaemic contracture. Circulatory status requires monitoring in the first 24 hours following injury. The collar and cuff should be used for 6 weeks. The invariably stiff elbow quickly resolves without a need for formal therapy.
+++
Fracture of the lateral humeral condyle
++
Fractures of the lateral humeral condyle also result from a fall onto the outstretched arm in children (see FIG. 133.10). The fracture line passes vertically or obliquely through the lateral condyle and thus crosses the distal humeral growth plate. It occurs in an age group prior to the appearance of the epiphysis of the lateral epicondyle. Pain and swelling over the lateral elbow, but without the gross deformity of a supracondylar fracture of the humerus, could make one suspect this injury. The fracture is commonly overlooked on X-ray. Comparison views of the opposite elbow are particularly helpful in diagnosing this injury.
++
Recognition of the fracture and early open reduction and internal fixation with wires are vital to reduce the risk of premature plate closure. Such growth plate disturbance may result in a progressive valgus deformity of the elbow and the late development of an ulnar nerve palsy.
++
The Salter–Harris classification of epiphyseal injuries (FIG. 133.11), which is widely used, has therapeutic and prognostic implications. Most of these injuries heal well but some have the potential for growth arrest or asymmetrical bone growth, leading to deformity and permanent disability, especially type V. Types I and II (the most common) have an excellent prognosis but type III and IV require precise reduction.11
++
+++
Fracture of the medial humeral epicondyle
++
This problem occurs typically in adolescents following a fall onto the outstretched hand. The medial epicondyle may be avulsed by massive flexor pronator muscle contraction together with abduction stresses on the forearm. Avulsion of the epicondyle occurs in the young patient before the epiphysis is united. If displaced, this fracture is best treated by open reduction and internal fixation. Untreated injuries commonly result in non-union, elbow pain and restricted elbow extension.
+++
Fractured neck of radius
++
This fracture is caused by a child falling on to the outstretched hand. The fracture line is transverse and is situated immediately distal to the epiphysis.
++
The degree of tilt is critical. Up to 15° of tilt is acceptable but, beyond that, reduction (preferably closed) will be necessary. The head of the radius must never be excised in children.
++
A dislocated elbow is caused by a fall onto the outstretched hand, forcing the forearm backwards to result in posterior and lateral displacement (see FIGS 133.12 and 133.13). The peripheral pulses and sensation in the hand must be assessed carefully. It may result in vascular injury to the brachial artery or injury to the median and ulnar nerves. Check the function of the ulnar nerve before and after reduction.
++
++
++
Attempt reduction with patient fully relaxed under anaesthesia. It is important to apply traction to the flexed elbow while allowing it to extend (to approximately 20–30° of flexion) to enable correction of the lateral displacement and then the posterior displacement.
++
Encourage early mobilisation with gentle exercises in between resting the elbow for 2–3 weeks in a collar and cuff with the elbow flexed above 90°, avoiding passive movements. A plaster cast should not be used because of the risk of ischaemic necrosis of muscle. This will minimise the possibility of myositis ossificans. Recurrent dislocation of the elbow is uncommon.
+++
A simple method of reduction
++
This method reduces an uncomplicated posterior dislocation of the elbow without the need for anaesthesia or an assistant. The manipulation must be gentle and without sudden movement.
++
The patient lies prone on a stretcher or couch, with the forearm dangling towards the floor.
Grasp the wrist and slowly apply traction in the direction of the long axis of the forearm (see FIG. 133.14).
When the muscles feel relaxed (this might take several minutes), use the thumb and index finger of the other hand to grasp the olecranon and guide it to a reduced position, correcting any lateral shift.
++
++
Incomplete reduction: ulna articulates with capitellum and not the trochlea
Injury to ulnar nerve (spontaneous recovery usually occurs after 6–8 weeks)
Associated fractures (e.g. coronoid process), which may cause instability
++
+++
Fractured head of radius (adults)
++
If the fracture is very slight and undisplaced, treat conservatively with the elbow at right angles in a collar and cuff until the pain subsides sufficiently to allow flexion/extension and pronation/supination exercises.
++
Elbow stiffness is a major problem even after apparently trivial radial head fractures. Early mobilisation is vital. Excision of the radial head should be considered for highly comminuted fractures that limit the ability to mobilise the elbow early or predispose to post-traumatic osteoarthritis. Associated distal radio-ulnar joint or wrist injuries are often overlooked.
++
+++
Monteggia fracture–dislocation of the radial head
++
Fractures of the proximal third of the ulna with dislocation of the radial head (Monteggia fracture–dislocation) (see FIG. 133.15) have a history of mismanagement during treatment. The radial head dislocation is easily overlooked.
++
++
Redislocation or subluxation of the radial head is common.
++
Since surgical intervention is advisable, referral of displaced forearm fractures for early surgery is recommended. Surgical plating of the ulnar shaft maintains the radial head in a reduced position. Follow-up X-rays are mandatory to ensure that there has not been a late redislocation of the radial head.
+++
Fracture–dislocation in the lower forearm (Galeazzi injury)
++
This injury is usually caused by a fall on to the hand and is a combination of a fractured radius (at the junction of its middle and distal thirds) and subluxation of the distal radio-ulnar joint. The patient should be referred, as open reduction is often required.
+++
Fractures of the radius and ulna shafts
++
In adults, it is more common to break both forearm bones. Displaced fractures of both bones require perfect reduction, which can generally only be achieved by surgical reduction and plating. Less-than-satisfactory reduction interferes with normal pronation and supination. A fracture of one bone alone is uncommon and usually caused by a direct blow. For a fracture of one bone alone, look for evidence of an associated dislocation of the other forearm bone. In children, greenstick fractures are common. Fractured radial shafts tend to slip and ulnar fractures heal slowly. Dislocation of the head of the radius or inferior radio-ulnar joint can be missed if X-rays do not include the elbows and wrist joints. The rule is to X-ray the joints above and below any injury.
++
A greenstick fracture is readily straightened by firm pressure.
A complete fracture (spiral or transverse) is reduced by traction and rotation.
A slight overlap and angulation is permissible in children, but perfect reduction is essential in adults.
A plaster cast should include both the elbow and the wrist joints.
++
Healing time: (adults) spiral fracture—6 weeks; transverse fracture—12 weeks.
+++
INJURIES OF THE WRIST
++
+++
Colles fracture of lower end of radius
++
Colles fractures rival clavicular in being the most common of all fractures. A Colles is a supination fracture of the distal 3 cm of the radius, caused by a fall onto the outstretched hand.
++
Usually an elderly woman
Osteoporosis is common
Fall on dorsiflexed hand
Fracture features:
– impaction
– posterior displacement and angulation
– lateral displacement and angulation
– supination
– dinner fork deformity (see FIG. 133.16)
++
++
If minimal displacement—below-elbow plaster for 4 weeks, then a crepe bandage
If displaced: meticulous reduction under anaesthesia:
– set in flexion 10°, ulnar deviation 10° and pronation (see FIG. 133.17)
– below-elbow plaster 4–6 weeks (6 weeks maximum time)
– unstable fractures may require an above-elbow cast initially with the forearm in pronation
– check X-ray at 10–14 days; position may be lost as swelling subsides and plaster becomes loose
++
++
Problems associated with Colles fracture:
++
watch for ruptured extensor pollicus longus tendon
stiffness of the elbow, MCP joints and IP joints
discomfort at inferior radio-ulnar joint due to disruption
regional pain syndrome
+++
Pitfall: the unstable Colles fracture7
++
With the advent of modern imaging techniques and power equipment it has become a simple procedure to pin unstable Colles fractures percutaneously, even in the elderly. Thus, severe deformities are now unacceptable. An early percutaneous pin is much simpler than a late osteotomy. Colles fractures deserve more respect than they received in the past.
++
Remember the basic classification into intra-articular and extra-articular fractures. Restoring reasonable joint surface alignment is an important part of the treatment and fortunately is usually relieved with simple traction under local or general anaesthesia.
+++
Smith fracture of lower end of radius
++
This is often referred to as a ‘reverse Colles’. It is caused by a fall onto the back of the hand. The lower fragment is flexed and impacted on the upper fragment. It is reduced and immobilised for 6 weeks in a cast as for Colles fracture but with the wrist extended. Unstable fractures may require an above-elbow cast initially with the forearm in supination.
+++
Ulna styloid fracture
++
Treat symptomatically. Delayed union or non-union is common, but rarely symptomatic.
+++
Radial styloid fracture
++
Undisplaced: plaster slab for 3 weeks.
++
Displaced: closed reduction and plaster slab for 6 weeks. If this fails—open reduction.
++
Scaphoid fractures account for almost 75% of all carpal fractures (see FIG. 133.18), but are rare in children and the elderly.11 A scaphoid fracture is caused typically by a fall onto the outstretched hand.
++
++
Pain on lateral aspect of wrist
Tenderness in the anatomical snuffbox (the key sign)
Swelling in and around the snuffbox
Pain or clicking on movement of the wrist
Pain on axial compression of the thumb towards the radius
++
There is a 20% rate of false positive reporting of scaphoid radiographs and clinical confirmation of the diagnosis is mandatory.12
++
If a scaphoid fracture is highly suspected in the presence of a normal X-ray of wrist, immobilise the wrist in a scaphoid plaster for 10 days (ensure 1st MCP joint is immobilised), remove it and then re-X-ray. Isotopic bone scan may be indicated in cases where suspicion of fracture is high despite normal X-rays. For undisplaced and stable fractures, 6–8 weeks in a below-elbow scaphoid cast usually suffices (see FIG. 133.19). Displaced fractures of the scaphoid require reduction (either open or closed) and, if unstable, internal fixation.
++
++
All scaphoid fractures require late X-ray evaluation of treatment to diagnose non-union before they become symptomatic from late degenerative changes. Early bone grafting of a non-union can prevent fragment collapse and radioscaphoid degenerative changes.
++
The fracture may not be apparent on routine wrist X-rays. Request lateral, antero-posterior and specific scaphoid views.
+++
Scapholunate dissociation
++
This not uncommon carpal injury results from disruption of the scapholunate interosseous ligament and palmar radiocarpal ligaments. It results in a gap appearing between the scaphoid and lunate bones (the so-called ‘Terry Thomas’ sign on plain AP X-rays of the wrist) and the scaphoid rotating into a vertical position on lateral X-rays. It is associated with pain in the wrist on dorsiflexion. Median nerve compression may occur after wrist or carpal dislocations.
++
Early diagnosis with referral simplifies treatment. This injury has been recognised only in recent times.
++
The management of hand fractures is all about restoring function. A single stiff or deformed joint can have a lifelong impact on hand function.
++
The thumb’s special function renders injuries more difficult than other digits. Fractures well clear of the joints in the proximal and distal phalanges are treated in a similar way to other digits. However, intra-articular injuries are more common and internal fixation is more likely on the thumb than other digits.13
++
This is a fracture–dislocation of the first carpometacarpal joint. The larger fragment of the first metacarpal dislocates proximally and laterally (see FIG. 133.20).
++
++
Under anaesthesia, the thumb is reduced using the forces indicated (see FIG. 133.20). A scaphoid plaster is applied with the thumb in the open grasp position. If anatomical reduction cannot be achieved by closed means, then open reduction and internal fixation is indicated. Percutaneous pinning with wires under X-ray control is also commonly used to hold an anatomical reduction.
+++
Gamekeeper’s (or skier’s) thumb
++
This problematic injury of the metacarpophalangeal joint is presented in more detail in CHAPTER 64.
++
Metacarpal fractures can be stable or unstable, intra-articular or extra-articular, and closed or open. They include the ‘knuckle’ injuries resulting from a punch, which is prone to cause a fracture of the neck of the fourth and fifth metacarpal. As a general rule, most metacarpal (shaft and neck) fractures are treated by correcting marked displacements with manipulation (under anaesthesia) and splinting with a below-elbow, padded posterior plaster slab that extends up to the dorsum of the proximal phalanx and holds the metacarpophalangeal joints in a position of function (see FIG. 133.21).
++
++
There is often a tendency for metacarpal fractures to rotate and this must be prevented. This is best achieved by splinting the metacarpophalangeal joints at 90°, which corrects any tendency to malrotation. If there is gross displacement, shortening or rotation then surgical intervention is indicated. A felt pad acts as a suitable grip. The patient should exercise the free fingers vigorously. Remove the splint after 3 weeks and start active mobilisation.
++
These fractures result from either direct trauma causing a transverse or a comminuted fracture, or a torsional force causing an oblique fracture. The tendency to regard fractures of phalanges (especially middle and proximal phalanges) as minor injuries (with scant attention paid to management and particularly to follow-up care) is worth highlighting. These fractures require as near-perfect reduction as possible, careful splintage and, above all, early mobilisation once the fracture is stable—usually in 2–3 weeks.
++
Nevertheless, overzealous mobilisation can be as dangerous as prolonged immobilisation. Early operative intervention should be considered if the fracture is unstable.
++
Angulation is usually obvious but it is most important to check for rotational malalignment, especially with torsional fracture. A simple method is to get the patient to make a fist of the hand and check the direction in which the nails are facing. Furthermore, each finger can be flexed in turn and checked to see if the fingertips point towards the tubercule of the scaphoid (palpable halfway along the base of the thenar eminence and 1.5 cm distal to the distal wrist crease).
++
Distal phalanges: usually crush fractures; generally heal simply unless intra-articular. Disturbance of nail growth is common.
Middle phalanges: tend to be displaced and unstable—beware of rotation.
Proximal phalanges: of the greatest concern, especially of the little finger; intra-articular fractures usually need internal fixation.
++
Non-displaced phalanges with no rotational malalignment. Strap the injured finger to the adjacent normal finger with an elastic garter or adhesive tape for 2–3 weeks (i.e. ‘buddy strapping’) (see FIG. 133.22). Start the patient on active exercises.
++
++
++
If pain and swelling is a problem, splint the finger with a narrow dorsal or anterior slab (a felt-lined strip of malleable aluminium can be used).
++
An alternative is to bandage the hand while the patient holds a tennis ball or appropriate roll of bandage in order to maintain appropriate flexion of all interphalangeal joints.
++
Displaced phalangeal fractures (usually proximal and middle). With suitable anaesthesia, correct the deformity by traction and direct digital pressure. Maintain correction by splintage for 2–3 weeks. Ensure flexion at the interphalangeal joints with a dorsal padded plaster slab from above the wrist to the base of the fingernail (see FIG. 133.23).
++
+++
Intra-articular phalangeal fractures
++
Intra-articular phalangeal fractures are a great problem to manage as subsequent stiffness of even a single interphalangeal joint can be a significant disability. Subsequent degenerative changes are common.
++
These fractures often occur in association with subluxation or dislocation of the joint. Reduction and fixation of the fracture may be an integral part of restoring joint stability. Displaced intra-articular phalangeal fractures, especially with joint instability, require referral.
++
+++
Penetrating injuries to the hand
++
Assessing these injuries requires a careful history and examination. The pugilist who sustains a seemingly minor cut over a ‘knuckle’ may have a tooth-penetrating injury to the metacarpophalangeal joint. In the flexed position, the dorsal hood is drawn over the joint. The point of penetration of the hood retracts as the finger extends and ‘locks’ saliva into the joint. This injury invariably results in a severe septic arthritis unless aggressively treated with surgical debridement and high-dose antibiotics. Given the common occurrence of oral pathogens, antibiotic cover should include anaerobic organisms.
++
++
In most cases, the distal part dislocates dorsally.
++
For dislocated fingers, immediate reduction is advisable. Test for an associated fracture and X-ray if appropriate. General anaesthesia may be necessary for reduction of a dislocated thumb.
+++
Simple reduction of a dislocated interphalangeal joint
++
This method employs the principles of using the patient’s body weight as the distracting force to achieve reduction of the dislocation. It is relatively painless and very effective.
++
Face the patient, both in standing positions.
Firmly grasp the distal part of the dislocated finger. A better grip is achieved by wrapping simple adhesive tape around the end of the finger.
Ask the patient to lean backward, while maintaining the finger in the fixed position (see FIG. 133.24).
As the patient leans back, sudden, painless reduction should spontaneously occur. Otherwise under a ring block or sedation apply traction and push the proximal phalangeal head dorsally. Splint the joint for 3 weeks to allow soft-tissue healing.
++
++
Instability—torn collateral ligaments: unstable in lateral direction
Interposed volar plate—postreduction full flexion absent
Fractures of base of phalanx
Extensor mechanism rupture (e.g. buttonhole deformity at PIP joint or mallet finger deformity at DIP joint)
++
These problems may need surgical reduction.
+++
INJURIES TO THE PELVIS AND HIP
++
+++
Fractures of the pelvis
++
Fractures of the pelvic ring are either:
++
stable: a single fracture
unstable: a break at two sites or association with disruption of the symphysis pubis or sacroiliac articulation
++
++
symptomatic, especially analgesics
bed rest as pain symptoms dictate
attempt walking with an aid as soon as comfortable
++
Unstable fractures: these are usually serious with possible associated visceral damage or blood loss. Patients should be referred for expert help.
++
Femoral neck fractures include:
++
++
Subcapital fractures are usually treated by pinning. Greatly displaced subcapital fractures in the elderly have a high risk of femoral head avascular necrosis. Thus, prosthetic replacement of the femoral head may be considered as a primary option.
++
A trap can be the impacted subcapital fracture that may allow partial weight-bearing, thus making radiological investigation essential in elderly patients complaining of hip pain. The fracture may not be evident on plain X-rays. If suspicion of fracture is still high, a bone scan should be performed.
++
Beware of the teenage athlete who complains of hip pain after running. Exclude a slipped upper femoral epiphysis and then a stress fracture. A technetium-99m bone scan will detect the fracture. A stress fracture may displace without warning, posing a serious risk of femoral head avascular necrosis. Thus, stress fractures must be considered for prophylactic pinning.
++
A summary of the management of other femoral fractures is presented in FIGURE 133.25.
++
+++
Posterior dislocation of the hip
++
This causes a very painful shortened leg, which is held adducted, medially rotated and slightly flexed. Be careful of sciatic nerve damage. Early reduction within hours minimises the risk of avascular necrosis of the femoral head.
++
Adequate analgesia
X-rays to confirm diagnosis and exclude associated fracture
Reduction of the dislocated hip under relaxant anaesthesia
Follow-up X-ray to confirm reduction and exclude any fracture not visible on the first X-ray
Intra-articular bone fragments need to be excluded by CT scanning
++
Note: Femoral neurovascular injury may occur in the rare cases of anterior dislocation of the hip.
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INJURIES OF THE LOWER LIMBS
++
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Patella dislocation and subluxation
++
An acute dislocation needs to be reduced as a medical emergency.
++
The dislocated patella, which occurs mainly in children and young adults, especially girls, is always displaced laterally (see FIG. 133.26), often following a rotational and valgus force. The patient may feel the patella dislocate and it may sometimes reduce spontaneously. It may be associated with an osteochondral injury on the medial facet of the patella or the lateral femoral condyle. There is often a tense joint effusion, especially in the presence of an osteochondral fracture. Predisposing factors include valgus knees, a small mobile patella, a laterally placed tibial tuberosity, a shallow patellofemoral groove and ligamentous laxity. Immediate reduction can be attempted by gently flexing the hip to relax the quadriceps, placing the thumb under the lateral edge of the patella and pushing it medially as the knee is extended. This may be attempted without anaesthesia or by using morphine and intravenous diazepam as a relaxant.
++
++
X-rays with anteroposterior, lateral, skyline and intracondylar views should be taken to exclude an associated osteochondral fracture.
++
The usual RICE treatment should be given initially and crutches provided. Rest of the injured knee is achieved using a knee splint with the knee held in extension and crutches for 4 weeks.
++
Weight-bearing is permitted when the swelling has subsided and the patient is gradually taken off the crutches. Introduce quadriceps exercises with the knee in extension.
++
Patellar subluxation is when the patella is mobile and does not actually dislocate, but results in episodic pain and feelings of instability. Physiotherapy and appropriate splinting for sporting activities is helpful before surgical stabilisation is considered.
++
Recurrent dislocations/subluxations in young females (14–18 years) require surgery—combined tibial tubercle transfer with lateral release of the capsule. Immediate surgery in the acute phase is undertaken only in the presence of haemarthrosis with an osteochondral fracture.
+++
Fractures of the patella
++
Fractures without displacement: walking plaster cylinder 4 weeks
Displaced single transverse fracture: surgical reduction with Kirschner wires
Displaced and comminuted fracture: refer to consider patellectomy
+++
Fractures of both tibia and fibula
++
The nature and management of these fractures vary considerably. Some fractures are caused by blunt injuries, such as a blow from a motor car bumper, while twisting forces cause a spiral fracture of both bones at different levels. As a general rule, referral of patients to a specialist is necessary, especially where soft-tissue damage is significant. Management of fractures with minimal soft-tissue damage can be summarised thus:
++
no or minimal displacement: full-length cast as for isolated fracture of tibia
displacement: reduction under general anaesthesia, then application of cast as above (meticulous alignment essential)
period of immobilisation: adults 16 weeks, children 8 weeks
++
An isolated fracture of the fibula is usually due to stress or to a direct blow. The patient is generally able to stand and move the knee and ankle joints. However, most spiral fractures are associated with injuries of the ankle or knee. The ankle in particular should be examined and X-rayed.
++
Treatment is usually with analgesics to control the pain and no more than a crepe bandage or a walking stick is necessary. A below-knee walking plaster for about 3 weeks will help those with severe discomfort.
+++
Fracture of the tibial shaft
++
A fracture of the tibia alone is uncommon in adults but more common in children, due to a twisting injury. Reduction may not be necessary in some patients. Many can be reduced to a satisfactory position in the anaesthetised patient by letting the fractured leg hang over the edge of the table with the knee at a right angle.
++
A padded cast from the groin to the metatarsal necks is applied with the knee joint at 10° of flexion, and the ankle at a right angle. This should be maintained for 3–4 months.
++
Toddler’s fracture is a hairline spiral fracture of the tibia that is common in children aged 1–2 years. They may present with failure to weight-bear after minimal or no known trauma. The fracture may not be seen on X-ray. A backslab for 4 weeks may relieve discomfort.
+++
Fracture around the ankle
++
The ankle is one of the areas liable to fractures. The commonest mechanism is forceful inversion of the foot, which can cause fracture of the fibula on a level with the joint line and tearing of the lateral collateral ligament. Other injuries can also occur, such as fracture of the medial malleolus and tearing of the tibiofibular syndesmosis. At least three views on X-ray are needed: AP, lateral and a half oblique ‘mortise’ view.
++
Undisplaced, uncomplicated fractures are treated with a plaster cast from just below the knee to the toes for 6–8 weeks. The foot must be plantigrade (i.e. with the foot at 90° to the leg and neither in varus nor in valgus).11 Fractures treated in plaster need X-ray monitoring. Unsuspected displacement may occur as swelling subsides and the plaster loosens. Occult displacement of the fracture leading to mal-union will predispose to ankle osteoarthritis. Fractures that are displaced or cause instability of the ankle joint require surgery to achieve stability followed by a longer period of immobilisation.
+++
Ankle/talus/subtalar joint dislocations
++
These dislocations may result in vascular compromise. The stretched overlying skin may rapidly necrose. Refer early.10
+++
Stress fractures of the foot
++
Stress fractures of the navicular, calcaneus and metatarsal bones can be found in otherwise healthy people from the age of 7 onwards. Long-distance runners and high-performance athletes are also susceptible.
++
Localised pain during weight-bearing activity
Localised tenderness and swelling (not inevitable)
Plain X-rays are necessary but show no fracture in about 50% of cases;8 X-rays can be repeated in 2–3 weeks if a fracture is suspected
A nuclear bone scan may confirm the diagnosis
++
This hitherto unrecognised stress fracture has become apparent with the advent of CT scanning, which shows up the fracture better than nuclear scanning. It is seen in athletes involved with running sports and presents as poorly localised midfoot pain. Plain X-ray is usually normal. The fracture, like the scaphoid fracture, is difficult to manage since delayed union and non-union are common. Cast immobilisation for 8 weeks may avoid the need for an operation.
++
The second metatarsal is probably the most common site of all for stress fracture because it is invariably the largest metatarsal and absorbs a greater load than the others.
++
Rest is the basis of treatment
Resting the foot with crutches for 6 weeks provides optimal healing
Healing usually takes 6–8 weeks
Gradual resumption of activity
+++
Lisfranc joint injury (midfoot sprain)14
++
This is basically a dislocation of the tarsometatarsal joints of the foot. The spectrum ranges from partial strains with no displacement to complete tears with separation of the first and second metatarsal bones (FIG. 133.27). Causes range from low-energy compression and twisting to high-energy crush forces. Diagnosis is usually confirmed by weight-bearing plain X-rays. Treatment depends on the degree of stability. Surgical reduction and fixation is required if there is evidence of instability.
++
+++
Fractures of the toes
++
Most toe injuries are easy to treat but, like the fingers, the great and little toes demand special attention. Intra-articular injuries of the great toe (unless undisplaced) should be treated by internal fixation.
++
‘Buddy strapping’ can be used for many uncomplicated fractured phalanges of the toes, which tend to angulate and rotate more readily and are often harder to control than finger fractures. Strapping them to their adjacent toes on both sides simultaneously tends to counteract this problem.
++
Like the little finger, the little toe is injured by forceful abduction and if allowed to heal in that position may leave difficulties in wearing shoes.11
++
Approximate average immobilisation times for various fractures are given in TABLE 133.3.
++
++
Dislocations occur mainly at the metatarsophalangeal joint and are rare; they require special care because of the strong tendons crossing the joint. Perfect reduction of the dislocated great toe is essential and it should be supported by a below-knee plaster cast extending beyond the toes. Temporary internal fixation with a Kirschner wire or open ligamentous repair may be required.12