Chapter 133: Common fractures and dislocations

Common fractures and dislocations usually apply to the limbs, the shoulder girdle and the pelvic girdle and their management requires an early diagnosis to ensure optimum treatment and to prevent complications. Early diagnosis depends on the physician being vigilant and on having knowledge of the less common conditions so that a careful search for the diagnosis can be made.

The diagnosis is dependent on a good history followed by a careful examination, good-quality X-rays appropriate to the injury (e.g. stress view) and, if necessary, special investigations. The family doctor should develop the habit of looking at a patient’s X-rays. Such a back-up to the radiologist’s report can help avoid missed diagnoses.

The usual rule is: if in doubt, X-ray. However, in response to over-ordering of X-rays in many circumstances where a fracture is very unlikely, handy algorithms have been developed, such as the Ottawa Ankle and Knee rules and the Canadian C-spine Rule.¹

There are many pitfalls involved in managing fractures and dislocations. Many injuries, such as fractures of the arm and hand, may seem trivial but can lead to long-term disability. This chapter presents guidelines to help avoid these pitfalls.

This method describes the simple principle of applying axial compression for the clinical diagnosis of fractures of bones of the forearm and hand, but also applies to bones of the limbs.

Many fractures are obvious when applying the classic methods of diagnosis but it is sometimes more difficult if there is associated soft-tissue injury from a blow or if there is only a minor fracture such as a greenstick fracture of the distal radius.

A soft-tissue injury of the forearm will, like a fracture, show pain, tenderness, swelling and possibly loss of function. It will not, however, be painful if the bone is compressed axially—that is, in its long axis. Therefore, asking about pain while compressing the bone from end to end (avoiding any direct pressure on the traumatised area) is a useful way to highlight a fracture.

Walking is another method of applying axial compression; pain makes walking very difficult in the presence of a fracture in the weight-bearing axis or pelvis.

Method

1. Grasp the affected area both distally and proximally with your hands.

2. Compress along the long axis of the bones by pushing in both directions, so that the forces focus on the affected area (fracture site, see FIG. 133.1A). Alternatively, compression can be applied from the distal end with stabilising counterpressure applied proximally (see FIG. 133.1B).

3. The patient will accurately localise the pain at the fracture site.

Skull fractures

Closed fractures without any neurological symptoms do not require active intervention. Depressed fractures may require elevation of the depressed fragment. Compound fractures of the vault require careful evaluation and referral. Special care is required over the midline as manipulation (usually by elevation) of any depressed fragment can tear the sagittal sinus, causing profuse and fatal bleeding. Beware of the associated extradural or subdural haematoma (see CHAPTER 75).

Base of skull fractures

These fractures are difficult to diagnose on radiography but their presence is indicated by bleeding from the nose, throat or ears, or by ‘raccoon eyes’. CSF may be observed escaping, especially through the nose, if the dura is also torn.

Treatment of basal fractures is based on looking for and treating intracranial infection, and avoidance of excessive interference with the nose or ear; avoid packing and nasogastric tubes. There is no role for antibiotic prophylaxis as this does not reduce the risk of meningitis.⁴

Malar fracture

A fractured zygomaticomaxillary complex (malar) is a common body contact sports injury or injury resulting from a fight. See FIGURE 133.2.

Clinical features

• Swelling of cheek

• Circumocular haematoma

• Subconjunctival haemorrhage

• Palpable step in infraorbital margin

• Flat malar eminence when viewed from above

• Paraesthesia due to infraorbital nerve injury

• Loss of function (i.e. difficulty opening mouth)

Management

• Head injury assessment

• Exclude ‘blow-out’ fracture of the orbit

• Exclude ocular trauma:

  • – remove contact lenses if worn

  • – check visual acuity

  • – check for diplopia

  • – check for hyphaema

  • – check for retinal haemorrhage

• Persuade patient not to blow nose (can cause surgical emphysema)

• If fracture displaced, refer for reduction under general anaesthesia

Reduction methods

• Elevation by temporal or intraoral approach—healing can be expected in 3–4 weeks

• Some require interosseous wiring or plating or pinning

Fracture of mandible

A fracture of the mandible follows a blow to the jaw. The patient may have swelling (which can vary from virtually none to severe), pain, deformity, inability to chew, malalignment of the jaw and teeth and drooling of saliva. Intraoral examination is important as submucosal ecchymosis in the floor of the mouth is a pathognomonic sign.

A simple office test for a suspected fractured mandible is to ask patients to bite on a wooden tongue depressor (or similar firm object). Ask them to maintain the bite as you twist the spatula. If they have a fracture they cannot hang onto the spatula because of the pain.⁵

X-rays:

• AP views and lateral obliques

• an orthopantomogram provides a global view

First aid management

• Check the patient’s bite and airway

• Remove any free-floating tooth fragments and retain them

• Replace any avulsed or subluxed teeth in their sockets

  Note: Never discard teeth.

• First aid immobilisation with a four-tailed bandage, which can be made by splitting a bandage from both ends, leaving an intact central area to support the chin (see FIG. 133.3)

Treatment

Refer for possible internal fixation.

A fracture of the body of the mandible will usually heal in 6–12 weeks (depending on the nature of the fracture and fitness of the patient).

Dislocated jaw

The patient may present with unilateral or bilateral dislocation. The jaw will be ‘locked’ and the patient unable to articulate or close the mouth. It is very distressing.

Method of reduction

• Get the patient to sit upright with the head against the wall. Wear protective gloves, if available.

• Wrap a handkerchief or cloth around both thumbs and place the thumbs over the lower molar teeth, with the fingers firmly grasping the mandible on the outside.

• Firmly thrusting with the thumbs, push downwards towards the floor (see FIG. 133.4).

This action invariably reduces the dislocation, but the reduction can be reinforced by the fingers rotating the mandible upwards as the thumbs thrust downwards.

Cervical fractures, especially of the atlas (C1), axis (C2) and odontoid process, require early referral with the neck immobilised in a cervical collar, in a supine position. A hard collar is preferred, but a soft collar with sandbags on either side of the head to prevent movement will suffice.

Thoracolumbar fractures

Fractures or fracture dislocations of the thoracic and lumbar vertebrae, without neurological deficit, are classified as either stable or unstable. Due to the forces involved, these fractures often coexist with other injuries.

Stable fractures

• Compression fractures of vertebral body with <50% loss of vertical height

• Minor fractures

• Laminar fractures

Treatment: a custom-fitted back brace is worn, usually for 6–12 weeks, with physiotherapy involvement to restore function.

Special problems:

• retroperitoneal haematoma

• paralytic ileus

• associated kidney rupture with L1 fractures

• underlying vertebral body pathology in the elderly (e.g. myeloma or metastases)

Unstable fractures

Burst fractures and shearing fractures are usually unstable. They are often associated with partial or complete paraplegia and require urgent referral.

Fractures of sacrum and coccyx

No treatment apart from symptomatic treatment is required. Manual reduction per rectum can be attempted for significant forward displacement of the coccyx. Advise the use of a rubber ring or special cushion (such as a Sorbo cushion) when sitting. Consider excision of the coccyx for persistent discomfort.

Fractured rib

Clinical features

• Pain over the fracture site, especially with deep inspiration and coughing

• Localised tenderness and swelling

• Pain in the site upon whole-chest compression (rib springing)

• X-ray confirms diagnosis and excludes underlying lung damage (e.g. pneumothorax). There is a high incidence of false negative fractures on X-ray, so caution is necessary.

• Suspect splenic, hepatic and kidney trauma with lower rib fractures

Treatment

A simple rib fracture can be extremely painful. The first treatment strategy is to prescribe analgesics, such as paracetamol, and encourage breathing within the limits of pain. An intercostal nerve block is effective in the acute situation, but is very temporary. An elastic rib belt with Velcro fastening has often been used for single or double rib fractures, although the evidence for effectiveness is scanty (see FIG. 133.5).

Healing time

Healing may take 3–6 weeks; local discomfort may persist much longer.

Fractures of the sternum

These are treated symptomatically with analgesics but careful evaluation of thoracic injuries, including cardiac tamponade or myocardial contusion, is essential. A significantly depressed fracture should be referred. An ECG is advisable.

To properly reduce any displaced fracture, the following steps must be taken (see FIG. 133.6A).⁶

1. Disimpact the fragments, usually by increasing the deformity.

2. Re-establish the correct length of the bone.

3. Re-establish the correct alignment by proper reduction of the fracture.

4. 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.

Treatment

• 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

Special problem

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

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)

Treatment

• 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 time

Healing takes several weeks to months.

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

Treatment

• 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.

Special problem

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.

Treatment

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.

Types of dislocation

• 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

Management

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.

Kocher method

(See FIG. 133.8.)

• 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)

Hippocratic method

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.

Postreduction

• 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.

The Bankart lesion

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.

Pitfalls

• 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

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.

Healing

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.

Treatment

• 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.

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.

Dislocated elbow

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.

Treatment

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.

Follow-up

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.

Method

1. The patient lies prone on a stretcher or couch, with the forearm dangling towards the floor.

2. Grasp the wrist and slowly apply traction in the direction of the long axis of the forearm (see FIG. 133.14).

3. 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.

Pitfalls

• 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

‘Pulled’ elbow

See CHAPTER 64.

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.

Fractured olecranon

• Comminuted fracture (with little displacement): sling for 3 weeks and active movements

• Transverse (gap) fracture: open reduction with screw or wire

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

General features

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.

Reduction

• 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.

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.

Clinical features

• 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)

Treatment

• 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

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.

Features

• 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.

Pitfall

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.

Thumb fractures

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

Bennett fracture

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).

Treatment

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

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.

Phalangeal fractures

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).

The phalanges

• 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.

Treatment

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.

or

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.

Mallet finger

Refer to CHAPTER 64.

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.

Refer to CHAPTER 132.

Dislocated fingers

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.

Method

1. Face the patient, both in standing positions.

2. 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.

3. Ask the patient to lean backward, while maintaining the finger in the fixed position (see FIG. 133.24).

4. 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.

Pitfalls

• 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.

Fractures of the pelvis

Fractures of the pelvic ring are either:

1. stable: a single fracture

2. unstable: a break at two sites or association with disruption of the symphysis pubis or sacroiliac articulation

Treatment

Stable pelvic fracture:

• 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 fractures

Femoral neck fractures include:

• subcapital fractures

• intertrochanteric fractures

• stress fractures in the young

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.

Management

• 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.

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

Fracture of fibula¹¹

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 fracture¹¹

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.

Clinical features

• 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

Navicular

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.

Metatarsal bones

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.

Treatment

• 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.

Dislocation of toes

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

For the reduction of dislocations, analgesia and relaxation are appropriate. Resuscitation facilities and an experienced practitioner are required to handle this procedure. All drugs should be given intravenously and titrated to achieve the desired effect. Adverse effects include respiratory depression and hypotension.¹⁰ The choice of agents is presented in TABLE 133.4.

Plaster of Paris

The bucket of water

• Line the bucket with a plastic bag for easy cleaning.

• The water should be deep enough to allow complete vertical immersion.

• Use cold water for slow setting.

• Use tepid water for faster setting.

• Do not use hot water: it produces rapid-setting and brittle plaster.

The plaster rolls

• Do not use plaster rolls if water has been splashed on them.

• Hold the roll loosely but with the free end firm and secure (see FIG. 133.28).

• Ensure that the centre of the plaster is fully wet.

• Drain surface water after removal from the bucket.

• Gently squeeze the roll in the middle: do not indent.

Padding

• Use Velband or stockinette under the plaster.

• With Velband, moisten the end of the roll in water to allow it to adhere to the limb.

• For legs, make extra padding around the ankle and heel.

• Avoid multiple layers of padding.

Method

• Use an assistant to support the limb where possible (e.g. hold the arm up with fingers of stockinet).

• Lay the bandage on firmly but do not pull tight.

• Lay it on quickly.

• Overlap the bandage by about 25% of its width.

Note: It is good practice to review the patient the next day.

Hand-out sheets from Murtagh’s Patient Education 7th edition:

• Plaster cast instructions