Ortho Flashcards

Question

An 86 year old retired pharmacist is admitted to A&E following a fall. She complains of right hip pain. She is known to have hypertension and is currently on bendrofluazide. She lives alone and mobilises with a Zimmer frame. Her right leg is shortened and externally rotated. A hip x-ray confirms a displaced intracapsular fracture. ``` A. Conservative management B. Percutaneous pinning C. Fracture reduction and internal fixation D. Hemiarthroplasty E. Total hip replacement F. Dynamic hip screw G. Intramedullary femoral nail ```

Answer 1

Hemiarthroplasty Hemiarthroplasty is offered to older, less mobile individuals compared to fracture reduction and fixation in younger patients. Neck of femur (NOF) fracture is a common orthopaedic presentation, with over 65000 fractures in the UK per year. Like many orthopaedic injuries, there is a bimodal age distribution. It is imperative to distinguish between the high energy injury in a young patient, and the low energy osteoporotic fracture in the elderly, as their management aims are very different: Young patient - Usually high energy trauma (e.g road traffic accident, horse riding) and needs treating in accordance with Advanced Trauma Life Support (ATLS) principles. Will often have associated injuries. Aim is to retain the patients own anatomy, and optimise their function. Elderly patient - Predominantly female, fall from standing height (fragility fracture). Often patients have multiple comorbidities that will ultimately dictate their prognosis. Aim of orthopaedic treatment is to immediately regain patient mobility so that morbidity (infection, thromboembolic events, pressure sores etc) and mortality associated with prolonged bed rest is avoided. Left untreated, a neck of femur fracture can be considered a terminal event. Historically, mortality associated with elderly hip fracture is 10% at one month, and 30% at one year. However, this has been improved in the UK with the introduction of multidisciplinary, orthogeriatric lead care and the National Hip Fracture Database and Best Practice Tariff. Pertinent anatomy Osteology - normal neck-shaft angle is 130 +/- 7 degrees, and 10 +/- 7 degrees of neck anteversion. Vascular supply - The predominant blood supply to the femoral head and neck is from the medial and lateral femoral circumflex arteries (branches of profunda femoris). These anastomose and pierce the joint capsule at the base of the neck, mainly posteriorly. There is a small vascular contribution from the artery of the ligament teres. Understanding the blood supply is fundamental to the decision making process in treating NOF fractures. Presentation and initial management Typically, patients present with pain in the hip/groin, a shortened, abducted, externally rotated leg (due to the unopposed pull of the muscles that act across the hip joint) and the inability to straight-leg-raise. With undisplaced fractures, signs are more subtle. High energy injuries should be treated in line with ATLS principles. All patients should be fluid resuscitated, have adequate pain relief (often with a fascio-iliiaca nerve block), and be optimised for surgery. In addition, elderly patients should be assessed by an orthogeriatrician. Imaging Anteroposterior and cross-table lateral plain radiographs are sufficient to diagnose the majority of NOF fractures. If the fracture extends below the level of the lesser trochanter, or there is any possibility of pathological fracture, full length femur views are essential to plan surgery. Where there is a high index of suspicion of fracture, but plain radiographs are inconclusive, gold standard investigation is MRI. However, if unavailable within 24 hours, or if the patient will not tolerate MRI, CT is appropriate. The majority of fractures can be seen with modern CT techniques, and so this is becoming first line in many hospitals. Classification There has been a move away from named classification systems towards descriptive classification systems. Two main types of NOF exist: Intra-capsular, and extra-capsular. Extra-capsular fractures are further divided into pertrochanteric or subtrochanteric (within 5cm distal to the lesser trochanter). All fractures are then described as undisplaced, minimally displaced, or displaced. Femoral neck and head blood supply disruption is common with intracapsular NOF fractures, and rare with extracapsular fractures. This fundamental principle underpins the practise of arthroplasty for intracapsular fractures, and fixation for extracapsular fractures. If you wish to use a named classification system, the most commonly used are below: Elderly intracapsular - Garden Classification Young intrasapsular - Pauvels Classification Intertrochanteric - Evans Subtrochanteric - Russell Taylor Treatment In general, NOF fractures are treated operatively except if the patient is deemed unlikely to survive an anaesthetic. Best Practice Tarif (BPT) dictates that surgery should happen within 36 hours, as delay of greater than 48 hours is associated with increased morbidity and mortality. * The priority with the young patient is to retain the femoral head if possible, even with a displaced intracapsular fracture. The risk of avascular necrosis and non-union (and therefore revision surgery) associated with internal fixation needs weighing up against the sequelae of total hip replacement in the young (wear, dislocation, revision). Discussion is necessary with the patient, on a case by case basis. ** Undisplaced fractures in the elderly can be treated with internal fixation, often with cannulated screws. This is appropriate for valgus impacted subcapital fractures which are inherently stable, to prevent secondary displacement. This does still carry the risk of AVN or non-union, and therefore a future revision. For this reason, many surgeons advocate arthroplasty as a single surgery. *** NICE guidance - patients who fulfil these criteria should be offered total hip replacement which conveys better function and prosthetic survivorship, compared with hemiarthroplasty, but at an increased risk of dislocation. * Intertrochanteric fractures vary greatly in their stability. If the trochanter (and therefore lateral wall), and medial calcar is in tact, then the fracture configuration bears stability. This can be treated with a DHS, as collapse of the fracture is predictable. Where either or both structures are involved in the fracture, stability becomes compromised and many surgeons will favour using an intramedullary device. This is an ongoing debate, and difficult to test in an exam setting. Post operative management Patients should be mobilised fully weight bearing where possible. Care is multidisciplinary in its delivery. Elderly patients should have orthogeriatrician assessment of comorbidity, and bone health with secondary prevention measures if appropriate. There should be early involvement of physiotherapy and occupational therapy services.

Answer 2

Total hip replacement This patient has pre-existing joint disease, good level of activity and a relatively high life expectancy, therefore THR is preferable to hemiarthroplasty. Neck of femur (NOF) fracture is a common orthopaedic presentation, with over 65000 fractures in the UK per year. Like many orthopaedic injuries, there is a bimodal age distribution. It is imperative to distinguish between the high energy injury in a young patient, and the low energy osteoporotic fracture in the elderly, as their management aims are very different: Young patient - Usually high energy trauma (e.g road traffic accident, horse riding) and needs treating in accordance with Advanced Trauma Life Support (ATLS) principles. Will often have associated injuries. Aim is to retain the patients own anatomy, and optimise their function. Elderly patient - Predominantly female, fall from standing height (fragility fracture). Often patients have multiple comorbidities that will ultimately dictate their prognosis. Aim of orthopaedic treatment is to immediately regain patient mobility so that morbidity (infection, thromboembolic events, pressure sores etc) and mortality associated with prolonged bed rest is avoided. Left untreated, a neck of femur fracture can be considered a terminal event. Historically, mortality associated with elderly hip fracture is 10% at one month, and 30% at one year. However, this has been improved in the UK with the introduction of multidisciplinary, orthogeriatric lead care and the National Hip Fracture Database and Best Practice Tariff. Pertinent anatomy Osteology - normal neck-shaft angle is 130 +/- 7 degrees, and 10 +/- 7 degrees of neck anteversion. Vascular supply - The predominant blood supply to the femoral head and neck is from the medial and lateral femoral circumflex arteries (branches of profunda femoris). These anastomose and pierce the joint capsule at the base of the neck, mainly posteriorly. There is a small vascular contribution from the artery of the ligament teres. Understanding the blood supply is fundamental to the decision making process in treating NOF fractures. Presentation and initial management Typically, patients present with pain in the hip/groin, a shortened, abducted, externally rotated leg (due to the unopposed pull of the muscles that act across the hip joint) and the inability to straight-leg-raise. With undisplaced fractures, signs are more subtle. High energy injuries should be treated in line with ATLS principles. All patients should be fluid resuscitated, have adequate pain relief (often with a fascio-iliiaca nerve block), and be optimised for surgery. In addition, elderly patients should be assessed by an orthogeriatrician. Imaging Anteroposterior and cross-table lateral plain radiographs are sufficient to diagnose the majority of NOF fractures. If the fracture extends below the level of the lesser trochanter, or there is any possibility of pathological fracture, full length femur views are essential to plan surgery. Where there is a high index of suspicion of fracture, but plain radiographs are inconclusive, gold standard investigation is MRI. However, if unavailable within 24 hours, or if the patient will not tolerate MRI, CT is appropriate. The majority of fractures can be seen with modern CT techniques, and so this is becoming first line in many hospitals. Classification There has been a move away from named classification systems towards descriptive classification systems. Two main types of NOF exist: Intra-capsular, and extra-capsular. Extra-capsular fractures are further divided into pertrochanteric or subtrochanteric (within 5cm distal to the lesser trochanter). All fractures are then described as undisplaced, minimally displaced, or displaced. Femoral neck and head blood supply disruption is common with intracapsular NOF fractures, and rare with extracapsular fractures. This fundamental principle underpins the practise of arthroplasty for intracapsular fractures, and fixation for extracapsular fractures. If you wish to use a named classification system, the most commonly used are below: Elderly intracapsular - Garden Classification Young intrasapsular - Pauvels Classification Intertrochanteric - Evans Subtrochanteric - Russell Taylor Treatment In general, NOF fractures are treated operatively except if the patient is deemed unlikely to survive an anaesthetic. Best Practice Tarif (BPT) dictates that surgery should happen within 36 hours, as delay of greater than 48 hours is associated with increased morbidity and mortality. * The priority with the young patient is to retain the femoral head if possible, even with a displaced intracapsular fracture. The risk of avascular necrosis and non-union (and therefore revision surgery) associated with internal fixation needs weighing up against the sequelae of total hip replacement in the young (wear, dislocation, revision). Discussion is necessary with the patient, on a case by case basis. ** Undisplaced fractures in the elderly can be treated with internal fixation, often with cannulated screws. This is appropriate for valgus impacted subcapital fractures which are inherently stable, to prevent secondary displacement. This does still carry the risk of AVN or non-union, and therefore a future revision. For this reason, many surgeons advocate arthroplasty as a single surgery. *** NICE guidance - patients who fulfil these criteria should be offered total hip replacement which conveys better function and prosthetic survivorship, compared with hemiarthroplasty, but at an increased risk of dislocation. * Intertrochanteric fractures vary greatly in their stability. If the trochanter (and therefore lateral wall), and medial calcar is in tact, then the fracture configuration bears stability. This can be treated with a DHS, as collapse of the fracture is predictable. Where either or both structures are involved in the fracture, stability becomes compromised and many surgeons will favour using an intramedullary device. This is an ongoing debate, and difficult to test in an exam setting. Post operative management Patients should be mobilised fully weight bearing where possible. Care is multidisciplinary in its delivery. Elderly patients should have orthogeriatrician assessment of comorbidity, and bone health with secondary prevention measures if appropriate. There should be early involvement of physiotherapy and occupational therapy services.

Answer 3

Myeloma Steroid containing therapy for myeloma may induce avascular necrosis, however the disease itself does not cause it. Caisson disease as may occur in deep sea divers is a recognised cause. Avascular necrosis Cellular death of bone components due to interruption of the blood supply, causing bone destruction Main joints affected are hip, scaphoid, lunate and the talus. It is not the same as non union. The fracture has usually united. Radiological evidence is slow to appear. Vascular ingrowth into the affected bone may occur. However, many joints will develop secondary osteoarthritis. ``` Causes P ancreatitis L upus A lcohol S teroids T rauma I diopathic, infection C aisson disease, collagen vascular disease R adiation, rheumatoid arthritis A myloid G aucher disease S ickle cell disease ``` Presentation Usually pain. Often despite apparent fracture union. Investigation MRI scanning will show changes earlier than plain films. Treatment In fractures at high risk sites anticipation is key. Early prompt and accurate reduction is essential. Non weight bearing may help to facilitate vascular regeneration. Joint replacement may be necessary, or even the preferred option (e.g. Hip in the elderly).

Answer 4

Sclerosis of the femoral head In Catterall stage I disease there may be no radiological abnormality at all. In Stage II disease there may be sclerosis of the femoral head. Indication for treatment (aide memoire):Half a dozen, half a head Those aged greater than 6 years with >50% involvement of the femoral head should almost always be treated. Perthes disease Idiopathic avascular necrosis of the femoral epiphysis of the femoral head Impaired blood supply to femoral head, causing bone infarction. New vessels develop and ossification occurs. The bone either heals or a subchondral fracture occurs. ``` Clinical features Males 4x's greater than females Age between 2-12 years (the younger the age of onset, the better the prognosis) Limp Hip pain Bilateral in 20% ``` Diagnosis Plain x-ray, Technetium bone scan or magnetic resonance imaging if normal x-ray and symptoms persist. Catterall staging Stage Features Stage 1 Clinical and histological features only Stage 2 Sclerosis with or without cystic changes and preservation of the articular surface Stage 3 Loss of structural integrity of the femoral head Stage 4 Loss of acetabular integrity Management To keep the femoral head within the acetabulum: cast, braces If less than 6 years: observation Older: surgical management with moderate results Operate on severe deformities Prognosis Most cases will resolve with conservative management. Early diagnosis improves outcomes.

Answer 5

Injury to the medial collateral ligament A knee injury in the footballer with a positive valgus stress test is usually associated with MCL injury. Knee collateral ligament Anatomy The tibial collateral ligament is a broad, flat band. Its upper end has an extensive attachment to the medial epicondyle of the femur with some fibres projecting onto the adductor magnus tendon. The ligament passes downwards and forwards to the medial side of the tibia. The deepest fibres are fused with the medial meniscus. The fibular collateral ligament is round and cord like and stands clear of the thin, lateral part of the fibrous capsule. It is enclosed within the fascia lata. It passes from the lateral epicondyle of the femur to the head of the fibula in front of its highest point and splits the tendon of biceps femoris. On the lateral side of the joint the fibres are short and weak and bridge the interval between the femoral and tibial condyles. The popliteus tendon intervenes between the lateral meniscus and the capsule. The tibial and fibular collateral ligaments prevent disruption of the joint at the sides. They are most tightly stretched in extension, and then their direction- the fibular ligament downwards and backwards, the tibial downwards and forwards- prevents rotation of the tibia laterally or the femur medially. Rotation may be demonstrated in the flexed knee. Injury The collateral ligaments are commonly injured, the medial is most often affected. It requires a significant force such as sporting tackle or motor vehicle to strike the side of the leg. Associated injuries to both the tibial plateau or menisci are not uncommon. Grading and treatment Grade of injury Features Treatment 1 Minor tearing of ligament fibres Negative instability tests Conservative (analgesia and physiotherapy) 2 Ligament laxity (seen with knee in 30o flexion) Knee stable when joint extended Usually splinting or casting for 4-6 weeks 3 Ligament completely torn Joint instability Surgical ligament reconstruction

Answer 6

Combined skeletal and soft tissue reconstruction on a scheduled operating list This patient has a Gustillo-Anderson Grade 3B open fracture. He will require definitive skeletal and soft tissue reconstruction, which should be performed on a combined ortho-plastic scheduled operating list, as per the BOA/BAPRAS guidelines. The surgery does not have to be performed out of scheduled hours unless there is marine/ sewage contamination, vascular compromise or it is a polytrauma. Whilst it is reasonable to apply an external fixator prior to definitive skeletal and soft tissue reconstruction, this should be converted to internal fixation within 72 hours. Open fractures The term open fracture refers to a disruption of the bony cortex associated with a breach in the overlying skin. Any wound that is present in the same limb as a fracture should be suspected as being representative of an open fracture. One of the main problems with open fractures is the associated injuries to the surrounding soft tissues. Whilst the skin is usually relatively resistant to trauma, underlying muscle can be damaged or devitalised, nerves, blood vessels and periosteum may all be disrupted the degree to which this occurs correlates with the severity of the injury and the outcome. These can be graded using the Gustilo and Anderson system (see below). Grade Injury 1 Low energy wound <1cm 2 Greater than 1cm wound with moderate soft tissue damage 3 High energy wound > 1cm with extensive soft tissue damage 3 A (sub group of 3) Adequate soft tissue coverage 3 B (sub group of 3) Inadequate soft tissue coverage 3 C (sub group of 3) Associated arterial injury In Type IIIc injuries, the mangled extremity scoring system (MESS) can help to predict the need for primary amputation. Initial management should focus on careful patient examination to check for associated injuries, control of haemorrhage and the extent of injury. The area should be carefully imaged, distal neurovascular status established the wound covered with a dressing and antibiotics administered. Early debridement is the cornerstone of the management of open fractures. The aim of the debridement is to remove foreign material and devitalised tissue. In most cases the wound is left open. The wound should be irrigated, generally, 6 litres of saline is used. The fracture should be stabilised and an external fixator is often used in the first instance

Answer 7

Intravenous antibiotics, photography and application of saline soaked gauze with impermeable dressing The initial management of open fractures should include administration of intravenous antibiotics, photography of wound and application of a sterile soaked gauze and impermeable film. The wound should only be handled to remove gross contamination. The patient is then likely to require definitive skeletal and soft tissue reconstruction. Open fractures The term open fracture refers to a disruption of the bony cortex associated with a breach in the overlying skin. Any wound that is present in the same limb as a fracture should be suspected as being representative of an open fracture. One of the main problems with open fractures is the associated injuries to the surrounding soft tissues. Whilst the skin is usually relatively resistant to trauma, underlying muscle can be damaged or devitalised, nerves, blood vessels and periosteum may all be disrupted the degree to which this occurs correlates with the severity of the injury and the outcome. These can be graded using the Gustilo and Anderson system (see below). Grade Injury 1 Low energy wound <1cm 2 Greater than 1cm wound with moderate soft tissue damage 3 High energy wound > 1cm with extensive soft tissue damage 3 A (sub group of 3) Adequate soft tissue coverage 3 B (sub group of 3) Inadequate soft tissue coverage 3 C (sub group of 3) Associated arterial injury In Type IIIc injuries, the mangled extremity scoring system (MESS) can help to predict the need for primary amputation. Initial management should focus on careful patient examination to check for associated injuries, control of haemorrhage and the extent of injury. The area should be carefully imaged, distal neurovascular status established the wound covered with a dressing and antibiotics administered. Early debridement is the cornerstone of the management of open fractures. The aim of the debridement is to remove foreign material and devitalised tissue. In most cases the wound is left open. The wound should be irrigated, generally, 6 litres of saline is used. The fracture should be stabilised and an external fixator is often used in the first instance

Answer 8

Immediate vascuIar shunting, followed by temporary skeletal stabilisation and vascular reconstruction This patient has a Gustillo-Anderson Grade 3C open fracture with vascular injury. Vascular impairment requires immediate surgery and restoration of circulation, ideally within 3-4 hours. This should follow the sequence of shunting, temporary skeletal stabilisation and then vascular reconstruction as per BOA / BAPRAS guidelines. Revascularisation using vascular shunts should be performed before skeletal fixation. Open fractures The term open fracture refers to a disruption of the bony cortex associated with a breach in the overlying skin. Any wound that is present in the same limb as a fracture should be suspected as being representative of an open fracture. One of the main problems with open fractures is the associated injuries to the surrounding soft tissues. Whilst the skin is usually relatively resistant to trauma, underlying muscle can be damaged or devitalised, nerves, blood vessels and periosteum may all be disrupted the degree to which this occurs correlates with the severity of the injury and the outcome. These can be graded using the Gustilo and Anderson system (see below). Grade Injury 1 Low energy wound <1cm 2 Greater than 1cm wound with moderate soft tissue damage 3 High energy wound > 1cm with extensive soft tissue damage 3 A (sub group of 3) Adequate soft tissue coverage 3 B (sub group of 3) Inadequate soft tissue coverage 3 C (sub group of 3) Associated arterial injury In Type IIIc injuries, the mangled extremity scoring system (MESS) can help to predict the need for primary amputation. Initial management should focus on careful patient examination to check for associated injuries, control of haemorrhage and the extent of injury. The area should be carefully imaged, distal neurovascular status established the wound covered with a dressing and antibiotics administered. Early debridement is the cornerstone of the management of open fractures. The aim of the debridement is to remove foreign material and devitalised tissue. In most cases the wound is left open. The wound should be irrigated, generally, 6 litres of saline is used. The fracture should be stabilised and an external fixator is often used in the first instance

Answer 9

Scaphoid fracture Scaphoid fractures usually occur as a result of direct hard blow to the palm or following a fall on the out-stretched hand. The main physical signs are swelling and tenderness in the anatomical snuff box, and pain on wrist movements and on longitudinal compression of the thumb Colles' fracture Fall onto extended outstretched hands Described as a dinner fork type deformity Classical Colles' fractures have the following 3 features: Features of the injury 1. Transverse fracture of the radius 2. 1 inch proximal to the radio-carpal joint 3. Dorsal displacement and angulation Smith's fracture (reverse Colles' fracture) Volar angulation of distal radius fragment (Garden spade deformity) Caused by falling backwards onto the palm of an outstretched hand or falling with wrists flexed Bennett's fracture Intra-articular fracture of the first carpometacarpal joint Impact on flexed metacarpal, caused by fist fights X-ray: triangular fragment at ulnar base of metacarpal Monteggia's fracture Dislocation of the proximal radioulnar joint in association with an ulna fracture Fall on outstretched hand with forced pronation Needs prompt diagnosis to avoid disability Galeazzi fracture Radial shaft fracture with associated dislocation of the distal radioulnar joint Occur after a fall on the hand with a rotational force superimposed on it. On examination, there is bruising, swelling and tenderness over the lower end of the forearm. X Rays reveal the displaced fracture of the radius and a prominent ulnar head due to dislocation of the inferior radio-ulnar joint. Barton's fracture Distal radius fracture (Colles'/Smith's) with associated radiocarpal dislocation Fall onto extended and pronated wrist Scaphoid fractures Scaphoid fractures are the commonest carpal fractures. Surface of scaphoid is covered by articular cartilage with small area available for blood vessels (fracture risks blood supply) Forms floor of anatomical snuffbox Risk of fracture associated with fall onto outstretched hand (tubercle, waist, or proximal 1/3) The main physical signs are swelling and tenderness in the anatomical snuff box, and pain on wrist movements and on longitudinal compression of the thumb. Ulnar deviation AP needed for visualization of scaphoid Immobilization of scaphoid fractures difficult Radial head fracture Fracture of the radial head is common in young adults. It is usually caused by a fall on the outstretched hand. On examination, there is marked local tenderness over the head of the radius, impaired movements at the elbow, and a sharp pain at the lateral side of the elbow at the extremes of rotation (pronation and supination).

Answer 10

Fracture of the radial head Fracture of the radial head is common in young adults. It is usually caused by a fall on the outstretched hand. On examination, there is marked local tenderness over the head of the radius, impaired movements at the elbow, and a sharp pain at the lateral side of the elbow at the extremes of rotation (pronation and supination). Colles' fracture Fall onto extended outstretched hands Described as a dinner fork type deformity Classical Colles' fractures have the following 3 features: Features of the injury 1. Transverse fracture of the radius 2. 1 inch proximal to the radio-carpal joint 3. Dorsal displacement and angulation Smith's fracture (reverse Colles' fracture) Volar angulation of distal radius fragment (Garden spade deformity) Caused by falling backwards onto the palm of an outstretched hand or falling with wrists flexed Bennett's fracture Intra-articular fracture of the first carpometacarpal joint Impact on flexed metacarpal, caused by fist fights X-ray: triangular fragment at ulnar base of metacarpal Monteggia's fracture Dislocation of the proximal radioulnar joint in association with an ulna fracture Fall on outstretched hand with forced pronation Needs prompt diagnosis to avoid disability Galeazzi fracture Radial shaft fracture with associated dislocation of the distal radioulnar joint Occur after a fall on the hand with a rotational force superimposed on it. On examination, there is bruising, swelling and tenderness over the lower end of the forearm. X Rays reveal the displaced fracture of the radius and a prominent ulnar head due to dislocation of the inferior radio-ulnar joint. Barton's fracture Distal radius fracture (Colles'/Smith's) with associated radiocarpal dislocation Fall onto extended and pronated wrist Scaphoid fractures Scaphoid fractures are the commonest carpal fractures. Surface of scaphoid is covered by articular cartilage with small area available for blood vessels (fracture risks blood supply) Forms floor of anatomical snuffbox Risk of fracture associated with fall onto outstretched hand (tubercle, waist, or proximal 1/3) The main physical signs are swelling and tenderness in the anatomical snuff box, and pain on wrist movements and on longitudinal compression of the thumb. Ulnar deviation AP needed for visualization of scaphoid Immobilization of scaphoid fractures difficult Radial head fracture Fracture of the radial head is common in young adults. It is usually caused by a fall on the outstretched hand. On examination, there is marked local tenderness over the head of the radius, impaired movements at the elbow, and a sharp pain at the lateral side of the elbow at the extremes of rotation (pronation and supination).

Answer 11

Galeazzi fracture Galeazzi fractures occur after a fall on the hand with a rotational force superimposed on it. On examination, there is bruising, swelling and tenderness over the lower end of the forearm. X- Rays reveal a displaced fracture of the radius and a prominent ulnar head due to dislocation of the inferior radio-ulnar joint. Colles' fracture Fall onto extended outstretched hands Described as a dinner fork type deformity Classical Colles' fractures have the following 3 features: Features of the injury 1. Transverse fracture of the radius 2. 1 inch proximal to the radio-carpal joint 3. Dorsal displacement and angulation Smith's fracture (reverse Colles' fracture) Volar angulation of distal radius fragment (Garden spade deformity) Caused by falling backwards onto the palm of an outstretched hand or falling with wrists flexed Bennett's fracture Intra-articular fracture of the first carpometacarpal joint Impact on flexed metacarpal, caused by fist fights X-ray: triangular fragment at ulnar base of metacarpal Monteggia's fracture Dislocation of the proximal radioulnar joint in association with an ulna fracture Fall on outstretched hand with forced pronation Needs prompt diagnosis to avoid disability Galeazzi fracture Radial shaft fracture with associated dislocation of the distal radioulnar joint Occur after a fall on the hand with a rotational force superimposed on it. On examination, there is bruising, swelling and tenderness over the lower end of the forearm. X Rays reveal the displaced fracture of the radius and a prominent ulnar head due to dislocation of the inferior radio-ulnar joint. Barton's fracture Distal radius fracture (Colles'/Smith's) with associated radiocarpal dislocation Fall onto extended and pronated wrist Scaphoid fractures Scaphoid fractures are the commonest carpal fractures. Surface of scaphoid is covered by articular cartilage with small area available for blood vessels (fracture risks blood supply) Forms floor of anatomical snuffbox Risk of fracture associated with fall onto outstretched hand (tubercle, waist, or proximal 1/3) The main physical signs are swelling and tenderness in the anatomical snuff box, and pain on wrist movements and on longitudinal compression of the thumb. Ulnar deviation AP needed for visualization of scaphoid Immobilization of scaphoid fractures difficult Radial head fracture Fracture of the radial head is common in young adults. It is usually caused by a fall on the outstretched hand. On examination, there is marked local tenderness over the head of the radius, impaired movements at the elbow, and a sharp pain at the lateral side of the elbow at the extremes of rotation (pronation and supination).

Answer 12

Application of futura splint and fracture clinic review A fracture may still be present and should be immobilised until repeat imaging can be performed. If clinical suspicion persists then subsequent imaging should be with MRI scanning or CT if MRI is contra-indicated. Scaphoid fractures: 80% of all carpal fractures 80% occur in men 80% occur at the waist of the scaphoid Scaphoid fractures are the commonest carpal fractures. Surface of scaphoid is covered by articular cartilage with small area available for blood vessels (fracture risks blood supply) Forms floor of anatomical snuffbox Risk of fracture associated with fall onto outstretched hand (tubercle, waist, or proximal third) Ulnar deviation AP needed for visualization of scaphoid Immobilization of scaphoid fractures difficult Management Non-displaced fractures - Casts or splints - Percutaneous scaphoid fixation Displaced fracture Surgical fixation, usually with a screw Complications Non union of scaphoid Avascular necrosis of the scaphoid Scapholunate disruption and wrist collapse Degenerative changes of the adjacent joint

Answer 13

Discharge with reassurance This patient is at extremely low risk of having sustained a scaphoid injury and may be discharged. Scaphoid fractures: 80% of all carpal fractures 80% occur in men 80% occur at the waist of the scaphoid Scaphoid fractures are the commonest carpal fractures. Surface of scaphoid is covered by articular cartilage with small area available for blood vessels (fracture risks blood supply) Forms floor of anatomical snuffbox Risk of fracture associated with fall onto outstretched hand (tubercle, waist, or proximal third) Ulnar deviation AP needed for visualization of scaphoid Immobilization of scaphoid fractures difficult Management Non-displaced fractures - Casts or splints - Percutaneous scaphoid fixation Displaced fracture Surgical fixation, usually with a screw Complications Non union of scaphoid Avascular necrosis of the scaphoid Scapholunate disruption and wrist collapse Degenerative changes of the adjacent joint

Answer 14

Admission and surgical debridement This is technically an open fracture and should be debrided prior to attempted fixation (which should occur soon after). Scaphoid fractures: 80% of all carpal fractures 80% occur in men 80% occur at the waist of the scaphoid Scaphoid fractures are the commonest carpal fractures. Surface of scaphoid is covered by articular cartilage with small area available for blood vessels (fracture risks blood supply) Forms floor of anatomical snuffbox Risk of fracture associated with fall onto outstretched hand (tubercle, waist, or proximal third) Ulnar deviation AP needed for visualization of scaphoid Immobilization of scaphoid fractures difficult Management Non-displaced fractures - Casts or splints - Percutaneous scaphoid fixation Displaced fracture Surgical fixation, usually with a screw Complications Non union of scaphoid Avascular necrosis of the scaphoid Scapholunate disruption and wrist collapse Degenerative changes of the adjacent joint

Answer 15

Transient synovitis Viral illnesses can be associated with transient synovitis. The WCC should ideally be > 12 and the ESR > 40 to suggest septic arthritis. Developmental dysplasia of the hip Usually diagnosed in infancy by screening tests. May be bilateral, when disease is unilateral there may be leg length inequality. As disease progresses child may limp and then early onset arthritis. More common in extended breech babies. Splints and harnesses or traction. In later years osteotomy and hip realignment procedures may be needed. In arthritis a joint replacement may be needed. However, this is best deferred if possible as it will almost certainly require revision Initially no obvious change on plain films and USS gives best resolution until 3 months of age. On plain films Shentons line should form a smooth arc Perthes Disease Hip pain (may be referred to the knee) usually occurring between 5 and 12 years of age. Bilateral disease in 20%. Remove pressure from joint to allow normal development. Physiotherapy. Usually self-limiting if diagnosed and treated promptly. X-rays will show flattened femoral head. Eventually in untreated cases the femoral head will fragment. Slipped upper femoral epiphysis Typically seen in obese male adolescents. Pain is often referred to the knee. Limitation to internal rotation is usually seen. Knee pain is usually present 2 months prior to hip slipping. Bilateral in 20%. Bed rest and non-weight bearing. Aim to avoid avascular necrosis. If severe slippage or risk of it occurring then percutaneous pinning of the hip may be required. X-rays will show the femoral head displaced and falling inferolaterally (like a melting ice cream cone) The Southwick angle gives indication of disease severity

Answer 16

Perthes disease This child is short, has hyperactivity (disruptive behaviour) and is within the age range for Perthes disease. Hyperactivity and short stature are associated with Perthes disease. Developmental dysplasia of the hip Usually diagnosed in infancy by screening tests. May be bilateral, when disease is unilateral there may be leg length inequality. As disease progresses child may limp and then early onset arthritis. More common in extended breech babies. Splints and harnesses or traction. In later years osteotomy and hip realignment procedures may be needed. In arthritis a joint replacement may be needed. However, this is best deferred if possible as it will almost certainly require revision Initially no obvious change on plain films and USS gives best resolution until 3 months of age. On plain films Shentons line should form a smooth arc Perthes Disease Hip pain (may be referred to the knee) usually occurring between 5 and 12 years of age. Bilateral disease in 20%. Remove pressure from joint to allow normal development. Physiotherapy. Usually self-limiting if diagnosed and treated promptly. X-rays will show flattened femoral head. Eventually in untreated cases the femoral head will fragment. Slipped upper femoral epiphysis Typically seen in obese male adolescents. Pain is often referred to the knee. Limitation to internal rotation is usually seen. Knee pain is usually present 2 months prior to hip slipping. Bilateral in 20%. Bed rest and non-weight bearing. Aim to avoid avascular necrosis. If severe slippage or risk of it occurring then percutaneous pinning of the hip may be required. X-rays will show the femoral head displaced and falling inferolaterally (like a melting ice cream cone) The Southwick angle gives indication of disease severity

Answer 17

Slipped upper femoral epiphysis Slipped upper femoral epiphysis is commonest in obese adolescent males. The x-ray will show displacement of the femoral epiphysis inferolaterally. Treatment is usually with rest and non weight bearing crutches. Developmental dysplasia of the hip Usually diagnosed in infancy by screening tests. May be bilateral, when disease is unilateral there may be leg length inequality. As disease progresses child may limp and then early onset arthritis. More common in extended breech babies. Splints and harnesses or traction. In later years osteotomy and hip realignment procedures may be needed. In arthritis a joint replacement may be needed. However, this is best deferred if possible as it will almost certainly require revision Initially no obvious change on plain films and USS gives best resolution until 3 months of age. On plain films Shentons line should form a smooth arc Perthes Disease Hip pain (may be referred to the knee) usually occurring between 5 and 12 years of age. Bilateral disease in 20%. Remove pressure from joint to allow normal development. Physiotherapy. Usually self-limiting if diagnosed and treated promptly. X-rays will show flattened femoral head. Eventually in untreated cases the femoral head will fragment. Slipped upper femoral epiphysis Typically seen in obese male adolescents. Pain is often referred to the knee. Limitation to internal rotation is usually seen. Knee pain is usually present 2 months prior to hip slipping. Bilateral in 20%. Bed rest and non-weight bearing. Aim to avoid avascular necrosis. If severe slippage or risk of it occurring then percutaneous pinning of the hip may be required. X-rays will show the femoral head displaced and falling inferolaterally (like a melting ice cream cone) The Southwick angle gives indication of disease severity

Answer 18

Smith's This is a Smith fracture (reverse Colles' fracture); unlike a Colles' this is a high velocity injury and may require surgical correction. Note that Colles' fractures are usually dorsally displaced. Eponymous fractures Colles' fracture (dinner fork deformity) Fall onto extended outstretched hand Classical Colles' fractures have the following 3 features: 1. Transverse fracture of the radius 2. 1 inch proximal to the radio-carpal joint 3. Dorsal displacement and angulation Smith's fracture (reverse Colles' fracture) Volar angulation of distal radius fragment (Garden spade deformity) Caused by falling backwards onto the palm of an outstretched hand or falling with wrists flexed Bennett's fracture Intra-articular fracture of the first carpometacarpal joint Impact on flexed metacarpal, caused by fist fights X-ray: triangular fragment at ulnar base of metacarpal Image sourced from Wikipedia Monteggia's fracture Dislocation of the proximal radioulnar joint in association with an ulna fracture Fall on outstretched hand with forced pronation Needs prompt diagnosis to avoid disability Image sourced from Wikipedia Galeazzi fracture Radial shaft fracture with associated dislocation of the distal radioulnar joint Direct blow Pott's fracture Bimalleolar ankle fracture Forced foot eversion Barton's fracture Distal radius fracture (Colles'/Smith's) with associated radiocarpal dislocation Fall onto extended and pronated wrist Involvement of the joint is a defining feature

Answer 19

Monteggia's This constellation of injuries is referred to as a Monteggia's fracture. Eponymous fractures Colles' fracture (dinner fork deformity) Fall onto extended outstretched hand Classical Colles' fractures have the following 3 features: 1. Transverse fracture of the radius 2. 1 inch proximal to the radio-carpal joint 3. Dorsal displacement and angulation Smith's fracture (reverse Colles' fracture) Volar angulation of distal radius fragment (Garden spade deformity) Caused by falling backwards onto the palm of an outstretched hand or falling with wrists flexed Bennett's fracture Intra-articular fracture of the first carpometacarpal joint Impact on flexed metacarpal, caused by fist fights X-ray: triangular fragment at ulnar base of metacarpal Image sourced from Wikipedia Monteggia's fracture Dislocation of the proximal radioulnar joint in association with an ulna fracture Fall on outstretched hand with forced pronation Needs prompt diagnosis to avoid disability Image sourced from Wikipedia Galeazzi fracture Radial shaft fracture with associated dislocation of the distal radioulnar joint Direct blow Pott's fracture Bimalleolar ankle fracture Forced foot eversion Barton's fracture Distal radius fracture (Colles'/Smith's) with associated radiocarpal dislocation Fall onto extended and pronated wrist Involvement of the joint is a defining feature

Answer 20

Galeazzi Isolated fracture of the radius alone can occur but is rare. Always check for associated injury. Eponymous fractures Colles' fracture (dinner fork deformity) Fall onto extended outstretched hand Classical Colles' fractures have the following 3 features: 1. Transverse fracture of the radius 2. 1 inch proximal to the radio-carpal joint 3. Dorsal displacement and angulation Smith's fracture (reverse Colles' fracture) Volar angulation of distal radius fragment (Garden spade deformity) Caused by falling backwards onto the palm of an outstretched hand or falling with wrists flexed Bennett's fracture Intra-articular fracture of the first carpometacarpal joint Impact on flexed metacarpal, caused by fist fights X-ray: triangular fragment at ulnar base of metacarpal Image sourced from Wikipedia Monteggia's fracture Dislocation of the proximal radioulnar joint in association with an ulna fracture Fall on outstretched hand with forced pronation Needs prompt diagnosis to avoid disability Image sourced from Wikipedia Galeazzi fracture Radial shaft fracture with associated dislocation of the distal radioulnar joint Direct blow Pott's fracture Bimalleolar ankle fracture Forced foot eversion Barton's fracture Distal radius fracture (Colles'/Smith's) with associated radiocarpal dislocation Fall onto extended and pronated wrist Involvement of the joint is a defining feature

Answer 21

This is a typical presentation of pseudogout. An elevated transferrin saturation may indicate haemochromatosis, a recognised cause of pseudogout. A high ferritin level is also seen in haemochromatosis but can be raised in a variety of infective and inflammatory processes, including pseudogout, as part of an acute phase response. Pseudogout is a form of microcrystal synovitis caused by the deposition of calcium pyrophosphate dihydrate in the synovium ``` Risk factors hyperparathyroidism hypothyroidism haemochromatosis acromegaly low magnesium, low phosphate Wilson's disease ``` Features knee, wrist and shoulders most commonly affected joint aspiration: weakly-positively birefringent rhomboid shaped crystals x-ray: chondrocalcinosis Management aspiration of joint fluid, to exclude septic arthritis NSAIDs or intra-articular, intra-muscular or oral steroids as for gout

Answer 22

Stress Fracture A short history of pain together with clinical examination and radiological signs affecting the second metatarsal favour a stress fracture. The fact that callus is present suggests that immobilisation is unlikely to be beneficial. Freibergs disease is an anterior metatarsalgia affecting the head of the second metarsal, it typically occurs in the pubertal growth spurt. The initial injury was thought to be due to stress microfractures at the growth plate. The key feature in the history which distinguishes the injury as being stress fracture is the radiology. In Freibergs disease the x-ray changes include; joint space widening, formation of bony spurs, sclerosis and flattening of the metatarsal head.

Answer 23

Osteomalacia low: calcium, phosphate raised: alkaline phosphatase The low calcium and phosphate combined with the raised alkaline phosphatase point towards osteomalacia. Osteomalacia Basics normal bony tissue but decreased mineral content rickets if when growing osteomalacia if after epiphysis fusion ``` Types vitamin D deficiency e.g. malabsorption, lack of sunlight, diet renal failure drug induced e.g. anticonvulsants vitamin D resistant; inherited liver disease, e.g. cirrhosis ``` Features rickets: knock-knee, bow leg, features of hypocalcaemia osteomalacia: bone pain, fractures, muscle tenderness, proximal myopathy Investigation low calcium, phosphate, 25(OH) vitamin D raised alkaline phosphatase x-ray: children - cupped, ragged metaphyseal surfaces; adults - translucent bands (Looser's zones or pseudofractures) Treatment calcium with vitamin D tablets

Answer 24

Alendronate, calcium and vitamin D supplementation A bisphosphonate, calcium and vitamin D supplementation should be given to all patients aged over 75 years after having a fracture. A DEXA scan is only needed of the patient is aged below 75 years. Hormone replacement therapy has been shown to reduce vertebral and non vertebral fractures, however the risks of cardiovascular disease and breast malignancy make this a less favourable option. Osteoporosis: secondary prevention NICE guidelines were updated in 2008 on the secondary prevention of osteoporotic fractures in postmenopausal women. Key points include Treatment is indicated following osteoporotic fragility fractures in postmenopausal women who are confirmed to have osteoporosis (a T-score of - 2.5 SD or below). In women aged 75 years or older, a DEXA scan may not be required 'if the responsible clinician considers it to be clinically inappropriate or unfeasible' Vitamin D and calcium supplementation should be offered to all women unless the clinician is confident they have adequate calcium intake and are vitamin D replete Alendronate is first-line Around 25% of patients cannot tolerate alendronate, usually due to upper gastrointestinal problems. These patients should be offered risedronate or etidronate (see treatment criteria below) Strontium ranelate and raloxifene are recommended if patients cannot tolerate bisphosphonates (see treatment criteria below) Supplementary notes on treatment Bisphosphonates Alendronate, risedronate and etidronate are all licensed for the prevention and treatment of post-menopausal and glucocorticoid-induced osteoporosis All three have been shown to reduce the risk of both vertebral and non-vertebral fractures although alendronate, risedronate may be superior to etidronate in preventing hip fractures Ibandronate is a once-monthly oral bisphosphonate Vitamin D and calcium Poor evidence base to suggest reduced fracture rates in the general population at risk of osteoporotic fractures - may reduce rates in frail, housebound patients Raloxifene - selective oestrogen receptor modulator (SERM) Has been shown to prevent bone loss and to reduce the risk of vertebral fractures, but has not yet been shown to reduce the risk of non-vertebral fractures Has been shown to increase bone density in the spine and proximal femur May worsen menopausal symptoms Increased risk of thromboembolic events May decrease risk of breast cancer Strontium ranelate 'Dual action bone agent' - increases deposition of new bone by osteoblasts and reduces the resorption of bone by osteoclasts Strong evidence base, may be second-line treatment in near future Increased risk of thromboembolic events

Answer 25

The earliest detectable radiological evidence is a radiolucency of the affected area coupled with subchondral collapse. - FALSE Avascular necrosis- radiological changes occur late. Radiolucency and subchondral collapse are late changes. The earliest evidence on plain films is the affected area appearing as being more radio-opaque due to hyperaemia and resorption of the neighboring area. It may be diagnosed earlier using bone scans and MRI. Avascular necrosis Cellular death of bone components due to interruption of the blood supply, causing bone destruction Main joints affected are hip, scaphoid, lunate and the talus. It is not the same as non union. The fracture has usually united. Radiological evidence is slow to appear. Vascular ingrowth into the affected bone may occur. However, many joints will develop secondary osteoarthritis. ``` Causes P ancreatitis L upus A lcohol S teroids T rauma I diopathic, infection C aisson disease, collagen vascular disease R adiation, rheumatoid arthritis A myloid G aucher disease S ickle cell disease ``` Presentation Usually pain. Often despite apparent fracture union. Investigation MRI scanning will show changes earlier than plain films. Treatment In fractures at high risk sites anticipation is key. Early prompt and accurate reduction is essential. Non weight bearing may help to facilitate vascular regeneration. Joint replacement may be necessary, or even the preferred option (e.g. Hip in the elderly).

Answer 26

Admit for open reduction and fixation Unlike an osteoporotic fracture in an elderly lady this is a high velocity injury and will require surgical fixation. Fracture management Bony injury resulting in a fracture may arise from trauma (excessive forces applied to bone), stress related (repetitive low velocity injury) or pathological (abnormal bone which fractures during normal use of following minimal trauma) Diagnosis involves not just evaluating the fracture ; such as site and type of injury but also other associated injuries and distal neurovascular deficits. This may entail not just clinical examination but radiographs of proximal and distal joints. When assessing x-rays it is important to assess for changes in length of the bone, the angulation of the distal bone, rotational effects, presence of material such as glass. Fracture types Fracture type Description Oblique fracture Fracture lies obliquely to long axis of bone Comminuted fracture >2 fragments Segmental fracture More than one fracture along a bone Transverse fracture Perpendicular to long axis of bone Spiral fracture Severe oblique fracture with rotation along long axis of bone Open Vs Closed It is also important to distinguish open from closed injuries. The most common classification system for open fractures is the Gustilo and Anderson classification system (given below): Grade Injury 1 Low energy wound <1cm 2 Greater than 1cm wound with moderate soft tissue damage 3 High energy wound > 1cm with extensive soft tissue damage 3 A (sub group of 3) Adequate soft tissue coverage 3 B (sub group of 3) Inadequate soft tissue coverage 3 C (sub group of 3) Associated arterial injury Key points in management of fractures Immobilise the fracture including the proximal and distal joints Carefully monitor and document neurovascular status, particularly following reduction and immobilisation Manage infection including tetanus prophylaxis IV broad spectrum antibiotics for open injuries As a general principle all open fractures should be thoroughly debrided ( and internal fixation devices avoided or used with extreme caution) Open fractures constitute an emergency and should be debrided and lavaged within 6 hours of injury

Answer 27

Fasciotomy The delay is the significant factor here. These injuries often have neurovascular compromise and inactivity now places him at risk of developing complications. In compartment syndrome the loss of arterial pulsation occurs late. Fracture management Bony injury resulting in a fracture may arise from trauma (excessive forces applied to bone), stress related (repetitive low velocity injury) or pathological (abnormal bone which fractures during normal use of following minimal trauma) Diagnosis involves not just evaluating the fracture ; such as site and type of injury but also other associated injuries and distal neurovascular deficits. This may entail not just clinical examination but radiographs of proximal and distal joints. When assessing x-rays it is important to assess for changes in length of the bone, the angulation of the distal bone, rotational effects, presence of material such as glass. Fracture types Fracture type Description Oblique fracture Fracture lies obliquely to long axis of bone Comminuted fracture >2 fragments Segmental fracture More than one fracture along a bone Transverse fracture Perpendicular to long axis of bone Spiral fracture Severe oblique fracture with rotation along long axis of bone Open Vs Closed It is also important to distinguish open from closed injuries. The most common classification system for open fractures is the Gustilo and Anderson classification system (given below): Grade Injury 1 Low energy wound <1cm 2 Greater than 1cm wound with moderate soft tissue damage 3 High energy wound > 1cm with extensive soft tissue damage 3 A (sub group of 3) Adequate soft tissue coverage 3 B (sub group of 3) Inadequate soft tissue coverage 3 C (sub group of 3) Associated arterial injury Key points in management of fractures Immobilise the fracture including the proximal and distal joints Carefully monitor and document neurovascular status, particularly following reduction and immobilisation Manage infection including tetanus prophylaxis IV broad spectrum antibiotics for open injuries As a general principle all open fractures should be thoroughly debrided ( and internal fixation devices avoided or used with extreme caution) Open fractures constitute an emergency and should be debrided and lavaged within 6 hours of injury

Answer 28

Discharge home with futura splint and fracture clinic appointment This could well be a scaphoid fracture and should be temporarily immobilised pending further review. A futura splint will immobilise better than an arm sling for this problem. Fracture management Bony injury resulting in a fracture may arise from trauma (excessive forces applied to bone), stress related (repetitive low velocity injury) or pathological (abnormal bone which fractures during normal use of following minimal trauma) Diagnosis involves not just evaluating the fracture ; such as site and type of injury but also other associated injuries and distal neurovascular deficits. This may entail not just clinical examination but radiographs of proximal and distal joints. When assessing x-rays it is important to assess for changes in length of the bone, the angulation of the distal bone, rotational effects, presence of material such as glass. Fracture types Fracture type Description Oblique fracture Fracture lies obliquely to long axis of bone Comminuted fracture >2 fragments Segmental fracture More than one fracture along a bone Transverse fracture Perpendicular to long axis of bone Spiral fracture Severe oblique fracture with rotation along long axis of bone Open Vs Closed It is also important to distinguish open from closed injuries. The most common classification system for open fractures is the Gustilo and Anderson classification system (given below): Grade Injury 1 Low energy wound <1cm 2 Greater than 1cm wound with moderate soft tissue damage 3 High energy wound > 1cm with extensive soft tissue damage 3 A (sub group of 3) Adequate soft tissue coverage 3 B (sub group of 3) Inadequate soft tissue coverage 3 C (sub group of 3) Associated arterial injury Key points in management of fractures Immobilise the fracture including the proximal and distal joints Carefully monitor and document neurovascular status, particularly following reduction and immobilisation Manage infection including tetanus prophylaxis IV broad spectrum antibiotics for open injuries As a general principle all open fractures should be thoroughly debrided ( and internal fixation devices avoided or used with extreme caution) Open fractures constitute an emergency and should be debrided and lavaged within 6 hours of injury

Answer 29

The mnemonic 'SALTR' can be used to help remember the first five types. This mnemonic requires the reader to imagine the bones as long bones, with the epiphyses at the base. I "S" = Slip (separated or straight across). Fracture of the cartilage of the physis (growth plate) II "A" = Above. The fracture lies above the physis, or Away from the joint. III "L" = Lower. The fracture is below the physis in the epiphysis. IV "TE" = Through Everything. The fracture is through the metaphysis, physis, and epiphysis. V "R" = Rammed (crushed). The physis has been crushed The Salter - Harris system is most commonly used. The radiological signs in Type 1 and 5 injuries may be identical. Which is unfortunate as type 5 injuries do not do well (and may be missed!). One of our users has helpfully supplied a mnemonic for remembering the types (see above). Paediatric fracture types Type Injury pattern Complete fracture Both sides of cortex are breached Toddlers fracture Oblique tibial fracture in infants Plastic deformity Stress on bone resulting in deformity without cortical disruption Greenstick fracture Unilateral cortical breach only Buckle fracture Incomplete cortical disruption resulting in periosteal haematoma only Growth plate fractures In paediatric practice fractures may also involve the growth plate and these injuries are classified according to the Salter- Harris system (given below): Type Injury pattern I Fracture through the physis only (x-ray often normal) II Fracture through the physis and metaphysis III Fracture through the physis and epiphyisis to include the joint IV Fracture involving the physis, metaphysis and epiphysis V Crush injury involving the physis (x-ray may resemble type I, and appear normal) As a general rule it is safer to assume that growth plate tenderness is indicative of an underlying fracture even if the x-ray appears normal. Injuries of Types III, IV and V will usually require surgery. Type V injuries are often associated with disruption to growth. Non accidental injury Delayed presentation Delay in attaining milestones Lack of concordance between proposed and actual mechanism of injury Multiple injuries Injuries at sites not commonly exposed to trauma Children on the at risk register Pathological fractures Genetic conditions, such as osteogenesis imperfecta, may cause pathological fractures. Osteogenesis imperfecta Defective osteoid formation due to congenital inability to produce adequate intercellular substances like osteoid, collagen and dentine. Failure of maturation of collagen in all the connective tissues. Radiology may show translucent bones, multiple fractures, particularly of the long bones, wormian bones (irregular patches of ossification) and a trefoil pelvis. Subtypes Type I The collagen is normal quality but insufficient quantity. Type II- Poor collagen quantity and quality. Type III- Collagen poorly formed. Normal quantity. Type IV- Sufficient collagen quantity but poor quality. ``` Osteopetrosis Bones become harder and more dense. Autosomal recessive condition. It is commonest in young adults. Radiology reveals a lack of differentiation between the cortex and the medulla described as marble bone. ```

Answer 30

Metastatic breast cancer Increasing pain at rest, together with increased serum calcium and alkaline phosphatase are most likely to represent metastatic tumour to bone. Chondrosarcomas do occur in the pelvis but are not associated with increased serum calcium and typically have a longer history. Pagets Focal bone resorption followed by excessive and chaotic bone deposition Affects (in order): spine, skull, pelvis and femur Serum alkaline phosphatase raised (other parameters normal) Abnormal thickened, sclerotic bone on x-rays Risk of cardiac failure with >15% bony involvement Small risk of sarcomatous change Bisphosphonates Osteoporosis Excessive bone resorption resulting in demineralised bone Commoner in old age Increased risk of pathological fracture, otherwise asymptomatic Alkaline phosphatase normal, calcium normal Bisphosphonates, calcium and vitamin D Secondary bone tumours Bone destruction and tumour infiltration Mirel scoring used to predict risk of fracture Appearances depend on primary (e.g.sclerotic - prostate, lytic - breast) Elevated serum calcium and alkaline phosphatase may be seen Radiotherapy, prophylactic fixation and analgesia

Answer 31

Pagets disease This is a typical scenario for Pagets disease. Pagets Focal bone resorption followed by excessive and chaotic bone deposition Affects (in order): spine, skull, pelvis and femur Serum alkaline phosphatase raised (other parameters normal) Abnormal thickened, sclerotic bone on x-rays Risk of cardiac failure with >15% bony involvement Small risk of sarcomatous change Bisphosphonates Osteoporosis Excessive bone resorption resulting in demineralised bone Commoner in old age Increased risk of pathological fracture, otherwise asymptomatic Alkaline phosphatase normal, calcium normal Bisphosphonates, calcium and vitamin D Secondary bone tumours Bone destruction and tumour infiltration Mirel scoring used to predict risk of fracture Appearances depend on primary (e.g.sclerotic - prostate, lytic - breast) Elevated serum calcium and alkaline phosphatase may be seen Radiotherapy, prophylactic fixation and analgesia

Answer 32

Osteoporosis The combination of age, female gender and steroids coupled with hip pain on minor trauma are strongly suggestive of osteoporosis. Pagets Focal bone resorption followed by excessive and chaotic bone deposition Affects (in order): spine, skull, pelvis and femur Serum alkaline phosphatase raised (other parameters normal) Abnormal thickened, sclerotic bone on x-rays Risk of cardiac failure with >15% bony involvement Small risk of sarcomatous change Bisphosphonates Osteoporosis Excessive bone resorption resulting in demineralised bone Commoner in old age Increased risk of pathological fracture, otherwise asymptomatic Alkaline phosphatase normal, calcium normal Bisphosphonates, calcium and vitamin D Secondary bone tumours Bone destruction and tumour infiltration Mirel scoring used to predict risk of fracture Appearances depend on primary (e.g.sclerotic - prostate, lytic - breast) Elevated serum calcium and alkaline phosphatase may be seen Radiotherapy, prophylactic fixation and analgesia Ankylosing spondylitis Chronic inflammatory disorder affecting the axial skeleton Sacro-ilitis is a usually visible in plain films Up to 20% of those who are HLA B27 positive will develop the condition Affected articulations develop bony or fibrous changes Typical spinal features include loss of the lumbar lordosis and progressive kyphosis of the cervico-thoracic spine Scheuermann's disease Epiphysitis of the vertebral joints is the main pathological process Predominantly affects adolescents Symptoms include back pain and stiffness X-ray changes include epiphyseal plate disturbance and anterior wedging Clinical features include progressive kyphosis (at least 3 vertebrae must be involved) Minor cases may be managed with physiotherapy and analgesia, more severe cases may require bracing or surgical stabilisation Scoliosis Consists of curvature of the spine in the coronal plane Divisible into structural and non structural, the latter being commonest in adolescent females who develop minor postural changes only. Postural scoliosis will typically disappear on manoeuvres such as bending forwards Structural scoliosis affects > 1 vertebral body and is divisible into idiopathic, congential and neuromuscular in origin. It is not correctable by alterations in posture Within structural scoliosis, idiopathic is the most common type Severe, or progressive structural disease is often managed surgically with bilateral rod stabilisation of the spine Spina bifida Non fusion of the vertebral arches during embryonic development Three categories; myelomeningocele, spina bifida occulta and meningocele Myelomeningocele is the most severe type with associated neurological defects that may persist in spite of anatomical closure of the defect Up to 10% of the population may have spina bifida occulta, in this condition the skin and tissues (but not not bones) may develop over the distal cord. The site may be identifiable by a birth mark or hair patch The incidence of the condition is reduced by use of folic acid supplements during pregnancy Spondylolysis Congenital or acquired deficiency of the pars interarticularis of the neural arch of a particular vertebral body, usually affects L4/ L5 May be asymptomatic and affects up to 5% of the population Spondylolysis is the commonest cause of spondylolisthesis in children Asymptomatic cases do not require treatment Spondylolisthesis This occurs when one vertebra is displaced relative to its immediate inferior vertebral body May occur as a result of stress fracture or spondylolysis Traumatic cases may show the classic "Scotty Dog" appearance on plain films Treatment depends upon the extent of deformity and associated neurological symptoms, minor cases may be actively monitored. Individuals with radicular symptoms or signs will usually require spinal decompression and stabilisation

Answer 33

Spondylolisthesis Young athletic females are the group most frequently affected by spondylolythesis who have a background of spondylolysis. Whilst the latter condition is a risk factor for spondylolythesis the former condition is most likely in a young athletic female who presents with sudden pain. Ankylosing spondylitis Chronic inflammatory disorder affecting the axial skeleton Sacro-ilitis is a usually visible in plain films Up to 20% of those who are HLA B27 positive will develop the condition Affected articulations develop bony or fibrous changes Typical spinal features include loss of the lumbar lordosis and progressive kyphosis of the cervico-thoracic spine Scheuermann's disease Epiphysitis of the vertebral joints is the main pathological process Predominantly affects adolescents Symptoms include back pain and stiffness X-ray changes include epiphyseal plate disturbance and anterior wedging Clinical features include progressive kyphosis (at least 3 vertebrae must be involved) Minor cases may be managed with physiotherapy and analgesia, more severe cases may require bracing or surgical stabilisation Scoliosis Consists of curvature of the spine in the coronal plane Divisible into structural and non structural, the latter being commonest in adolescent females who develop minor postural changes only. Postural scoliosis will typically disappear on manoeuvres such as bending forwards Structural scoliosis affects > 1 vertebral body and is divisible into idiopathic, congential and neuromuscular in origin. It is not correctable by alterations in posture Within structural scoliosis, idiopathic is the most common type Severe, or progressive structural disease is often managed surgically with bilateral rod stabilisation of the spine Spina bifida Non fusion of the vertebral arches during embryonic development Three categories; myelomeningocele, spina bifida occulta and meningocele Myelomeningocele is the most severe type with associated neurological defects that may persist in spite of anatomical closure of the defect Up to 10% of the population may have spina bifida occulta, in this condition the skin and tissues (but not not bones) may develop over the distal cord. The site may be identifiable by a birth mark or hair patch The incidence of the condition is reduced by use of folic acid supplements during pregnancy Spondylolysis Congenital or acquired deficiency of the pars interarticularis of the neural arch of a particular vertebral body, usually affects L4/ L5 May be asymptomatic and affects up to 5% of the population Spondylolysis is the commonest cause of spondylolisthesis in children Asymptomatic cases do not require treatment Spondylolisthesis This occurs when one vertebra is displaced relative to its immediate inferior vertebral body May occur as a result of stress fracture or spondylolysis Traumatic cases may show the classic "Scotty Dog" appearance on plain films Treatment depends upon the extent of deformity and associated neurological symptoms, minor cases may be actively monitored. Individuals with radicular symptoms or signs will usually require spinal decompression and stabilisation

Answer 34

Spina bifida occulta Spina bifida occulta is a common condition and may affect up to 10% of the population. The more severe types of spina bifida have more characteristic skin changes. Occasionally the unwary surgeon is persuaded to operate on these cutaneous changes and we would advocate performing an MRI scan prior to any such surgical procedure in this region. Ankylosing spondylitis Chronic inflammatory disorder affecting the axial skeleton Sacro-ilitis is a usually visible in plain films Up to 20% of those who are HLA B27 positive will develop the condition Affected articulations develop bony or fibrous changes Typical spinal features include loss of the lumbar lordosis and progressive kyphosis of the cervico-thoracic spine Scheuermann's disease Epiphysitis of the vertebral joints is the main pathological process Predominantly affects adolescents Symptoms include back pain and stiffness X-ray changes include epiphyseal plate disturbance and anterior wedging Clinical features include progressive kyphosis (at least 3 vertebrae must be involved) Minor cases may be managed with physiotherapy and analgesia, more severe cases may require bracing or surgical stabilisation Scoliosis Consists of curvature of the spine in the coronal plane Divisible into structural and non structural, the latter being commonest in adolescent females who develop minor postural changes only. Postural scoliosis will typically disappear on manoeuvres such as bending forwards Structural scoliosis affects > 1 vertebral body and is divisible into idiopathic, congential and neuromuscular in origin. It is not correctable by alterations in posture Within structural scoliosis, idiopathic is the most common type Severe, or progressive structural disease is often managed surgically with bilateral rod stabilisation of the spine Spina bifida Non fusion of the vertebral arches during embryonic development Three categories; myelomeningocele, spina bifida occulta and meningocele Myelomeningocele is the most severe type with associated neurological defects that may persist in spite of anatomical closure of the defect Up to 10% of the population may have spina bifida occulta, in this condition the skin and tissues (but not not bones) may develop over the distal cord. The site may be identifiable by a birth mark or hair patch The incidence of the condition is reduced by use of folic acid supplements during pregnancy Spondylolysis Congenital or acquired deficiency of the pars interarticularis of the neural arch of a particular vertebral body, usually affects L4/ L5 May be asymptomatic and affects up to 5% of the population Spondylolysis is the commonest cause of spondylolisthesis in children Asymptomatic cases do not require treatment Spondylolisthesis This occurs when one vertebra is displaced relative to its immediate inferior vertebral body May occur as a result of stress fracture or spondylolysis Traumatic cases may show the classic "Scotty Dog" appearance on plain films Treatment depends upon the extent of deformity and associated neurological symptoms, minor cases may be actively monitored. Individuals with radicular symptoms or signs will usually require spinal decompression and stabilisation

Answer 35

Ankylosing spondylitis Ankylosing spondylitis is associated with HLA B27, there is a strong association with ulcerative colitis in such individuals. The clinical findings are usually of a kyphosis affecting the cervical and thoracic spine. Considerable symptomatic benefit may be obtained using non steroidal anti inflammatory drugs. These should be used carefully in patients with inflammatory bowel disease who may be taking steroids. Ankylosing spondylitis Chronic inflammatory disorder affecting the axial skeleton Sacro-ilitis is a usually visible in plain films Up to 20% of those who are HLA B27 positive will develop the condition Affected articulations develop bony or fibrous changes Typical spinal features include loss of the lumbar lordosis and progressive kyphosis of the cervico-thoracic spine Scheuermann's disease Epiphysitis of the vertebral joints is the main pathological process Predominantly affects adolescents Symptoms include back pain and stiffness X-ray changes include epiphyseal plate disturbance and anterior wedging Clinical features include progressive kyphosis (at least 3 vertebrae must be involved) Minor cases may be managed with physiotherapy and analgesia, more severe cases may require bracing or surgical stabilisation Scoliosis Consists of curvature of the spine in the coronal plane Divisible into structural and non structural, the latter being commonest in adolescent females who develop minor postural changes only. Postural scoliosis will typically disappear on manoeuvres such as bending forwards Structural scoliosis affects > 1 vertebral body and is divisible into idiopathic, congential and neuromuscular in origin. It is not correctable by alterations in posture Within structural scoliosis, idiopathic is the most common type Severe, or progressive structural disease is often managed surgically with bilateral rod stabilisation of the spine Spina bifida Non fusion of the vertebral arches during embryonic development Three categories; myelomeningocele, spina bifida occulta and meningocele Myelomeningocele is the most severe type with associated neurological defects that may persist in spite of anatomical closure of the defect Up to 10% of the population may have spina bifida occulta, in this condition the skin and tissues (but not not bones) may develop over the distal cord. The site may be identifiable by a birth mark or hair patch The incidence of the condition is reduced by use of folic acid supplements during pregnancy Spondylolysis Congenital or acquired deficiency of the pars interarticularis of the neural arch of a particular vertebral body, usually affects L4/ L5 May be asymptomatic and affects up to 5% of the population Spondylolysis is the commonest cause of spondylolisthesis in children Asymptomatic cases do not require treatment Spondylolisthesis This occurs when one vertebra is displaced relative to its immediate inferior vertebral body May occur as a result of stress fracture or spondylolysis Traumatic cases may show the classic "Scotty Dog" appearance on plain films Treatment depends upon the extent of deformity and associated neurological symptoms, minor cases may be actively monitored. Individuals with radicular symptoms or signs will usually require spinal decompression and stabilisation

Answer 36

Adhesive capsulitis Frozen shoulder passes through an initial painful stage followed by a period of joint stiffness. With physiotherapy the problem will usually resolve although it may take up to 2 years to do so. Shoulder fractures and dislocations Fractures Proximal humerus Background Third most common fragility fracture in the elderly. Results from low energy fall in predominantly elderly females, or from high energy trauma in young males. Can be associated with nerve injury (commonly axillary), and fracture-dislocation of the humeral head. Detailed neurological assessment is essential for all upper limb injuries. Anatomy Osteology Consists of articular head, greater tuberosity, lesser tuberosity, metaphysis and diaphysis. Between the articular head and the tuberosities is the anatomical neck (previous physis). Between the tuberosities and the metaphysis is the surgical neck. The supraspinatus, infraspinatus and teres minor muscles attach to the greater tuberosity. The subscapularis muscle attaches to the lesser tuberosity. Vascular Supply Humeral head is supplied by the anterior and posterior humeral circumflex arteries. Anatomical neck fractures are at greatest risk of osteonecrosis. Imaging Imaging aims to both delineate the fracture pattern, and confirm/exlude the presence of an associated dislocation. Radiographs - True anteroposterior (AP), axillary lateral and/or scapula Y view. CT - indicated to better define intra-articular involvement and to aid pre-operative planning. MRI is not useful for fracture imaging. Classification Description of the fracture is often more useful than classification. Particular attention should be paid to humeral alignment, fracture displacement, and greater tuberosity position (rotator cuff will pull the GT supero-posterioly, which can cause impingement problems with malunion). - Neer Classification: Most commonly used. Describes fracture as 2,3,or 4 part depending upon the number main fragments. Also comments on the degree of displacement. Fragments: -greater tuberosity -lesser tuberosity - articular surface - shaft Displacement: >1cm or angulation >45 degrees. Treatment The vast majority of proximal humeral fractures are minimally displaced, and therefore can be managed conservatively. This involves immobilisation in a polysling, and progressive mobilisation. Pendular exercise can commence at 14 days, and active abduction from 4-6 weeks. Irreducible fracture dislocation is an indication for operative management. Other indications include large displacement, younger patient, head splitting (intra-articular fractures). However, the recent PROFHER trial (1) has suggested no benefit to operative intervention on patient outcome (it must be applied cautiously as majority of patients were elderly with extraarticular fractures). Options available for surgical management include: ORIF Most commonly used. Plate and screw fixation. Can reconstruct complex fractures. Intramedullary nail Suitable for extra-articular configuration, predominantly surgical neck +/- GT fractures. Hemiarthroplasty Used for un-reconstructable fractures in the older patient who has good glenoid quality. Total shoulder arthroplasty Unconstructable fractures where high functioning shoulder is required (hemiarthroplasty will cause glenoid erosion) Reverse shoulder arthroplasty Total shoulder arthroplasty that provides better functional outcome than conventional total shoulder replacement. Scapula Background Uncommon fractures usually associated with high energy trauma. Most commonly involve scapula body or spine (50%), glenoid fossa and glenoid neck. Important to exclude associated life threatening injury. Imaging Plain radiographs should include true anteroposterior (AP), axillary lateral and/or scapula Y view. CT scanning is useful for defining intra-articular involvement, displacement and for three dimensional reconstruction. Classification Based on the location of the fracture (coracoid, acromion, glenoid neck, glenoid fossa, scapula body). Beware of ipsilateral glenoid neck and clavicle fracture -floating shoulder - where limb is effectively dissociated from axial skeleton. Treatment The vast majority of scapula fractures are amenable to conservative management, consisting of sling immobilisation for two weeks followed by early rehabilitation. Floating shoulder will usually require fixation, and consideration of surgery should also be given to intra-articular and displaced/angulated glenoid fractures. Dislocations Types Dislocations around the shoulder joint include glenohumeral dislocation, acromioclavicular joint disruption and sternoclavicular dislocation. Only glenohumeral dislocation will be covered here. Glenohumeral dislocation Diagnosis, classification and management are covered here. Background Shoulder dislocation is commonly seen in A&E. It has a high recurrence rate that is as high as 80% in teenagers. Initial management requires emergent reduction to prevent lasting chondral damage. Early assessment and management Usually a traumatic cause (multi-directional instability in frequent dislocations requires discussion with orthopaedics and is not covered here). Careful history, examination and documentation of neurovascular status of the limb, in particular the axillary nerve (regimental badge sensation). This should be re-assessed post manipulation. Early radiographs to confirm direction of dislocation. Initial management consists of emergent closed reduction under under entanox and analgesia, but often requires conscious sedation. Arm should then be immobilised in a polysling, and XR to confirm relocation. Imaging - True anteroposterior (AP), axillary lateral and/or scapula Y view. Reduced humeral head should lie between acromion and coracoid on lateral/scapula view. Types Direction Features Cause Examination Reduction techniques Anterior Most Common >90% Usually traumatic - anterior force on arm when shoulder is abducted, eternally rotated Loss of shoulder contour - sulcus sign. Humeral head can be felt anteriorly. Hippocratic. Milch. Stimson. Kocher not advised due to complication of fracture Posterior 50% missed in A&E 50% traumatic, but classically post seizure or electrocution Shoulder locked in internal rotation. XR may show lightbulb appearance. Gentle lateral traction to adducted arm. Inferior Rare Associated with pectorals and rotator cuff tears, and glenoid fracture As for primary injury Management of primary injury Superior Rare Associated with acrominon/clavicle fracture As for primary injury Management of primary injury Associated injuries Bankart lesion - avulsion of the anterior glenoid labrum with an anterior shoulder dislocation (reverse Bankart if poster labrum in posterior dislocation). Hill Sachs defect - chondral impaction on posteriosuperior humeral head from contact with gleonoid rim. Can be large enough to lock shoulder, requiring open reduction. (Reverse Hill Sachs in posterior dislocation). Rotator cuff tear - increases with age. Greater or lesser tuberosity fracture - increases with age. Humeral neck fracture - shoulder fracture dislocation. More common in high energy trauma and elderly. Should be discussed with orthopaedics prior to any attempted reduction. Rotator Cuff Disease Rotator cuff disease is a spectrum of conditions that ranges from subacromial impingement to rotator cuff tears and eventually to rotator cuff arthropathy (arthritis). Anatomy The rotator cuff is a group of four muscles that are important in shoulder movements, and maintenance of glenohumeral stability. Muscle Scapular attachment Humeral attachment Action Innervation Supraspinatus Supraspinatus fossa Superior facet of greater tuberosity Initiation of abduction of humerus Suprascapular nerve Infraspinatus Infraspinatus fossa Posterior facet of greater tuberosity External rotation of humerus Suprascapular nerve Teres Minor Lateral border Inferior facet of greater tuberosity External rotation of humerus Axillary Nerve Subscapularis Subscapular fossa Lesser tuberosity Internal rotation of humerus Upper and lower subscapular nerve The inferior rotator cuff muscles (infraspinatus, teres minor, and subscapularis) balance the superior pull of the deltoid. Injury/tear results in upward migration of the humeral head on the glenoid (can be seen on AP radiograph). Likewise, the anterior muscles (subscapularis) are balanced with the posterior muscles (infraspinatus, teres minor). Subacromial Impingement The most common cause of shoulder pain, which results from impingement of the superior cuff on the undersurface of the acromion, and an inflammatory bursitis. Associated with certain types of acromial morphology (Bigliani classification). Presents as insidious pain which is exacerbated by overhead activities. Rotator Cuff Tear Often presents as an acute event on the background of chronic subacromial impingement in the older patient, but can present as an avulsion injury in younger patients. Majority of tears are to the superior cuff (supraspinatus, infraspinatus, teres minor), though a tear to subscapularis is associated with subcoracoid impingement. Tears present as pain and weakness when using the muscles in question. Rotator Cuff Arthropathy Defined as shoulder arthritis in the setting of rotator cuff dysfunction. Results from superior migration due to the loss of rotator cuff function and integrity. Unopposed deltoid pulls the humeral head superiorly. Associated with massive chronic cuff tears. Imaging Plain radiographs AP of the shoulder may show superior migration of the humerus with a cuff tear, and features of arthritis with arthropathy. Other causes of pain may also be identified (e.g. calcific tendonitis/fracture) Outlet view is useful for defining the acromial morphology USS Allows dynamic imaging of the cuff, and is inexpensive. However, it is very user dependent. MRI Best imaging modality for cuff pathology. Also allows imaging of the rest of the shoulder. When intra-articular pathology is suspected, can be combined with an arthrogram for improved sensitivity and specificity. Treatment Subacromial impingement Physiotherapy, oral anti-inflammatory medication Subacromial steroid injection can settle inflammation Arthroscopic subacromial decompression by shaving away the undersurface of the acromion, more space is created for the rotator cuff. Cuff integrity is assessed also at time of surgery, and can be repaired if necessary. Rotator cuff tear When considering repair of a cuff tear, the age and activity of the patient, the nature of the tear (degenerative vs. acute traumatic), and the size and retraction of the tear should be considered when making a surgical plan. Mild tears or tears in the elderly can be managed conservatively, as outlined above. Moderate tears can be repaired arthroscopically. Massive or retracted tears will often require an open repair (occasionally with a tendon transfer). Subacromial decompression is performed at the same time to reduce impingement, symptoms and recurrence. Calcific tendonitis Calcific tendonitis involves calcific deposits within tendons anywhere in the body, but most commonly in the rotator cuff (specifically the supraspinatus tendon). When present in the shoulder, it is associated with subacromial impingement and pain. Pathology More common in women aged 30-60 years. Association with diabetes and hypothyroidism There are three stages of calcification Formative phase characterized by calcific deposits Resting phase deposit is stable, but presents with impingement problems Resorptive phase phagocytic resorption. Most painful stage. Presentation Similar in presentation to subacromial impingement, with pain especially with over head activities. Atraumatic in nature. Imaging Plain radiographs show calcification of the rotator cuff, usually within 1.5cm of its insertion on the humerus. Supraspinatus outlet views can show level of impingment. Further imaging is rarely needed. Treatment Non-operative NSAIDS, steroid injection (controversial, but practiced) and physiotherapy. Approximately 75% will resolve by 6 months with conservative management. Ultrasound guided or surgical needle barbotage can break down deposits and resolve symptoms. Occasionally surgical excision is required. Adhesive capsulitis (Frozen Shoulder) Pain and loss of movement of shoulder joint, which involves fibroplastic proliferation of capsular tissue, causing soft tissue scarring and contracture. Patients present with a painful and decreased arc of motion. Associated with prolonged immobilization, previous surgery, thyroid disorders (AI) and diabetes Classically three stages which can take up to two years to resolve: Stage one the freezing and painful stage Stage two the frozen and stiff stage Stage three the thawing stage, where shoulder movement slowly improves Imaging Plain radiographs to exclude other causes of a painful shoulder MRI arthrogram may show capsular contracture, and again may be used to exclude cuff pathology. However, often not performed as diagnosis is largely clinical. Treatment Non-operative NSAIDS, steroid injection and physiotherapy. Patience is required as condition can take up to 2 years to improve. Operative MUA or arthroscopic adhesiolysis (release of adhesions) can expedite recovery, followed by intensive physiotherapy. Glenohumeral Arthritis Background May be osteoarthritis (primary or secondary to cuff tear or trauma), rheumatoid arthritis, or as part of a spondyloarthropathy. Majority of those with RA will develop symptoms. More common in the elderly Presents like any other arthritis - pain at night and with movement Imaging AP and axillary radiographs will show features of arthritis. CT/MRI is often useful to classify the shape of the glenoid and extent of bone loss when considering arthroplasty. MRI also essential to asses integrity of rotator cuff if considering shoulder replacement. Treatment Like all orthopaedics, start with simple measures: NSAIDS, management of RA, physiotherapy, steroid injection. Hemiarthroplasty can sometimes be considered if glenoid is in excellent condition or if patient has large comorbidity. Arthroscopic debridement is useful if patient has isolated ACJ arthritis, but is rarely used for glenohumeral arthritis. Total shoulder replacement is shown to produce superior outcome when compared to hemiarthroplasty in terms of pain relief, function and implant survival. Total shoulder replacement can be anatomical (ball on humerus, with cup on glenoid), or reverse geometry (ball on glenoid, with cup on humerus). Anatomical TSR requires an in tact rotator cuff, so often reverse is preferable when the cuff if questionable in integrity.

Answer 37

Rotator cuff tear Rotator cuff tears are common in elderly people and may occur following minor trauma or as a result of long standing impingement. Tears greater than 2cm should generally be repaired surgically. The length of the history in this scenario is suggestive of a tear complicating impingement. Shoulder fractures and dislocations Fractures Proximal humerus Background Third most common fragility fracture in the elderly. Results from low energy fall in predominantly elderly females, or from high energy trauma in young males. Can be associated with nerve injury (commonly axillary), and fracture-dislocation of the humeral head. Detailed neurological assessment is essential for all upper limb injuries. Anatomy Osteology Consists of articular head, greater tuberosity, lesser tuberosity, metaphysis and diaphysis. Between the articular head and the tuberosities is the anatomical neck (previous physis). Between the tuberosities and the metaphysis is the surgical neck. The supraspinatus, infraspinatus and teres minor muscles attach to the greater tuberosity. The subscapularis muscle attaches to the lesser tuberosity. Vascular Supply Humeral head is supplied by the anterior and posterior humeral circumflex arteries. Anatomical neck fractures are at greatest risk of osteonecrosis. Imaging Imaging aims to both delineate the fracture pattern, and confirm/exlude the presence of an associated dislocation. Radiographs - True anteroposterior (AP), axillary lateral and/or scapula Y view. CT - indicated to better define intra-articular involvement and to aid pre-operative planning. MRI is not useful for fracture imaging. Classification Description of the fracture is often more useful than classification. Particular attention should be paid to humeral alignment, fracture displacement, and greater tuberosity position (rotator cuff will pull the GT supero-posterioly, which can cause impingement problems with malunion). - Neer Classification: Most commonly used. Describes fracture as 2,3,or 4 part depending upon the number main fragments. Also comments on the degree of displacement. Fragments: -greater tuberosity -lesser tuberosity - articular surface - shaft Displacement: >1cm or angulation >45 degrees. Treatment The vast majority of proximal humeral fractures are minimally displaced, and therefore can be managed conservatively. This involves immobilisation in a polysling, and progressive mobilisation. Pendular exercise can commence at 14 days, and active abduction from 4-6 weeks. Irreducible fracture dislocation is an indication for operative management. Other indications include large displacement, younger patient, head splitting (intra-articular fractures). However, the recent PROFHER trial (1) has suggested no benefit to operative intervention on patient outcome (it must be applied cautiously as majority of patients were elderly with extraarticular fractures). Options available for surgical management include: ORIF Most commonly used. Plate and screw fixation. Can reconstruct complex fractures. Intramedullary nail Suitable for extra-articular configuration, predominantly surgical neck +/- GT fractures. Hemiarthroplasty Used for un-reconstructable fractures in the older patient who has good glenoid quality. Total shoulder arthroplasty Unconstructable fractures where high functioning shoulder is required (hemiarthroplasty will cause glenoid erosion) Reverse shoulder arthroplasty Total shoulder arthroplasty that provides better functional outcome than conventional total shoulder replacement. Scapula Background Uncommon fractures usually associated with high energy trauma. Most commonly involve scapula body or spine (50%), glenoid fossa and glenoid neck. Important to exclude associated life threatening injury. Imaging Plain radiographs should include true anteroposterior (AP), axillary lateral and/or scapula Y view. CT scanning is useful for defining intra-articular involvement, displacement and for three dimensional reconstruction. Classification Based on the location of the fracture (coracoid, acromion, glenoid neck, glenoid fossa, scapula body). Beware of ipsilateral glenoid neck and clavicle fracture -floating shoulder - where limb is effectively dissociated from axial skeleton. Treatment The vast majority of scapula fractures are amenable to conservative management, consisting of sling immobilisation for two weeks followed by early rehabilitation. Floating shoulder will usually require fixation, and consideration of surgery should also be given to intra-articular and displaced/angulated glenoid fractures. Dislocations Types Dislocations around the shoulder joint include glenohumeral dislocation, acromioclavicular joint disruption and sternoclavicular dislocation. Only glenohumeral dislocation will be covered here. Glenohumeral dislocation Diagnosis, classification and management are covered here. Background Shoulder dislocation is commonly seen in A&E. It has a high recurrence rate that is as high as 80% in teenagers. Initial management requires emergent reduction to prevent lasting chondral damage. Early assessment and management Usually a traumatic cause (multi-directional instability in frequent dislocations requires discussion with orthopaedics and is not covered here). Careful history, examination and documentation of neurovascular status of the limb, in particular the axillary nerve (regimental badge sensation). This should be re-assessed post manipulation. Early radiographs to confirm direction of dislocation. Initial management consists of emergent closed reduction under under entanox and analgesia, but often requires conscious sedation. Arm should then be immobilised in a polysling, and XR to confirm relocation. Imaging - True anteroposterior (AP), axillary lateral and/or scapula Y view. Reduced humeral head should lie between acromion and coracoid on lateral/scapula view. Types Direction Features Cause Examination Reduction techniques Anterior Most Common >90% Usually traumatic - anterior force on arm when shoulder is abducted, eternally rotated Loss of shoulder contour - sulcus sign. Humeral head can be felt anteriorly. Hippocratic. Milch. Stimson. Kocher not advised due to complication of fracture Posterior 50% missed in A&E 50% traumatic, but classically post seizure or electrocution Shoulder locked in internal rotation. XR may show lightbulb appearance. Gentle lateral traction to adducted arm. Inferior Rare Associated with pectorals and rotator cuff tears, and glenoid fracture As for primary injury Management of primary injury Superior Rare Associated with acrominon/clavicle fracture As for primary injury Management of primary injury Associated injuries Bankart lesion - avulsion of the anterior glenoid labrum with an anterior shoulder dislocation (reverse Bankart if poster labrum in posterior dislocation). Hill Sachs defect - chondral impaction on posteriosuperior humeral head from contact with gleonoid rim. Can be large enough to lock shoulder, requiring open reduction. (Reverse Hill Sachs in posterior dislocation). Rotator cuff tear - increases with age. Greater or lesser tuberosity fracture - increases with age. Humeral neck fracture - shoulder fracture dislocation. More common in high energy trauma and elderly. Should be discussed with orthopaedics prior to any attempted reduction. Rotator Cuff Disease Rotator cuff disease is a spectrum of conditions that ranges from subacromial impingement to rotator cuff tears and eventually to rotator cuff arthropathy (arthritis). Anatomy The rotator cuff is a group of four muscles that are important in shoulder movements, and maintenance of glenohumeral stability. Muscle Scapular attachment Humeral attachment Action Innervation Supraspinatus Supraspinatus fossa Superior facet of greater tuberosity Initiation of abduction of humerus Suprascapular nerve Infraspinatus Infraspinatus fossa Posterior facet of greater tuberosity External rotation of humerus Suprascapular nerve Teres Minor Lateral border Inferior facet of greater tuberosity External rotation of humerus Axillary Nerve Subscapularis Subscapular fossa Lesser tuberosity Internal rotation of humerus Upper and lower subscapular nerve The inferior rotator cuff muscles (infraspinatus, teres minor, and subscapularis) balance the superior pull of the deltoid. Injury/tear results in upward migration of the humeral head on the glenoid (can be seen on AP radiograph). Likewise, the anterior muscles (subscapularis) are balanced with the posterior muscles (infraspinatus, teres minor). Subacromial Impingement The most common cause of shoulder pain, which results from impingement of the superior cuff on the undersurface of the acromion, and an inflammatory bursitis. Associated with certain types of acromial morphology (Bigliani classification). Presents as insidious pain which is exacerbated by overhead activities. Rotator Cuff Tear Often presents as an acute event on the background of chronic subacromial impingement in the older patient, but can present as an avulsion injury in younger patients. Majority of tears are to the superior cuff (supraspinatus, infraspinatus, teres minor), though a tear to subscapularis is associated with subcoracoid impingement. Tears present as pain and weakness when using the muscles in question. Rotator Cuff Arthropathy Defined as shoulder arthritis in the setting of rotator cuff dysfunction. Results from superior migration due to the loss of rotator cuff function and integrity. Unopposed deltoid pulls the humeral head superiorly. Associated with massive chronic cuff tears. Imaging Plain radiographs AP of the shoulder may show superior migration of the humerus with a cuff tear, and features of arthritis with arthropathy. Other causes of pain may also be identified (e.g. calcific tendonitis/fracture) Outlet view is useful for defining the acromial morphology USS Allows dynamic imaging of the cuff, and is inexpensive. However, it is very user dependent. MRI Best imaging modality for cuff pathology. Also allows imaging of the rest of the shoulder. When intra-articular pathology is suspected, can be combined with an arthrogram for improved sensitivity and specificity. Treatment Subacromial impingement Physiotherapy, oral anti-inflammatory medication Subacromial steroid injection can settle inflammation Arthroscopic subacromial decompression by shaving away the undersurface of the acromion, more space is created for the rotator cuff. Cuff integrity is assessed also at time of surgery, and can be repaired if necessary. Rotator cuff tear When considering repair of a cuff tear, the age and activity of the patient, the nature of the tear (degenerative vs. acute traumatic), and the size and retraction of the tear should be considered when making a surgical plan. Mild tears or tears in the elderly can be managed conservatively, as outlined above. Moderate tears can be repaired arthroscopically. Massive or retracted tears will often require an open repair (occasionally with a tendon transfer). Subacromial decompression is performed at the same time to reduce impingement, symptoms and recurrence. Calcific tendonitis Calcific tendonitis involves calcific deposits within tendons anywhere in the body, but most commonly in the rotator cuff (specifically the supraspinatus tendon). When present in the shoulder, it is associated with subacromial impingement and pain. Pathology More common in women aged 30-60 years. Association with diabetes and hypothyroidism There are three stages of calcification Formative phase characterized by calcific deposits Resting phase deposit is stable, but presents with impingement problems Resorptive phase phagocytic resorption. Most painful stage. Presentation Similar in presentation to subacromial impingement, with pain especially with over head activities. Atraumatic in nature. Imaging Plain radiographs show calcification of the rotator cuff, usually within 1.5cm of its insertion on the humerus. Supraspinatus outlet views can show level of impingment. Further imaging is rarely needed. Treatment Non-operative NSAIDS, steroid injection (controversial, but practiced) and physiotherapy. Approximately 75% will resolve by 6 months with conservative management. Ultrasound guided or surgical needle barbotage can break down deposits and resolve symptoms. Occasionally surgical excision is required. Adhesive capsulitis (Frozen Shoulder) Pain and loss of movement of shoulder joint, which involves fibroplastic proliferation of capsular tissue, causing soft tissue scarring and contracture. Patients present with a painful and decreased arc of motion. Associated with prolonged immobilization, previous surgery, thyroid disorders (AI) and diabetes Classically three stages which can take up to two years to resolve: Stage one the freezing and painful stage Stage two the frozen and stiff stage Stage three the thawing stage, where shoulder movement slowly improves Imaging Plain radiographs to exclude other causes of a painful shoulder MRI arthrogram may show capsular contracture, and again may be used to exclude cuff pathology. However, often not performed as diagnosis is largely clinical. Treatment Non-operative NSAIDS, steroid injection and physiotherapy. Patience is required as condition can take up to 2 years to improve. Operative MUA or arthroscopic adhesiolysis (release of adhesions) can expedite recovery, followed by intensive physiotherapy. Glenohumeral Arthritis Background May be osteoarthritis (primary or secondary to cuff tear or trauma), rheumatoid arthritis, or as part of a spondyloarthropathy. Majority of those with RA will develop symptoms. More common in the elderly Presents like any other arthritis - pain at night and with movement Imaging AP and axillary radiographs will show features of arthritis. CT/MRI is often useful to classify the shape of the glenoid and extent of bone loss when considering arthroplasty. MRI also essential to asses integrity of rotator cuff if considering shoulder replacement. Treatment Like all orthopaedics, start with simple measures: NSAIDS, management of RA, physiotherapy, steroid injection. Hemiarthroplasty can sometimes be considered if glenoid is in excellent condition or if patient has large comorbidity. Arthroscopic debridement is useful if patient has isolated ACJ arthritis, but is rarely used for glenohumeral arthritis. Total shoulder replacement is shown to produce superior outcome when compared to hemiarthroplasty in terms of pain relief, function and implant survival. Total shoulder replacement can be anatomical (ball on humerus, with cup on glenoid), or reverse geometry (ball on glenoid, with cup on humerus). Anatomical TSR requires an in tact rotator cuff, so often reverse is preferable when the cuff if questionable in integrity.

Answer 38

Parsonage - Turner syndrome This is a peripheral neuropathy that may complicate viral illnesses and usually resolves spontaneously. Shoulder fractures and dislocations Fractures Proximal humerus Background Third most common fragility fracture in the elderly. Results from low energy fall in predominantly elderly females, or from high energy trauma in young males. Can be associated with nerve injury (commonly axillary), and fracture-dislocation of the humeral head. Detailed neurological assessment is essential for all upper limb injuries. Anatomy Osteology Consists of articular head, greater tuberosity, lesser tuberosity, metaphysis and diaphysis. Between the articular head and the tuberosities is the anatomical neck (previous physis). Between the tuberosities and the metaphysis is the surgical neck. The supraspinatus, infraspinatus and teres minor muscles attach to the greater tuberosity. The subscapularis muscle attaches to the lesser tuberosity. Vascular Supply Humeral head is supplied by the anterior and posterior humeral circumflex arteries. Anatomical neck fractures are at greatest risk of osteonecrosis. Imaging Imaging aims to both delineate the fracture pattern, and confirm/exlude the presence of an associated dislocation. Radiographs - True anteroposterior (AP), axillary lateral and/or scapula Y view. CT - indicated to better define intra-articular involvement and to aid pre-operative planning. MRI is not useful for fracture imaging. Classification Description of the fracture is often more useful than classification. Particular attention should be paid to humeral alignment, fracture displacement, and greater tuberosity position (rotator cuff will pull the GT supero-posterioly, which can cause impingement problems with malunion). - Neer Classification: Most commonly used. Describes fracture as 2,3,or 4 part depending upon the number main fragments. Also comments on the degree of displacement. Fragments: -greater tuberosity -lesser tuberosity - articular surface - shaft Displacement: >1cm or angulation >45 degrees. Treatment The vast majority of proximal humeral fractures are minimally displaced, and therefore can be managed conservatively. This involves immobilisation in a polysling, and progressive mobilisation. Pendular exercise can commence at 14 days, and active abduction from 4-6 weeks. Irreducible fracture dislocation is an indication for operative management. Other indications include large displacement, younger patient, head splitting (intra-articular fractures). However, the recent PROFHER trial (1) has suggested no benefit to operative intervention on patient outcome (it must be applied cautiously as majority of patients were elderly with extraarticular fractures). Options available for surgical management include: ORIF Most commonly used. Plate and screw fixation. Can reconstruct complex fractures. Intramedullary nail Suitable for extra-articular configuration, predominantly surgical neck +/- GT fractures. Hemiarthroplasty Used for un-reconstructable fractures in the older patient who has good glenoid quality. Total shoulder arthroplasty Unconstructable fractures where high functioning shoulder is required (hemiarthroplasty will cause glenoid erosion) Reverse shoulder arthroplasty Total shoulder arthroplasty that provides better functional outcome than conventional total shoulder replacement. Scapula Background Uncommon fractures usually associated with high energy trauma. Most commonly involve scapula body or spine (50%), glenoid fossa and glenoid neck. Important to exclude associated life threatening injury. Imaging Plain radiographs should include true anteroposterior (AP), axillary lateral and/or scapula Y view. CT scanning is useful for defining intra-articular involvement, displacement and for three dimensional reconstruction. Classification Based on the location of the fracture (coracoid, acromion, glenoid neck, glenoid fossa, scapula body). Beware of ipsilateral glenoid neck and clavicle fracture -floating shoulder - where limb is effectively dissociated from axial skeleton. Treatment The vast majority of scapula fractures are amenable to conservative management, consisting of sling immobilisation for two weeks followed by early rehabilitation. Floating shoulder will usually require fixation, and consideration of surgery should also be given to intra-articular and displaced/angulated glenoid fractures. Dislocations Types Dislocations around the shoulder joint include glenohumeral dislocation, acromioclavicular joint disruption and sternoclavicular dislocation. Only glenohumeral dislocation will be covered here. Glenohumeral dislocation Diagnosis, classification and management are covered here. Background Shoulder dislocation is commonly seen in A&E. It has a high recurrence rate that is as high as 80% in teenagers. Initial management requires emergent reduction to prevent lasting chondral damage. Early assessment and management Usually a traumatic cause (multi-directional instability in frequent dislocations requires discussion with orthopaedics and is not covered here). Careful history, examination and documentation of neurovascular status of the limb, in particular the axillary nerve (regimental badge sensation). This should be re-assessed post manipulation. Early radiographs to confirm direction of dislocation. Initial management consists of emergent closed reduction under under entanox and analgesia, but often requires conscious sedation. Arm should then be immobilised in a polysling, and XR to confirm relocation. Imaging - True anteroposterior (AP), axillary lateral and/or scapula Y view. Reduced humeral head should lie between acromion and coracoid on lateral/scapula view. Types Direction Features Cause Examination Reduction techniques Anterior Most Common >90% Usually traumatic - anterior force on arm when shoulder is abducted, eternally rotated Loss of shoulder contour - sulcus sign. Humeral head can be felt anteriorly. Hippocratic. Milch. Stimson. Kocher not advised due to complication of fracture Posterior 50% missed in A&E 50% traumatic, but classically post seizure or electrocution Shoulder locked in internal rotation. XR may show lightbulb appearance. Gentle lateral traction to adducted arm. Inferior Rare Associated with pectorals and rotator cuff tears, and glenoid fracture As for primary injury Management of primary injury Superior Rare Associated with acrominon/clavicle fracture As for primary injury Management of primary injury Associated injuries Bankart lesion - avulsion of the anterior glenoid labrum with an anterior shoulder dislocation (reverse Bankart if poster labrum in posterior dislocation). Hill Sachs defect - chondral impaction on posteriosuperior humeral head from contact with gleonoid rim. Can be large enough to lock shoulder, requiring open reduction. (Reverse Hill Sachs in posterior dislocation). Rotator cuff tear - increases with age. Greater or lesser tuberosity fracture - increases with age. Humeral neck fracture - shoulder fracture dislocation. More common in high energy trauma and elderly. Should be discussed with orthopaedics prior to any attempted reduction. Rotator Cuff Disease Rotator cuff disease is a spectrum of conditions that ranges from subacromial impingement to rotator cuff tears and eventually to rotator cuff arthropathy (arthritis). Anatomy The rotator cuff is a group of four muscles that are important in shoulder movements, and maintenance of glenohumeral stability. Muscle Scapular attachment Humeral attachment Action Innervation Supraspinatus Supraspinatus fossa Superior facet of greater tuberosity Initiation of abduction of humerus Suprascapular nerve Infraspinatus Infraspinatus fossa Posterior facet of greater tuberosity External rotation of humerus Suprascapular nerve Teres Minor Lateral border Inferior facet of greater tuberosity External rotation of humerus Axillary Nerve Subscapularis Subscapular fossa Lesser tuberosity Internal rotation of humerus Upper and lower subscapular nerve The inferior rotator cuff muscles (infraspinatus, teres minor, and subscapularis) balance the superior pull of the deltoid. Injury/tear results in upward migration of the humeral head on the glenoid (can be seen on AP radiograph). Likewise, the anterior muscles (subscapularis) are balanced with the posterior muscles (infraspinatus, teres minor). Subacromial Impingement The most common cause of shoulder pain, which results from impingement of the superior cuff on the undersurface of the acromion, and an inflammatory bursitis. Associated with certain types of acromial morphology (Bigliani classification). Presents as insidious pain which is exacerbated by overhead activities. Rotator Cuff Tear Often presents as an acute event on the background of chronic subacromial impingement in the older patient, but can present as an avulsion injury in younger patients. Majority of tears are to the superior cuff (supraspinatus, infraspinatus, teres minor), though a tear to subscapularis is associated with subcoracoid impingement. Tears present as pain and weakness when using the muscles in question. Rotator Cuff Arthropathy Defined as shoulder arthritis in the setting of rotator cuff dysfunction. Results from superior migration due to the loss of rotator cuff function and integrity. Unopposed deltoid pulls the humeral head superiorly. Associated with massive chronic cuff tears. Imaging Plain radiographs AP of the shoulder may show superior migration of the humerus with a cuff tear, and features of arthritis with arthropathy. Other causes of pain may also be identified (e.g. calcific tendonitis/fracture) Outlet view is useful for defining the acromial morphology USS Allows dynamic imaging of the cuff, and is inexpensive. However, it is very user dependent. MRI Best imaging modality for cuff pathology. Also allows imaging of the rest of the shoulder. When intra-articular pathology is suspected, can be combined with an arthrogram for improved sensitivity and specificity. Treatment Subacromial impingement Physiotherapy, oral anti-inflammatory medication Subacromial steroid injection can settle inflammation Arthroscopic subacromial decompression by shaving away the undersurface of the acromion, more space is created for the rotator cuff. Cuff integrity is assessed also at time of surgery, and can be repaired if necessary. Rotator cuff tear When considering repair of a cuff tear, the age and activity of the patient, the nature of the tear (degenerative vs. acute traumatic), and the size and retraction of the tear should be considered when making a surgical plan. Mild tears or tears in the elderly can be managed conservatively, as outlined above. Moderate tears can be repaired arthroscopically. Massive or retracted tears will often require an open repair (occasionally with a tendon transfer). Subacromial decompression is performed at the same time to reduce impingement, symptoms and recurrence. Calcific tendonitis Calcific tendonitis involves calcific deposits within tendons anywhere in the body, but most commonly in the rotator cuff (specifically the supraspinatus tendon). When present in the shoulder, it is associated with subacromial impingement and pain. Pathology More common in women aged 30-60 years. Association with diabetes and hypothyroidism There are three stages of calcification Formative phase characterized by calcific deposits Resting phase deposit is stable, but presents with impingement problems Resorptive phase phagocytic resorption. Most painful stage. Presentation Similar in presentation to subacromial impingement, with pain especially with over head activities. Atraumatic in nature. Imaging Plain radiographs show calcification of the rotator cuff, usually within 1.5cm of its insertion on the humerus. Supraspinatus outlet views can show level of impingment. Further imaging is rarely needed. Treatment Non-operative NSAIDS, steroid injection (controversial, but practiced) and physiotherapy. Approximately 75% will resolve by 6 months with conservative management. Ultrasound guided or surgical needle barbotage can break down deposits and resolve symptoms. Occasionally surgical excision is required. Adhesive capsulitis (Frozen Shoulder) Pain and loss of movement of shoulder joint, which involves fibroplastic proliferation of capsular tissue, causing soft tissue scarring and contracture. Patients present with a painful and decreased arc of motion. Associated with prolonged immobilization, previous surgery, thyroid disorders (AI) and diabetes Classically three stages which can take up to two years to resolve: Stage one the freezing and painful stage Stage two the frozen and stiff stage Stage three the thawing stage, where shoulder movement slowly improves Imaging Plain radiographs to exclude other causes of a painful shoulder MRI arthrogram may show capsular contracture, and again may be used to exclude cuff pathology. However, often not performed as diagnosis is largely clinical. Treatment Non-operative NSAIDS, steroid injection and physiotherapy. Patience is required as condition can take up to 2 years to improve. Operative MUA or arthroscopic adhesiolysis (release of adhesions) can expedite recovery, followed by intensive physiotherapy. Glenohumeral Arthritis Background May be osteoarthritis (primary or secondary to cuff tear or trauma), rheumatoid arthritis, or as part of a spondyloarthropathy. Majority of those with RA will develop symptoms. More common in the elderly Presents like any other arthritis - pain at night and with movement Imaging AP and axillary radiographs will show features of arthritis. CT/MRI is often useful to classify the shape of the glenoid and extent of bone loss when considering arthroplasty. MRI also essential to asses integrity of rotator cuff if considering shoulder replacement. Treatment Like all orthopaedics, start with simple measures: NSAIDS, management of RA, physiotherapy, steroid injection. Hemiarthroplasty can sometimes be considered if glenoid is in excellent condition or if patient has large comorbidity. Arthroscopic debridement is useful if patient has isolated ACJ arthritis, but is rarely used for glenohumeral arthritis. Total shoulder replacement is shown to produce superior outcome when compared to hemiarthroplasty in terms of pain relief, function and implant survival. Total shoulder replacement can be anatomical (ball on humerus, with cup on glenoid), or reverse geometry (ball on glenoid, with cup on humerus). Anatomical TSR requires an in tact rotator cuff, so often reverse is preferable when the cuff if questionable in integrity.

Answer 39

Torn meniscus Twisting sporting injuries followed by delayed onset of knee swelling and locking are strongly suggestive of a menisceal tear. Arthroscopic menisectomy is the usual treatment. Ruptured anterior cruciate ligament Sport injury Mechanism: high twisting force applied to a bent knee Typically presents with: loud crack, pain and RAPID joint swelling (haemoarthrosis) Poor healing Management: intense physiotherapy or surgery Ruptured posterior cruciate ligament Mechanism: hyperextension injuries Tibia lies back on the femur Paradoxical anterior draw test Rupture of medial collateral ligament Mechanism: leg forced into valgus via force outside the leg Knee unstable when put into valgus position Menisceal tear Rotational sporting injuries Delayed knee swelling Joint locking (Patient may develop skills to "unlock" the knee Recurrent episodes of pain and effusions are common, often following minor trauma Chondromalacia patellae Teenage girls, following an injury to knee e.g. Dislocation patella Typical history of pain on going downstairs or at rest Tenderness, quadriceps wasting Dislocation of the patella Most commonly occurs as a traumatic primary event, either through direct trauma or through severe contraction of quadriceps with knee stretched in valgus and external rotation Genu valgum, tibial torsion and high riding patella are risk factors Skyline x-ray views of patella are required, although displaced patella may be clinically obvious An osteochondral fracture is present in 5% The condition has a 20% recurrence rate Fractured patella 2 types: i. Direct blow to patella causing undisplaced fragments ii. Avulsion fracture Tibial plateau fracture Occur in the elderly (or following significant trauma in young) Mechanism: knee forced into valgus or varus, but the knee fractures before the ligaments rupture Varus injury affects medial plateau and if valgus injury, lateral plateau depressed fracture occurs Classified using the Schatzker system (see below) Schatzker Classification system for tibial plateau fractures Type Anatomical description Features 1 Vertical split of lateral condyle Fracture through dense bone, usually in the young. It may be virtually undisplaced, or the condylar fragment may be pushed inferiorly and tilted 2 Vertical split of the lateral condyle combined with an adjacent load bearing part of the condyle The wedge fragment (which may be of variable size), is displaced laterally; the joint is widened. Untreated, a valgus deformity may develop 3 Depression of the articular surface with intact condylar rim The split does not extend to the edge of the plateau. Depressed fragments may be firmly embedded in subchondral bone, the joint is stable 4 Fragment of the medial tibial condyle Two injuries are seen in this category; (1) a depressed fracture of osteoporotic bone in the elderly. (2) a high energy fracture resulting in a condylar split that runs from the intercondylar eminence to the medial cortex. Associated ligamentous injury may be severe 5 Fracture of both condyles Both condyles fractured but the column of the metaphysis remains in continuity with the tibial shaft 6 Combined condylar and subcondylar fractures High energy fracture with marked comminution

Answer 40

Posterior cruciate ligament rupture In ruptured posterior cruciate ligament the tibia lies back on the femur and can be drawn forward during a paradoxical draw test. Ruptured anterior cruciate ligament Sport injury Mechanism: high twisting force applied to a bent knee Typically presents with: loud crack, pain and RAPID joint swelling (haemoarthrosis) Poor healing Management: intense physiotherapy or surgery Ruptured posterior cruciate ligament Mechanism: hyperextension injuries Tibia lies back on the femur Paradoxical anterior draw test Rupture of medial collateral ligament Mechanism: leg forced into valgus via force outside the leg Knee unstable when put into valgus position Menisceal tear Rotational sporting injuries Delayed knee swelling Joint locking (Patient may develop skills to "unlock" the knee Recurrent episodes of pain and effusions are common, often following minor trauma Chondromalacia patellae Teenage girls, following an injury to knee e.g. Dislocation patella Typical history of pain on going downstairs or at rest Tenderness, quadriceps wasting Dislocation of the patella Most commonly occurs as a traumatic primary event, either through direct trauma or through severe contraction of quadriceps with knee stretched in valgus and external rotation Genu valgum, tibial torsion and high riding patella are risk factors Skyline x-ray views of patella are required, although displaced patella may be clinically obvious An osteochondral fracture is present in 5% The condition has a 20% recurrence rate Fractured patella 2 types: i. Direct blow to patella causing undisplaced fragments ii. Avulsion fracture Tibial plateau fracture Occur in the elderly (or following significant trauma in young) Mechanism: knee forced into valgus or varus, but the knee fractures before the ligaments rupture Varus injury affects medial plateau and if valgus injury, lateral plateau depressed fracture occurs Classified using the Schatzker system (see below) Schatzker Classification system for tibial plateau fractures Type Anatomical description Features 1 Vertical split of lateral condyle Fracture through dense bone, usually in the young. It may be virtually undisplaced, or the condylar fragment may be pushed inferiorly and tilted 2 Vertical split of the lateral condyle combined with an adjacent load bearing part of the condyle The wedge fragment (which may be of variable size), is displaced laterally; the joint is widened. Untreated, a valgus deformity may develop 3 Depression of the articular surface with intact condylar rim The split does not extend to the edge of the plateau. Depressed fragments may be firmly embedded in subchondral bone, the joint is stable 4 Fragment of the medial tibial condyle Two injuries are seen in this category; (1) a depressed fracture of osteoporotic bone in the elderly. (2) a high energy fracture resulting in a condylar split that runs from the intercondylar eminence to the medial cortex. Associated ligamentous injury may be severe 5 Fracture of both condyles Both condyles fractured but the column of the metaphysis remains in continuity with the tibial shaft 6 Combined condylar and subcondylar fractures High energy fracture with marked comminution

Answer 41

Anterior cruciate ligament rupture This is common in footballers as the football boot studs stick to the ground and high twisting force is applied to a flexed knee. Rapid joint swelling also supports the diagnosis. Ruptured anterior cruciate ligament Sport injury Mechanism: high twisting force applied to a bent knee Typically presents with: loud crack, pain and RAPID joint swelling (haemoarthrosis) Poor healing Management: intense physiotherapy or surgery Ruptured posterior cruciate ligament Mechanism: hyperextension injuries Tibia lies back on the femur Paradoxical anterior draw test Rupture of medial collateral ligament Mechanism: leg forced into valgus via force outside the leg Knee unstable when put into valgus position Menisceal tear Rotational sporting injuries Delayed knee swelling Joint locking (Patient may develop skills to "unlock" the knee Recurrent episodes of pain and effusions are common, often following minor trauma Chondromalacia patellae Teenage girls, following an injury to knee e.g. Dislocation patella Typical history of pain on going downstairs or at rest Tenderness, quadriceps wasting Dislocation of the patella Most commonly occurs as a traumatic primary event, either through direct trauma or through severe contraction of quadriceps with knee stretched in valgus and external rotation Genu valgum, tibial torsion and high riding patella are risk factors Skyline x-ray views of patella are required, although displaced patella may be clinically obvious An osteochondral fracture is present in 5% The condition has a 20% recurrence rate Fractured patella 2 types: i. Direct blow to patella causing undisplaced fragments ii. Avulsion fracture Tibial plateau fracture Occur in the elderly (or following significant trauma in young) Mechanism: knee forced into valgus or varus, but the knee fractures before the ligaments rupture Varus injury affects medial plateau and if valgus injury, lateral plateau depressed fracture occurs Classified using the Schatzker system (see below) Schatzker Classification system for tibial plateau fractures Type Anatomical description Features 1 Vertical split of lateral condyle Fracture through dense bone, usually in the young. It may be virtually undisplaced, or the condylar fragment may be pushed inferiorly and tilted 2 Vertical split of the lateral condyle combined with an adjacent load bearing part of the condyle The wedge fragment (which may be of variable size), is displaced laterally; the joint is widened. Untreated, a valgus deformity may develop 3 Depression of the articular surface with intact condylar rim The split does not extend to the edge of the plateau. Depressed fragments may be firmly embedded in subchondral bone, the joint is stable 4 Fragment of the medial tibial condyle Two injuries are seen in this category; (1) a depressed fracture of osteoporotic bone in the elderly. (2) a high energy fracture resulting in a condylar split that runs from the intercondylar eminence to the medial cortex. Associated ligamentous injury may be severe 5 Fracture of both condyles Both condyles fractured but the column of the metaphysis remains in continuity with the tibial shaft 6 Combined condylar and subcondylar fractures High energy fracture with marked comminution

Answer 42

This is a typical description of Perthes disease. Management involves keeping the femoral head in the acetabulum by braces, casts or surgery. Perthes disease Idiopathic avascular necrosis of the femoral epiphysis of the femoral head Impaired blood supply to femoral head, causing bone infarction. New vessels develop and ossification occurs. The bone either heals or a subchondral fracture occurs. ``` Clinical features Males 4x's greater than females Age between 2-12 years (the younger the age of onset, the better the prognosis) Limp Hip pain Bilateral in 20% ``` Diagnosis Plain x-ray, Technetium bone scan or magnetic resonance imaging if normal x-ray and symptoms persist. Catterall staging Stage Features Stage 1 Clinical and histological features only Stage 2 Sclerosis with or without cystic changes and preservation of the articular surface Stage 3 Loss of structural integrity of the femoral head Stage 4 Loss of acetabular integrity Management To keep the femoral head within the acetabulum: cast, braces If less than 6 years: observation Older: surgical management with moderate results Operate on severe deformities Prognosis Most cases will resolve with conservative management. Early diagnosis improves outcomes.

Answer 43

All cases should be treated with an Ilizarov frame initially unless there is minor deformity - FALSE ``` In most cases of Club Foot conservative measures should be tried first. The Ponsetti method is a popular approach. Severe cases may benefit from Ilizarov frame re-aligment. Congenital talipes equinovarus. Features: Equinus of the hindfoot. Adduction and varus of the midfoot. High arch. ``` Most cases in developing countries. Incidence in UK is 1 per 1000 live births. It is more common in males and is bilateral in 50% cases. There is a strong familial link(1). It may also be associated with other developmental disorders such as Down's syndrome. ``` Key anatomical deformities (2): Adducted and inverted calcaneus Wedge shaped distal calcaneal articular surface Severe Tibio-talar plantar flexion. Medial Talar neck inclination Displacement of the navicular bone (medially) Wedge shaped head of talus Displacement of the cuboid (medially) ``` Management Conservative first, the Ponseti method is best described and gives comparable results to surgery. It consists of serial casting to mold the foot into correct shape. Following casting around 90% will require a Achilles tenotomy. This is then followed by a phase of walking braces to maintain the correction. Surgical correction is reserved for those cases that fail to respond to conservative measures. The procedures involve multiple tenotomies and lengthening procedures. In patients who fail to respond surgically an Ilizarov frame reconstruction may be attempted and gives good results.

Answer 44

Periosteal preservation helps fractures to heal. Bone fracture - Bleeding vessels in the bone and periosteum - Clot and haematoma formation - The clot organises over a week (improved structure and collagen) - The periosteum contains osteoblasts which produce new bone - Mesenchymal cells produce cartilage (fibrocartilage and hyaline cartilage) in the soft tissue around the fracture - Connective tissue + hyaline cartilage = callus - As the new bone approaches the new cartilage, endochondral ossification occurs to bridge the gap - Trabecular bone forms - Trabecular bone is resorbed by osteoclasts and replaced with compact bone Factors affecting fracture healing Age Malnutrition Bone disorders: osteoporosis Systemic disorders: diabetes, Marfan's syndrome and Ehlers-Danlos syndrome cause abnormal musculoskeletal healing. Drugs: steroids, non steroidal anti inflammatory agents. Type of bone: Cancellous (spongy) bone fractures are usually more stable, involve greater surface areas, and have a better blood supply than cortical (compact) bone fractures. Degree of Trauma: The more extensive the injury to bone and surrounding soft tissue, the poorer the outcome. Vascular Injury: Especially the femoral head, talus, and scaphoid bones. Degree of Immobilization Intra-articular Fractures: These fractures communicate with synovial fluid, which contains collagenases that retard bone healing. Separation of Bone Ends: Normal apposition of fracture fragments is needed for union to occur. Inadequate reduction, excessive traction, or interposition of soft tissue will prevent healing. Infection

Answer 45

Slipped upper femoral epiphysis Slipped upper femoral epiphysis is the commonest adolescent hip disorder. It occurs most commonly in obese males. It may often present as knee pain which is usually referred from the ipsilateral hip. The knee itself is normal. The hip often limits internal rotation. The diagnosis is easily missed. X-rays will show displacement of the femoral epiphysis and the degree of its displacement may be calculated using the Southwick angle. Treatment is directed at preventing further slippage which may result in avascular necrosis of the femoral head. Developmental dysplasia of the hip Usually diagnosed in infancy by screening tests. May be bilateral, when disease is unilateral there may be leg length inequality. As disease progresses child may limp and then early onset arthritis. More common in extended breech babies. Splints and harnesses or traction. In later years osteotomy and hip realignment procedures may be needed. In arthritis a joint replacement may be needed. However, this is best deferred if possible as it will almost certainly require revision Initially no obvious change on plain films and USS gives best resolution until 3 months of age. On plain films Shentons line should form a smooth arc Perthes Disease Hip pain (may be referred to the knee) usually occurring between 5 and 12 years of age. Bilateral disease in 20%. Remove pressure from joint to allow normal development. Physiotherapy. Usually self-limiting if diagnosed and treated promptly. X-rays will show flattened femoral head. Eventually in untreated cases the femoral head will fragment. Slipped upper femoral epiphysis Typically seen in obese male adolescents. Pain is often referred to the knee. Limitation to internal rotation is usually seen. Knee pain is usually present 2 months prior to hip slipping. Bilateral in 20%. Bed rest and non-weight bearing. Aim to avoid avascular necrosis. If severe slippage or risk of it occurring then percutaneous pinning of the hip may be required. X-rays will show the femoral head displaced and falling inferolaterally (like a melting ice cream cone) The Southwick angle gives indication of disease severity

Answer 46

Perthes disease This is a typical presentation for Perthes disease. X-ray may show flattening of the femoral head or fragmentation in more advanced cases. Early plain x-ray changes in Perthes Disease: Widening of the joint space. Sub chondral linear lucency Developmental dysplasia of the hip Usually diagnosed in infancy by screening tests. May be bilateral, when disease is unilateral there may be leg length inequality. As disease progresses child may limp and then early onset arthritis. More common in extended breech babies. Splints and harnesses or traction. In later years osteotomy and hip realignment procedures may be needed. In arthritis a joint replacement may be needed. However, this is best deferred if possible as it will almost certainly require revision Initially no obvious change on plain films and USS gives best resolution until 3 months of age. On plain films Shentons line should form a smooth arc Perthes Disease Hip pain (may be referred to the knee) usually occurring between 5 and 12 years of age. Bilateral disease in 20%. Remove pressure from joint to allow normal development. Physiotherapy. Usually self-limiting if diagnosed and treated promptly. X-rays will show flattened femoral head. Eventually in untreated cases the femoral head will fragment. Slipped upper femoral epiphysis Typically seen in obese male adolescents. Pain is often referred to the knee. Limitation to internal rotation is usually seen. Knee pain is usually present 2 months prior to hip slipping. Bilateral in 20%. Bed rest and non-weight bearing. Aim to avoid avascular necrosis. If severe slippage or risk of it occurring then percutaneous pinning of the hip may be required. X-rays will show the femoral head displaced and falling inferolaterally (like a melting ice cream cone) The Southwick angle gives indication of disease severity

Answer 47

Developmental dysplasia of the hip Developmental dysplasia of the hip. Usually diagnosed by Barlow and Ortolani tests in early childhood. Most Breech deliveries are also routinely subjected to USS of the hip joint. At this young age an arthrodesis may be preferable to hip replacement. Developmental dysplasia of the hip Usually diagnosed in infancy by screening tests. May be bilateral, when disease is unilateral there may be leg length inequality. As disease progresses child may limp and then early onset arthritis. More common in extended breech babies. Splints and harnesses or traction. In later years osteotomy and hip realignment procedures may be needed. In arthritis a joint replacement may be needed. However, this is best deferred if possible as it will almost certainly require revision Initially no obvious change on plain films and USS gives best resolution until 3 months of age. On plain films Shentons line should form a smooth arc Perthes Disease Hip pain (may be referred to the knee) usually occurring between 5 and 12 years of age. Bilateral disease in 20%. Remove pressure from joint to allow normal development. Physiotherapy. Usually self-limiting if diagnosed and treated promptly. X-rays will show flattened femoral head. Eventually in untreated cases the femoral head will fragment. Slipped upper femoral epiphysis Typically seen in obese male adolescents. Pain is often referred to the knee. Limitation to internal rotation is usually seen. Knee pain is usually present 2 months prior to hip slipping. Bilateral in 20%. Bed rest and non-weight bearing. Aim to avoid avascular necrosis. If severe slippage or risk of it occurring then percutaneous pinning of the hip may be required. X-rays will show the femoral head displaced and falling inferolaterally (like a melting ice cream cone) The Southwick angle gives indication of disease severity

Answer 48

Non accidental injury Delayed presentation is unusual and should raise concern. In addition spiral fractures are usually the result of rotational injury which is not compatible with the mechanism proposed by the parent. Paediatric fracture types Type Injury pattern Complete fracture Both sides of cortex are breached Toddlers fracture Oblique tibial fracture in infants Plastic deformity Stress on bone resulting in deformity without cortical disruption Greenstick fracture Unilateral cortical breach only Buckle fracture Incomplete cortical disruption resulting in periosteal haematoma only Growth plate fractures In paediatric practice fractures may also involve the growth plate and these injuries are classified according to the Salter- Harris system (given below): Type Injury pattern I Fracture through the physis only (x-ray often normal) II Fracture through the physis and metaphysis III Fracture through the physis and epiphyisis to include the joint IV Fracture involving the physis, metaphysis and epiphysis V Crush injury involving the physis (x-ray may resemble type I, and appear normal) As a general rule it is safer to assume that growth plate tenderness is indicative of an underlying fracture even if the x-ray appears normal. Injuries of Types III, IV and V will usually require surgery. Type V injuries are often associated with disruption to growth. Non accidental injury Delayed presentation Delay in attaining milestones Lack of concordance between proposed and actual mechanism of injury Multiple injuries Injuries at sites not commonly exposed to trauma Children on the at risk register Pathological fractures Genetic conditions, such as osteogenesis imperfecta, may cause pathological fractures. Osteogenesis imperfecta Defective osteoid formation due to congenital inability to produce adequate intercellular substances like osteoid, collagen and dentine. Failure of maturation of collagen in all the connective tissues. Radiology may show translucent bones, multiple fractures, particularly of the long bones, wormian bones (irregular patches of ossification) and a trefoil pelvis. Subtypes Type I The collagen is normal quality but insufficient quantity. Type II- Poor collagen quantity and quality. Type III- Collagen poorly formed. Normal quantity. Type IV- Sufficient collagen quantity but poor quality. ``` Osteopetrosis Bones become harder and more dense. Autosomal recessive condition. It is commonest in young adults. Radiology reveals a lack of differentiation between the cortex and the medulla described as marble bone. ```

Answer 49

Accidental fracture The mechanism fits with the fracture pattern and the presentation is not delayed. Paediatric fracture types Type Injury pattern Complete fracture Both sides of cortex are breached Toddlers fracture Oblique tibial fracture in infants Plastic deformity Stress on bone resulting in deformity without cortical disruption Greenstick fracture Unilateral cortical breach only Buckle fracture Incomplete cortical disruption resulting in periosteal haematoma only Growth plate fractures In paediatric practice fractures may also involve the growth plate and these injuries are classified according to the Salter- Harris system (given below): Type Injury pattern I Fracture through the physis only (x-ray often normal) II Fracture through the physis and metaphysis III Fracture through the physis and epiphyisis to include the joint IV Fracture involving the physis, metaphysis and epiphysis V Crush injury involving the physis (x-ray may resemble type I, and appear normal) As a general rule it is safer to assume that growth plate tenderness is indicative of an underlying fracture even if the x-ray appears normal. Injuries of Types III, IV and V will usually require surgery. Type V injuries are often associated with disruption to growth. Non accidental injury Delayed presentation Delay in attaining milestones Lack of concordance between proposed and actual mechanism of injury Multiple injuries Injuries at sites not commonly exposed to trauma Children on the at risk register Pathological fractures Genetic conditions, such as osteogenesis imperfecta, may cause pathological fractures. Osteogenesis imperfecta Defective osteoid formation due to congenital inability to produce adequate intercellular substances like osteoid, collagen and dentine. Failure of maturation of collagen in all the connective tissues. Radiology may show translucent bones, multiple fractures, particularly of the long bones, wormian bones (irregular patches of ossification) and a trefoil pelvis. Subtypes Type I The collagen is normal quality but insufficient quantity. Type II- Poor collagen quantity and quality. Type III- Collagen poorly formed. Normal quantity. Type IV- Sufficient collagen quantity but poor quality. ``` Osteopetrosis Bones become harder and more dense. Autosomal recessive condition. It is commonest in young adults. Radiology reveals a lack of differentiation between the cortex and the medulla described as marble bone. ```

Answer 50

Non accidental injury Posterior rib fractures are extremely unusual in neonates. The change in head size may be accounted for by hydrocephalus which may occur as a sequelae from head injury. Paediatric fracture types Type Injury pattern Complete fracture Both sides of cortex are breached Toddlers fracture Oblique tibial fracture in infants Plastic deformity Stress on bone resulting in deformity without cortical disruption Greenstick fracture Unilateral cortical breach only Buckle fracture Incomplete cortical disruption resulting in periosteal haematoma only Growth plate fractures In paediatric practice fractures may also involve the growth plate and these injuries are classified according to the Salter- Harris system (given below): Type Injury pattern I Fracture through the physis only (x-ray often normal) II Fracture through the physis and metaphysis III Fracture through the physis and epiphyisis to include the joint IV Fracture involving the physis, metaphysis and epiphysis V Crush injury involving the physis (x-ray may resemble type I, and appear normal) As a general rule it is safer to assume that growth plate tenderness is indicative of an underlying fracture even if the x-ray appears normal. Injuries of Types III, IV and V will usually require surgery. Type V injuries are often associated with disruption to growth. Non accidental injury Delayed presentation Delay in attaining milestones Lack of concordance between proposed and actual mechanism of injury Multiple injuries Injuries at sites not commonly exposed to trauma Children on the at risk register Pathological fractures Genetic conditions, such as osteogenesis imperfecta, may cause pathological fractures. Osteogenesis imperfecta Defective osteoid formation due to congenital inability to produce adequate intercellular substances like osteoid, collagen and dentine. Failure of maturation of collagen in all the connective tissues. Radiology may show translucent bones, multiple fractures, particularly of the long bones, wormian bones (irregular patches of ossification) and a trefoil pelvis. Subtypes Type I The collagen is normal quality but insufficient quantity. Type II- Poor collagen quantity and quality. Type III- Collagen poorly formed. Normal quantity. Type IV- Sufficient collagen quantity but poor quality. ``` Osteopetrosis Bones become harder and more dense. Autosomal recessive condition. It is commonest in young adults. Radiology reveals a lack of differentiation between the cortex and the medulla described as marble bone. ```

Answer 51

Kocher criteria 1. Non weight bearing on affected side 2. ESR > 40 mm/hr 3. Fever 4. WBC count of >12,000 mm3 - When 4/4 criteria are met, there is a 99% chance that the child has septic arthritis The Kocher criteria do not consider blood culture results. Septic arthritis Staph aureus commonest organism Urgent washout and antibiotics otherwise high risk of joint destruction Diagnosis Plain x-rays Consider aspiration Utilise the Kocher criteria (see below) Kocher criteria: 1. Non weight bearing on affected side 2. ESR > 40 mm/hr 3. Fever 4. WBC count of >12,000 mm3 - when 4/4 criteria are met, there is a 99% chance that the child has septic arthritis Treatment Surgical drainage of the affected joint is required, this should be done as soon as possible since permanent damage to the joint may occur. In some cases repeated procedures are necessary. Appropriate intravenous antibiotics should be administered.

Answer 52

Total hip replacement In otherwise fit patients aged over 70, the best long term functional outcomes are obtained with total hip arthroplasty. Neck of femur (NOF) fracture is a common orthopaedic presentation, with over 65000 fractures in the UK per year. Like many orthopaedic injuries, there is a bimodal age distribution. It is imperative to distinguish between the high energy injury in a young patient, and the low energy osteoporotic fracture in the elderly, as their management aims are very different: Young patient - Usually high energy trauma (e.g road traffic accident, horse riding) and needs treating in accordance with Advanced Trauma Life Support (ATLS) principles. Will often have associated injuries. Aim is to retain the patients own anatomy, and optimise their function. Elderly patient - Predominantly female, fall from standing height (fragility fracture). Often patients have multiple comorbidities that will ultimately dictate their prognosis. Aim of orthopaedic treatment is to immediately regain patient mobility so that morbidity (infection, thromboembolic events, pressure sores etc) and mortality associated with prolonged bed rest is avoided. Left untreated, a neck of femur fracture can be considered a terminal event. Historically, mortality associated with elderly hip fracture is 10% at one month, and 30% at one year. However, this has been improved in the UK with the introduction of multidisciplinary, orthogeriatric lead care and the National Hip Fracture Database and Best Practice Tariff. Pertinent anatomy Osteology - normal neck-shaft angle is 130 +/- 7 degrees, and 10 +/- 7 degrees of neck anteversion. Vascular supply - The predominant blood supply to the femoral head and neck is from the medial and lateral femoral circumflex arteries (branches of profunda femoris). These anastomose and pierce the joint capsule at the base of the neck, mainly posteriorly. There is a small vascular contribution from the artery of the ligament teres. Understanding the blood supply is fundamental to the decision making process in treating NOF fractures. Presentation and initial management Typically, patients present with pain in the hip/groin, a shortened, abducted, externally rotated leg (due to the unopposed pull of the muscles that act across the hip joint) and the inability to straight-leg-raise. With undisplaced fractures, signs are more subtle. High energy injuries should be treated in line with ATLS principles. All patients should be fluid resuscitated, have adequate pain relief (often with a fascio-iliiaca nerve block), and be optimised for surgery. In addition, elderly patients should be assessed by an orthogeriatrician. Imaging Anteroposterior and cross-table lateral plain radiographs are sufficient to diagnose the majority of NOF fractures. If the fracture extends below the level of the lesser trochanter, or there is any possibility of pathological fracture, full length femur views are essential to plan surgery. Where there is a high index of suspicion of fracture, but plain radiographs are inconclusive, gold standard investigation is MRI. However, if unavailable within 24 hours, or if the patient will not tolerate MRI, CT is appropriate. The majority of fractures can be seen with modern CT techniques, and so this is becoming first line in many hospitals. Classification There has been a move away from named classification systems towards descriptive classification systems. Two main types of NOF exist: Intra-capsular, and extra-capsular. Extra-capsular fractures are further divided into pertrochanteric or subtrochanteric (within 5cm distal to the lesser trochanter). All fractures are then described as undisplaced, minimally displaced, or displaced. Femoral neck and head blood supply disruption is common with intracapsular NOF fractures, and rare with extracapsular fractures. This fundamental principle underpins the practise of arthroplasty for intracapsular fractures, and fixation for extracapsular fractures. If you wish to use a named classification system, the most commonly used are below: Elderly intracapsular - Garden Classification Young intrasapsular - Pauvels Classification Intertrochanteric - Evans Subtrochanteric - Russell Taylor Treatment In general, NOF fractures are treated operatively except if the patient is deemed unlikely to survive an anaesthetic. Best Practice Tarif (BPT) dictates that surgery should happen within 36 hours, as delay of greater than 48 hours is associated with increased morbidity and mortality. Below are suggested algorithms for the treatment of NOF. There are some areas of debate/controversy which are detailed below. Image sourced from Wikipedia * The priority with the young patient is to retain the femoral head if possible, even with a displaced intracapsular fracture. The risk of avascular necrosis and non-union (and therefore revision surgery) associated with internal fixation needs weighing up against the sequelae of total hip replacement in the young (wear, dislocation, revision). Discussion is necessary with the patient, on a case by case basis. ** Undisplaced fractures in the elderly can be treated with internal fixation, often with cannulated screws. This is appropriate for valgus impacted subcapital fractures which are inherently stable, to prevent secondary displacement. This does still carry the risk of AVN or non-union, and therefore a future revision. For this reason, many surgeons advocate arthroplasty as a single surgery. *** NICE guidance - patients who fulfil these criteria should be offered total hip replacement which conveys better function and prosthetic survivorship, compared with hemiarthroplasty, but at an increased risk of dislocation. Image sourced from Wikipedia * Intertrochanteric fractures vary greatly in their stability. If the trochanter (and therefore lateral wall), and medial calcar is in tact, then the fracture configuration bears stability. This can be treated with a DHS, as collapse of the fracture is predictable. Where either or both structures are involved in the fracture, stability becomes compromised and many surgeons will favour using an intramedullary device. This is an ongoing debate, and difficult to test in an exam setting. Post operative management Patients should be mobilised fully weight bearing where possible. Care is multidisciplinary in its delivery. Elderly patients should have orthogeriatrician assessment of comorbidity, and bone health with secondary prevention measures if appropriate. There should be early involvement of physiotherapy and occupational therapy services.

Answer 53

Insertion of intra medullary nail Intramedullary devices are normally recommended for reverse oblique, transverse subtrochanteric fractures. Neck of femur (NOF) fracture is a common orthopaedic presentation, with over 65000 fractures in the UK per year. Like many orthopaedic injuries, there is a bimodal age distribution. It is imperative to distinguish between the high energy injury in a young patient, and the low energy osteoporotic fracture in the elderly, as their management aims are very different: Young patient - Usually high energy trauma (e.g road traffic accident, horse riding) and needs treating in accordance with Advanced Trauma Life Support (ATLS) principles. Will often have associated injuries. Aim is to retain the patients own anatomy, and optimise their function. Elderly patient - Predominantly female, fall from standing height (fragility fracture). Often patients have multiple comorbidities that will ultimately dictate their prognosis. Aim of orthopaedic treatment is to immediately regain patient mobility so that morbidity (infection, thromboembolic events, pressure sores etc) and mortality associated with prolonged bed rest is avoided. Left untreated, a neck of femur fracture can be considered a terminal event. Historically, mortality associated with elderly hip fracture is 10% at one month, and 30% at one year. However, this has been improved in the UK with the introduction of multidisciplinary, orthogeriatric lead care and the National Hip Fracture Database and Best Practice Tariff. Pertinent anatomy Osteology - normal neck-shaft angle is 130 +/- 7 degrees, and 10 +/- 7 degrees of neck anteversion. Vascular supply - The predominant blood supply to the femoral head and neck is from the medial and lateral femoral circumflex arteries (branches of profunda femoris). These anastomose and pierce the joint capsule at the base of the neck, mainly posteriorly. There is a small vascular contribution from the artery of the ligament teres. Understanding the blood supply is fundamental to the decision making process in treating NOF fractures. Presentation and initial management Typically, patients present with pain in the hip/groin, a shortened, abducted, externally rotated leg (due to the unopposed pull of the muscles that act across the hip joint) and the inability to straight-leg-raise. With undisplaced fractures, signs are more subtle. High energy injuries should be treated in line with ATLS principles. All patients should be fluid resuscitated, have adequate pain relief (often with a fascio-iliiaca nerve block), and be optimised for surgery. In addition, elderly patients should be assessed by an orthogeriatrician. Imaging Anteroposterior and cross-table lateral plain radiographs are sufficient to diagnose the majority of NOF fractures. If the fracture extends below the level of the lesser trochanter, or there is any possibility of pathological fracture, full length femur views are essential to plan surgery. Where there is a high index of suspicion of fracture, but plain radiographs are inconclusive, gold standard investigation is MRI. However, if unavailable within 24 hours, or if the patient will not tolerate MRI, CT is appropriate. The majority of fractures can be seen with modern CT techniques, and so this is becoming first line in many hospitals. Classification There has been a move away from named classification systems towards descriptive classification systems. Two main types of NOF exist: Intra-capsular, and extra-capsular. Extra-capsular fractures are further divided into pertrochanteric or subtrochanteric (within 5cm distal to the lesser trochanter). All fractures are then described as undisplaced, minimally displaced, or displaced. Femoral neck and head blood supply disruption is common with intracapsular NOF fractures, and rare with extracapsular fractures. This fundamental principle underpins the practise of arthroplasty for intracapsular fractures, and fixation for extracapsular fractures. If you wish to use a named classification system, the most commonly used are below: Elderly intracapsular - Garden Classification Young intrasapsular - Pauvels Classification Intertrochanteric - Evans Subtrochanteric - Russell Taylor Treatment In general, NOF fractures are treated operatively except if the patient is deemed unlikely to survive an anaesthetic. Best Practice Tarif (BPT) dictates that surgery should happen within 36 hours, as delay of greater than 48 hours is associated with increased morbidity and mortality. Below are suggested algorithms for the treatment of NOF. There are some areas of debate/controversy which are detailed below. Image sourced from Wikipedia * The priority with the young patient is to retain the femoral head if possible, even with a displaced intracapsular fracture. The risk of avascular necrosis and non-union (and therefore revision surgery) associated with internal fixation needs weighing up against the sequelae of total hip replacement in the young (wear, dislocation, revision). Discussion is necessary with the patient, on a case by case basis. ** Undisplaced fractures in the elderly can be treated with internal fixation, often with cannulated screws. This is appropriate for valgus impacted subcapital fractures which are inherently stable, to prevent secondary displacement. This does still carry the risk of AVN or non-union, and therefore a future revision. For this reason, many surgeons advocate arthroplasty as a single surgery. *** NICE guidance - patients who fulfil these criteria should be offered total hip replacement which conveys better function and prosthetic survivorship, compared with hemiarthroplasty, but at an increased risk of dislocation. Image sourced from Wikipedia * Intertrochanteric fractures vary greatly in their stability. If the trochanter (and therefore lateral wall), and medial calcar is in tact, then the fracture configuration bears stability. This can be treated with a DHS, as collapse of the fracture is predictable. Where either or both structures are involved in the fracture, stability becomes compromised and many surgeons will favour using an intramedullary device. This is an ongoing debate, and difficult to test in an exam setting. Post operative management Patients should be mobilised fully weight bearing where possible. Care is multidisciplinary in its delivery. Elderly patients should have orthogeriatrician assessment of comorbidity, and bone health with secondary prevention measures if appropriate. There should be early involvement of physiotherapy and occupational therapy services.

Answer 54

MRI scan In those patients who present with a suspected hip fracture, but normal plain films, the most accurate investigation is an MRI or CT scan. Neck of femur (NOF) fracture is a common orthopaedic presentation, with over 65000 fractures in the UK per year. Like many orthopaedic injuries, there is a bimodal age distribution. It is imperative to distinguish between the high energy injury in a young patient, and the low energy osteoporotic fracture in the elderly, as their management aims are very different: Young patient - Usually high energy trauma (e.g road traffic accident, horse riding) and needs treating in accordance with Advanced Trauma Life Support (ATLS) principles. Will often have associated injuries. Aim is to retain the patients own anatomy, and optimise their function. Elderly patient - Predominantly female, fall from standing height (fragility fracture). Often patients have multiple comorbidities that will ultimately dictate their prognosis. Aim of orthopaedic treatment is to immediately regain patient mobility so that morbidity (infection, thromboembolic events, pressure sores etc) and mortality associated with prolonged bed rest is avoided. Left untreated, a neck of femur fracture can be considered a terminal event. Historically, mortality associated with elderly hip fracture is 10% at one month, and 30% at one year. However, this has been improved in the UK with the introduction of multidisciplinary, orthogeriatric lead care and the National Hip Fracture Database and Best Practice Tariff. Pertinent anatomy Osteology - normal neck-shaft angle is 130 +/- 7 degrees, and 10 +/- 7 degrees of neck anteversion. Vascular supply - The predominant blood supply to the femoral head and neck is from the medial and lateral femoral circumflex arteries (branches of profunda femoris). These anastomose and pierce the joint capsule at the base of the neck, mainly posteriorly. There is a small vascular contribution from the artery of the ligament teres. Understanding the blood supply is fundamental to the decision making process in treating NOF fractures. Presentation and initial management Typically, patients present with pain in the hip/groin, a shortened, abducted, externally rotated leg (due to the unopposed pull of the muscles that act across the hip joint) and the inability to straight-leg-raise. With undisplaced fractures, signs are more subtle. High energy injuries should be treated in line with ATLS principles. All patients should be fluid resuscitated, have adequate pain relief (often with a fascio-iliiaca nerve block), and be optimised for surgery. In addition, elderly patients should be assessed by an orthogeriatrician. Imaging Anteroposterior and cross-table lateral plain radiographs are sufficient to diagnose the majority of NOF fractures. If the fracture extends below the level of the lesser trochanter, or there is any possibility of pathological fracture, full length femur views are essential to plan surgery. Where there is a high index of suspicion of fracture, but plain radiographs are inconclusive, gold standard investigation is MRI. However, if unavailable within 24 hours, or if the patient will not tolerate MRI, CT is appropriate. The majority of fractures can be seen with modern CT techniques, and so this is becoming first line in many hospitals. Classification There has been a move away from named classification systems towards descriptive classification systems. Two main types of NOF exist: Intra-capsular, and extra-capsular. Extra-capsular fractures are further divided into pertrochanteric or subtrochanteric (within 5cm distal to the lesser trochanter). All fractures are then described as undisplaced, minimally displaced, or displaced. Femoral neck and head blood supply disruption is common with intracapsular NOF fractures, and rare with extracapsular fractures. This fundamental principle underpins the practise of arthroplasty for intracapsular fractures, and fixation for extracapsular fractures. If you wish to use a named classification system, the most commonly used are below: Elderly intracapsular - Garden Classification Young intrasapsular - Pauvels Classification Intertrochanteric - Evans Subtrochanteric - Russell Taylor Treatment In general, NOF fractures are treated operatively except if the patient is deemed unlikely to survive an anaesthetic. Best Practice Tarif (BPT) dictates that surgery should happen within 36 hours, as delay of greater than 48 hours is associated with increased morbidity and mortality. Below are suggested algorithms for the treatment of NOF. There are some areas of debate/controversy which are detailed below. Image sourced from Wikipedia * The priority with the young patient is to retain the femoral head if possible, even with a displaced intracapsular fracture. The risk of avascular necrosis and non-union (and therefore revision surgery) associated with internal fixation needs weighing up against the sequelae of total hip replacement in the young (wear, dislocation, revision). Discussion is necessary with the patient, on a case by case basis. ** Undisplaced fractures in the elderly can be treated with internal fixation, often with cannulated screws. This is appropriate for valgus impacted subcapital fractures which are inherently stable, to prevent secondary displacement. This does still carry the risk of AVN or non-union, and therefore a future revision. For this reason, many surgeons advocate arthroplasty as a single surgery. *** NICE guidance - patients who fulfil these criteria should be offered total hip replacement which conveys better function and prosthetic survivorship, compared with hemiarthroplasty, but at an increased risk of dislocation. Image sourced from Wikipedia * Intertrochanteric fractures vary greatly in their stability. If the trochanter (and therefore lateral wall), and medial calcar is in tact, then the fracture configuration bears stability. This can be treated with a DHS, as collapse of the fracture is predictable. Where either or both structures are involved in the fracture, stability becomes compromised and many surgeons will favour using an intramedullary device. This is an ongoing debate, and difficult to test in an exam setting. Post operative management Patients should be mobilised fully weight bearing where possible. Care is multidisciplinary in its delivery. Elderly patients should have orthogeriatrician assessment of comorbidity, and bone health with secondary prevention measures if appropriate. There should be early involvement of physiotherapy and occupational therapy services.

Answer 55

Immediate reduction and application of backslab This is an unstable ankle injury that is likely to require surgical fixation. The immediate management of a displaced ankle fracture is to reduce the fracture to prevent soft tissues compromise and help reduce swelling. This can be performed before an x-ray is obtained if performing the x-ray will significantly delay reduction. An ankle fracture relates to a fracture around the tibio-talar joint. It generally refers to a fracture involving the lateral, and/or medial and/or posterior malleolus. Pilon and Tillaux fractures are also considered to be ankle fractures, but are not covered here. Ankle fractures are common. They effect men and women in equal numbers, but men have a higher rate as young adults (sports and contact injuries), and women a higher rate post-menopausal (fragility type fracture). ``` Osseous anatomy The ankle (or mortise) joint consists of the distal tibia (tibial plafond and posterior malleolus), the distal fibula (lateral malleolus), and the talus. The main movement at the ankle joint is plantar and dorsiflexion. ``` Ligamentous anatomy Medial side: Deltoid ligament. This is divided into superficial and deep portions. It is the primary restraint to valgus tilting of the talus. Lateral side: Lateral ligament complex consisting from anterior to posterior of the anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL), and the posterior talofibular ligament (PTFL). Together they resist valgus stress to the ankle, and are a restraint to anterior translation of the talus within the mortise joint. Syndesmosis: The syndesmosis is a ligament complex between the distal tibia and fibula, holding the two bones together. It is fundamental to the integrity of the ankle joint, and its disruption leads to instability. It consists of (from anterior to posterior) the anterior-inferior tibiofibular ligament (AITFL), the transverse tibiofibular ligament (TTFL), the interosseous membrane, and the posterior-inferior tibiofibular ligament (PITFL). Presentation and initial management Patients will present following a traumatic event with a painful, swollen ankle, and reluctance/inability to weight bear. The Ottawa rules can be applied to differentiate between an ankle fracture and sprain, but can be unreliable. In high energy injuries, management should follow ATLS principles to identify more significant injuries first. Neurovascular status of the foot should be documented, and open injuries should be excluded. If an open injury is identified, it should be managed in line with BOAST 4 principles1. If an obvious deformity exists, it should be reduced as soon as possible with appropriate analgesia or conscious sedation. Radiographs of clearly deformed or dislocated joints are not necessary, and removing the pressure on the surrounding soft tissues from the underlying bony deformity is the priority. If the fracture pattern is not clinically obvious then plain radiographs are appropriate and will guide the subsequent manipulation during plaster-of-paris below knee backslab application. Imaging AP, lateral and mortise views (20o internal rotation) are essential to evaluate fracture displacement and syndesmotic injury. Decreased tibiofibular overlap, medial joint clear space and lateral talar shift all indicate a syndesmotic injury. (In subtle cases of shift, imaging the uninjured ankle can be helpful as a proportion of the population have little or no tibiotalar overlap 2.) Where there is suspicion of syndesmosis involvement in the absence of radiographic evidence, stress radiographs can be diagnostic. Complex fracture patterns (and increasingly posterior malleolar fractures) are best defined using CT. Classification The most commonly used classifications are Lauge-Hansen and Danis-Weber. Lauge-Hansen Comprises two parts: first part is the foot position, and the second part is the force applied. Useful for understanding the forces involved and therefore predict the ligamentous or bony injury. Results in four injury patterns: Supination - Adduction (SA) - 10-20% Supination - External rotation (SER) - 40-75% Pronation - Abduction (PA) - 5-20% Pronation - External rotation (PER) - 5-20% Not often used in clinical practice but good for understanding the principles of ankle fracture. Danis-Weber Commonly used. Based on the level of the fibula fracture in relation to the syndesmosis. The more proximal, the greater the risk of syndesmotic injury and therefore fracture instability. A - fracture below the level of the syndesmosis B - fracture at the level of the syndesmosis / level of the tibial plafond C - fracture above the level of the syndesmosis. This includes Maisonneuve fractures (proximal fibula fracture), which can be associated with ankle instability. Beware the high fibula fracture - it may be an ankle fracture! The Weber classification is based purely on the the lateral side. All injuries can include a medial or posterior bony or ligamentous injury which also dictates fracture stability (bimalleolar and trimalleolar fractures are more unstable). Treatment When deciding upon treatment for an ankle fracture, one must consider both the fracture and the patient. Diabetic patients and smokers are at greater risk of post-operative complication, especially wound problems and infection. Likewise, the long term outcome of post-traumatic arthritis from a malunited ankle fracture is extremely important for a young patient, but not as relevant in the elderly. Therefore, normal surgical decision processes apply as with all fractures. Defining stability of an ankle fracture underpins the treatment decision. Weber A - Unimalleolar Weber A Weber fractures by definition are stable and therefore can be mobilised fully weight bearing in an ankle boot. Weber C - Fractures tend to include syndesmotic disruption and are usually bimalleolar (either bony or ligamentous). They are therefore unstable and usually require operative fixation. In addition to the fracture fixation, the syndesmosis usually requires reconstruction/augmentation with screws to restore the joint integrity and function. Weber B - B fractures vary greatly. They can be part of a trimalleolar injury and therefore extremely unstable, requiring fixation. Alternatively, a uni-malleolar Weber B fracture can be a stable injury, and therefore mobilised immediately in an ankle boot. Defining the stability can be challenging, and often involves stress radiographs, or a trial of mobilisation and repeat radiographs. Defining stability is the subject of much ongoing research. However, treating undisplaced ankle fractures in a below knee plaster, non-weight bearing for six weeks is still widely practised, and a safe approach. When operative fixation is appropriate, it is usually via open reduction and internal fixation using plates and screws. It must be carried out when soft tissue swelling has settled in order to minimise the risk of wound problems. This can often take a week to settle. The use of fibula nails is expanding, but is not yet mainstream. Ankle fractures can also be treated with external fixation, or with a hind foot nail in patients who need fixation but where soft tissue or bone quality is poor. Post operative management Ankle fractures generally take 6 weeks to unite enough to prevent secondary displacement. This is therefore an appropriate time period to keep a cast on in a conservatively managed patient. Weight bearing post-operatively depends on the quality of the fixation and bone quality, and preference varies between surgeons, ranging from aggressive early mobilisation to a period of non-weight bearing. Return to activities takes approximately three months, and often requires assistance of a physiotherapist to improve range-of-movement and muscle strengthening.

Answer 56

Surgical fixation This is a Maisonneuve fracture of the proximal fibula. It indicates an unstable ankle injury with likely injury to the interosseous membrane. In the setting of radiographic evidence of syndesmotic widening, this requires surgical fixation to reduce and stabilise the syndesmosis. An ankle fracture relates to a fracture around the tibio-talar joint. It generally refers to a fracture involving the lateral, and/or medial and/or posterior malleolus. Pilon and Tillaux fractures are also considered to be ankle fractures, but are not covered here. Ankle fractures are common. They effect men and women in equal numbers, but men have a higher rate as young adults (sports and contact injuries), and women a higher rate post-menopausal (fragility type fracture). ``` Osseous anatomy The ankle (or mortise) joint consists of the distal tibia (tibial plafond and posterior malleolus), the distal fibula (lateral malleolus), and the talus. The main movement at the ankle joint is plantar and dorsiflexion. ``` Ligamentous anatomy Medial side: Deltoid ligament. This is divided into superficial and deep portions. It is the primary restraint to valgus tilting of the talus. Lateral side: Lateral ligament complex consisting from anterior to posterior of the anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL), and the posterior talofibular ligament (PTFL). Together they resist valgus stress to the ankle, and are a restraint to anterior translation of the talus within the mortise joint. Syndesmosis: The syndesmosis is a ligament complex between the distal tibia and fibula, holding the two bones together. It is fundamental to the integrity of the ankle joint, and its disruption leads to instability. It consists of (from anterior to posterior) the anterior-inferior tibiofibular ligament (AITFL), the transverse tibiofibular ligament (TTFL), the interosseous membrane, and the posterior-inferior tibiofibular ligament (PITFL). Presentation and initial management Patients will present following a traumatic event with a painful, swollen ankle, and reluctance/inability to weight bear. The Ottawa rules can be applied to differentiate between an ankle fracture and sprain, but can be unreliable. In high energy injuries, management should follow ATLS principles to identify more significant injuries first. Neurovascular status of the foot should be documented, and open injuries should be excluded. If an open injury is identified, it should be managed in line with BOAST 4 principles1. If an obvious deformity exists, it should be reduced as soon as possible with appropriate analgesia or conscious sedation. Radiographs of clearly deformed or dislocated joints are not necessary, and removing the pressure on the surrounding soft tissues from the underlying bony deformity is the priority. If the fracture pattern is not clinically obvious then plain radiographs are appropriate and will guide the subsequent manipulation during plaster-of-paris below knee backslab application. Imaging AP, lateral and mortise views (20o internal rotation) are essential to evaluate fracture displacement and syndesmotic injury. Decreased tibiofibular overlap, medial joint clear space and lateral talar shift all indicate a syndesmotic injury. (In subtle cases of shift, imaging the uninjured ankle can be helpful as a proportion of the population have little or no tibiotalar overlap 2.) Where there is suspicion of syndesmosis involvement in the absence of radiographic evidence, stress radiographs can be diagnostic. Complex fracture patterns (and increasingly posterior malleolar fractures) are best defined using CT. Classification The most commonly used classifications are Lauge-Hansen and Danis-Weber. Lauge-Hansen Comprises two parts: first part is the foot position, and the second part is the force applied. Useful for understanding the forces involved and therefore predict the ligamentous or bony injury. Results in four injury patterns: Supination - Adduction (SA) - 10-20% Supination - External rotation (SER) - 40-75% Pronation - Abduction (PA) - 5-20% Pronation - External rotation (PER) - 5-20% Not often used in clinical practice but good for understanding the principles of ankle fracture. Danis-Weber Commonly used. Based on the level of the fibula fracture in relation to the syndesmosis. The more proximal, the greater the risk of syndesmotic injury and therefore fracture instability. A - fracture below the level of the syndesmosis B - fracture at the level of the syndesmosis / level of the tibial plafond C - fracture above the level of the syndesmosis. This includes Maisonneuve fractures (proximal fibula fracture), which can be associated with ankle instability. Beware the high fibula fracture - it may be an ankle fracture! The Weber classification is based purely on the the lateral side. All injuries can include a medial or posterior bony or ligamentous injury which also dictates fracture stability (bimalleolar and trimalleolar fractures are more unstable). Treatment When deciding upon treatment for an ankle fracture, one must consider both the fracture and the patient. Diabetic patients and smokers are at greater risk of post-operative complication, especially wound problems and infection. Likewise, the long term outcome of post-traumatic arthritis from a malunited ankle fracture is extremely important for a young patient, but not as relevant in the elderly. Therefore, normal surgical decision processes apply as with all fractures. Defining stability of an ankle fracture underpins the treatment decision. Weber A - Unimalleolar Weber A Weber fractures by definition are stable and therefore can be mobilised fully weight bearing in an ankle boot. Weber C - Fractures tend to include syndesmotic disruption and are usually bimalleolar (either bony or ligamentous). They are therefore unstable and usually require operative fixation. In addition to the fracture fixation, the syndesmosis usually requires reconstruction/augmentation with screws to restore the joint integrity and function. Weber B - B fractures vary greatly. They can be part of a trimalleolar injury and therefore extremely unstable, requiring fixation. Alternatively, a uni-malleolar Weber B fracture can be a stable injury, and therefore mobilised immediately in an ankle boot. Defining the stability can be challenging, and often involves stress radiographs, or a trial of mobilisation and repeat radiographs. Defining stability is the subject of much ongoing research. However, treating undisplaced ankle fractures in a below knee plaster, non-weight bearing for six weeks is still widely practised, and a safe approach. When operative fixation is appropriate, it is usually via open reduction and internal fixation using plates and screws. It must be carried out when soft tissue swelling has settled in order to minimise the risk of wound problems. This can often take a week to settle. The use of fibula nails is expanding, but is not yet mainstream. Ankle fractures can also be treated with external fixation, or with a hind foot nail in patients who need fixation but where soft tissue or bone quality is poor. Post operative management Ankle fractures generally take 6 weeks to unite enough to prevent secondary displacement. This is therefore an appropriate time period to keep a cast on in a conservatively managed patient. Weight bearing post-operatively depends on the quality of the fixation and bone quality, and preference varies between surgeons, ranging from aggressive early mobilisation to a period of non-weight bearing. Return to activities takes approximately three months, and often requires assistance of a physiotherapist to improve range-of-movement and muscle strengthening.

Answer 57

Application of external fixation device This is a pilon fracture, which a high energy injury of the distal tibia. The patient will ultimately require surgical fixation but early management involves applying a spanning external fixator to temporarily reduce the fracture and allow soft tissue swelling to settle. A CT scan should then be performed to aid surgical planning. An ankle fracture relates to a fracture around the tibio-talar joint. It generally refers to a fracture involving the lateral, and/or medial and/or posterior malleolus. Pilon and Tillaux fractures are also considered to be ankle fractures, but are not covered here. Ankle fractures are common. They effect men and women in equal numbers, but men have a higher rate as young adults (sports and contact injuries), and women a higher rate post-menopausal (fragility type fracture). ``` Osseous anatomy The ankle (or mortise) joint consists of the distal tibia (tibial plafond and posterior malleolus), the distal fibula (lateral malleolus), and the talus. The main movement at the ankle joint is plantar and dorsiflexion. ``` Ligamentous anatomy Medial side: Deltoid ligament. This is divided into superficial and deep portions. It is the primary restraint to valgus tilting of the talus. Lateral side: Lateral ligament complex consisting from anterior to posterior of the anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL), and the posterior talofibular ligament (PTFL). Together they resist valgus stress to the ankle, and are a restraint to anterior translation of the talus within the mortise joint. Syndesmosis: The syndesmosis is a ligament complex between the distal tibia and fibula, holding the two bones together. It is fundamental to the integrity of the ankle joint, and its disruption leads to instability. It consists of (from anterior to posterior) the anterior-inferior tibiofibular ligament (AITFL), the transverse tibiofibular ligament (TTFL), the interosseous membrane, and the posterior-inferior tibiofibular ligament (PITFL). Presentation and initial management Patients will present following a traumatic event with a painful, swollen ankle, and reluctance/inability to weight bear. The Ottawa rules can be applied to differentiate between an ankle fracture and sprain, but can be unreliable. In high energy injuries, management should follow ATLS principles to identify more significant injuries first. Neurovascular status of the foot should be documented, and open injuries should be excluded. If an open injury is identified, it should be managed in line with BOAST 4 principles1. If an obvious deformity exists, it should be reduced as soon as possible with appropriate analgesia or conscious sedation. Radiographs of clearly deformed or dislocated joints are not necessary, and removing the pressure on the surrounding soft tissues from the underlying bony deformity is the priority. If the fracture pattern is not clinically obvious then plain radiographs are appropriate and will guide the subsequent manipulation during plaster-of-paris below knee backslab application. Imaging AP, lateral and mortise views (20o internal rotation) are essential to evaluate fracture displacement and syndesmotic injury. Decreased tibiofibular overlap, medial joint clear space and lateral talar shift all indicate a syndesmotic injury. (In subtle cases of shift, imaging the uninjured ankle can be helpful as a proportion of the population have little or no tibiotalar overlap 2.) Where there is suspicion of syndesmosis involvement in the absence of radiographic evidence, stress radiographs can be diagnostic. Complex fracture patterns (and increasingly posterior malleolar fractures) are best defined using CT. Classification The most commonly used classifications are Lauge-Hansen and Danis-Weber. Lauge-Hansen Comprises two parts: first part is the foot position, and the second part is the force applied. Useful for understanding the forces involved and therefore predict the ligamentous or bony injury. Results in four injury patterns: Supination - Adduction (SA) - 10-20% Supination - External rotation (SER) - 40-75% Pronation - Abduction (PA) - 5-20% Pronation - External rotation (PER) - 5-20% Not often used in clinical practice but good for understanding the principles of ankle fracture. Danis-Weber Commonly used. Based on the level of the fibula fracture in relation to the syndesmosis. The more proximal, the greater the risk of syndesmotic injury and therefore fracture instability. A - fracture below the level of the syndesmosis B - fracture at the level of the syndesmosis / level of the tibial plafond C - fracture above the level of the syndesmosis. This includes Maisonneuve fractures (proximal fibula fracture), which can be associated with ankle instability. Beware the high fibula fracture - it may be an ankle fracture! The Weber classification is based purely on the the lateral side. All injuries can include a medial or posterior bony or ligamentous injury which also dictates fracture stability (bimalleolar and trimalleolar fractures are more unstable). Treatment When deciding upon treatment for an ankle fracture, one must consider both the fracture and the patient. Diabetic patients and smokers are at greater risk of post-operative complication, especially wound problems and infection. Likewise, the long term outcome of post-traumatic arthritis from a malunited ankle fracture is extremely important for a young patient, but not as relevant in the elderly. Therefore, normal surgical decision processes apply as with all fractures. Defining stability of an ankle fracture underpins the treatment decision. Weber A - Unimalleolar Weber A Weber fractures by definition are stable and therefore can be mobilised fully weight bearing in an ankle boot. Weber C - Fractures tend to include syndesmotic disruption and are usually bimalleolar (either bony or ligamentous). They are therefore unstable and usually require operative fixation. In addition to the fracture fixation, the syndesmosis usually requires reconstruction/augmentation with screws to restore the joint integrity and function. Weber B - B fractures vary greatly. They can be part of a trimalleolar injury and therefore extremely unstable, requiring fixation. Alternatively, a uni-malleolar Weber B fracture can be a stable injury, and therefore mobilised immediately in an ankle boot. Defining the stability can be challenging, and often involves stress radiographs, or a trial of mobilisation and repeat radiographs. Defining stability is the subject of much ongoing research. However, treating undisplaced ankle fractures in a below knee plaster, non-weight bearing for six weeks is still widely practised, and a safe approach. When operative fixation is appropriate, it is usually via open reduction and internal fixation using plates and screws. It must be carried out when soft tissue swelling has settled in order to minimise the risk of wound problems. This can often take a week to settle. The use of fibula nails is expanding, but is not yet mainstream. Ankle fractures can also be treated with external fixation, or with a hind foot nail in patients who need fixation but where soft tissue or bone quality is poor. Post operative management Ankle fractures generally take 6 weeks to unite enough to prevent secondary displacement. This is therefore an appropriate time period to keep a cast on in a conservatively managed patient. Weight bearing post-operatively depends on the quality of the fixation and bone quality, and preference varies between surgeons, ranging from aggressive early mobilisation to a period of non-weight bearing. Return to activities takes approximately three months, and often requires assistance of a physiotherapist to improve range-of-movement and muscle strengthening.

Answer 58

Hip x-ray The main differential diagnosis in a boy over 10 years old is of slipped upper femoral epiphysis. Knee pain is a common presenting feature. An anteroposterior pelvic x-ray may miss a minor slip, therefore request a hip film. Developmental dysplasia of the hip Usually diagnosed in infancy by screening tests. May be bilateral, when disease is unilateral there may be leg length inequality. As disease progresses child may limp and then early onset arthritis. More common in extended breech babies. Splints and harnesses or traction. In later years osteotomy and hip realignment procedures may be needed. In arthritis a joint replacement may be needed. However, this is best deferred if possible as it will almost certainly require revision Initially no obvious change on plain films and USS gives best resolution until 3 months of age. On plain films Shentons line should form a smooth arc Perthes Disease Hip pain (may be referred to the knee) usually occurring between 5 and 12 years of age. Bilateral disease in 20%. Remove pressure from joint to allow normal development. Physiotherapy. Usually self-limiting if diagnosed and treated promptly. X-rays will show flattened femoral head. Eventually in untreated cases the femoral head will fragment. Slipped upper femoral epiphysis Typically seen in obese male adolescents. Pain is often referred to the knee. Limitation to internal rotation is usually seen. Knee pain is usually present 2 months prior to hip slipping. Bilateral in 20%. Bed rest and non-weight bearing. Aim to avoid avascular necrosis. If severe slippage or risk of it occurring then percutaneous pinning of the hip may be required. X-rays will show the femoral head displaced and falling inferolaterally (like a melting ice cream cone) The Southwick angle gives indication of disease severity

Answer 59

USS hip This child is at risk of developmental dysplasia of the hip (up to 20% will have DDH), so should have the hip joints scanned to exclude this. Developmental dysplasia of the hip Usually diagnosed in infancy by screening tests. May be bilateral, when disease is unilateral there may be leg length inequality. As disease progresses child may limp and then early onset arthritis. More common in extended breech babies. Splints and harnesses or traction. In later years osteotomy and hip realignment procedures may be needed. In arthritis a joint replacement may be needed. However, this is best deferred if possible as it will almost certainly require revision Initially no obvious change on plain films and USS gives best resolution until 3 months of age. On plain films Shentons line should form a smooth arc Perthes Disease Hip pain (may be referred to the knee) usually occurring between 5 and 12 years of age. Bilateral disease in 20%. Remove pressure from joint to allow normal development. Physiotherapy. Usually self-limiting if diagnosed and treated promptly. X-rays will show flattened femoral head. Eventually in untreated cases the femoral head will fragment. Slipped upper femoral epiphysis Typically seen in obese male adolescents. Pain is often referred to the knee. Limitation to internal rotation is usually seen. Knee pain is usually present 2 months prior to hip slipping. Bilateral in 20%. Bed rest and non-weight bearing. Aim to avoid avascular necrosis. If severe slippage or risk of it occurring then percutaneous pinning of the hip may be required. X-rays will show the femoral head displaced and falling inferolaterally (like a melting ice cream cone) The Southwick angle gives indication of disease severity

Answer 60

MRI Perthes disease should be suspected in boys over 4 years old presenting with a limp. Early disease can be missed on x-ray. An MRI will often demonstrate areas of hypoperfusion and subtle changes that allow for earlier diagnosis. A bone scan is an alternative option. Developmental dysplasia of the hip Usually diagnosed in infancy by screening tests. May be bilateral, when disease is unilateral there may be leg length inequality. As disease progresses child may limp and then early onset arthritis. More common in extended breech babies. Splints and harnesses or traction. In later years osteotomy and hip realignment procedures may be needed. In arthritis a joint replacement may be needed. However, this is best deferred if possible as it will almost certainly require revision Initially no obvious change on plain films and USS gives best resolution until 3 months of age. On plain films Shentons line should form a smooth arc Perthes Disease Hip pain (may be referred to the knee) usually occurring between 5 and 12 years of age. Bilateral disease in 20%. Remove pressure from joint to allow normal development. Physiotherapy. Usually self-limiting if diagnosed and treated promptly. X-rays will show flattened femoral head. Eventually in untreated cases the femoral head will fragment. Slipped upper femoral epiphysis Typically seen in obese male adolescents. Pain is often referred to the knee. Limitation to internal rotation is usually seen. Knee pain is usually present 2 months prior to hip slipping. Bilateral in 20%. Bed rest and non-weight bearing. Aim to avoid avascular necrosis. If severe slippage or risk of it occurring then percutaneous pinning of the hip may be required. X-rays will show the femoral head displaced and falling inferolaterally (like a melting ice cream cone) The Southwick angle gives indication of disease severity

Answer 61

Greenstick fractures are common childhood injuries. Unilateral cortical disruption is the main radiological feature, since involvement of both cortices makes the injury a complete fracture. Buckle fractures will show periosteal haematoma formation only. Paediatric fracture types Type Injury pattern Complete fracture Both sides of cortex are breached Toddlers fracture Oblique tibial fracture in infants Plastic deformity Stress on bone resulting in deformity without cortical disruption Greenstick fracture Unilateral cortical breach only Buckle fracture Incomplete cortical disruption resulting in periosteal haematoma only Growth plate fractures In paediatric practice fractures may also involve the growth plate and these injuries are classified according to the Salter- Harris system (given below): Type Injury pattern I Fracture through the physis only (x-ray often normal) II Fracture through the physis and metaphysis III Fracture through the physis and epiphyisis to include the joint IV Fracture involving the physis, metaphysis and epiphysis V Crush injury involving the physis (x-ray may resemble type I, and appear normal) As a general rule it is safer to assume that growth plate tenderness is indicative of an underlying fracture even if the x-ray appears normal. Injuries of Types III, IV and V will usually require surgery. Type V injuries are often associated with disruption to growth. Non accidental injury Delayed presentation Delay in attaining milestones Lack of concordance between proposed and actual mechanism of injury Multiple injuries Injuries at sites not commonly exposed to trauma Children on the at risk register Pathological fractures Genetic conditions, such as osteogenesis imperfecta, may cause pathological fractures. Osteogenesis imperfecta Defective osteoid formation due to congenital inability to produce adequate intercellular substances like osteoid, collagen and dentine. Failure of maturation of collagen in all the connective tissues. Radiology may show translucent bones, multiple fractures, particularly of the long bones, wormian bones (irregular patches of ossification) and a trefoil pelvis. Subtypes Type I The collagen is normal quality but insufficient quantity. Type II- Poor collagen quantity and quality. Type III- Collagen poorly formed. Normal quantity. Type IV- Sufficient collagen quantity but poor quality. ``` Osteopetrosis Bones become harder and more dense. Autosomal recessive condition. It is commonest in young adults. Radiology reveals a lack of differentiation between the cortex and the medulla described as marble bone. ```

Answer 62

Malunion would be unusual with a femoral neck fracture. Because it is a weight bearing joint, if the fracture is not united then it does not heal at all. It is for this reason that most femoral neck fractures are fixed. Avascular necrosis is a well recognised complication and a total hip replacement or hemiarthroplasty is usually considered in the elderly. Neck of femur (NOF) fracture is a common orthopaedic presentation, with over 65000 fractures in the UK per year. Like many orthopaedic injuries, there is a bimodal age distribution. It is imperative to distinguish between the high energy injury in a young patient, and the low energy osteoporotic fracture in the elderly, as their management aims are very different: Young patient - Usually high energy trauma (e.g road traffic accident, horse riding) and needs treating in accordance with Advanced Trauma Life Support (ATLS) principles. Will often have associated injuries. Aim is to retain the patients own anatomy, and optimise their function. Elderly patient - Predominantly female, fall from standing height (fragility fracture). Often patients have multiple comorbidities that will ultimately dictate their prognosis. Aim of orthopaedic treatment is to immediately regain patient mobility so that morbidity (infection, thromboembolic events, pressure sores etc) and mortality associated with prolonged bed rest is avoided. Left untreated, a neck of femur fracture can be considered a terminal event. Historically, mortality associated with elderly hip fracture is 10% at one month, and 30% at one year. However, this has been improved in the UK with the introduction of multidisciplinary, orthogeriatric lead care and the National Hip Fracture Database and Best Practice Tariff. Pertinent anatomy Osteology - normal neck-shaft angle is 130 +/- 7 degrees, and 10 +/- 7 degrees of neck anteversion. Vascular supply - The predominant blood supply to the femoral head and neck is from the medial and lateral femoral circumflex arteries (branches of profunda femoris). These anastomose and pierce the joint capsule at the base of the neck, mainly posteriorly. There is a small vascular contribution from the artery of the ligament teres. Understanding the blood supply is fundamental to the decision making process in treating NOF fractures. Presentation and initial management Typically, patients present with pain in the hip/groin, a shortened, abducted, externally rotated leg (due to the unopposed pull of the muscles that act across the hip joint) and the inability to straight-leg-raise. With undisplaced fractures, signs are more subtle. High energy injuries should be treated in line with ATLS principles. All patients should be fluid resuscitated, have adequate pain relief (often with a fascio-iliiaca nerve block), and be optimised for surgery. In addition, elderly patients should be assessed by an orthogeriatrician. Imaging Anteroposterior and cross-table lateral plain radiographs are sufficient to diagnose the majority of NOF fractures. If the fracture extends below the level of the lesser trochanter, or there is any possibility of pathological fracture, full length femur views are essential to plan surgery. Where there is a high index of suspicion of fracture, but plain radiographs are inconclusive, gold standard investigation is MRI. However, if unavailable within 24 hours, or if the patient will not tolerate MRI, CT is appropriate. The majority of fractures can be seen with modern CT techniques, and so this is becoming first line in many hospitals. Classification There has been a move away from named classification systems towards descriptive classification systems. Two main types of NOF exist: Intra-capsular, and extra-capsular. Extra-capsular fractures are further divided into pertrochanteric or subtrochanteric (within 5cm distal to the lesser trochanter). All fractures are then described as undisplaced, minimally displaced, or displaced. Femoral neck and head blood supply disruption is common with intracapsular NOF fractures, and rare with extracapsular fractures. This fundamental principle underpins the practise of arthroplasty for intracapsular fractures, and fixation for extracapsular fractures. If you wish to use a named classification system, the most commonly used are below: Elderly intracapsular - Garden Classification Young intrasapsular - Pauvels Classification Intertrochanteric - Evans Subtrochanteric - Russell Taylor Treatment In general, NOF fractures are treated operatively except if the patient is deemed unlikely to survive an anaesthetic. Best Practice Tarif (BPT) dictates that surgery should happen within 36 hours, as delay of greater than 48 hours is associated with increased morbidity and mortality. Below are suggested algorithms for the treatment of NOF. There are some areas of debate/controversy which are detailed below. Image sourced from Wikipedia * The priority with the young patient is to retain the femoral head if possible, even with a displaced intracapsular fracture. The risk of avascular necrosis and non-union (and therefore revision surgery) associated with internal fixation needs weighing up against the sequelae of total hip replacement in the young (wear, dislocation, revision). Discussion is necessary with the patient, on a case by case basis. ** Undisplaced fractures in the elderly can be treated with internal fixation, often with cannulated screws. This is appropriate for valgus impacted subcapital fractures which are inherently stable, to prevent secondary displacement. This does still carry the risk of AVN or non-union, and therefore a future revision. For this reason, many surgeons advocate arthroplasty as a single surgery. *** NICE guidance - patients who fulfil these criteria should be offered total hip replacement which conveys better function and prosthetic survivorship, compared with hemiarthroplasty, but at an increased risk of dislocation. Image sourced from Wikipedia * Intertrochanteric fractures vary greatly in their stability. If the trochanter (and therefore lateral wall), and medial calcar is in tact, then the fracture configuration bears stability. This can be treated with a DHS, as collapse of the fracture is predictable. Where either or both structures are involved in the fracture, stability becomes compromised and many surgeons will favour using an intramedullary device. This is an ongoing debate, and difficult to test in an exam setting. Post operative management Patients should be mobilised fully weight bearing where possible. Care is multidisciplinary in its delivery. Elderly patients should have orthogeriatrician assessment of comorbidity, and bone health with secondary prevention measures if appropriate. There should be early involvement of physiotherapy and occupational therapy services.

Answer 63

Pott's Colles' fracture (dinner fork deformity) Fall onto extended outstretched hand Classical Colles' fractures have the following 3 features: 1. Transverse fracture of the radius 2. 1 inch proximal to the radio-carpal joint 3. Dorsal displacement and angulation Smith's fracture (reverse Colles' fracture) Volar angulation of distal radius fragment (Garden spade deformity) Caused by falling backwards onto the palm of an outstretched hand or falling with wrists flexed Bennett's fracture Intra-articular fracture of the first carpometacarpal joint Impact on flexed metacarpal, caused by fist fights X-ray: triangular fragment at ulnar base of metacarpal Image sourced from Wikipedia Monteggia's fracture Dislocation of the proximal radioulnar joint in association with an ulna fracture Fall on outstretched hand with forced pronation Needs prompt diagnosis to avoid disability Image sourced from Wikipedia Galeazzi fracture Radial shaft fracture with associated dislocation of the distal radioulnar joint Direct blow Pott's fracture Bimalleolar ankle fracture Forced foot eversion Barton's fracture Distal radius fracture (Colles'/Smith's) with associated radiocarpal dislocation Fall onto extended and pronated wrist Involvement of the joint is a defining feature

Answer 64

Bennett's Colles' fracture (dinner fork deformity) Fall onto extended outstretched hand Classical Colles' fractures have the following 3 features: 1. Transverse fracture of the radius 2. 1 inch proximal to the radio-carpal joint 3. Dorsal displacement and angulation Smith's fracture (reverse Colles' fracture) Volar angulation of distal radius fragment (Garden spade deformity) Caused by falling backwards onto the palm of an outstretched hand or falling with wrists flexed Bennett's fracture Intra-articular fracture of the first carpometacarpal joint Impact on flexed metacarpal, caused by fist fights X-ray: triangular fragment at ulnar base of metacarpal Image sourced from Wikipedia Monteggia's fracture Dislocation of the proximal radioulnar joint in association with an ulna fracture Fall on outstretched hand with forced pronation Needs prompt diagnosis to avoid disability Image sourced from Wikipedia Galeazzi fracture Radial shaft fracture with associated dislocation of the distal radioulnar joint Direct blow Pott's fracture Bimalleolar ankle fracture Forced foot eversion Barton's fracture Distal radius fracture (Colles'/Smith's) with associated radiocarpal dislocation Fall onto extended and pronated wrist Involvement of the joint is a defining feature

Answer 65

Barton's Bartons fractures tend to have intra-articular involvement and dislocation may sometimes be present. Colles' fracture (dinner fork deformity) Fall onto extended outstretched hand Classical Colles' fractures have the following 3 features: 1. Transverse fracture of the radius 2. 1 inch proximal to the radio-carpal joint 3. Dorsal displacement and angulation Smith's fracture (reverse Colles' fracture) Volar angulation of distal radius fragment (Garden spade deformity) Caused by falling backwards onto the palm of an outstretched hand or falling with wrists flexed Bennett's fracture Intra-articular fracture of the first carpometacarpal joint Impact on flexed metacarpal, caused by fist fights X-ray: triangular fragment at ulnar base of metacarpal Image sourced from Wikipedia Monteggia's fracture Dislocation of the proximal radioulnar joint in association with an ulna fracture Fall on outstretched hand with forced pronation Needs prompt diagnosis to avoid disability Image sourced from Wikipedia Galeazzi fracture Radial shaft fracture with associated dislocation of the distal radioulnar joint Direct blow Pott's fracture Bimalleolar ankle fracture Forced foot eversion Barton's fracture Distal radius fracture (Colles'/Smith's) with associated radiocarpal dislocation Fall onto extended and pronated wrist Involvement of the joint is a defining feature

Answer 66

Fasciotomy Pain and neurological symptoms in a tight fascial compartment coupled with a high velocity injury carry a high risk of compartment syndrome and prompt fasciotomy should be performed. Fracture management Bony injury resulting in a fracture may arise from trauma (excessive forces applied to bone), stress related (repetitive low velocity injury) or pathological (abnormal bone which fractures during normal use of following minimal trauma) Diagnosis involves not just evaluating the fracture ; such as site and type of injury but also other associated injuries and distal neurovascular deficits. This may entail not just clinical examination but radiographs of proximal and distal joints. When assessing x-rays it is important to assess for changes in length of the bone, the angulation of the distal bone, rotational effects, presence of material such as glass. Fracture types Fracture type Description Oblique fracture Fracture lies obliquely to long axis of bone Comminuted fracture >2 fragments Segmental fracture More than one fracture along a bone Transverse fracture Perpendicular to long axis of bone Spiral fracture Severe oblique fracture with rotation along long axis of bone Open Vs Closed It is also important to distinguish open from closed injuries. The most common classification system for open fractures is the Gustilo and Anderson classification system (given below): Grade Injury 1 Low energy wound <1cm 2 Greater than 1cm wound with moderate soft tissue damage 3 High energy wound > 1cm with extensive soft tissue damage 3 A (sub group of 3) Adequate soft tissue coverage 3 B (sub group of 3) Inadequate soft tissue coverage 3 C (sub group of 3) Associated arterial injury Key points in management of fractures Immobilise the fracture including the proximal and distal joints Carefully monitor and document neurovascular status, particularly following reduction and immobilisation Manage infection including tetanus prophylaxis IV broad spectrum antibiotics for open injuries As a general principle all open fractures should be thoroughly debrided ( and internal fixation devices avoided or used with extreme caution) Open fractures constitute an emergency and should be debrided and lavaged within 6 hours of injury

Answer 67

Application of external fixator Wide exposure to plate the humerus is generally inadvisable owing to its many important anatomical relations. Both intramedullary nailing and external fixation are reasonable treatments. However, in the presence of an open fracture application of an external fixator and appropriate tissue debridement would be most appropriate. Fracture management Bony injury resulting in a fracture may arise from trauma (excessive forces applied to bone), stress related (repetitive low velocity injury) or pathological (abnormal bone which fractures during normal use of following minimal trauma) Diagnosis involves not just evaluating the fracture ; such as site and type of injury but also other associated injuries and distal neurovascular deficits. This may entail not just clinical examination but radiographs of proximal and distal joints. When assessing x-rays it is important to assess for changes in length of the bone, the angulation of the distal bone, rotational effects, presence of material such as glass. Fracture types Fracture type Description Oblique fracture Fracture lies obliquely to long axis of bone Comminuted fracture >2 fragments Segmental fracture More than one fracture along a bone Transverse fracture Perpendicular to long axis of bone Spiral fracture Severe oblique fracture with rotation along long axis of bone Open Vs Closed It is also important to distinguish open from closed injuries. The most common classification system for open fractures is the Gustilo and Anderson classification system (given below): Grade Injury 1 Low energy wound <1cm 2 Greater than 1cm wound with moderate soft tissue damage 3 High energy wound > 1cm with extensive soft tissue damage 3 A (sub group of 3) Adequate soft tissue coverage 3 B (sub group of 3) Inadequate soft tissue coverage 3 C (sub group of 3) Associated arterial injury Key points in management of fractures Immobilise the fracture including the proximal and distal joints Carefully monitor and document neurovascular status, particularly following reduction and immobilisation Manage infection including tetanus prophylaxis IV broad spectrum antibiotics for open injuries As a general principle all open fractures should be thoroughly debrided ( and internal fixation devices avoided or used with extreme caution) Open fractures constitute an emergency and should be debrided and lavaged within 6 hours of injury

Answer 68

Open reduction and internal fixation Meticulous anatomical alignment of the fracture segments is crucial to avoid the development of osteoarthritis and risk of malunion. Fracture management Bony injury resulting in a fracture may arise from trauma (excessive forces applied to bone), stress related (repetitive low velocity injury) or pathological (abnormal bone which fractures during normal use of following minimal trauma) Diagnosis involves not just evaluating the fracture ; such as site and type of injury but also other associated injuries and distal neurovascular deficits. This may entail not just clinical examination but radiographs of proximal and distal joints. When assessing x-rays it is important to assess for changes in length of the bone, the angulation of the distal bone, rotational effects, presence of material such as glass. Fracture types Fracture type Description Oblique fracture Fracture lies obliquely to long axis of bone Comminuted fracture >2 fragments Segmental fracture More than one fracture along a bone Transverse fracture Perpendicular to long axis of bone Spiral fracture Severe oblique fracture with rotation along long axis of bone Open Vs Closed It is also important to distinguish open from closed injuries. The most common classification system for open fractures is the Gustilo and Anderson classification system (given below): Grade Injury 1 Low energy wound <1cm 2 Greater than 1cm wound with moderate soft tissue damage 3 High energy wound > 1cm with extensive soft tissue damage 3 A (sub group of 3) Adequate soft tissue coverage 3 B (sub group of 3) Inadequate soft tissue coverage 3 C (sub group of 3) Associated arterial injury Key points in management of fractures Immobilise the fracture including the proximal and distal joints Carefully monitor and document neurovascular status, particularly following reduction and immobilisation Manage infection including tetanus prophylaxis IV broad spectrum antibiotics for open injuries As a general principle all open fractures should be thoroughly debrided ( and internal fixation devices avoided or used with extreme caution) Open fractures constitute an emergency and should be debrided and lavaged within 6 hours of injury

Answer 69

Amputation This man is unstable, and at 7 hours after extraction, the limb is not viable. The safest option is primary amputation. Fracture management Bony injury resulting in a fracture may arise from trauma (excessive forces applied to bone), stress related (repetitive low velocity injury) or pathological (abnormal bone which fractures during normal use of following minimal trauma) Diagnosis involves not just evaluating the fracture ; such as site and type of injury but also other associated injuries and distal neurovascular deficits. This may entail not just clinical examination but radiographs of proximal and distal joints. When assessing x-rays it is important to assess for changes in length of the bone, the angulation of the distal bone, rotational effects, presence of material such as glass. Fracture types Fracture type Description Oblique fracture Fracture lies obliquely to long axis of bone Comminuted fracture >2 fragments Segmental fracture More than one fracture along a bone Transverse fracture Perpendicular to long axis of bone Spiral fracture Severe oblique fracture with rotation along long axis of bone Open Vs Closed It is also important to distinguish open from closed injuries. The most common classification system for open fractures is the Gustilo and Anderson classification system (given below): Grade Injury 1 Low energy wound <1cm 2 Greater than 1cm wound with moderate soft tissue damage 3 High energy wound > 1cm with extensive soft tissue damage 3 A (sub group of 3) Adequate soft tissue coverage 3 B (sub group of 3) Inadequate soft tissue coverage 3 C (sub group of 3) Associated arterial injury Key points in management of fractures Immobilise the fracture including the proximal and distal joints Carefully monitor and document neurovascular status, particularly following reduction and immobilisation Manage infection including tetanus prophylaxis IV broad spectrum antibiotics for open injuries As a general principle all open fractures should be thoroughly debrided ( and internal fixation devices avoided or used with extreme caution) Open fractures constitute an emergency and should be debrided and lavaged within 6 hours of injury

Answer 70

Intramedullary nail This would be a good case for intramedullary nailing. Open reduction and external fixation would strip off otherwise healthy tissues and hence is unsuitable. In some units the injury may be managed with an Ilizarov frame device but the majority would treat with IM nailing. Fracture management Bony injury resulting in a fracture may arise from trauma (excessive forces applied to bone), stress related (repetitive low velocity injury) or pathological (abnormal bone which fractures during normal use of following minimal trauma) Diagnosis involves not just evaluating the fracture ; such as site and type of injury but also other associated injuries and distal neurovascular deficits. This may entail not just clinical examination but radiographs of proximal and distal joints. When assessing x-rays it is important to assess for changes in length of the bone, the angulation of the distal bone, rotational effects, presence of material such as glass. Fracture types Fracture type Description Oblique fracture Fracture lies obliquely to long axis of bone Comminuted fracture >2 fragments Segmental fracture More than one fracture along a bone Transverse fracture Perpendicular to long axis of bone Spiral fracture Severe oblique fracture with rotation along long axis of bone Open Vs Closed It is also important to distinguish open from closed injuries. The most common classification system for open fractures is the Gustilo and Anderson classification system (given below): Grade Injury 1 Low energy wound <1cm 2 Greater than 1cm wound with moderate soft tissue damage 3 High energy wound > 1cm with extensive soft tissue damage 3 A (sub group of 3) Adequate soft tissue coverage 3 B (sub group of 3) Inadequate soft tissue coverage 3 C (sub group of 3) Associated arterial injury Key points in management of fractures Immobilise the fracture including the proximal and distal joints Carefully monitor and document neurovascular status, particularly following reduction and immobilisation Manage infection including tetanus prophylaxis IV broad spectrum antibiotics for open injuries As a general principle all open fractures should be thoroughly debrided ( and internal fixation devices avoided or used with extreme caution) Open fractures constitute an emergency and should be debrided and lavaged within 6 hours of injury

Answer 71

Copious lavage and generous surgical debridement, followed by external fixation At the tissues are in better shape than in the first case and as there is no associated vascular injury the patient may be suitable for debridement of the area and external fixation. If debridement leaves a tissue defect then plastic surgical repair will be needed at a later stage. Fracture management Bony injury resulting in a fracture may arise from trauma (excessive forces applied to bone), stress related (repetitive low velocity injury) or pathological (abnormal bone which fractures during normal use of following minimal trauma) Diagnosis involves not just evaluating the fracture ; such as site and type of injury but also other associated injuries and distal neurovascular deficits. This may entail not just clinical examination but radiographs of proximal and distal joints. When assessing x-rays it is important to assess for changes in length of the bone, the angulation of the distal bone, rotational effects, presence of material such as glass. Fracture types Fracture type Description Oblique fracture Fracture lies obliquely to long axis of bone Comminuted fracture >2 fragments Segmental fracture More than one fracture along a bone Transverse fracture Perpendicular to long axis of bone Spiral fracture Severe oblique fracture with rotation along long axis of bone Open Vs Closed It is also important to distinguish open from closed injuries. The most common classification system for open fractures is the Gustilo and Anderson classification system (given below): Grade Injury 1 Low energy wound <1cm 2 Greater than 1cm wound with moderate soft tissue damage 3 High energy wound > 1cm with extensive soft tissue damage 3 A (sub group of 3) Adequate soft tissue coverage 3 B (sub group of 3) Inadequate soft tissue coverage 3 C (sub group of 3) Associated arterial injury Key points in management of fractures Immobilise the fracture including the proximal and distal joints Carefully monitor and document neurovascular status, particularly following reduction and immobilisation Manage infection including tetanus prophylaxis IV broad spectrum antibiotics for open injuries As a general principle all open fractures should be thoroughly debrided ( and internal fixation devices avoided or used with extreme caution) Open fractures constitute an emergency and should be debrided and lavaged within 6 hours of injury

Answer 72

Developmental dysplasia of the hip. Usually diagnosed by Barlow and Ortolani tests in early childhood. Most Breech deliveries are also routinely subjected to USS of the hip joint. At this young age an arthrodesis may be preferable to hip replacement. Developmental dysplasia of the hip Usually diagnosed in infancy by screening tests. May be bilateral, when disease is unilateral there may be leg length inequality. As disease progresses child may limp and then early onset arthritis. More common in extended breech babies. Splints and harnesses or traction. In later years osteotomy and hip realignment procedures may be needed. In arthritis a joint replacement may be needed. However, this is best deferred if possible as it will almost certainly require revision Initially no obvious change on plain films and USS gives best resolution until 3 months of age. On plain films Shentons line should form a smooth arc Perthes Disease Hip pain (may be referred to the knee) usually occurring between 5 and 12 years of age. Bilateral disease in 20%. Remove pressure from joint to allow normal development. Physiotherapy. Usually self-limiting if diagnosed and treated promptly. X-rays will show flattened femoral head. Eventually in untreated cases the femoral head will fragment. Slipped upper femoral epiphysis Typically seen in obese male adolescents. Pain is often referred to the knee. Limitation to internal rotation is usually seen. Knee pain is usually present 2 months prior to hip slipping. Bilateral in 20%. Bed rest and non-weight bearing. Aim to avoid avascular necrosis. If severe slippage or risk of it occurring then percutaneous pinning of the hip may be required. X-rays will show the femoral head displaced and falling inferolaterally (like a melting ice cream cone) The Southwick angle gives indication of disease severity

Answer 73

Vitamin D, calcium supplements and bisphosphonates The osteoporosis guidelines state if a postmenopausal woman has a fracture she should be put on bisphosphonates (there is no need for a DEXA scan). Osteoporosis is a condition of bone atrophy. It is a lesion in which the volume of bone tissue per unit volume of anatomical bone is reduced. It may be generalized (most common) or localized (following pressure or disuse). The hallmark is a reduction in the amount of osteoid matrix, which, however, remains normally mineralized. It is therefore distinct from osteomalacia in which there is abundant osteoid which is poorly calcified. In osteoporosis the bony trabeculae are greatly thinned which significantly reduces the tensile strength of the bone and renders it at increased risk of pathological fracture. It is only visible on plain films when the calcium content is approximately halved. More subtle changes can be appreciated by use of DEXA scanning. Treatment Fractures are treated according to their site and mechanism of injury. Those deemed to occur as a result of osteoporosis should also be addressed medically to treat the underlying osteoporosis. Drugs that can be prescribed to prevent fragility fractures include bisphosphonates (alendronate, ibandronate, risedronate and zoledronic acid) and non-bisphosphonates (raloxifene, denosumab, teriparatide, calcitriol and hormone replacement therapy). Calcium and vitamin D supplements are also administered. Individuals at risk of fragility fractures should also be considered for prophylactic medical treatment as outlined above.

Answer 74

Application of below knee plaster cast This is a Weber B fracture and therefore potentially unstable. Medial malleolar tenderness indicates deltoid ligament injury. As the fracture is currently undisplaced and the ankle mortice is congruent, the injury can be initially managed conservatively in a below knee plaster but the patient should be monitored in the outpatient clinic for fracture displacement in the first few weeks. An ankle fracture relates to a fracture around the tibio-talar joint. It generally refers to a fracture involving the lateral, and/or medial and/or posterior malleolus. Pilon and Tillaux fractures are also considered to be ankle fractures, but are not covered here. Ankle fractures are common. They effect men and women in equal numbers, but men have a higher rate as young adults (sports and contact injuries), and women a higher rate post-menopausal (fragility type fracture). ``` Osseous anatomy The ankle (or mortise) joint consists of the distal tibia (tibial plafond and posterior malleolus), the distal fibula (lateral malleolus), and the talus. The main movement at the ankle joint is plantar and dorsiflexion. ``` Ligamentous anatomy Medial side: Deltoid ligament. This is divided into superficial and deep portions. It is the primary restraint to valgus tilting of the talus. Lateral side: Lateral ligament complex consisting from anterior to posterior of the anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL), and the posterior talofibular ligament (PTFL). Together they resist valgus stress to the ankle, and are a restraint to anterior translation of the talus within the mortise joint. Syndesmosis: The syndesmosis is a ligament complex between the distal tibia and fibula, holding the two bones together. It is fundamental to the integrity of the ankle joint, and its disruption leads to instability. It consists of (from anterior to posterior) the anterior-inferior tibiofibular ligament (AITFL), the transverse tibiofibular ligament (TTFL), the interosseous membrane, and the posterior-inferior tibiofibular ligament (PITFL). Presentation and initial management Patients will present following a traumatic event with a painful, swollen ankle, and reluctance/inability to weight bear. The Ottawa rules can be applied to differentiate between an ankle fracture and sprain, but can be unreliable. In high energy injuries, management should follow ATLS principles to identify more significant injuries first. Neurovascular status of the foot should be documented, and open injuries should be excluded. If an open injury is identified, it should be managed in line with BOAST 4 principles1. If an obvious deformity exists, it should be reduced as soon as possible with appropriate analgesia or conscious sedation. Radiographs of clearly deformed or dislocated joints are not necessary, and removing the pressure on the surrounding soft tissues from the underlying bony deformity is the priority. If the fracture pattern is not clinically obvious then plain radiographs are appropriate and will guide the subsequent manipulation during plaster-of-paris below knee backslab application. Imaging AP, lateral and mortise views (20o internal rotation) are essential to evaluate fracture displacement and syndesmotic injury. Decreased tibiofibular overlap, medial joint clear space and lateral talar shift all indicate a syndesmotic injury. (In subtle cases of shift, imaging the uninjured ankle can be helpful as a proportion of the population have little or no tibiotalar overlap 2.) Where there is suspicion of syndesmosis involvement in the absence of radiographic evidence, stress radiographs can be diagnostic. Complex fracture patterns (and increasingly posterior malleolar fractures) are best defined using CT. Classification The most commonly used classifications are Lauge-Hansen and Danis-Weber. Lauge-Hansen Comprises two parts: first part is the foot position, and the second part is the force applied. Useful for understanding the forces involved and therefore predict the ligamentous or bony injury. Results in four injury patterns: Supination - Adduction (SA) - 10-20% Supination - External rotation (SER) - 40-75% Pronation - Abduction (PA) - 5-20% Pronation - External rotation (PER) - 5-20% Not often used in clinical practice but good for understanding the principles of ankle fracture. Danis-Weber Commonly used. Based on the level of the fibula fracture in relation to the syndesmosis. The more proximal, the greater the risk of syndesmotic injury and therefore fracture instability. A - fracture below the level of the syndesmosis B - fracture at the level of the syndesmosis / level of the tibial plafond C - fracture above the level of the syndesmosis. This includes Maisonneuve fractures (proximal fibula fracture), which can be associated with ankle instability. Beware the high fibula fracture - it may be an ankle fracture! The Weber classification is based purely on the the lateral side. All injuries can include a medial or posterior bony or ligamentous injury which also dictates fracture stability (bimalleolar and trimalleolar fractures are more unstable). Treatment When deciding upon treatment for an ankle fracture, one must consider both the fracture and the patient. Diabetic patients and smokers are at greater risk of post-operative complication, especially wound problems and infection. Likewise, the long term outcome of post-traumatic arthritis from a malunited ankle fracture is extremely important for a young patient, but not as relevant in the elderly. Therefore, normal surgical decision processes apply as with all fractures. Defining stability of an ankle fracture underpins the treatment decision. Weber A - Unimalleolar Weber A Weber fractures by definition are stable and therefore can be mobilised fully weight bearing in an ankle boot. Weber C - Fractures tend to include syndesmotic disruption and are usually bimalleolar (either bony or ligamentous). They are therefore unstable and usually require operative fixation. In addition to the fracture fixation, the syndesmosis usually requires reconstruction/augmentation with screws to restore the joint integrity and function. Weber B - B fractures vary greatly. They can be part of a trimalleolar injury and therefore extremely unstable, requiring fixation. Alternatively, a uni-malleolar Weber B fracture can be a stable injury, and therefore mobilised immediately in an ankle boot. Defining the stability can be challenging, and often involves stress radiographs, or a trial of mobilisation and repeat radiographs. Defining stability is the subject of much ongoing research. However, treating undisplaced ankle fractures in a below knee plaster, non-weight bearing for six weeks is still widely practised, and a safe approach. When operative fixation is appropriate, it is usually via open reduction and internal fixation using plates and screws. It must be carried out when soft tissue swelling has settled in order to minimise the risk of wound problems. This can often take a week to settle. The use of fibula nails is expanding, but is not yet mainstream. Ankle fractures can also be treated with external fixation, or with a hind foot nail in patients who need fixation but where soft tissue or bone quality is poor. Post operative management Ankle fractures generally take 6 weeks to unite enough to prevent secondary displacement. This is therefore an appropriate time period to keep a cast on in a conservatively managed patient. Weight bearing post-operatively depends on the quality of the fixation and bone quality, and preference varies between surgeons, ranging from aggressive early mobilisation to a period of non-weight bearing. Return to activities takes approximately three months, and often requires assistance of a physiotherapist to improve range-of-movement and muscle strengthening.

Answer 75

Rotator cuff tears are common in elderly people and may occur following minor trauma or as a result of long standing impingement. Tears greater than 2cm should generally be repaired surgically. The length of the history in this scenario is suggestive of a tear complicating impingement. Shoulder fractures and dislocations Fractures Proximal humerus Background Third most common fragility fracture in the elderly. Results from low energy fall in predominantly elderly females, or from high energy trauma in young males. Can be associated with nerve injury (commonly axillary), and fracture-dislocation of the humeral head. Detailed neurological assessment is essential for all upper limb injuries. Anatomy Osteology Consists of articular head, greater tuberosity, lesser tuberosity, metaphysis and diaphysis. Between the articular head and the tuberosities is the anatomical neck (previous physis). Between the tuberosities and the metaphysis is the surgical neck. The supraspinatus, infraspinatus and teres minor muscles attach to the greater tuberosity. The subscapularis muscle attaches to the lesser tuberosity. Vascular Supply Humeral head is supplied by the anterior and posterior humeral circumflex arteries. Anatomical neck fractures are at greatest risk of osteonecrosis. Imaging Imaging aims to both delineate the fracture pattern, and confirm/exlude the presence of an associated dislocation. Radiographs - True anteroposterior (AP), axillary lateral and/or scapula Y view. CT - indicated to better define intra-articular involvement and to aid pre-operative planning. MRI is not useful for fracture imaging. Classification Description of the fracture is often more useful than classification. Particular attention should be paid to humeral alignment, fracture displacement, and greater tuberosity position (rotator cuff will pull the GT supero-posterioly, which can cause impingement problems with malunion). - Neer Classification: Most commonly used. Describes fracture as 2,3,or 4 part depending upon the number main fragments. Also comments on the degree of displacement. Fragments: -greater tuberosity -lesser tuberosity - articular surface - shaft Displacement: >1cm or angulation >45 degrees. Treatment The vast majority of proximal humeral fractures are minimally displaced, and therefore can be managed conservatively. This involves immobilisation in a polysling, and progressive mobilisation. Pendular exercise can commence at 14 days, and active abduction from 4-6 weeks. Irreducible fracture dislocation is an indication for operative management. Other indications include large displacement, younger patient, head splitting (intra-articular fractures). However, the recent PROFHER trial (1) has suggested no benefit to operative intervention on patient outcome (it must be applied cautiously as majority of patients were elderly with extraarticular fractures). Options available for surgical management include: ORIF Most commonly used. Plate and screw fixation. Can reconstruct complex fractures. Intramedullary nail Suitable for extra-articular configuration, predominantly surgical neck +/- GT fractures. Hemiarthroplasty Used for un-reconstructable fractures in the older patient who has good glenoid quality. Total shoulder arthroplasty Unconstructable fractures where high functioning shoulder is required (hemiarthroplasty will cause glenoid erosion) Reverse shoulder arthroplasty Total shoulder arthroplasty that provides better functional outcome than conventional total shoulder replacement. Scapula Background Uncommon fractures usually associated with high energy trauma. Most commonly involve scapula body or spine (50%), glenoid fossa and glenoid neck. Important to exclude associated life threatening injury. Imaging Plain radiographs should include true anteroposterior (AP), axillary lateral and/or scapula Y view. CT scanning is useful for defining intra-articular involvement, displacement and for three dimensional reconstruction. Classification Based on the location of the fracture (coracoid, acromion, glenoid neck, glenoid fossa, scapula body). Beware of ipsilateral glenoid neck and clavicle fracture -floating shoulder - where limb is effectively dissociated from axial skeleton. Treatment The vast majority of scapula fractures are amenable to conservative management, consisting of sling immobilisation for two weeks followed by early rehabilitation. Floating shoulder will usually require fixation, and consideration of surgery should also be given to intra-articular and displaced/angulated glenoid fractures. Dislocations Types Dislocations around the shoulder joint include glenohumeral dislocation, acromioclavicular joint disruption and sternoclavicular dislocation. Only glenohumeral dislocation will be covered here. Glenohumeral dislocation Diagnosis, classification and management are covered here. Background Shoulder dislocation is commonly seen in A&E. It has a high recurrence rate that is as high as 80% in teenagers. Initial management requires emergent reduction to prevent lasting chondral damage. Early assessment and management Usually a traumatic cause (multi-directional instability in frequent dislocations requires discussion with orthopaedics and is not covered here). Careful history, examination and documentation of neurovascular status of the limb, in particular the axillary nerve (regimental badge sensation). This should be re-assessed post manipulation. Early radiographs to confirm direction of dislocation. Initial management consists of emergent closed reduction under under entanox and analgesia, but often requires conscious sedation. Arm should then be immobilised in a polysling, and XR to confirm relocation. Imaging - True anteroposterior (AP), axillary lateral and/or scapula Y view. Reduced humeral head should lie between acromion and coracoid on lateral/scapula view. Types Direction Features Cause Examination Reduction techniques Anterior Most Common >90% Usually traumatic - anterior force on arm when shoulder is abducted, eternally rotated Loss of shoulder contour - sulcus sign. Humeral head can be felt anteriorly. Hippocratic. Milch. Stimson. Kocher not advised due to complication of fracture Posterior 50% missed in A&E 50% traumatic, but classically post seizure or electrocution Shoulder locked in internal rotation. XR may show lightbulb appearance. Gentle lateral traction to adducted arm. Inferior Rare Associated with pectorals and rotator cuff tears, and glenoid fracture As for primary injury Management of primary injury Superior Rare Associated with acrominon/clavicle fracture As for primary injury Management of primary injury Associated injuries Bankart lesion - avulsion of the anterior glenoid labrum with an anterior shoulder dislocation (reverse Bankart if poster labrum in posterior dislocation). Hill Sachs defect - chondral impaction on posteriosuperior humeral head from contact with gleonoid rim. Can be large enough to lock shoulder, requiring open reduction. (Reverse Hill Sachs in posterior dislocation). Rotator cuff tear - increases with age. Greater or lesser tuberosity fracture - increases with age. Humeral neck fracture - shoulder fracture dislocation. More common in high energy trauma and elderly. Should be discussed with orthopaedics prior to any attempted reduction. Rotator Cuff Disease Rotator cuff disease is a spectrum of conditions that ranges from subacromial impingement to rotator cuff tears and eventually to rotator cuff arthropathy (arthritis). Anatomy The rotator cuff is a group of four muscles that are important in shoulder movements, and maintenance of glenohumeral stability. Muscle Scapular attachment Humeral attachment Action Innervation Supraspinatus Supraspinatus fossa Superior facet of greater tuberosity Initiation of abduction of humerus Suprascapular nerve Infraspinatus Infraspinatus fossa Posterior facet of greater tuberosity External rotation of humerus Suprascapular nerve Teres Minor Lateral border Inferior facet of greater tuberosity External rotation of humerus Axillary Nerve Subscapularis Subscapular fossa Lesser tuberosity Internal rotation of humerus Upper and lower subscapular nerve The inferior rotator cuff muscles (infraspinatus, teres minor, and subscapularis) balance the superior pull of the deltoid. Injury/tear results in upward migration of the humeral head on the glenoid (can be seen on AP radiograph). Likewise, the anterior muscles (subscapularis) are balanced with the posterior muscles (infraspinatus, teres minor). Subacromial Impingement The most common cause of shoulder pain, which results from impingement of the superior cuff on the undersurface of the acromion, and an inflammatory bursitis. Associated with certain types of acromial morphology (Bigliani classification). Presents as insidious pain which is exacerbated by overhead activities. Rotator Cuff Tear Often presents as an acute event on the background of chronic subacromial impingement in the older patient, but can present as an avulsion injury in younger patients. Majority of tears are to the superior cuff (supraspinatus, infraspinatus, teres minor), though a tear to subscapularis is associated with subcoracoid impingement. Tears present as pain and weakness when using the muscles in question. Rotator Cuff Arthropathy Defined as shoulder arthritis in the setting of rotator cuff dysfunction. Results from superior migration due to the loss of rotator cuff function and integrity. Unopposed deltoid pulls the humeral head superiorly. Associated with massive chronic cuff tears. Imaging Plain radiographs AP of the shoulder may show superior migration of the humerus with a cuff tear, and features of arthritis with arthropathy. Other causes of pain may also be identified (e.g. calcific tendonitis/fracture) Outlet view is useful for defining the acromial morphology USS Allows dynamic imaging of the cuff, and is inexpensive. However, it is very user dependent. MRI Best imaging modality for cuff pathology. Also allows imaging of the rest of the shoulder. When intra-articular pathology is suspected, can be combined with an arthrogram for improved sensitivity and specificity. Treatment Subacromial impingement Physiotherapy, oral anti-inflammatory medication Subacromial steroid injection can settle inflammation Arthroscopic subacromial decompression by shaving away the undersurface of the acromion, more space is created for the rotator cuff. Cuff integrity is assessed also at time of surgery, and can be repaired if necessary. Rotator cuff tear When considering repair of a cuff tear, the age and activity of the patient, the nature of the tear (degenerative vs. acute traumatic), and the size and retraction of the tear should be considered when making a surgical plan. Mild tears or tears in the elderly can be managed conservatively, as outlined above. Moderate tears can be repaired arthroscopically. Massive or retracted tears will often require an open repair (occasionally with a tendon transfer). Subacromial decompression is performed at the same time to reduce impingement, symptoms and recurrence. Calcific tendonitis Calcific tendonitis involves calcific deposits within tendons anywhere in the body, but most commonly in the rotator cuff (specifically the supraspinatus tendon). When present in the shoulder, it is associated with subacromial impingement and pain. Pathology More common in women aged 30-60 years. Association with diabetes and hypothyroidism There are three stages of calcification Formative phase characterized by calcific deposits Resting phase deposit is stable, but presents with impingement problems Resorptive phase phagocytic resorption. Most painful stage. Presentation Similar in presentation to subacromial impingement, with pain especially with over head activities. Atraumatic in nature. Imaging Plain radiographs show calcification of the rotator cuff, usually within 1.5cm of its insertion on the humerus. Supraspinatus outlet views can show level of impingment. Further imaging is rarely needed. Treatment Non-operative NSAIDS, steroid injection (controversial, but practiced) and physiotherapy. Approximately 75% will resolve by 6 months with conservative management. Ultrasound guided or surgical needle barbotage can break down deposits and resolve symptoms. Occasionally surgical excision is required. Adhesive capsulitis (Frozen Shoulder) Pain and loss of movement of shoulder joint, which involves fibroplastic proliferation of capsular tissue, causing soft tissue scarring and contracture. Patients present with a painful and decreased arc of motion. Associated with prolonged immobilization, previous surgery, thyroid disorders (AI) and diabetes Classically three stages which can take up to two years to resolve: Stage one the freezing and painful stage Stage two the frozen and stiff stage Stage three the thawing stage, where shoulder movement slowly improves Imaging Plain radiographs to exclude other causes of a painful shoulder MRI arthrogram may show capsular contracture, and again may be used to exclude cuff pathology. However, often not performed as diagnosis is largely clinical. Treatment Non-operative NSAIDS, steroid injection and physiotherapy. Patience is required as condition can take up to 2 years to improve. Operative MUA or arthroscopic adhesiolysis (release of adhesions) can expedite recovery, followed by intensive physiotherapy. Glenohumeral Arthritis Background May be osteoarthritis (primary or secondary to cuff tear or trauma), rheumatoid arthritis, or as part of a spondyloarthropathy. Majority of those with RA will develop symptoms. More common in the elderly Presents like any other arthritis - pain at night and with movement Imaging AP and axillary radiographs will show features of arthritis. CT/MRI is often useful to classify the shape of the glenoid and extent of bone loss when considering arthroplasty. MRI also essential to asses integrity of rotator cuff if considering shoulder replacement. Treatment Like all orthopaedics, start with simple measures: NSAIDS, management of RA, physiotherapy, steroid injection. Hemiarthroplasty can sometimes be considered if glenoid is in excellent condition or if patient has large comorbidity. Arthroscopic debridement is useful if patient has isolated ACJ arthritis, but is rarely used for glenohumeral arthritis. Total shoulder replacement is shown to produce superior outcome when compared to hemiarthroplasty in terms of pain relief, function and implant survival. Total shoulder replacement can be anatomical (ball on humerus, with cup on glenoid), or reverse geometry (ball on glenoid, with cup on humerus). Anatomical TSR requires an in tact rotator cuff, so often reverse is preferable when the cuff if questionable in integrity.

Answer 76

Open reduction and internal fixation Meticulous anatomical alignment of the fracture segments is crucial to avoid the development of osteoarthritis and risk of malunion. Distal radius fracture Common, usual mechanism is fall onto an outstretched hand in elderly females with underlying osteoporosis Typically it is a distal radius fracture occurring about 1 inch proximal to the wrist joint with dorsal angulation of the fracture fragment. The distal end of the ulna is sometimes involved Management is usually conservative with reduction of the fracture under either a haematoma or Biers block and immobilisation in a cast Potentially unstable injuries should be managed with surgical fixation. Factors favoring instability include; dorsal tilt of more than 20 degrees, comminuted fracture, injury to the ulnar styloid, intra articular disruption Young patients, who typically have a higher energy mechanism of injury are usually managed surgically In the elderly it is important to initiate treatment for osteoporosis

Answer 77

Spina bifida occulta is a common condition and may affect up to 10% of the population. The more severe types of spina bifida have more characteristic skin changes. Occasionally the unwary surgeon is persuaded to operate on these cutaneous changes and we would advocate performing an MRI scan prior to any such surgical procedure in this region. Ankylosing spondylitis Chronic inflammatory disorder affecting the axial skeleton Sacro-ilitis is a usually visible in plain films Up to 20% of those who are HLA B27 positive will develop the condition Affected articulations develop bony or fibrous changes Typical spinal features include loss of the lumbar lordosis and progressive kyphosis of the cervico-thoracic spine Scheuermann's disease Epiphysitis of the vertebral joints is the main pathological process Predominantly affects adolescents Symptoms include back pain and stiffness X-ray changes include epiphyseal plate disturbance and anterior wedging Clinical features include progressive kyphosis (at least 3 vertebrae must be involved) Minor cases may be managed with physiotherapy and analgesia, more severe cases may require bracing or surgical stabilisation Scoliosis Consists of curvature of the spine in the coronal plane Divisible into structural and non structural, the latter being commonest in adolescent females who develop minor postural changes only. Postural scoliosis will typically disappear on manoeuvres such as bending forwards Structural scoliosis affects > 1 vertebral body and is divisible into idiopathic, congential and neuromuscular in origin. It is not correctable by alterations in posture Within structural scoliosis, idiopathic is the most common type Severe, or progressive structural disease is often managed surgically with bilateral rod stabilisation of the spine Spina bifida Non fusion of the vertebral arches during embryonic development Three categories; myelomeningocele, spina bifida occulta and meningocele Myelomeningocele is the most severe type with associated neurological defects that may persist in spite of anatomical closure of the defect Up to 10% of the population may have spina bifida occulta, in this condition the skin and tissues (but not not bones) may develop over the distal cord. The site may be identifiable by a birth mark or hair patch The incidence of the condition is reduced by use of folic acid supplements during pregnancy Spondylolysis Congenital or acquired deficiency of the pars interarticularis of the neural arch of a particular vertebral body, usually affects L4/ L5 May be asymptomatic and affects up to 5% of the population Spondylolysis is the commonest cause of spondylolisthesis in children Asymptomatic cases do not require treatment Spondylolisthesis This occurs when one vertebra is displaced relative to its immediate inferior vertebral body May occur as a result of stress fracture or spondylolysis Traumatic cases may show the classic "Scotty Dog" appearance on plain films Treatment depends upon the extent of deformity and associated neurological symptoms, minor cases may be actively monitored. Individuals with radicular symptoms or signs will usually require spinal decompression and stabilisation

Answer 78

A supraspinatus tear is the most common of rotator cuff tears. It occurs as a result of degeneration and is rare in younger adults Shoulder fractures and dislocations Fractures Proximal humerus Background Third most common fragility fracture in the elderly. Results from low energy fall in predominantly elderly females, or from high energy trauma in young males. Can be associated with nerve injury (commonly axillary), and fracture-dislocation of the humeral head. Detailed neurological assessment is essential for all upper limb injuries. Anatomy Osteology Consists of articular head, greater tuberosity, lesser tuberosity, metaphysis and diaphysis. Between the articular head and the tuberosities is the anatomical neck (previous physis). Between the tuberosities and the metaphysis is the surgical neck. The supraspinatus, infraspinatus and teres minor muscles attach to the greater tuberosity. The subscapularis muscle attaches to the lesser tuberosity. Vascular Supply Humeral head is supplied by the anterior and posterior humeral circumflex arteries. Anatomical neck fractures are at greatest risk of osteonecrosis. Imaging Imaging aims to both delineate the fracture pattern, and confirm/exlude the presence of an associated dislocation. Radiographs - True anteroposterior (AP), axillary lateral and/or scapula Y view. CT - indicated to better define intra-articular involvement and to aid pre-operative planning. MRI is not useful for fracture imaging. Classification Description of the fracture is often more useful than classification. Particular attention should be paid to humeral alignment, fracture displacement, and greater tuberosity position (rotator cuff will pull the GT supero-posterioly, which can cause impingement problems with malunion). - Neer Classification: Most commonly used. Describes fracture as 2,3,or 4 part depending upon the number main fragments. Also comments on the degree of displacement. Fragments: -greater tuberosity -lesser tuberosity - articular surface - shaft Displacement: >1cm or angulation >45 degrees. Treatment The vast majority of proximal humeral fractures are minimally displaced, and therefore can be managed conservatively. This involves immobilisation in a polysling, and progressive mobilisation. Pendular exercise can commence at 14 days, and active abduction from 4-6 weeks. Irreducible fracture dislocation is an indication for operative management. Other indications include large displacement, younger patient, head splitting (intra-articular fractures). However, the recent PROFHER trial (1) has suggested no benefit to operative intervention on patient outcome (it must be applied cautiously as majority of patients were elderly with extraarticular fractures). Options available for surgical management include: ORIF Most commonly used. Plate and screw fixation. Can reconstruct complex fractures. Intramedullary nail Suitable for extra-articular configuration, predominantly surgical neck +/- GT fractures. Hemiarthroplasty Used for un-reconstructable fractures in the older patient who has good glenoid quality. Total shoulder arthroplasty Unconstructable fractures where high functioning shoulder is required (hemiarthroplasty will cause glenoid erosion) Reverse shoulder arthroplasty Total shoulder arthroplasty that provides better functional outcome than conventional total shoulder replacement. Scapula Background Uncommon fractures usually associated with high energy trauma. Most commonly involve scapula body or spine (50%), glenoid fossa and glenoid neck. Important to exclude associated life threatening injury. Imaging Plain radiographs should include true anteroposterior (AP), axillary lateral and/or scapula Y view. CT scanning is useful for defining intra-articular involvement, displacement and for three dimensional reconstruction. Classification Based on the location of the fracture (coracoid, acromion, glenoid neck, glenoid fossa, scapula body). Beware of ipsilateral glenoid neck and clavicle fracture -floating shoulder - where limb is effectively dissociated from axial skeleton. Treatment The vast majority of scapula fractures are amenable to conservative management, consisting of sling immobilisation for two weeks followed by early rehabilitation. Floating shoulder will usually require fixation, and consideration of surgery should also be given to intra-articular and displaced/angulated glenoid fractures. Dislocations Types Dislocations around the shoulder joint include glenohumeral dislocation, acromioclavicular joint disruption and sternoclavicular dislocation. Only glenohumeral dislocation will be covered here. Glenohumeral dislocation Diagnosis, classification and management are covered here. Background Shoulder dislocation is commonly seen in A&E. It has a high recurrence rate that is as high as 80% in teenagers. Initial management requires emergent reduction to prevent lasting chondral damage. Early assessment and management Usually a traumatic cause (multi-directional instability in frequent dislocations requires discussion with orthopaedics and is not covered here). Careful history, examination and documentation of neurovascular status of the limb, in particular the axillary nerve (regimental badge sensation). This should be re-assessed post manipulation. Early radiographs to confirm direction of dislocation. Initial management consists of emergent closed reduction under under entanox and analgesia, but often requires conscious sedation. Arm should then be immobilised in a polysling, and XR to confirm relocation. Imaging - True anteroposterior (AP), axillary lateral and/or scapula Y view. Reduced humeral head should lie between acromion and coracoid on lateral/scapula view. Types Direction Features Cause Examination Reduction techniques Anterior Most Common >90% Usually traumatic - anterior force on arm when shoulder is abducted, eternally rotated Loss of shoulder contour - sulcus sign. Humeral head can be felt anteriorly. Hippocratic. Milch. Stimson. Kocher not advised due to complication of fracture Posterior 50% missed in A&E 50% traumatic, but classically post seizure or electrocution Shoulder locked in internal rotation. XR may show lightbulb appearance. Gentle lateral traction to adducted arm. Inferior Rare Associated with pectorals and rotator cuff tears, and glenoid fracture As for primary injury Management of primary injury Superior Rare Associated with acrominon/clavicle fracture As for primary injury Management of primary injury Associated injuries Bankart lesion - avulsion of the anterior glenoid labrum with an anterior shoulder dislocation (reverse Bankart if poster labrum in posterior dislocation). Hill Sachs defect - chondral impaction on posteriosuperior humeral head from contact with gleonoid rim. Can be large enough to lock shoulder, requiring open reduction. (Reverse Hill Sachs in posterior dislocation). Rotator cuff tear - increases with age. Greater or lesser tuberosity fracture - increases with age. Humeral neck fracture - shoulder fracture dislocation. More common in high energy trauma and elderly. Should be discussed with orthopaedics prior to any attempted reduction. Rotator Cuff Disease Rotator cuff disease is a spectrum of conditions that ranges from subacromial impingement to rotator cuff tears and eventually to rotator cuff arthropathy (arthritis). Anatomy The rotator cuff is a group of four muscles that are important in shoulder movements, and maintenance of glenohumeral stability. Muscle Scapular attachment Humeral attachment Action Innervation Supraspinatus Supraspinatus fossa Superior facet of greater tuberosity Initiation of abduction of humerus Suprascapular nerve Infraspinatus Infraspinatus fossa Posterior facet of greater tuberosity External rotation of humerus Suprascapular nerve Teres Minor Lateral border Inferior facet of greater tuberosity External rotation of humerus Axillary Nerve Subscapularis Subscapular fossa Lesser tuberosity Internal rotation of humerus Upper and lower subscapular nerve The inferior rotator cuff muscles (infraspinatus, teres minor, and subscapularis) balance the superior pull of the deltoid. Injury/tear results in upward migration of the humeral head on the glenoid (can be seen on AP radiograph). Likewise, the anterior muscles (subscapularis) are balanced with the posterior muscles (infraspinatus, teres minor). Subacromial Impingement The most common cause of shoulder pain, which results from impingement of the superior cuff on the undersurface of the acromion, and an inflammatory bursitis. Associated with certain types of acromial morphology (Bigliani classification). Presents as insidious pain which is exacerbated by overhead activities. Rotator Cuff Tear Often presents as an acute event on the background of chronic subacromial impingement in the older patient, but can present as an avulsion injury in younger patients. Majority of tears are to the superior cuff (supraspinatus, infraspinatus, teres minor), though a tear to subscapularis is associated with subcoracoid impingement. Tears present as pain and weakness when using the muscles in question. Rotator Cuff Arthropathy Defined as shoulder arthritis in the setting of rotator cuff dysfunction. Results from superior migration due to the loss of rotator cuff function and integrity. Unopposed deltoid pulls the humeral head superiorly. Associated with massive chronic cuff tears. Imaging Plain radiographs AP of the shoulder may show superior migration of the humerus with a cuff tear, and features of arthritis with arthropathy. Other causes of pain may also be identified (e.g. calcific tendonitis/fracture) Outlet view is useful for defining the acromial morphology USS Allows dynamic imaging of the cuff, and is inexpensive. However, it is very user dependent. MRI Best imaging modality for cuff pathology. Also allows imaging of the rest of the shoulder. When intra-articular pathology is suspected, can be combined with an arthrogram for improved sensitivity and specificity. Treatment Subacromial impingement Physiotherapy, oral anti-inflammatory medication Subacromial steroid injection can settle inflammation Arthroscopic subacromial decompression by shaving away the undersurface of the acromion, more space is created for the rotator cuff. Cuff integrity is assessed also at time of surgery, and can be repaired if necessary. Rotator cuff tear When considering repair of a cuff tear, the age and activity of the patient, the nature of the tear (degenerative vs. acute traumatic), and the size and retraction of the tear should be considered when making a surgical plan. Mild tears or tears in the elderly can be managed conservatively, as outlined above. Moderate tears can be repaired arthroscopically. Massive or retracted tears will often require an open repair (occasionally with a tendon transfer). Subacromial decompression is performed at the same time to reduce impingement, symptoms and recurrence. Calcific tendonitis Calcific tendonitis involves calcific deposits within tendons anywhere in the body, but most commonly in the rotator cuff (specifically the supraspinatus tendon). When present in the shoulder, it is associated with subacromial impingement and pain. Pathology More common in women aged 30-60 years. Association with diabetes and hypothyroidism There are three stages of calcification Formative phase characterized by calcific deposits Resting phase deposit is stable, but presents with impingement problems Resorptive phase phagocytic resorption. Most painful stage. Presentation Similar in presentation to subacromial impingement, with pain especially with over head activities. Atraumatic in nature. Imaging Plain radiographs show calcification of the rotator cuff, usually within 1.5cm of its insertion on the humerus. Supraspinatus outlet views can show level of impingment. Further imaging is rarely needed. Treatment Non-operative NSAIDS, steroid injection (controversial, but practiced) and physiotherapy. Approximately 75% will resolve by 6 months with conservative management. Ultrasound guided or surgical needle barbotage can break down deposits and resolve symptoms. Occasionally surgical excision is required. Adhesive capsulitis (Frozen Shoulder) Pain and loss of movement of shoulder joint, which involves fibroplastic proliferation of capsular tissue, causing soft tissue scarring and contracture. Patients present with a painful and decreased arc of motion. Associated with prolonged immobilization, previous surgery, thyroid disorders (AI) and diabetes Classically three stages which can take up to two years to resolve: Stage one the freezing and painful stage Stage two the frozen and stiff stage Stage three the thawing stage, where shoulder movement slowly improves Imaging Plain radiographs to exclude other causes of a painful shoulder MRI arthrogram may show capsular contracture, and again may be used to exclude cuff pathology. However, often not performed as diagnosis is largely clinical. Treatment Non-operative NSAIDS, steroid injection and physiotherapy. Patience is required as condition can take up to 2 years to improve. Operative MUA or arthroscopic adhesiolysis (release of adhesions) can expedite recovery, followed by intensive physiotherapy. Glenohumeral Arthritis Background May be osteoarthritis (primary or secondary to cuff tear or trauma), rheumatoid arthritis, or as part of a spondyloarthropathy. Majority of those with RA will develop symptoms. More common in the elderly Presents like any other arthritis - pain at night and with movement Imaging AP and axillary radiographs will show features of arthritis. CT/MRI is often useful to classify the shape of the glenoid and extent of bone loss when considering arthroplasty. MRI also essential to asses integrity of rotator cuff if considering shoulder replacement. Treatment Like all orthopaedics, start with simple measures: NSAIDS, management of RA, physiotherapy, steroid injection. Hemiarthroplasty can sometimes be considered if glenoid is in excellent condition or if patient has large comorbidity. Arthroscopic debridement is useful if patient has isolated ACJ arthritis, but is rarely used for glenohumeral arthritis. Total shoulder replacement is shown to produce superior outcome when compared to hemiarthroplasty in terms of pain relief, function and implant survival. Total shoulder replacement can be anatomical (ball on humerus, with cup on glenoid), or reverse geometry (ball on glenoid, with cup on humerus). Anatomical TSR requires an in tact rotator cuff, so often reverse is preferable when the cuff if questionable in integrity.

Answer 79

As there is no associated vascular injury the patient may be suitable for debridement of the area and external fixation. If debridement leaves a tissue defect then plastic surgical repair will be needed at a later stage. With open fractures, its best not to place intramedullary metalwork as this may become infected. Fracture management Bony injury resulting in a fracture may arise from trauma (excessive forces applied to bone), stress related (repetitive low velocity injury) or pathological (abnormal bone which fractures during normal use of following minimal trauma) Diagnosis involves not just evaluating the fracture ; such as site and type of injury but also other associated injuries and distal neurovascular deficits. This may entail not just clinical examination but radiographs of proximal and distal joints. When assessing x-rays it is important to assess for changes in length of the bone, the angulation of the distal bone, rotational effects, presence of material such as glass. Fracture types Fracture type Description Oblique fracture Fracture lies obliquely to long axis of bone Comminuted fracture >2 fragments Segmental fracture More than one fracture along a bone Transverse fracture Perpendicular to long axis of bone Spiral fracture Severe oblique fracture with rotation along long axis of bone Open Vs Closed It is also important to distinguish open from closed injuries. The most common classification system for open fractures is the Gustilo and Anderson classification system (given below): Grade Injury 1 Low energy wound <1cm 2 Greater than 1cm wound with moderate soft tissue damage 3 High energy wound > 1cm with extensive soft tissue damage 3 A (sub group of 3) Adequate soft tissue coverage 3 B (sub group of 3) Inadequate soft tissue coverage 3 C (sub group of 3) Associated arterial injury Key points in management of fractures Immobilise the fracture including the proximal and distal joints Carefully monitor and document neurovascular status, particularly following reduction and immobilisation Manage infection including tetanus prophylaxis IV broad spectrum antibiotics for open injuries As a general principle all open fractures should be thoroughly debrided ( and internal fixation devices avoided or used with extreme caution) Open fractures constitute an emergency and should be debrided and lavaged within 6 hours of injury

Answer 80

This is an unstable fracture pattern with a Weber B fracture of the distal fibula and a fracture of the medial malleolus. Talar shift indicates loss of ankle mortice congruity. This injury should therefore be treated with surgical fixation. An ankle fracture relates to a fracture around the tibio-talar joint. It generally refers to a fracture involving the lateral, and/or medial and/or posterior malleolus. Pilon and Tillaux fractures are also considered to be ankle fractures, but are not covered here. Ankle fractures are common. They effect men and women in equal numbers, but men have a higher rate as young adults (sports and contact injuries), and women a higher rate post-menopausal (fragility type fracture). ``` Osseous anatomy The ankle (or mortise) joint consists of the distal tibia (tibial plafond and posterior malleolus), the distal fibula (lateral malleolus), and the talus. The main movement at the ankle joint is plantar and dorsiflexion. ``` Ligamentous anatomy Medial side: Deltoid ligament. This is divided into superficial and deep portions. It is the primary restraint to valgus tilting of the talus. Lateral side: Lateral ligament complex consisting from anterior to posterior of the anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL), and the posterior talofibular ligament (PTFL). Together they resist valgus stress to the ankle, and are a restraint to anterior translation of the talus within the mortise joint. Syndesmosis: The syndesmosis is a ligament complex between the distal tibia and fibula, holding the two bones together. It is fundamental to the integrity of the ankle joint, and its disruption leads to instability. It consists of (from anterior to posterior) the anterior-inferior tibiofibular ligament (AITFL), the transverse tibiofibular ligament (TTFL), the interosseous membrane, and the posterior-inferior tibiofibular ligament (PITFL). Presentation and initial management Patients will present following a traumatic event with a painful, swollen ankle, and reluctance/inability to weight bear. The Ottawa rules can be applied to differentiate between an ankle fracture and sprain, but can be unreliable. In high energy injuries, management should follow ATLS principles to identify more significant injuries first. Neurovascular status of the foot should be documented, and open injuries should be excluded. If an open injury is identified, it should be managed in line with BOAST 4 principles1. If an obvious deformity exists, it should be reduced as soon as possible with appropriate analgesia or conscious sedation. Radiographs of clearly deformed or dislocated joints are not necessary, and removing the pressure on the surrounding soft tissues from the underlying bony deformity is the priority. If the fracture pattern is not clinically obvious then plain radiographs are appropriate and will guide the subsequent manipulation during plaster-of-paris below knee backslab application. Imaging AP, lateral and mortise views (20o internal rotation) are essential to evaluate fracture displacement and syndesmotic injury. Decreased tibiofibular overlap, medial joint clear space and lateral talar shift all indicate a syndesmotic injury. (In subtle cases of shift, imaging the uninjured ankle can be helpful as a proportion of the population have little or no tibiotalar overlap 2.) Where there is suspicion of syndesmosis involvement in the absence of radiographic evidence, stress radiographs can be diagnostic. Complex fracture patterns (and increasingly posterior malleolar fractures) are best defined using CT. Classification The most commonly used classifications are Lauge-Hansen and Danis-Weber. Lauge-Hansen Comprises two parts: first part is the foot position, and the second part is the force applied. Useful for understanding the forces involved and therefore predict the ligamentous or bony injury. Results in four injury patterns: Supination - Adduction (SA) - 10-20% Supination - External rotation (SER) - 40-75% Pronation - Abduction (PA) - 5-20% Pronation - External rotation (PER) - 5-20% Not often used in clinical practice but good for understanding the principles of ankle fracture. Danis-Weber Commonly used. Based on the level of the fibula fracture in relation to the syndesmosis. The more proximal, the greater the risk of syndesmotic injury and therefore fracture instability. A - fracture below the level of the syndesmosis B - fracture at the level of the syndesmosis / level of the tibial plafond C - fracture above the level of the syndesmosis. This includes Maisonneuve fractures (proximal fibula fracture), which can be associated with ankle instability. Beware the high fibula fracture - it may be an ankle fracture! The Weber classification is based purely on the the lateral side. All injuries can include a medial or posterior bony or ligamentous injury which also dictates fracture stability (bimalleolar and trimalleolar fractures are more unstable). Treatment When deciding upon treatment for an ankle fracture, one must consider both the fracture and the patient. Diabetic patients and smokers are at greater risk of post-operative complication, especially wound problems and infection. Likewise, the long term outcome of post-traumatic arthritis from a malunited ankle fracture is extremely important for a young patient, but not as relevant in the elderly. Therefore, normal surgical decision processes apply as with all fractures. Defining stability of an ankle fracture underpins the treatment decision. Weber A - Unimalleolar Weber A Weber fractures by definition are stable and therefore can be mobilised fully weight bearing in an ankle boot. Weber C - Fractures tend to include syndesmotic disruption and are usually bimalleolar (either bony or ligamentous). They are therefore unstable and usually require operative fixation. In addition to the fracture fixation, the syndesmosis usually requires reconstruction/augmentation with screws to restore the joint integrity and function. Weber B - B fractures vary greatly. They can be part of a trimalleolar injury and therefore extremely unstable, requiring fixation. Alternatively, a uni-malleolar Weber B fracture can be a stable injury, and therefore mobilised immediately in an ankle boot. Defining the stability can be challenging, and often involves stress radiographs, or a trial of mobilisation and repeat radiographs. Defining stability is the subject of much ongoing research. However, treating undisplaced ankle fractures in a below knee plaster, non-weight bearing for six weeks is still widely practised, and a safe approach. When operative fixation is appropriate, it is usually via open reduction and internal fixation using plates and screws. It must be carried out when soft tissue swelling has settled in order to minimise the risk of wound problems. This can often take a week to settle. The use of fibula nails is expanding, but is not yet mainstream. Ankle fractures can also be treated with external fixation, or with a hind foot nail in patients who need fixation but where soft tissue or bone quality is poor. Post operative management Ankle fractures generally take 6 weeks to unite enough to prevent secondary displacement. This is therefore an appropriate time period to keep a cast on in a conservatively managed patient. Weight bearing post-operatively depends on the quality of the fixation and bone quality, and preference varies between surgeons, ranging from aggressive early mobilisation to a period of non-weight bearing. Return to activities takes approximately three months, and often requires assistance of a physiotherapist to improve range-of-movement and muscle strengthening.

Answer 81

Slipped upper femoral epiphysis is commonest in obese adolescent males. The x-ray will show displacement of the femoral epiphysis inferolaterally. Treatment is usually with rest and non weight bearing crutches. Developmental dysplasia of the hip Usually diagnosed in infancy by screening tests. May be bilateral, when disease is unilateral there may be leg length inequality. As disease progresses child may limp and then early onset arthritis. More common in extended breech babies. Splints and harnesses or traction. In later years osteotomy and hip realignment procedures may be needed. In arthritis a joint replacement may be needed. However, this is best deferred if possible as it will almost certainly require revision Initially no obvious change on plain films and USS gives best resolution until 3 months of age. On plain films Shentons line should form a smooth arc Perthes Disease Hip pain (may be referred to the knee) usually occurring between 5 and 12 years of age. Bilateral disease in 20%. Remove pressure from joint to allow normal development. Physiotherapy. Usually self-limiting if diagnosed and treated promptly. X-rays will show flattened femoral head. Eventually in untreated cases the femoral head will fragment. Slipped upper femoral epiphysis Typically seen in obese male adolescents. Pain is often referred to the knee. Limitation to internal rotation is usually seen. Knee pain is usually present 2 months prior to hip slipping. Bilateral in 20%. Bed rest and non-weight bearing. Aim to avoid avascular necrosis. If severe slippage or risk of it occurring then percutaneous pinning of the hip may be required. X-rays will show the femoral head displaced and falling inferolaterally (like a melting ice cream cone) The Southwick angle gives indication of disease severity

Answer 82

Unlike an osteoporotic fracture in an elderly lady this is a high velocity injury and will require surgical fixation. Fracture management Bony injury resulting in a fracture may arise from trauma (excessive forces applied to bone), stress related (repetitive low velocity injury) or pathological (abnormal bone which fractures during normal use of following minimal trauma) Diagnosis involves not just evaluating the fracture ; such as site and type of injury but also other associated injuries and distal neurovascular deficits. This may entail not just clinical examination but radiographs of proximal and distal joints. When assessing x-rays it is important to assess for changes in length of the bone, the angulation of the distal bone, rotational effects, presence of material such as glass. Fracture types Fracture type Description Oblique fracture Fracture lies obliquely to long axis of bone Comminuted fracture >2 fragments Segmental fracture More than one fracture along a bone Transverse fracture Perpendicular to long axis of bone Spiral fracture Severe oblique fracture with rotation along long axis of bone Open Vs Closed It is also important to distinguish open from closed injuries. The most common classification system for open fractures is the Gustilo and Anderson classification system (given below): Grade Injury 1 Low energy wound <1cm 2 Greater than 1cm wound with moderate soft tissue damage 3 High energy wound > 1cm with extensive soft tissue damage 3 A (sub group of 3) Adequate soft tissue coverage 3 B (sub group of 3) Inadequate soft tissue coverage 3 C (sub group of 3) Associated arterial injury Key points in management of fractures Immobilise the fracture including the proximal and distal joints Carefully monitor and document neurovascular status, particularly following reduction and immobilisation Manage infection including tetanus prophylaxis IV broad spectrum antibiotics for open injuries As a general principle all open fractures should be thoroughly debrided ( and internal fixation devices avoided or used with extreme caution) Open fractures constitute an emergency and should be debrided and lavaged within 6 hours of injury

Answer 83

Acromioclavicular joint (ACJ) dislocation normally occurs secondary to direct injury to the superior aspect of the acromion. Loss of shoulder contour and prominent clavicle are key features. Note; rotator cuff tears rarely occur in the second decade. Shoulder fractures and dislocations Fractures Proximal humerus Background Third most common fragility fracture in the elderly. Results from low energy fall in predominantly elderly females, or from high energy trauma in young males. Can be associated with nerve injury (commonly axillary), and fracture-dislocation of the humeral head. Detailed neurological assessment is essential for all upper limb injuries. Anatomy Osteology Consists of articular head, greater tuberosity, lesser tuberosity, metaphysis and diaphysis. Between the articular head and the tuberosities is the anatomical neck (previous physis). Between the tuberosities and the metaphysis is the surgical neck. The supraspinatus, infraspinatus and teres minor muscles attach to the greater tuberosity. The subscapularis muscle attaches to the lesser tuberosity. Vascular Supply Humeral head is supplied by the anterior and posterior humeral circumflex arteries. Anatomical neck fractures are at greatest risk of osteonecrosis. Imaging Imaging aims to both delineate the fracture pattern, and confirm/exlude the presence of an associated dislocation. Radiographs - True anteroposterior (AP), axillary lateral and/or scapula Y view. CT - indicated to better define intra-articular involvement and to aid pre-operative planning. MRI is not useful for fracture imaging. Classification Description of the fracture is often more useful than classification. Particular attention should be paid to humeral alignment, fracture displacement, and greater tuberosity position (rotator cuff will pull the GT supero-posterioly, which can cause impingement problems with malunion). - Neer Classification: Most commonly used. Describes fracture as 2,3,or 4 part depending upon the number main fragments. Also comments on the degree of displacement. Fragments: -greater tuberosity -lesser tuberosity - articular surface - shaft Displacement: >1cm or angulation >45 degrees. Treatment The vast majority of proximal humeral fractures are minimally displaced, and therefore can be managed conservatively. This involves immobilisation in a polysling, and progressive mobilisation. Pendular exercise can commence at 14 days, and active abduction from 4-6 weeks. Irreducible fracture dislocation is an indication for operative management. Other indications include large displacement, younger patient, head splitting (intra-articular fractures). However, the recent PROFHER trial (1) has suggested no benefit to operative intervention on patient outcome (it must be applied cautiously as majority of patients were elderly with extraarticular fractures). Options available for surgical management include: ORIF Most commonly used. Plate and screw fixation. Can reconstruct complex fractures. Intramedullary nail Suitable for extra-articular configuration, predominantly surgical neck +/- GT fractures. Hemiarthroplasty Used for un-reconstructable fractures in the older patient who has good glenoid quality. Total shoulder arthroplasty Unconstructable fractures where high functioning shoulder is required (hemiarthroplasty will cause glenoid erosion) Reverse shoulder arthroplasty Total shoulder arthroplasty that provides better functional outcome than conventional total shoulder replacement. Scapula Background Uncommon fractures usually associated with high energy trauma. Most commonly involve scapula body or spine (50%), glenoid fossa and glenoid neck. Important to exclude associated life threatening injury. Imaging Plain radiographs should include true anteroposterior (AP), axillary lateral and/or scapula Y view. CT scanning is useful for defining intra-articular involvement, displacement and for three dimensional reconstruction. Classification Based on the location of the fracture (coracoid, acromion, glenoid neck, glenoid fossa, scapula body). Beware of ipsilateral glenoid neck and clavicle fracture -floating shoulder - where limb is effectively dissociated from axial skeleton. Treatment The vast majority of scapula fractures are amenable to conservative management, consisting of sling immobilisation for two weeks followed by early rehabilitation. Floating shoulder will usually require fixation, and consideration of surgery should also be given to intra-articular and displaced/angulated glenoid fractures. Dislocations Types Dislocations around the shoulder joint include glenohumeral dislocation, acromioclavicular joint disruption and sternoclavicular dislocation. Only glenohumeral dislocation will be covered here. Glenohumeral dislocation Diagnosis, classification and management are covered here. Background Shoulder dislocation is commonly seen in A&E. It has a high recurrence rate that is as high as 80% in teenagers. Initial management requires emergent reduction to prevent lasting chondral damage. Early assessment and management Usually a traumatic cause (multi-directional instability in frequent dislocations requires discussion with orthopaedics and is not covered here). Careful history, examination and documentation of neurovascular status of the limb, in particular the axillary nerve (regimental badge sensation). This should be re-assessed post manipulation. Early radiographs to confirm direction of dislocation. Initial management consists of emergent closed reduction under under entanox and analgesia, but often requires conscious sedation. Arm should then be immobilised in a polysling, and XR to confirm relocation. Imaging - True anteroposterior (AP), axillary lateral and/or scapula Y view. Reduced humeral head should lie between acromion and coracoid on lateral/scapula view. Types Direction Features Cause Examination Reduction techniques Anterior Most Common >90% Usually traumatic - anterior force on arm when shoulder is abducted, eternally rotated Loss of shoulder contour - sulcus sign. Humeral head can be felt anteriorly. Hippocratic. Milch. Stimson. Kocher not advised due to complication of fracture Posterior 50% missed in A&E 50% traumatic, but classically post seizure or electrocution Shoulder locked in internal rotation. XR may show lightbulb appearance. Gentle lateral traction to adducted arm. Inferior Rare Associated with pectorals and rotator cuff tears, and glenoid fracture As for primary injury Management of primary injury Superior Rare Associated with acrominon/clavicle fracture As for primary injury Management of primary injury Associated injuries Bankart lesion - avulsion of the anterior glenoid labrum with an anterior shoulder dislocation (reverse Bankart if poster labrum in posterior dislocation). Hill Sachs defect - chondral impaction on posteriosuperior humeral head from contact with gleonoid rim. Can be large enough to lock shoulder, requiring open reduction. (Reverse Hill Sachs in posterior dislocation). Rotator cuff tear - increases with age. Greater or lesser tuberosity fracture - increases with age. Humeral neck fracture - shoulder fracture dislocation. More common in high energy trauma and elderly. Should be discussed with orthopaedics prior to any attempted reduction. Rotator Cuff Disease Rotator cuff disease is a spectrum of conditions that ranges from subacromial impingement to rotator cuff tears and eventually to rotator cuff arthropathy (arthritis). Anatomy The rotator cuff is a group of four muscles that are important in shoulder movements, and maintenance of glenohumeral stability. Muscle Scapular attachment Humeral attachment Action Innervation Supraspinatus Supraspinatus fossa Superior facet of greater tuberosity Initiation of abduction of humerus Suprascapular nerve Infraspinatus Infraspinatus fossa Posterior facet of greater tuberosity External rotation of humerus Suprascapular nerve Teres Minor Lateral border Inferior facet of greater tuberosity External rotation of humerus Axillary Nerve Subscapularis Subscapular fossa Lesser tuberosity Internal rotation of humerus Upper and lower subscapular nerve The inferior rotator cuff muscles (infraspinatus, teres minor, and subscapularis) balance the superior pull of the deltoid. Injury/tear results in upward migration of the humeral head on the glenoid (can be seen on AP radiograph). Likewise, the anterior muscles (subscapularis) are balanced with the posterior muscles (infraspinatus, teres minor). Subacromial Impingement The most common cause of shoulder pain, which results from impingement of the superior cuff on the undersurface of the acromion, and an inflammatory bursitis. Associated with certain types of acromial morphology (Bigliani classification). Presents as insidious pain which is exacerbated by overhead activities. Rotator Cuff Tear Often presents as an acute event on the background of chronic subacromial impingement in the older patient, but can present as an avulsion injury in younger patients. Majority of tears are to the superior cuff (supraspinatus, infraspinatus, teres minor), though a tear to subscapularis is associated with subcoracoid impingement. Tears present as pain and weakness when using the muscles in question. Rotator Cuff Arthropathy Defined as shoulder arthritis in the setting of rotator cuff dysfunction. Results from superior migration due to the loss of rotator cuff function and integrity. Unopposed deltoid pulls the humeral head superiorly. Associated with massive chronic cuff tears. Imaging Plain radiographs AP of the shoulder may show superior migration of the humerus with a cuff tear, and features of arthritis with arthropathy. Other causes of pain may also be identified (e.g. calcific tendonitis/fracture) Outlet view is useful for defining the acromial morphology USS Allows dynamic imaging of the cuff, and is inexpensive. However, it is very user dependent. MRI Best imaging modality for cuff pathology. Also allows imaging of the rest of the shoulder. When intra-articular pathology is suspected, can be combined with an arthrogram for improved sensitivity and specificity. Treatment Subacromial impingement Physiotherapy, oral anti-inflammatory medication Subacromial steroid injection can settle inflammation Arthroscopic subacromial decompression by shaving away the undersurface of the acromion, more space is created for the rotator cuff. Cuff integrity is assessed also at time of surgery, and can be repaired if necessary. Rotator cuff tear When considering repair of a cuff tear, the age and activity of the patient, the nature of the tear (degenerative vs. acute traumatic), and the size and retraction of the tear should be considered when making a surgical plan. Mild tears or tears in the elderly can be managed conservatively, as outlined above. Moderate tears can be repaired arthroscopically. Massive or retracted tears will often require an open repair (occasionally with a tendon transfer). Subacromial decompression is performed at the same time to reduce impingement, symptoms and recurrence. Calcific tendonitis Calcific tendonitis involves calcific deposits within tendons anywhere in the body, but most commonly in the rotator cuff (specifically the supraspinatus tendon). When present in the shoulder, it is associated with subacromial impingement and pain. Pathology More common in women aged 30-60 years. Association with diabetes and hypothyroidism There are three stages of calcification Formative phase characterized by calcific deposits Resting phase deposit is stable, but presents with impingement problems Resorptive phase phagocytic resorption. Most painful stage. Presentation Similar in presentation to subacromial impingement, with pain especially with over head activities. Atraumatic in nature. Imaging Plain radiographs show calcification of the rotator cuff, usually within 1.5cm of its insertion on the humerus. Supraspinatus outlet views can show level of impingment. Further imaging is rarely needed. Treatment Non-operative NSAIDS, steroid injection (controversial, but practiced) and physiotherapy. Approximately 75% will resolve by 6 months with conservative management. Ultrasound guided or surgical needle barbotage can break down deposits and resolve symptoms. Occasionally surgical excision is required. Adhesive capsulitis (Frozen Shoulder) Pain and loss of movement of shoulder joint, which involves fibroplastic proliferation of capsular tissue, causing soft tissue scarring and contracture. Patients present with a painful and decreased arc of motion. Associated with prolonged immobilization, previous surgery, thyroid disorders (AI) and diabetes Classically three stages which can take up to two years to resolve: Stage one the freezing and painful stage Stage two the frozen and stiff stage Stage three the thawing stage, where shoulder movement slowly improves Imaging Plain radiographs to exclude other causes of a painful shoulder MRI arthrogram may show capsular contracture, and again may be used to exclude cuff pathology. However, often not performed as diagnosis is largely clinical. Treatment Non-operative NSAIDS, steroid injection and physiotherapy. Patience is required as condition can take up to 2 years to improve. Operative MUA or arthroscopic adhesiolysis (release of adhesions) can expedite recovery, followed by intensive physiotherapy. Glenohumeral Arthritis Background May be osteoarthritis (primary or secondary to cuff tear or trauma), rheumatoid arthritis, or as part of a spondyloarthropathy. Majority of those with RA will develop symptoms. More common in the elderly Presents like any other arthritis - pain at night and with movement Imaging AP and axillary radiographs will show features of arthritis. CT/MRI is often useful to classify the shape of the glenoid and extent of bone loss when considering arthroplasty. MRI also essential to asses integrity of rotator cuff if considering shoulder replacement. Treatment Like all orthopaedics, start with simple measures: NSAIDS, management of RA, physiotherapy, steroid injection. Hemiarthroplasty can sometimes be considered if glenoid is in excellent condition or if patient has large comorbidity. Arthroscopic debridement is useful if patient has isolated ACJ arthritis, but is rarely used for glenohumeral arthritis. Total shoulder replacement is shown to produce superior outcome when compared to hemiarthroplasty in terms of pain relief, function and implant survival. Total shoulder replacement can be anatomical (ball on humerus, with cup on glenoid), or reverse geometry (ball on glenoid, with cup on humerus). Anatomical TSR requires an in tact rotator cuff, so often reverse is preferable when the cuff if questionable in integrity.

Answer 84

Viral illnesses can be associated with transient synovitis. The WCC should ideally be > 12 and the ESR > 40 to suggest septic arthritis. Developmental dysplasia of the hip Usually diagnosed in infancy by screening tests. May be bilateral, when disease is unilateral there may be leg length inequality. As disease progresses child may limp and then early onset arthritis. More common in extended breech babies. Splints and harnesses or traction. In later years osteotomy and hip realignment procedures may be needed. In arthritis a joint replacement may be needed. However, this is best deferred if possible as it will almost certainly require revision Initially no obvious change on plain films and USS gives best resolution until 3 months of age. On plain films Shentons line should form a smooth arc Perthes Disease Hip pain (may be referred to the knee) usually occurring between 5 and 12 years of age. Bilateral disease in 20%. Remove pressure from joint to allow normal development. Physiotherapy. Usually self-limiting if diagnosed and treated promptly. X-rays will show flattened femoral head. Eventually in untreated cases the femoral head will fragment. Slipped upper femoral epiphysis Typically seen in obese male adolescents. Pain is often referred to the knee. Limitation to internal rotation is usually seen. Knee pain is usually present 2 months prior to hip slipping. Bilateral in 20%. Bed rest and non-weight bearing. Aim to avoid avascular necrosis. If severe slippage or risk of it occurring then percutaneous pinning of the hip may be required. X-rays will show the femoral head displaced and falling inferolaterally (like a melting ice cream cone) The Southwick angle gives indication of disease severity

Answer 85

This is an unstable ankle injury that is likely to require surgical fixation. The immediate management of a displaced ankle fracture is to reduce the fracture to prevent soft tissues compromise and help reduce swelling. This can be performed before an x-ray is obtained if performing the x-ray will significantly delay reduction. An ankle fracture relates to a fracture around the tibio-talar joint. It generally refers to a fracture involving the lateral, and/or medial and/or posterior malleolus. Pilon and Tillaux fractures are also considered to be ankle fractures, but are not covered here. Ankle fractures are common. They effect men and women in equal numbers, but men have a higher rate as young adults (sports and contact injuries), and women a higher rate post-menopausal (fragility type fracture). ``` Osseous anatomy The ankle (or mortise) joint consists of the distal tibia (tibial plafond and posterior malleolus), the distal fibula (lateral malleolus), and the talus. The main movement at the ankle joint is plantar and dorsiflexion. ``` Ligamentous anatomy Medial side: Deltoid ligament. This is divided into superficial and deep portions. It is the primary restraint to valgus tilting of the talus. Lateral side: Lateral ligament complex consisting from anterior to posterior of the anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL), and the posterior talofibular ligament (PTFL). Together they resist valgus stress to the ankle, and are a restraint to anterior translation of the talus within the mortise joint. Syndesmosis: The syndesmosis is a ligament complex between the distal tibia and fibula, holding the two bones together. It is fundamental to the integrity of the ankle joint, and its disruption leads to instability. It consists of (from anterior to posterior) the anterior-inferior tibiofibular ligament (AITFL), the transverse tibiofibular ligament (TTFL), the interosseous membrane, and the posterior-inferior tibiofibular ligament (PITFL). Presentation and initial management Patients will present following a traumatic event with a painful, swollen ankle, and reluctance/inability to weight bear. The Ottawa rules can be applied to differentiate between an ankle fracture and sprain, but can be unreliable. In high energy injuries, management should follow ATLS principles to identify more significant injuries first. Neurovascular status of the foot should be documented, and open injuries should be excluded. If an open injury is identified, it should be managed in line with BOAST 4 principles1. If an obvious deformity exists, it should be reduced as soon as possible with appropriate analgesia or conscious sedation. Radiographs of clearly deformed or dislocated joints are not necessary, and removing the pressure on the surrounding soft tissues from the underlying bony deformity is the priority. If the fracture pattern is not clinically obvious then plain radiographs are appropriate and will guide the subsequent manipulation during plaster-of-paris below knee backslab application. Imaging AP, lateral and mortise views (20o internal rotation) are essential to evaluate fracture displacement and syndesmotic injury. Decreased tibiofibular overlap, medial joint clear space and lateral talar shift all indicate a syndesmotic injury. (In subtle cases of shift, imaging the uninjured ankle can be helpful as a proportion of the population have little or no tibiotalar overlap 2.) Where there is suspicion of syndesmosis involvement in the absence of radiographic evidence, stress radiographs can be diagnostic. Complex fracture patterns (and increasingly posterior malleolar fractures) are best defined using CT. Classification The most commonly used classifications are Lauge-Hansen and Danis-Weber. Lauge-Hansen Comprises two parts: first part is the foot position, and the second part is the force applied. Useful for understanding the forces involved and therefore predict the ligamentous or bony injury. Results in four injury patterns: Supination - Adduction (SA) - 10-20% Supination - External rotation (SER) - 40-75% Pronation - Abduction (PA) - 5-20% Pronation - External rotation (PER) - 5-20% Not often used in clinical practice but good for understanding the principles of ankle fracture. Danis-Weber Commonly used. Based on the level of the fibula fracture in relation to the syndesmosis. The more proximal, the greater the risk of syndesmotic injury and therefore fracture instability. A - fracture below the level of the syndesmosis B - fracture at the level of the syndesmosis / level of the tibial plafond C - fracture above the level of the syndesmosis. This includes Maisonneuve fractures (proximal fibula fracture), which can be associated with ankle instability. Beware the high fibula fracture - it may be an ankle fracture! The Weber classification is based purely on the the lateral side. All injuries can include a medial or posterior bony or ligamentous injury which also dictates fracture stability (bimalleolar and trimalleolar fractures are more unstable). Treatment When deciding upon treatment for an ankle fracture, one must consider both the fracture and the patient. Diabetic patients and smokers are at greater risk of post-operative complication, especially wound problems and infection. Likewise, the long term outcome of post-traumatic arthritis from a malunited ankle fracture is extremely important for a young patient, but not as relevant in the elderly. Therefore, normal surgical decision processes apply as with all fractures. Defining stability of an ankle fracture underpins the treatment decision. Weber A - Unimalleolar Weber A Weber fractures by definition are stable and therefore can be mobilised fully weight bearing in an ankle boot. Weber C - Fractures tend to include syndesmotic disruption and are usually bimalleolar (either bony or ligamentous). They are therefore unstable and usually require operative fixation. In addition to the fracture fixation, the syndesmosis usually requires reconstruction/augmentation with screws to restore the joint integrity and function. Weber B - B fractures vary greatly. They can be part of a trimalleolar injury and therefore extremely unstable, requiring fixation. Alternatively, a uni-malleolar Weber B fracture can be a stable injury, and therefore mobilised immediately in an ankle boot. Defining the stability can be challenging, and often involves stress radiographs, or a trial of mobilisation and repeat radiographs. Defining stability is the subject of much ongoing research. However, treating undisplaced ankle fractures in a below knee plaster, non-weight bearing for six weeks is still widely practised, and a safe approach. When operative fixation is appropriate, it is usually via open reduction and internal fixation using plates and screws. It must be carried out when soft tissue swelling has settled in order to minimise the risk of wound problems. This can often take a week to settle. The use of fibula nails is expanding, but is not yet mainstream. Ankle fractures can also be treated with external fixation, or with a hind foot nail in patients who need fixation but where soft tissue or bone quality is poor. Post operative management Ankle fractures generally take 6 weeks to unite enough to prevent secondary displacement. This is therefore an appropriate time period to keep a cast on in a conservatively managed patient. Weight bearing post-operatively depends on the quality of the fixation and bone quality, and preference varies between surgeons, ranging from aggressive early mobilisation to a period of non-weight bearing. Return to activities takes approximately three months, and often requires assistance of a physiotherapist to improve range-of-movement and muscle strengthening.

Answer 86

This is a Maisonneuve fracture of the proximal fibula. It indicates an unstable ankle injury with likely injury to the interosseous membrane. In the setting of radiographic evidence of syndesmotic widening, this requires surgical fixation to reduce and stabilise the syndesmosis. An ankle fracture relates to a fracture around the tibio-talar joint. It generally refers to a fracture involving the lateral, and/or medial and/or posterior malleolus. Pilon and Tillaux fractures are also considered to be ankle fractures, but are not covered here. Ankle fractures are common. They effect men and women in equal numbers, but men have a higher rate as young adults (sports and contact injuries), and women a higher rate post-menopausal (fragility type fracture). ``` Osseous anatomy The ankle (or mortise) joint consists of the distal tibia (tibial plafond and posterior malleolus), the distal fibula (lateral malleolus), and the talus. The main movement at the ankle joint is plantar and dorsiflexion. ``` Ligamentous anatomy Medial side: Deltoid ligament. This is divided into superficial and deep portions. It is the primary restraint to valgus tilting of the talus. Lateral side: Lateral ligament complex consisting from anterior to posterior of the anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL), and the posterior talofibular ligament (PTFL). Together they resist valgus stress to the ankle, and are a restraint to anterior translation of the talus within the mortise joint. Syndesmosis: The syndesmosis is a ligament complex between the distal tibia and fibula, holding the two bones together. It is fundamental to the integrity of the ankle joint, and its disruption leads to instability. It consists of (from anterior to posterior) the anterior-inferior tibiofibular ligament (AITFL), the transverse tibiofibular ligament (TTFL), the interosseous membrane, and the posterior-inferior tibiofibular ligament (PITFL). Presentation and initial management Patients will present following a traumatic event with a painful, swollen ankle, and reluctance/inability to weight bear. The Ottawa rules can be applied to differentiate between an ankle fracture and sprain, but can be unreliable. In high energy injuries, management should follow ATLS principles to identify more significant injuries first. Neurovascular status of the foot should be documented, and open injuries should be excluded. If an open injury is identified, it should be managed in line with BOAST 4 principles1. If an obvious deformity exists, it should be reduced as soon as possible with appropriate analgesia or conscious sedation. Radiographs of clearly deformed or dislocated joints are not necessary, and removing the pressure on the surrounding soft tissues from the underlying bony deformity is the priority. If the fracture pattern is not clinically obvious then plain radiographs are appropriate and will guide the subsequent manipulation during plaster-of-paris below knee backslab application. Imaging AP, lateral and mortise views (20o internal rotation) are essential to evaluate fracture displacement and syndesmotic injury. Decreased tibiofibular overlap, medial joint clear space and lateral talar shift all indicate a syndesmotic injury. (In subtle cases of shift, imaging the uninjured ankle can be helpful as a proportion of the population have little or no tibiotalar overlap 2.) Where there is suspicion of syndesmosis involvement in the absence of radiographic evidence, stress radiographs can be diagnostic. Complex fracture patterns (and increasingly posterior malleolar fractures) are best defined using CT. Classification The most commonly used classifications are Lauge-Hansen and Danis-Weber. Lauge-Hansen Comprises two parts: first part is the foot position, and the second part is the force applied. Useful for understanding the forces involved and therefore predict the ligamentous or bony injury. Results in four injury patterns: Supination - Adduction (SA) - 10-20% Supination - External rotation (SER) - 40-75% Pronation - Abduction (PA) - 5-20% Pronation - External rotation (PER) - 5-20% Not often used in clinical practice but good for understanding the principles of ankle fracture. Danis-Weber Commonly used. Based on the level of the fibula fracture in relation to the syndesmosis. The more proximal, the greater the risk of syndesmotic injury and therefore fracture instability. A - fracture below the level of the syndesmosis B - fracture at the level of the syndesmosis / level of the tibial plafond C - fracture above the level of the syndesmosis. This includes Maisonneuve fractures (proximal fibula fracture), which can be associated with ankle instability. Beware the high fibula fracture - it may be an ankle fracture! The Weber classification is based purely on the the lateral side. All injuries can include a medial or posterior bony or ligamentous injury which also dictates fracture stability (bimalleolar and trimalleolar fractures are more unstable). Treatment When deciding upon treatment for an ankle fracture, one must consider both the fracture and the patient. Diabetic patients and smokers are at greater risk of post-operative complication, especially wound problems and infection. Likewise, the long term outcome of post-traumatic arthritis from a malunited ankle fracture is extremely important for a young patient, but not as relevant in the elderly. Therefore, normal surgical decision processes apply as with all fractures. Defining stability of an ankle fracture underpins the treatment decision. Weber A - Unimalleolar Weber A Weber fractures by definition are stable and therefore can be mobilised fully weight bearing in an ankle boot. Weber C - Fractures tend to include syndesmotic disruption and are usually bimalleolar (either bony or ligamentous). They are therefore unstable and usually require operative fixation. In addition to the fracture fixation, the syndesmosis usually requires reconstruction/augmentation with screws to restore the joint integrity and function. Weber B - B fractures vary greatly. They can be part of a trimalleolar injury and therefore extremely unstable, requiring fixation. Alternatively, a uni-malleolar Weber B fracture can be a stable injury, and therefore mobilised immediately in an ankle boot. Defining the stability can be challenging, and often involves stress radiographs, or a trial of mobilisation and repeat radiographs. Defining stability is the subject of much ongoing research. However, treating undisplaced ankle fractures in a below knee plaster, non-weight bearing for six weeks is still widely practised, and a safe approach. When operative fixation is appropriate, it is usually via open reduction and internal fixation using plates and screws. It must be carried out when soft tissue swelling has settled in order to minimise the risk of wound problems. This can often take a week to settle. The use of fibula nails is expanding, but is not yet mainstream. Ankle fractures can also be treated with external fixation, or with a hind foot nail in patients who need fixation but where soft tissue or bone quality is poor. Post operative management Ankle fractures generally take 6 weeks to unite enough to prevent secondary displacement. This is therefore an appropriate time period to keep a cast on in a conservatively managed patient. Weight bearing post-operatively depends on the quality of the fixation and bone quality, and preference varies between surgeons, ranging from aggressive early mobilisation to a period of non-weight bearing. Return to activities takes approximately three months, and often requires assistance of a physiotherapist to improve range-of-movement and muscle strengthening.

Answer 87

It is bilateral in 50% of cases. ``` Congenital talipes equinovarus. Features: Equinus of the hindfoot Adduction and varus of the midfoot High arch ``` Most cases in developing countries. Incidence in UK is 1 per 1000 live births. It is more common in males and is bilateral in 50% cases. There is a strong familial link(1). It may also be associated with other developmental disorders such as Down's syndrome. ``` Key anatomical deformities (2): Adducted and inverted calcaneus Wedge shaped distal calcaneal articular surface Severe Tibio-talar plantar flexion Medial Talar neck inclination Displacement of the navicular bone (medially) Wedge shaped head of talus Displacement of the cuboid (medially) ``` Management Conservative first, the Ponseti method is best described and gives comparable results to surgery. It consists of serial casting to mold the foot into correct shape. Following casting around 90% will require a Achilles tenotomy. This is then followed by a phase of walking braces to maintain the correction. Surgical correction is reserved for those cases that fail to respond to conservative measures. The procedures involve multiple tenotomies and lengthening procedures. In patients who fail to respond surgically an Ilizarov frame reconstruction may be attempted and gives good results.

Answer 88

This would be a good case for intramedullary nailing. Open reduction and external fixation would strip off otherwise healthy tissues and hence is unsuitable. In some units the injury may be managed with an Ilizarov frame device but the majority would treat with IM nailing. Fracture management Bony injury resulting in a fracture may arise from trauma (excessive forces applied to bone), stress related (repetitive low velocity injury) or pathological (abnormal bone which fractures during normal use of following minimal trauma) Diagnosis involves not just evaluating the fracture ; such as site and type of injury but also other associated injuries and distal neurovascular deficits. This may entail not just clinical examination but radiographs of proximal and distal joints. When assessing x-rays it is important to assess for changes in length of the bone, the angulation of the distal bone, rotational effects, presence of material such as glass. Fracture types Fracture type Description Oblique fracture Fracture lies obliquely to long axis of bone Comminuted fracture >2 fragments Segmental fracture More than one fracture along a bone Transverse fracture Perpendicular to long axis of bone Spiral fracture Severe oblique fracture with rotation along long axis of bone Open Vs Closed It is also important to distinguish open from closed injuries. The most common classification system for open fractures is the Gustilo and Anderson classification system (given below): Grade Injury 1 Low energy wound <1cm 2 Greater than 1cm wound with moderate soft tissue damage 3 High energy wound > 1cm with extensive soft tissue damage 3 A (sub group of 3) Adequate soft tissue coverage 3 B (sub group of 3) Inadequate soft tissue coverage 3 C (sub group of 3) Associated arterial injury Key points in management of fractures Immobilise the fracture including the proximal and distal joints Carefully monitor and document neurovascular status, particularly following reduction and immobilisation Manage infection including tetanus prophylaxis IV broad spectrum antibiotics for open injuries As a general principle all open fractures should be thoroughly debrided ( and internal fixation devices avoided or used with extreme caution) Open fractures constitute an emergency and should be debrided and lavaged within 6 hours of injury

Answer 89

Apply a collar and cuff system for three weeks and then commence physiotherapy Impacted fractures of the surgical neck are stable injuries and usually heal without complication. It is rare to need to resort to surgery. Its important to start physiotherapy early. Proximal humerus fractures Very common injury. Usually through the surgical neck. Number of classification systems though for practical purposes describing the number of fracture fragments is probably easier. Some key points: It is rare to have fractures through the anatomical neck. Anatomical neck fractures which are displaced by >1cm carry a risk of avascular necrosis to the humeral head. In children the commonest injury pattern is a greenstick fracture through the surgical neck. Impacted fractures of the surgical neck are usually managed with a collar and cuff for 3 weeks followed by physiotherapy. More significant displaced fractures may require open reduction and fixation or use of an intramedullary device.

Answer 90

Frozen shoulder is more likely. Metastatic cancer can cause pain. However, passive movements are normally unaffected. Frozen shoulder passes through an initial painful stage followed by a period of joint stiffness. With physiotherapy the problem will usually resolve although it may take up to 2 years to do so. Shoulder fractures and dislocations Fractures Proximal humerus Background Third most common fragility fracture in the elderly. Results from low energy fall in predominantly elderly females, or from high energy trauma in young males. Can be associated with nerve injury (commonly axillary), and fracture-dislocation of the humeral head. Detailed neurological assessment is essential for all upper limb injuries. Anatomy Osteology Consists of articular head, greater tuberosity, lesser tuberosity, metaphysis and diaphysis. Between the articular head and the tuberosities is the anatomical neck (previous physis). Between the tuberosities and the metaphysis is the surgical neck. The supraspinatus, infraspinatus and teres minor muscles attach to the greater tuberosity. The subscapularis muscle attaches to the lesser tuberosity. Vascular Supply Humeral head is supplied by the anterior and posterior humeral circumflex arteries. Anatomical neck fractures are at greatest risk of osteonecrosis. Imaging Imaging aims to both delineate the fracture pattern, and confirm/exlude the presence of an associated dislocation. Radiographs - True anteroposterior (AP), axillary lateral and/or scapula Y view. CT - indicated to better define intra-articular involvement and to aid pre-operative planning. MRI is not useful for fracture imaging. Classification Description of the fracture is often more useful than classification. Particular attention should be paid to humeral alignment, fracture displacement, and greater tuberosity position (rotator cuff will pull the GT supero-posterioly, which can cause impingement problems with malunion). - Neer Classification: Most commonly used. Describes fracture as 2,3,or 4 part depending upon the number main fragments. Also comments on the degree of displacement. Fragments: -greater tuberosity -lesser tuberosity - articular surface - shaft Displacement: >1cm or angulation >45 degrees. Treatment The vast majority of proximal humeral fractures are minimally displaced, and therefore can be managed conservatively. This involves immobilisation in a polysling, and progressive mobilisation. Pendular exercise can commence at 14 days, and active abduction from 4-6 weeks. Irreducible fracture dislocation is an indication for operative management. Other indications include large displacement, younger patient, head splitting (intra-articular fractures). However, the recent PROFHER trial (1) has suggested no benefit to operative intervention on patient outcome (it must be applied cautiously as majority of patients were elderly with extraarticular fractures). Options available for surgical management include: ORIF Most commonly used. Plate and screw fixation. Can reconstruct complex fractures. Intramedullary nail Suitable for extra-articular configuration, predominantly surgical neck +/- GT fractures. Hemiarthroplasty Used for un-reconstructable fractures in the older patient who has good glenoid quality. Total shoulder arthroplasty Unconstructable fractures where high functioning shoulder is required (hemiarthroplasty will cause glenoid erosion) Reverse shoulder arthroplasty Total shoulder arthroplasty that provides better functional outcome than conventional total shoulder replacement. Scapula Background Uncommon fractures usually associated with high energy trauma. Most commonly involve scapula body or spine (50%), glenoid fossa and glenoid neck. Important to exclude associated life threatening injury. Imaging Plain radiographs should include true anteroposterior (AP), axillary lateral and/or scapula Y view. CT scanning is useful for defining intra-articular involvement, displacement and for three dimensional reconstruction. Classification Based on the location of the fracture (coracoid, acromion, glenoid neck, glenoid fossa, scapula body). Beware of ipsilateral glenoid neck and clavicle fracture -floating shoulder - where limb is effectively dissociated from axial skeleton. Treatment The vast majority of scapula fractures are amenable to conservative management, consisting of sling immobilisation for two weeks followed by early rehabilitation. Floating shoulder will usually require fixation, and consideration of surgery should also be given to intra-articular and displaced/angulated glenoid fractures. Dislocations Types Dislocations around the shoulder joint include glenohumeral dislocation, acromioclavicular joint disruption and sternoclavicular dislocation. Only glenohumeral dislocation will be covered here. Glenohumeral dislocation Diagnosis, classification and management are covered here. Background Shoulder dislocation is commonly seen in A&E. It has a high recurrence rate that is as high as 80% in teenagers. Initial management requires emergent reduction to prevent lasting chondral damage. Early assessment and management Usually a traumatic cause (multi-directional instability in frequent dislocations requires discussion with orthopaedics and is not covered here). Careful history, examination and documentation of neurovascular status of the limb, in particular the axillary nerve (regimental badge sensation). This should be re-assessed post manipulation. Early radiographs to confirm direction of dislocation. Initial management consists of emergent closed reduction under under entanox and analgesia, but often requires conscious sedation. Arm should then be immobilised in a polysling, and XR to confirm relocation. Imaging - True anteroposterior (AP), axillary lateral and/or scapula Y view. Reduced humeral head should lie between acromion and coracoid on lateral/scapula view. Types Direction Features Cause Examination Reduction techniques Anterior Most Common >90% Usually traumatic - anterior force on arm when shoulder is abducted, eternally rotated Loss of shoulder contour - sulcus sign. Humeral head can be felt anteriorly. Hippocratic. Milch. Stimson. Kocher not advised due to complication of fracture Posterior 50% missed in A&E 50% traumatic, but classically post seizure or electrocution Shoulder locked in internal rotation. XR may show lightbulb appearance. Gentle lateral traction to adducted arm. Inferior Rare Associated with pectorals and rotator cuff tears, and glenoid fracture As for primary injury Management of primary injury Superior Rare Associated with acrominon/clavicle fracture As for primary injury Management of primary injury Associated injuries Bankart lesion - avulsion of the anterior glenoid labrum with an anterior shoulder dislocation (reverse Bankart if poster labrum in posterior dislocation). Hill Sachs defect - chondral impaction on posteriosuperior humeral head from contact with gleonoid rim. Can be large enough to lock shoulder, requiring open reduction. (Reverse Hill Sachs in posterior dislocation). Rotator cuff tear - increases with age. Greater or lesser tuberosity fracture - increases with age. Humeral neck fracture - shoulder fracture dislocation. More common in high energy trauma and elderly. Should be discussed with orthopaedics prior to any attempted reduction. Rotator Cuff Disease Rotator cuff disease is a spectrum of conditions that ranges from subacromial impingement to rotator cuff tears and eventually to rotator cuff arthropathy (arthritis). Anatomy The rotator cuff is a group of four muscles that are important in shoulder movements, and maintenance of glenohumeral stability. Muscle Scapular attachment Humeral attachment Action Innervation Supraspinatus Supraspinatus fossa Superior facet of greater tuberosity Initiation of abduction of humerus Suprascapular nerve Infraspinatus Infraspinatus fossa Posterior facet of greater tuberosity External rotation of humerus Suprascapular nerve Teres Minor Lateral border Inferior facet of greater tuberosity External rotation of humerus Axillary Nerve Subscapularis Subscapular fossa Lesser tuberosity Internal rotation of humerus Upper and lower subscapular nerve The inferior rotator cuff muscles (infraspinatus, teres minor, and subscapularis) balance the superior pull of the deltoid. Injury/tear results in upward migration of the humeral head on the glenoid (can be seen on AP radiograph). Likewise, the anterior muscles (subscapularis) are balanced with the posterior muscles (infraspinatus, teres minor). Subacromial Impingement The most common cause of shoulder pain, which results from impingement of the superior cuff on the undersurface of the acromion, and an inflammatory bursitis. Associated with certain types of acromial morphology (Bigliani classification). Presents as insidious pain which is exacerbated by overhead activities. Rotator Cuff Tear Often presents as an acute event on the background of chronic subacromial impingement in the older patient, but can present as an avulsion injury in younger patients. Majority of tears are to the superior cuff (supraspinatus, infraspinatus, teres minor), though a tear to subscapularis is associated with subcoracoid impingement. Tears present as pain and weakness when using the muscles in question. Rotator Cuff Arthropathy Defined as shoulder arthritis in the setting of rotator cuff dysfunction. Results from superior migration due to the loss of rotator cuff function and integrity. Unopposed deltoid pulls the humeral head superiorly. Associated with massive chronic cuff tears. Imaging Plain radiographs AP of the shoulder may show superior migration of the humerus with a cuff tear, and features of arthritis with arthropathy. Other causes of pain may also be identified (e.g. calcific tendonitis/fracture) Outlet view is useful for defining the acromial morphology USS Allows dynamic imaging of the cuff, and is inexpensive. However, it is very user dependent. MRI Best imaging modality for cuff pathology. Also allows imaging of the rest of the shoulder. When intra-articular pathology is suspected, can be combined with an arthrogram for improved sensitivity and specificity. Treatment Subacromial impingement Physiotherapy, oral anti-inflammatory medication Subacromial steroid injection can settle inflammation Arthroscopic subacromial decompression by shaving away the undersurface of the acromion, more space is created for the rotator cuff. Cuff integrity is assessed also at time of surgery, and can be repaired if necessary. Rotator cuff tear When considering repair of a cuff tear, the age and activity of the patient, the nature of the tear (degenerative vs. acute traumatic), and the size and retraction of the tear should be considered when making a surgical plan. Mild tears or tears in the elderly can be managed conservatively, as outlined above. Moderate tears can be repaired arthroscopically. Massive or retracted tears will often require an open repair (occasionally with a tendon transfer). Subacromial decompression is performed at the same time to reduce impingement, symptoms and recurrence. Calcific tendonitis Calcific tendonitis involves calcific deposits within tendons anywhere in the body, but most commonly in the rotator cuff (specifically the supraspinatus tendon). When present in the shoulder, it is associated with subacromial impingement and pain. Pathology More common in women aged 30-60 years. Association with diabetes and hypothyroidism There are three stages of calcification Formative phase characterized by calcific deposits Resting phase deposit is stable, but presents with impingement problems Resorptive phase phagocytic resorption. Most painful stage. Presentation Similar in presentation to subacromial impingement, with pain especially with over head activities. Atraumatic in nature. Imaging Plain radiographs show calcification of the rotator cuff, usually within 1.5cm of its insertion on the humerus. Supraspinatus outlet views can show level of impingment. Further imaging is rarely needed. Treatment Non-operative NSAIDS, steroid injection (controversial, but practiced) and physiotherapy. Approximately 75% will resolve by 6 months with conservative management. Ultrasound guided or surgical needle barbotage can break down deposits and resolve symptoms. Occasionally surgical excision is required. Adhesive capsulitis (Frozen Shoulder) Pain and loss of movement of shoulder joint, which involves fibroplastic proliferation of capsular tissue, causing soft tissue scarring and contracture. Patients present with a painful and decreased arc of motion. Associated with prolonged immobilization, previous surgery, thyroid disorders (AI) and diabetes Classically three stages which can take up to two years to resolve: Stage one the freezing and painful stage Stage two the frozen and stiff stage Stage three the thawing stage, where shoulder movement slowly improves Imaging Plain radiographs to exclude other causes of a painful shoulder MRI arthrogram may show capsular contracture, and again may be used to exclude cuff pathology. However, often not performed as diagnosis is largely clinical. Treatment Non-operative NSAIDS, steroid injection and physiotherapy. Patience is required as condition can take up to 2 years to improve. Operative MUA or arthroscopic adhesiolysis (release of adhesions) can expedite recovery, followed by intensive physiotherapy. Glenohumeral Arthritis Background May be osteoarthritis (primary or secondary to cuff tear or trauma), rheumatoid arthritis, or as part of a spondyloarthropathy. Majority of those with RA will develop symptoms. More common in the elderly Presents like any other arthritis - pain at night and with movement Imaging AP and axillary radiographs will show features of arthritis. CT/MRI is often useful to classify the shape of the glenoid and extent of bone loss when considering arthroplasty. MRI also essential to asses integrity of rotator cuff if considering shoulder replacement. Treatment Like all orthopaedics, start with simple measures: NSAIDS, management of RA, physiotherapy, steroid injection. Hemiarthroplasty can sometimes be considered if glenoid is in excellent condition or if patient has large comorbidity. Arthroscopic debridement is useful if patient has isolated ACJ arthritis, but is rarely used for glenohumeral arthritis. Total shoulder replacement is shown to produce superior outcome when compared to hemiarthroplasty in terms of pain relief, function and implant survival. Total shoulder replacement can be anatomical (ball on humerus, with cup on glenoid), or reverse geometry (ball on glenoid, with cup on humerus). Anatomical TSR requires an in tact rotator cuff, so often reverse is preferable when the cuff if questionable in integrity.

Answer 91

Young athletic females are the group most frequently affected by spondylolythesis who have a background of spondylolysis. Whilst the latter condition is a risk factor for spondylolythesis the former condition is most likely in a young athletic female who presents with sudden pain. Ankylosing spondylitis Chronic inflammatory disorder affecting the axial skeleton Sacro-ilitis is a usually visible in plain films Up to 20% of those who are HLA B27 positive will develop the condition Affected articulations develop bony or fibrous changes Typical spinal features include loss of the lumbar lordosis and progressive kyphosis of the cervico-thoracic spine Scheuermann's disease Epiphysitis of the vertebral joints is the main pathological process Predominantly affects adolescents Symptoms include back pain and stiffness X-ray changes include epiphyseal plate disturbance and anterior wedging Clinical features include progressive kyphosis (at least 3 vertebrae must be involved) Minor cases may be managed with physiotherapy and analgesia, more severe cases may require bracing or surgical stabilisation Scoliosis Consists of curvature of the spine in the coronal plane Divisible into structural and non structural, the latter being commonest in adolescent females who develop minor postural changes only. Postural scoliosis will typically disappear on manoeuvres such as bending forwards Structural scoliosis affects > 1 vertebral body and is divisible into idiopathic, congential and neuromuscular in origin. It is not correctable by alterations in posture Within structural scoliosis, idiopathic is the most common type Severe, or progressive structural disease is often managed surgically with bilateral rod stabilisation of the spine Spina bifida Non fusion of the vertebral arches during embryonic development Three categories; myelomeningocele, spina bifida occulta and meningocele Myelomeningocele is the most severe type with associated neurological defects that may persist in spite of anatomical closure of the defect Up to 10% of the population may have spina bifida occulta, in this condition the skin and tissues (but not not bones) may develop over the distal cord. The site may be identifiable by a birth mark or hair patch The incidence of the condition is reduced by use of folic acid supplements during pregnancy Spondylolysis Congenital or acquired deficiency of the pars interarticularis of the neural arch of a particular vertebral body, usually affects L4/ L5 May be asymptomatic and affects up to 5% of the population Spondylolysis is the commonest cause of spondylolisthesis in children Asymptomatic cases do not require treatment Spondylolisthesis This occurs when one vertebra is displaced relative to its immediate inferior vertebral body May occur as a result of stress fracture or spondylolysis Traumatic cases may show the classic "Scotty Dog" appearance on plain films Treatment depends upon the extent of deformity and associated neurological symptoms, minor cases may be actively monitored. Individuals with radicular symptoms or signs will usually require spinal decompression and stabilisation

Answer 92

This could well be a scaphoid fracture and should be temporarily immobilised pending further review. A futura splint will immobilise better than an arm sling for this problem. Fracture management Bony injury resulting in a fracture may arise from trauma (excessive forces applied to bone), stress related (repetitive low velocity injury) or pathological (abnormal bone which fractures during normal use of following minimal trauma) Diagnosis involves not just evaluating the fracture ; such as site and type of injury but also other associated injuries and distal neurovascular deficits. This may entail not just clinical examination but radiographs of proximal and distal joints. When assessing x-rays it is important to assess for changes in length of the bone, the angulation of the distal bone, rotational effects, presence of material such as glass. Fracture types Fracture type Description Oblique fracture Fracture lies obliquely to long axis of bone Comminuted fracture >2 fragments Segmental fracture More than one fracture along a bone Transverse fracture Perpendicular to long axis of bone Spiral fracture Severe oblique fracture with rotation along long axis of bone Open Vs Closed It is also important to distinguish open from closed injuries. The most common classification system for open fractures is the Gustilo and Anderson classification system (given below): Grade Injury 1 Low energy wound <1cm 2 Greater than 1cm wound with moderate soft tissue damage 3 High energy wound > 1cm with extensive soft tissue damage 3 A (sub group of 3) Adequate soft tissue coverage 3 B (sub group of 3) Inadequate soft tissue coverage 3 C (sub group of 3) Associated arterial injury Key points in management of fractures Immobilise the fracture including the proximal and distal joints Carefully monitor and document neurovascular status, particularly following reduction and immobilisation Manage infection including tetanus prophylaxis IV broad spectrum antibiotics for open injuries As a general principle all open fractures should be thoroughly debrided ( and internal fixation devices avoided or used with extreme caution) Open fractures constitute an emergency and should be debrided and lavaged within 6 hours of injury

Answer 93

This child is short, has hyperactivity (disruptive behaviour) and is within the age range for Perthes disease. Hyperactivity and short stature are associated with Perthes disease. Developmental dysplasia of the hip Usually diagnosed in infancy by screening tests. May be bilateral, when disease is unilateral there may be leg length inequality. As disease progresses child may limp and then early onset arthritis. More common in extended breech babies. Splints and harnesses or traction. In later years osteotomy and hip realignment procedures may be needed. In arthritis a joint replacement may be needed. However, this is best deferred if possible as it will almost certainly require revision Initially no obvious change on plain films and USS gives best resolution until 3 months of age. On plain films Shentons line should form a smooth arc Perthes Disease Hip pain (may be referred to the knee) usually occurring between 5 and 12 years of age. Bilateral disease in 20%. Remove pressure from joint to allow normal development. Physiotherapy. Usually self-limiting if diagnosed and treated promptly. X-rays will show flattened femoral head. Eventually in untreated cases the femoral head will fragment. Slipped upper femoral epiphysis Typically seen in obese male adolescents. Pain is often referred to the knee. Limitation to internal rotation is usually seen. Knee pain is usually present 2 months prior to hip slipping. Bilateral in 20%. Bed rest and non-weight bearing. Aim to avoid avascular necrosis. If severe slippage or risk of it occurring then percutaneous pinning of the hip may be required. X-rays will show the femoral head displaced and falling inferolaterally (like a melting ice cream cone) The Southwick angle gives indication of disease severity

Answer 94

Slipped upper femoral epiphysis is the commonest adolescent hip disorder. It occurs most commonly in obese males. It may often present as knee pain which is usually referred from the ipsilateral hip. The knee itself is normal. The hip often limits internal rotation. The diagnosis is easily missed. X-rays will show displacement of the femoral epiphysis and the degree of its displacement may be calculated using the Southwick angle. Treatment is directed at preventing further slippage which may result in avascular necrosis of the femoral head. Developmental dysplasia of the hip Usually diagnosed in infancy by screening tests. May be bilateral, when disease is unilateral there may be leg length inequality. As disease progresses child may limp and then early onset arthritis. More common in extended breech babies. Splints and harnesses or traction. In later years osteotomy and hip realignment procedures may be needed. In arthritis a joint replacement may be needed. However, this is best deferred if possible as it will almost certainly require revision Initially no obvious change on plain films and USS gives best resolution until 3 months of age. On plain films Shentons line should form a smooth arc Perthes Disease Hip pain (may be referred to the knee) usually occurring between 5 and 12 years of age. Bilateral disease in 20%. Remove pressure from joint to allow normal development. Physiotherapy. Usually self-limiting if diagnosed and treated promptly. X-rays will show flattened femoral head. Eventually in untreated cases the femoral head will fragment. Slipped upper femoral epiphysis Typically seen in obese male adolescents. Pain is often referred to the knee. Limitation to internal rotation is usually seen. Knee pain is usually present 2 months prior to hip slipping. Bilateral in 20%. Bed rest and non-weight bearing. Aim to avoid avascular necrosis. If severe slippage or risk of it occurring then percutaneous pinning of the hip may be required. X-rays will show the femoral head displaced and falling inferolaterally (like a melting ice cream cone) The Southwick angle gives indication of disease severity

Answer 95

Hemiarthroplasty - These injuries are at significant risk of avscular necrosis and consideration of surgery is important. A hemi arthroplasty may be needed. Proximal humerus fractures Very common injury. Usually through the surgical neck. Number of classification systems though for practical purposes describing the number of fracture fragments is probably easier. Some key points: It is rare to have fractures through the anatomical neck. Anatomical neck fractures which are displaced by >1cm carry a risk of avascular necrosis to the humeral head. In children the commonest injury pattern is a greenstick fracture through the surgical neck. Impacted fractures of the surgical neck are usually managed with a collar and cuff for 3 weeks followed by physiotherapy. More significant displaced fractures may require open reduction and fixation or use of an intramedullary device.

Answer 96

Removal of metal work implantation of gentamicin beads and delayed revision is the mainstay of managing this complication. Osteomyelitis Infection of the bone Causes S aureus and occasionally Enterobacter or Streptococcus species In sickle cell: Salmonella species Clinical features Erythema Pain Fever Investigation X-ray: lytic centre with a ring of sclerosis Bone biopsy and culture Treatment Prolonged antibiotics Sequestra may need surgical removal

Answer 97

The combination of age, female gender and steroids coupled with hip pain on minor trauma are strongly suggestive of osteoporosis complicated by pathological fracture. Pagets Focal bone resorption followed by excessive and chaotic bone deposition Affects (in order): spine, skull, pelvis and femur Serum alkaline phosphatase raised (other parameters normal) Abnormal thickened, sclerotic bone on x-rays Risk of cardiac failure with >15% bony involvement Small risk of sarcomatous change Bisphosphonates Osteoporosis Excessive bone resorption resulting in demineralised bone Commoner in old age Increased risk of pathological fracture, otherwise asymptomatic Alkaline phosphatase normal, calcium normal Bisphosphonates, calcium and vitamin D Secondary bone tumours Bone destruction and tumour infiltration Mirel scoring used to predict risk of fracture Appearances depend on primary (e.g.sclerotic - prostate, lytic - breast) Elevated serum calcium and alkaline phosphatase may be seen Radiotherapy, prophylactic fixation and analgesia

Answer 98

This is a pilon fracture, which a high energy injury of the distal tibia. The patient will ultimately require surgical fixation but early management involves applying a spanning external fixator to temporarily reduce the fracture and allow soft tissue swelling to settle. A CT scan should then be performed to aid surgical planning. An ankle fracture relates to a fracture around the tibio-talar joint. It generally refers to a fracture involving the lateral, and/or medial and/or posterior malleolus. Pilon and Tillaux fractures are also considered to be ankle fractures, but are not covered here. Ankle fractures are common. They effect men and women in equal numbers, but men have a higher rate as young adults (sports and contact injuries), and women a higher rate post-menopausal (fragility type fracture). ``` Osseous anatomy The ankle (or mortise) joint consists of the distal tibia (tibial plafond and posterior malleolus), the distal fibula (lateral malleolus), and the talus. The main movement at the ankle joint is plantar and dorsiflexion. ``` Ligamentous anatomy Medial side: Deltoid ligament. This is divided into superficial and deep portions. It is the primary restraint to valgus tilting of the talus. Lateral side: Lateral ligament complex consisting from anterior to posterior of the anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL), and the posterior talofibular ligament (PTFL). Together they resist valgus stress to the ankle, and are a restraint to anterior translation of the talus within the mortise joint. Syndesmosis: The syndesmosis is a ligament complex between the distal tibia and fibula, holding the two bones together. It is fundamental to the integrity of the ankle joint, and its disruption leads to instability. It consists of (from anterior to posterior) the anterior-inferior tibiofibular ligament (AITFL), the transverse tibiofibular ligament (TTFL), the interosseous membrane, and the posterior-inferior tibiofibular ligament (PITFL). Presentation and initial management Patients will present following a traumatic event with a painful, swollen ankle, and reluctance/inability to weight bear. The Ottawa rules can be applied to differentiate between an ankle fracture and sprain, but can be unreliable. In high energy injuries, management should follow ATLS principles to identify more significant injuries first. Neurovascular status of the foot should be documented, and open injuries should be excluded. If an open injury is identified, it should be managed in line with BOAST 4 principles1. If an obvious deformity exists, it should be reduced as soon as possible with appropriate analgesia or conscious sedation. Radiographs of clearly deformed or dislocated joints are not necessary, and removing the pressure on the surrounding soft tissues from the underlying bony deformity is the priority. If the fracture pattern is not clinically obvious then plain radiographs are appropriate and will guide the subsequent manipulation during plaster-of-paris below knee backslab application. Imaging AP, lateral and mortise views (20o internal rotation) are essential to evaluate fracture displacement and syndesmotic injury. Decreased tibiofibular overlap, medial joint clear space and lateral talar shift all indicate a syndesmotic injury. (In subtle cases of shift, imaging the uninjured ankle can be helpful as a proportion of the population have little or no tibiotalar overlap 2.) Where there is suspicion of syndesmosis involvement in the absence of radiographic evidence, stress radiographs can be diagnostic. Complex fracture patterns (and increasingly posterior malleolar fractures) are best defined using CT. Classification The most commonly used classifications are Lauge-Hansen and Danis-Weber. Lauge-Hansen Comprises two parts: first part is the foot position, and the second part is the force applied. Useful for understanding the forces involved and therefore predict the ligamentous or bony injury. Results in four injury patterns: Supination - Adduction (SA) - 10-20% Supination - External rotation (SER) - 40-75% Pronation - Abduction (PA) - 5-20% Pronation - External rotation (PER) - 5-20% Not often used in clinical practice but good for understanding the principles of ankle fracture. Danis-Weber Commonly used. Based on the level of the fibula fracture in relation to the syndesmosis. The more proximal, the greater the risk of syndesmotic injury and therefore fracture instability. A - fracture below the level of the syndesmosis B - fracture at the level of the syndesmosis / level of the tibial plafond C - fracture above the level of the syndesmosis. This includes Maisonneuve fractures (proximal fibula fracture), which can be associated with ankle instability. Beware the high fibula fracture - it may be an ankle fracture! The Weber classification is based purely on the the lateral side. All injuries can include a medial or posterior bony or ligamentous injury which also dictates fracture stability (bimalleolar and trimalleolar fractures are more unstable). Treatment When deciding upon treatment for an ankle fracture, one must consider both the fracture and the patient. Diabetic patients and smokers are at greater risk of post-operative complication, especially wound problems and infection. Likewise, the long term outcome of post-traumatic arthritis from a malunited ankle fracture is extremely important for a young patient, but not as relevant in the elderly. Therefore, normal surgical decision processes apply as with all fractures. Defining stability of an ankle fracture underpins the treatment decision. Weber A - Unimalleolar Weber A Weber fractures by definition are stable and therefore can be mobilised fully weight bearing in an ankle boot. Weber C - Fractures tend to include syndesmotic disruption and are usually bimalleolar (either bony or ligamentous). They are therefore unstable and usually require operative fixation. In addition to the fracture fixation, the syndesmosis usually requires reconstruction/augmentation with screws to restore the joint integrity and function. Weber B - B fractures vary greatly. They can be part of a trimalleolar injury and therefore extremely unstable, requiring fixation. Alternatively, a uni-malleolar Weber B fracture can be a stable injury, and therefore mobilised immediately in an ankle boot. Defining the stability can be challenging, and often involves stress radiographs, or a trial of mobilisation and repeat radiographs. Defining stability is the subject of much ongoing research. However, treating undisplaced ankle fractures in a below knee plaster, non-weight bearing for six weeks is still widely practised, and a safe approach. When operative fixation is appropriate, it is usually via open reduction and internal fixation using plates and screws. It must be carried out when soft tissue swelling has settled in order to minimise the risk of wound problems. This can often take a week to settle. The use of fibula nails is expanding, but is not yet mainstream. Ankle fractures can also be treated with external fixation, or with a hind foot nail in patients who need fixation but where soft tissue or bone quality is poor. Post operative management Ankle fractures generally take 6 weeks to unite enough to prevent secondary displacement. This is therefore an appropriate time period to keep a cast on in a conservatively managed patient. Weight bearing post-operatively depends on the quality of the fixation and bone quality, and preference varies between surgeons, ranging from aggressive early mobilisation to a period of non-weight bearing. Return to activities takes approximately three months, and often requires assistance of a physiotherapist to improve range-of-movement and muscle strengthening.

Answer 99

Parsonage-Turner syndrome - This is a peripheral neuropathy that may complicate viral illnesses and usually resolves spontaneously. Shoulder fractures and dislocations Fractures Proximal humerus Background Third most common fragility fracture in the elderly. Results from low energy fall in predominantly elderly females, or from high energy trauma in young males. Can be associated with nerve injury (commonly axillary), and fracture-dislocation of the humeral head. Detailed neurological assessment is essential for all upper limb injuries. Anatomy Osteology Consists of articular head, greater tuberosity, lesser tuberosity, metaphysis and diaphysis. Between the articular head and the tuberosities is the anatomical neck (previous physis). Between the tuberosities and the metaphysis is the surgical neck. The supraspinatus, infraspinatus and teres minor muscles attach to the greater tuberosity. The subscapularis muscle attaches to the lesser tuberosity. Vascular Supply Humeral head is supplied by the anterior and posterior humeral circumflex arteries. Anatomical neck fractures are at greatest risk of osteonecrosis. Imaging Imaging aims to both delineate the fracture pattern, and confirm/exlude the presence of an associated dislocation. Radiographs - True anteroposterior (AP), axillary lateral and/or scapula Y view. CT - indicated to better define intra-articular involvement and to aid pre-operative planning. MRI is not useful for fracture imaging. Classification Description of the fracture is often more useful than classification. Particular attention should be paid to humeral alignment, fracture displacement, and greater tuberosity position (rotator cuff will pull the GT supero-posterioly, which can cause impingement problems with malunion). - Neer Classification: Most commonly used. Describes fracture as 2,3,or 4 part depending upon the number main fragments. Also comments on the degree of displacement. Fragments: -greater tuberosity -lesser tuberosity - articular surface - shaft Displacement: >1cm or angulation >45 degrees. Treatment The vast majority of proximal humeral fractures are minimally displaced, and therefore can be managed conservatively. This involves immobilisation in a polysling, and progressive mobilisation. Pendular exercise can commence at 14 days, and active abduction from 4-6 weeks. Irreducible fracture dislocation is an indication for operative management. Other indications include large displacement, younger patient, head splitting (intra-articular fractures). However, the recent PROFHER trial (1) has suggested no benefit to operative intervention on patient outcome (it must be applied cautiously as majority of patients were elderly with extraarticular fractures). Options available for surgical management include: ORIF Most commonly used. Plate and screw fixation. Can reconstruct complex fractures. Intramedullary nail Suitable for extra-articular configuration, predominantly surgical neck +/- GT fractures. Hemiarthroplasty Used for un-reconstructable fractures in the older patient who has good glenoid quality. Total shoulder arthroplasty Unconstructable fractures where high functioning shoulder is required (hemiarthroplasty will cause glenoid erosion) Reverse shoulder arthroplasty Total shoulder arthroplasty that provides better functional outcome than conventional total shoulder replacement. Scapula Background Uncommon fractures usually associated with high energy trauma. Most commonly involve scapula body or spine (50%), glenoid fossa and glenoid neck. Important to exclude associated life threatening injury. Imaging Plain radiographs should include true anteroposterior (AP), axillary lateral and/or scapula Y view. CT scanning is useful for defining intra-articular involvement, displacement and for three dimensional reconstruction. Classification Based on the location of the fracture (coracoid, acromion, glenoid neck, glenoid fossa, scapula body). Beware of ipsilateral glenoid neck and clavicle fracture -floating shoulder - where limb is effectively dissociated from axial skeleton. Treatment The vast majority of scapula fractures are amenable to conservative management, consisting of sling immobilisation for two weeks followed by early rehabilitation. Floating shoulder will usually require fixation, and consideration of surgery should also be given to intra-articular and displaced/angulated glenoid fractures. Dislocations Types Dislocations around the shoulder joint include glenohumeral dislocation, acromioclavicular joint disruption and sternoclavicular dislocation. Only glenohumeral dislocation will be covered here. Glenohumeral dislocation Diagnosis, classification and management are covered here. Background Shoulder dislocation is commonly seen in A&E. It has a high recurrence rate that is as high as 80% in teenagers. Initial management requires emergent reduction to prevent lasting chondral damage. Early assessment and management Usually a traumatic cause (multi-directional instability in frequent dislocations requires discussion with orthopaedics and is not covered here). Careful history, examination and documentation of neurovascular status of the limb, in particular the axillary nerve (regimental badge sensation). This should be re-assessed post manipulation. Early radiographs to confirm direction of dislocation. Initial management consists of emergent closed reduction under under entanox and analgesia, but often requires conscious sedation. Arm should then be immobilised in a polysling, and XR to confirm relocation. Imaging - True anteroposterior (AP), axillary lateral and/or scapula Y view. Reduced humeral head should lie between acromion and coracoid on lateral/scapula view. Types Direction Features Cause Examination Reduction techniques Anterior Most Common >90% Usually traumatic - anterior force on arm when shoulder is abducted, eternally rotated Loss of shoulder contour - sulcus sign. Humeral head can be felt anteriorly. Hippocratic. Milch. Stimson. Kocher not advised due to complication of fracture Posterior 50% missed in A&E 50% traumatic, but classically post seizure or electrocution Shoulder locked in internal rotation. XR may show lightbulb appearance. Gentle lateral traction to adducted arm. Inferior Rare Associated with pectorals and rotator cuff tears, and glenoid fracture As for primary injury Management of primary injury Superior Rare Associated with acrominon/clavicle fracture As for primary injury Management of primary injury Associated injuries Bankart lesion - avulsion of the anterior glenoid labrum with an anterior shoulder dislocation (reverse Bankart if poster labrum in posterior dislocation). Hill Sachs defect - chondral impaction on posteriosuperior humeral head from contact with gleonoid rim. Can be large enough to lock shoulder, requiring open reduction. (Reverse Hill Sachs in posterior dislocation). Rotator cuff tear - increases with age. Greater or lesser tuberosity fracture - increases with age. Humeral neck fracture - shoulder fracture dislocation. More common in high energy trauma and elderly. Should be discussed with orthopaedics prior to any attempted reduction. Rotator Cuff Disease Rotator cuff disease is a spectrum of conditions that ranges from subacromial impingement to rotator cuff tears and eventually to rotator cuff arthropathy (arthritis). Anatomy The rotator cuff is a group of four muscles that are important in shoulder movements, and maintenance of glenohumeral stability. Muscle Scapular attachment Humeral attachment Action Innervation Supraspinatus Supraspinatus fossa Superior facet of greater tuberosity Initiation of abduction of humerus Suprascapular nerve Infraspinatus Infraspinatus fossa Posterior facet of greater tuberosity External rotation of humerus Suprascapular nerve Teres Minor Lateral border Inferior facet of greater tuberosity External rotation of humerus Axillary Nerve Subscapularis Subscapular fossa Lesser tuberosity Internal rotation of humerus Upper and lower subscapular nerve The inferior rotator cuff muscles (infraspinatus, teres minor, and subscapularis) balance the superior pull of the deltoid. Injury/tear results in upward migration of the humeral head on the glenoid (can be seen on AP radiograph). Likewise, the anterior muscles (subscapularis) are balanced with the posterior muscles (infraspinatus, teres minor). Subacromial Impingement The most common cause of shoulder pain, which results from impingement of the superior cuff on the undersurface of the acromion, and an inflammatory bursitis. Associated with certain types of acromial morphology (Bigliani classification). Presents as insidious pain which is exacerbated by overhead activities. Rotator Cuff Tear Often presents as an acute event on the background of chronic subacromial impingement in the older patient, but can present as an avulsion injury in younger patients. Majority of tears are to the superior cuff (supraspinatus, infraspinatus, teres minor), though a tear to subscapularis is associated with subcoracoid impingement. Tears present as pain and weakness when using the muscles in question. Rotator Cuff Arthropathy Defined as shoulder arthritis in the setting of rotator cuff dysfunction. Results from superior migration due to the loss of rotator cuff function and integrity. Unopposed deltoid pulls the humeral head superiorly. Associated with massive chronic cuff tears. Imaging Plain radiographs AP of the shoulder may show superior migration of the humerus with a cuff tear, and features of arthritis with arthropathy. Other causes of pain may also be identified (e.g. calcific tendonitis/fracture) Outlet view is useful for defining the acromial morphology USS Allows dynamic imaging of the cuff, and is inexpensive. However, it is very user dependent. MRI Best imaging modality for cuff pathology. Also allows imaging of the rest of the shoulder. When intra-articular pathology is suspected, can be combined with an arthrogram for improved sensitivity and specificity. Treatment Subacromial impingement Physiotherapy, oral anti-inflammatory medication Subacromial steroid injection can settle inflammation Arthroscopic subacromial decompression by shaving away the undersurface of the acromion, more space is created for the rotator cuff. Cuff integrity is assessed also at time of surgery, and can be repaired if necessary. Rotator cuff tear When considering repair of a cuff tear, the age and activity of the patient, the nature of the tear (degenerative vs. acute traumatic), and the size and retraction of the tear should be considered when making a surgical plan. Mild tears or tears in the elderly can be managed conservatively, as outlined above. Moderate tears can be repaired arthroscopically. Massive or retracted tears will often require an open repair (occasionally with a tendon transfer). Subacromial decompression is performed at the same time to reduce impingement, symptoms and recurrence. Calcific tendonitis Calcific tendonitis involves calcific deposits within tendons anywhere in the body, but most commonly in the rotator cuff (specifically the supraspinatus tendon). When present in the shoulder, it is associated with subacromial impingement and pain. Pathology More common in women aged 30-60 years. Association with diabetes and hypothyroidism There are three stages of calcification Formative phase characterized by calcific deposits Resting phase deposit is stable, but presents with impingement problems Resorptive phase phagocytic resorption. Most painful stage. Presentation Similar in presentation to subacromial impingement, with pain especially with over head activities. Atraumatic in nature. Imaging Plain radiographs show calcification of the rotator cuff, usually within 1.5cm of its insertion on the humerus. Supraspinatus outlet views can show level of impingment. Further imaging is rarely needed. Treatment Non-operative NSAIDS, steroid injection (controversial, but practiced) and physiotherapy. Approximately 75% will resolve by 6 months with conservative management. Ultrasound guided or surgical needle barbotage can break down deposits and resolve symptoms. Occasionally surgical excision is required. Adhesive capsulitis (Frozen Shoulder) Pain and loss of movement of shoulder joint, which involves fibroplastic proliferation of capsular tissue, causing soft tissue scarring and contracture. Patients present with a painful and decreased arc of motion. Associated with prolonged immobilization, previous surgery, thyroid disorders (AI) and diabetes Classically three stages which can take up to two years to resolve: Stage one the freezing and painful stage Stage two the frozen and stiff stage Stage three the thawing stage, where shoulder movement slowly improves Imaging Plain radiographs to exclude other causes of a painful shoulder MRI arthrogram may show capsular contracture, and again may be used to exclude cuff pathology. However, often not performed as diagnosis is largely clinical. Treatment Non-operative NSAIDS, steroid injection and physiotherapy. Patience is required as condition can take up to 2 years to improve. Operative MUA or arthroscopic adhesiolysis (release of adhesions) can expedite recovery, followed by intensive physiotherapy. Glenohumeral Arthritis Background May be osteoarthritis (primary or secondary to cuff tear or trauma), rheumatoid arthritis, or as part of a spondyloarthropathy. Majority of those with RA will develop symptoms. More common in the elderly Presents like any other arthritis - pain at night and with movement Imaging AP and axillary radiographs will show features of arthritis. CT/MRI is often useful to classify the shape of the glenoid and extent of bone loss when considering arthroplasty. MRI also essential to asses integrity of rotator cuff if considering shoulder replacement. Treatment Like all orthopaedics, start with simple measures: NSAIDS, management of RA, physiotherapy, steroid injection. Hemiarthroplasty can sometimes be considered if glenoid is in excellent condition or if patient has large comorbidity. Arthroscopic debridement is useful if patient has isolated ACJ arthritis, but is rarely used for glenohumeral arthritis. Total shoulder replacement is shown to produce superior outcome when compared to hemiarthroplasty in terms of pain relief, function and implant survival. Total shoulder replacement can be anatomical (ball on humerus, with cup on glenoid), or reverse geometry (ball on glenoid, with cup on humerus). Anatomical TSR requires an in tact rotator cuff, so often reverse is preferable when the cuff if questionable in integrity.

Answer 100

Ankylosing spondylitis is associated with HLA B27, there is a strong association with ulcerative colitis in such individuals. The clinical findings are usually of a kyphosis affecting the cervical and thoracic spine. Considerable symptomatic benefit may be obtained using non steroidal anti inflammatory drugs. These should be used carefully in patients with inflammatory bowel disease who may be taking steroids. Ankylosing spondylitis Chronic inflammatory disorder affecting the axial skeleton Sacro-ilitis is a usually visible in plain films Up to 20% of those who are HLA B27 positive will develop the condition Affected articulations develop bony or fibrous changes Typical spinal features include loss of the lumbar lordosis and progressive kyphosis of the cervico-thoracic spine Scheuermann's disease Epiphysitis of the vertebral joints is the main pathological process Predominantly affects adolescents Symptoms include back pain and stiffness X-ray changes include epiphyseal plate disturbance and anterior wedging Clinical features include progressive kyphosis (at least 3 vertebrae must be involved) Minor cases may be managed with physiotherapy and analgesia, more severe cases may require bracing or surgical stabilisation Scoliosis Consists of curvature of the spine in the coronal plane Divisible into structural and non structural, the latter being commonest in adolescent females who develop minor postural changes only. Postural scoliosis will typically disappear on manoeuvres such as bending forwards Structural scoliosis affects > 1 vertebral body and is divisible into idiopathic, congential and neuromuscular in origin. It is not correctable by alterations in posture Within structural scoliosis, idiopathic is the most common type Severe, or progressive structural disease is often managed surgically with bilateral rod stabilisation of the spine Spina bifida Non fusion of the vertebral arches during embryonic development Three categories; myelomeningocele, spina bifida occulta and meningocele Myelomeningocele is the most severe type with associated neurological defects that may persist in spite of anatomical closure of the defect Up to 10% of the population may have spina bifida occulta, in this condition the skin and tissues (but not not bones) may develop over the distal cord. The site may be identifiable by a birth mark or hair patch The incidence of the condition is reduced by use of folic acid supplements during pregnancy Spondylolysis Congenital or acquired deficiency of the pars interarticularis of the neural arch of a particular vertebral body, usually affects L4/ L5 May be asymptomatic and affects up to 5% of the population Spondylolysis is the commonest cause of spondylolisthesis in children Asymptomatic cases do not require treatment Spondylolisthesis This occurs when one vertebra is displaced relative to its immediate inferior vertebral body May occur as a result of stress fracture or spondylolysis Traumatic cases may show the classic "Scotty Dog" appearance on plain films Treatment depends upon the extent of deformity and associated neurological symptoms, minor cases may be actively monitored. Individuals with radicular symptoms or signs will usually require spinal decompression and stabilisation

Answer 101

It is worth attempting to try and resolve this situation with antibiotics at first presentation. A primary amputation will not heal well and may result in progressive surgery. Osteomyelitis Infection of the bone Causes S aureus and occasionally Enterobacter or Streptococcus species In sickle cell: Salmonella species Clinical features Erythema Pain Fever Investigation X-ray: lytic centre with a ring of sclerosis Bone biopsy and culture Treatment Prolonged antibiotics Sequestra may need surgical removal

Answer 102

A Hill-Sachs lesion occurs when the cartilage surface of the humerus is in contact with the rim of the glenoid. About 50% of anterior glenohumeral dislocations are associated with this lesion. Shoulder fractures and dislocations Fractures Proximal humerus Background Third most common fragility fracture in the elderly. Results from low energy fall in predominantly elderly females, or from high energy trauma in young males. Can be associated with nerve injury (commonly axillary), and fracture-dislocation of the humeral head. Detailed neurological assessment is essential for all upper limb injuries. Anatomy Osteology Consists of articular head, greater tuberosity, lesser tuberosity, metaphysis and diaphysis. Between the articular head and the tuberosities is the anatomical neck (previous physis). Between the tuberosities and the metaphysis is the surgical neck. The supraspinatus, infraspinatus and teres minor muscles attach to the greater tuberosity. The subscapularis muscle attaches to the lesser tuberosity. Vascular Supply Humeral head is supplied by the anterior and posterior humeral circumflex arteries. Anatomical neck fractures are at greatest risk of osteonecrosis. Imaging Imaging aims to both delineate the fracture pattern, and confirm/exlude the presence of an associated dislocation. Radiographs - True anteroposterior (AP), axillary lateral and/or scapula Y view. CT - indicated to better define intra-articular involvement and to aid pre-operative planning. MRI is not useful for fracture imaging. Classification Description of the fracture is often more useful than classification. Particular attention should be paid to humeral alignment, fracture displacement, and greater tuberosity position (rotator cuff will pull the GT supero-posterioly, which can cause impingement problems with malunion). - Neer Classification: Most commonly used. Describes fracture as 2,3,or 4 part depending upon the number main fragments. Also comments on the degree of displacement. Fragments: -greater tuberosity -lesser tuberosity - articular surface - shaft Displacement: >1cm or angulation >45 degrees. Treatment The vast majority of proximal humeral fractures are minimally displaced, and therefore can be managed conservatively. This involves immobilisation in a polysling, and progressive mobilisation. Pendular exercise can commence at 14 days, and active abduction from 4-6 weeks. Irreducible fracture dislocation is an indication for operative management. Other indications include large displacement, younger patient, head splitting (intra-articular fractures). However, the recent PROFHER trial (1) has suggested no benefit to operative intervention on patient outcome (it must be applied cautiously as majority of patients were elderly with extraarticular fractures). Options available for surgical management include: ORIF Most commonly used. Plate and screw fixation. Can reconstruct complex fractures. Intramedullary nail Suitable for extra-articular configuration, predominantly surgical neck +/- GT fractures. Hemiarthroplasty Used for un-reconstructable fractures in the older patient who has good glenoid quality. Total shoulder arthroplasty Unconstructable fractures where high functioning shoulder is required (hemiarthroplasty will cause glenoid erosion) Reverse shoulder arthroplasty Total shoulder arthroplasty that provides better functional outcome than conventional total shoulder replacement. Scapula Background Uncommon fractures usually associated with high energy trauma. Most commonly involve scapula body or spine (50%), glenoid fossa and glenoid neck. Important to exclude associated life threatening injury. Imaging Plain radiographs should include true anteroposterior (AP), axillary lateral and/or scapula Y view. CT scanning is useful for defining intra-articular involvement, displacement and for three dimensional reconstruction. Classification Based on the location of the fracture (coracoid, acromion, glenoid neck, glenoid fossa, scapula body). Beware of ipsilateral glenoid neck and clavicle fracture -floating shoulder - where limb is effectively dissociated from axial skeleton. Treatment The vast majority of scapula fractures are amenable to conservative management, consisting of sling immobilisation for two weeks followed by early rehabilitation. Floating shoulder will usually require fixation, and consideration of surgery should also be given to intra-articular and displaced/angulated glenoid fractures. Dislocations Types Dislocations around the shoulder joint include glenohumeral dislocation, acromioclavicular joint disruption and sternoclavicular dislocation. Only glenohumeral dislocation will be covered here. Glenohumeral dislocation Diagnosis, classification and management are covered here. Background Shoulder dislocation is commonly seen in A&E. It has a high recurrence rate that is as high as 80% in teenagers. Initial management requires emergent reduction to prevent lasting chondral damage. Early assessment and management Usually a traumatic cause (multi-directional instability in frequent dislocations requires discussion with orthopaedics and is not covered here). Careful history, examination and documentation of neurovascular status of the limb, in particular the axillary nerve (regimental badge sensation). This should be re-assessed post manipulation. Early radiographs to confirm direction of dislocation. Initial management consists of emergent closed reduction under under entanox and analgesia, but often requires conscious sedation. Arm should then be immobilised in a polysling, and XR to confirm relocation. Imaging - True anteroposterior (AP), axillary lateral and/or scapula Y view. Reduced humeral head should lie between acromion and coracoid on lateral/scapula view. Types Direction Features Cause Examination Reduction techniques Anterior Most Common >90% Usually traumatic - anterior force on arm when shoulder is abducted, eternally rotated Loss of shoulder contour - sulcus sign. Humeral head can be felt anteriorly. Hippocratic. Milch. Stimson. Kocher not advised due to complication of fracture Posterior 50% missed in A&E 50% traumatic, but classically post seizure or electrocution Shoulder locked in internal rotation. XR may show lightbulb appearance. Gentle lateral traction to adducted arm. Inferior Rare Associated with pectorals and rotator cuff tears, and glenoid fracture As for primary injury Management of primary injury Superior Rare Associated with acrominon/clavicle fracture As for primary injury Management of primary injury Associated injuries Bankart lesion - avulsion of the anterior glenoid labrum with an anterior shoulder dislocation (reverse Bankart if poster labrum in posterior dislocation). Hill Sachs defect - chondral impaction on posteriosuperior humeral head from contact with gleonoid rim. Can be large enough to lock shoulder, requiring open reduction. (Reverse Hill Sachs in posterior dislocation). Rotator cuff tear - increases with age. Greater or lesser tuberosity fracture - increases with age. Humeral neck fracture - shoulder fracture dislocation. More common in high energy trauma and elderly. Should be discussed with orthopaedics prior to any attempted reduction. Rotator Cuff Disease Rotator cuff disease is a spectrum of conditions that ranges from subacromial impingement to rotator cuff tears and eventually to rotator cuff arthropathy (arthritis). Anatomy The rotator cuff is a group of four muscles that are important in shoulder movements, and maintenance of glenohumeral stability. Muscle Scapular attachment Humeral attachment Action Innervation Supraspinatus Supraspinatus fossa Superior facet of greater tuberosity Initiation of abduction of humerus Suprascapular nerve Infraspinatus Infraspinatus fossa Posterior facet of greater tuberosity External rotation of humerus Suprascapular nerve Teres Minor Lateral border Inferior facet of greater tuberosity External rotation of humerus Axillary Nerve Subscapularis Subscapular fossa Lesser tuberosity Internal rotation of humerus Upper and lower subscapular nerve The inferior rotator cuff muscles (infraspinatus, teres minor, and subscapularis) balance the superior pull of the deltoid. Injury/tear results in upward migration of the humeral head on the glenoid (can be seen on AP radiograph). Likewise, the anterior muscles (subscapularis) are balanced with the posterior muscles (infraspinatus, teres minor). Subacromial Impingement The most common cause of shoulder pain, which results from impingement of the superior cuff on the undersurface of the acromion, and an inflammatory bursitis. Associated with certain types of acromial morphology (Bigliani classification). Presents as insidious pain which is exacerbated by overhead activities. Rotator Cuff Tear Often presents as an acute event on the background of chronic subacromial impingement in the older patient, but can present as an avulsion injury in younger patients. Majority of tears are to the superior cuff (supraspinatus, infraspinatus, teres minor), though a tear to subscapularis is associated with subcoracoid impingement. Tears present as pain and weakness when using the muscles in question. Rotator Cuff Arthropathy Defined as shoulder arthritis in the setting of rotator cuff dysfunction. Results from superior migration due to the loss of rotator cuff function and integrity. Unopposed deltoid pulls the humeral head superiorly. Associated with massive chronic cuff tears. Imaging Plain radiographs AP of the shoulder may show superior migration of the humerus with a cuff tear, and features of arthritis with arthropathy. Other causes of pain may also be identified (e.g. calcific tendonitis/fracture) Outlet view is useful for defining the acromial morphology USS Allows dynamic imaging of the cuff, and is inexpensive. However, it is very user dependent. MRI Best imaging modality for cuff pathology. Also allows imaging of the rest of the shoulder. When intra-articular pathology is suspected, can be combined with an arthrogram for improved sensitivity and specificity. Treatment Subacromial impingement Physiotherapy, oral anti-inflammatory medication Subacromial steroid injection can settle inflammation Arthroscopic subacromial decompression by shaving away the undersurface of the acromion, more space is created for the rotator cuff. Cuff integrity is assessed also at time of surgery, and can be repaired if necessary. Rotator cuff tear When considering repair of a cuff tear, the age and activity of the patient, the nature of the tear (degenerative vs. acute traumatic), and the size and retraction of the tear should be considered when making a surgical plan. Mild tears or tears in the elderly can be managed conservatively, as outlined above. Moderate tears can be repaired arthroscopically. Massive or retracted tears will often require an open repair (occasionally with a tendon transfer). Subacromial decompression is performed at the same time to reduce impingement, symptoms and recurrence. Calcific tendonitis Calcific tendonitis involves calcific deposits within tendons anywhere in the body, but most commonly in the rotator cuff (specifically the supraspinatus tendon). When present in the shoulder, it is associated with subacromial impingement and pain. Pathology More common in women aged 30-60 years. Association with diabetes and hypothyroidism There are three stages of calcification Formative phase characterized by calcific deposits Resting phase deposit is stable, but presents with impingement problems Resorptive phase phagocytic resorption. Most painful stage. Presentation Similar in presentation to subacromial impingement, with pain especially with over head activities. Atraumatic in nature. Imaging Plain radiographs show calcification of the rotator cuff, usually within 1.5cm of its insertion on the humerus. Supraspinatus outlet views can show level of impingment. Further imaging is rarely needed. Treatment Non-operative NSAIDS, steroid injection (controversial, but practiced) and physiotherapy. Approximately 75% will resolve by 6 months with conservative management. Ultrasound guided or surgical needle barbotage can break down deposits and resolve symptoms. Occasionally surgical excision is required. Adhesive capsulitis (Frozen Shoulder) Pain and loss of movement of shoulder joint, which involves fibroplastic proliferation of capsular tissue, causing soft tissue scarring and contracture. Patients present with a painful and decreased arc of motion. Associated with prolonged immobilization, previous surgery, thyroid disorders (AI) and diabetes Classically three stages which can take up to two years to resolve: Stage one the freezing and painful stage Stage two the frozen and stiff stage Stage three the thawing stage, where shoulder movement slowly improves Imaging Plain radiographs to exclude other causes of a painful shoulder MRI arthrogram may show capsular contracture, and again may be used to exclude cuff pathology. However, often not performed as diagnosis is largely clinical. Treatment Non-operative NSAIDS, steroid injection and physiotherapy. Patience is required as condition can take up to 2 years to improve. Operative MUA or arthroscopic adhesiolysis (release of adhesions) can expedite recovery, followed by intensive physiotherapy. Glenohumeral Arthritis Background May be osteoarthritis (primary or secondary to cuff tear or trauma), rheumatoid arthritis, or as part of a spondyloarthropathy. Majority of those with RA will develop symptoms. More common in the elderly Presents like any other arthritis - pain at night and with movement Imaging AP and axillary radiographs will show features of arthritis. CT/MRI is often useful to classify the shape of the glenoid and extent of bone loss when considering arthroplasty. MRI also essential to asses integrity of rotator cuff if considering shoulder replacement. Treatment Like all orthopaedics, start with simple measures: NSAIDS, management of RA, physiotherapy, steroid injection. Hemiarthroplasty can sometimes be considered if glenoid is in excellent condition or if patient has large comorbidity. Arthroscopic debridement is useful if patient has isolated ACJ arthritis, but is rarely used for glenohumeral arthritis. Total shoulder replacement is shown to produce superior outcome when compared to hemiarthroplasty in terms of pain relief, function and implant survival. Total shoulder replacement can be anatomical (ball on humerus, with cup on glenoid), or reverse geometry (ball on glenoid, with cup on humerus). Anatomical TSR requires an in tact rotator cuff, so often reverse is preferable when the cuff if questionable in integrity.

Answer 103

This is a Weber A fracture. It is a stable ankle injury and can therefore be managed conservatively. Whilst this patient could also be treated in a below knee plaster, most clinicians would nowadays treat this injury in an ankle boot. Patients should be advised to mobilise in the ankle boot, as pain allows, and can wean themselves out of the boot as the symptoms improve. An ankle fracture relates to a fracture around the tibio-talar joint. It generally refers to a fracture involving the lateral, and/or medial and/or posterior malleolus. Pilon and Tillaux fractures are also considered to be ankle fractures, but are not covered here. Ankle fractures are common. They effect men and women in equal numbers, but men have a higher rate as young adults (sports and contact injuries), and women a higher rate post-menopausal (fragility type fracture). ``` Osseous anatomy The ankle (or mortise) joint consists of the distal tibia (tibial plafond and posterior malleolus), the distal fibula (lateral malleolus), and the talus. The main movement at the ankle joint is plantar and dorsiflexion. ``` Ligamentous anatomy Medial side: Deltoid ligament. This is divided into superficial and deep portions. It is the primary restraint to valgus tilting of the talus. Lateral side: Lateral ligament complex consisting from anterior to posterior of the anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL), and the posterior talofibular ligament (PTFL). Together they resist valgus stress to the ankle, and are a restraint to anterior translation of the talus within the mortise joint. Syndesmosis: The syndesmosis is a ligament complex between the distal tibia and fibula, holding the two bones together. It is fundamental to the integrity of the ankle joint, and its disruption leads to instability. It consists of (from anterior to posterior) the anterior-inferior tibiofibular ligament (AITFL), the transverse tibiofibular ligament (TTFL), the interosseous membrane, and the posterior-inferior tibiofibular ligament (PITFL). Presentation and initial management Patients will present following a traumatic event with a painful, swollen ankle, and reluctance/inability to weight bear. The Ottawa rules can be applied to differentiate between an ankle fracture and sprain, but can be unreliable. In high energy injuries, management should follow ATLS principles to identify more significant injuries first. Neurovascular status of the foot should be documented, and open injuries should be excluded. If an open injury is identified, it should be managed in line with BOAST 4 principles1. If an obvious deformity exists, it should be reduced as soon as possible with appropriate analgesia or conscious sedation. Radiographs of clearly deformed or dislocated joints are not necessary, and removing the pressure on the surrounding soft tissues from the underlying bony deformity is the priority. If the fracture pattern is not clinically obvious then plain radiographs are appropriate and will guide the subsequent manipulation during plaster-of-paris below knee backslab application. Imaging AP, lateral and mortise views (20o internal rotation) are essential to evaluate fracture displacement and syndesmotic injury. Decreased tibiofibular overlap, medial joint clear space and lateral talar shift all indicate a syndesmotic injury. (In subtle cases of shift, imaging the uninjured ankle can be helpful as a proportion of the population have little or no tibiotalar overlap 2.) Where there is suspicion of syndesmosis involvement in the absence of radiographic evidence, stress radiographs can be diagnostic. Complex fracture patterns (and increasingly posterior malleolar fractures) are best defined using CT. Classification The most commonly used classifications are Lauge-Hansen and Danis-Weber. Lauge-Hansen Comprises two parts: first part is the foot position, and the second part is the force applied. Useful for understanding the forces involved and therefore predict the ligamentous or bony injury. Results in four injury patterns: Supination - Adduction (SA) - 10-20% Supination - External rotation (SER) - 40-75% Pronation - Abduction (PA) - 5-20% Pronation - External rotation (PER) - 5-20% Not often used in clinical practice but good for understanding the principles of ankle fracture. Danis-Weber Commonly used. Based on the level of the fibula fracture in relation to the syndesmosis. The more proximal, the greater the risk of syndesmotic injury and therefore fracture instability. A - fracture below the level of the syndesmosis B - fracture at the level of the syndesmosis / level of the tibial plafond C - fracture above the level of the syndesmosis. This includes Maisonneuve fractures (proximal fibula fracture), which can be associated with ankle instability. Beware the high fibula fracture - it may be an ankle fracture! The Weber classification is based purely on the the lateral side. All injuries can include a medial or posterior bony or ligamentous injury which also dictates fracture stability (bimalleolar and trimalleolar fractures are more unstable). Treatment When deciding upon treatment for an ankle fracture, one must consider both the fracture and the patient. Diabetic patients and smokers are at greater risk of post-operative complication, especially wound problems and infection. Likewise, the long term outcome of post-traumatic arthritis from a malunited ankle fracture is extremely important for a young patient, but not as relevant in the elderly. Therefore, normal surgical decision processes apply as with all fractures. Defining stability of an ankle fracture underpins the treatment decision. Weber A - Unimalleolar Weber A Weber fractures by definition are stable and therefore can be mobilised fully weight bearing in an ankle boot. Weber C - Fractures tend to include syndesmotic disruption and are usually bimalleolar (either bony or ligamentous). They are therefore unstable and usually require operative fixation. In addition to the fracture fixation, the syndesmosis usually requires reconstruction/augmentation with screws to restore the joint integrity and function. Weber B - B fractures vary greatly. They can be part of a trimalleolar injury and therefore extremely unstable, requiring fixation. Alternatively, a uni-malleolar Weber B fracture can be a stable injury, and therefore mobilised immediately in an ankle boot. Defining the stability can be challenging, and often involves stress radiographs, or a trial of mobilisation and repeat radiographs. Defining stability is the subject of much ongoing research. However, treating undisplaced ankle fractures in a below knee plaster, non-weight bearing for six weeks is still widely practised, and a safe approach. When operative fixation is appropriate, it is usually via open reduction and internal fixation using plates and screws. It must be carried out when soft tissue swelling has settled in order to minimise the risk of wound problems. This can often take a week to settle. The use of fibula nails is expanding, but is not yet mainstream. Ankle fractures can also be treated with external fixation, or with a hind foot nail in patients who need fixation but where soft tissue or bone quality is poor. Post operative management Ankle fractures generally take 6 weeks to unite enough to prevent secondary displacement. This is therefore an appropriate time period to keep a cast on in a conservatively managed patient. Weight bearing post-operatively depends on the quality of the fixation and bone quality, and preference varies between surgeons, ranging from aggressive early mobilisation to a period of non-weight bearing. Return to activities takes approximately three months, and often requires assistance of a physiotherapist to improve range-of-movement and muscle strengthening.

Answer 104

The delay is the significant factor here. These injuries often have neurovascular compromise and inactivity now places him at risk of developing complications. In compartment syndrome the loss of arterial pulsation occurs late. Fracture management Bony injury resulting in a fracture may arise from trauma (excessive forces applied to bone), stress related (repetitive low velocity injury) or pathological (abnormal bone which fractures during normal use of following minimal trauma) Diagnosis involves not just evaluating the fracture ; such as site and type of injury but also other associated injuries and distal neurovascular deficits. This may entail not just clinical examination but radiographs of proximal and distal joints. When assessing x-rays it is important to assess for changes in length of the bone, the angulation of the distal bone, rotational effects, presence of material such as glass. Fracture types Fracture type Description Oblique fracture Fracture lies obliquely to long axis of bone Comminuted fracture >2 fragments Segmental fracture More than one fracture along a bone Transverse fracture Perpendicular to long axis of bone Spiral fracture Severe oblique fracture with rotation along long axis of bone Open Vs Closed It is also important to distinguish open from closed injuries. The most common classification system for open fractures is the Gustilo and Anderson classification system (given below): Grade Injury 1 Low energy wound <1cm 2 Greater than 1cm wound with moderate soft tissue damage 3 High energy wound > 1cm with extensive soft tissue damage 3 A (sub group of 3) Adequate soft tissue coverage 3 B (sub group of 3) Inadequate soft tissue coverage 3 C (sub group of 3) Associated arterial injury Key points in management of fractures Immobilise the fracture including the proximal and distal joints Carefully monitor and document neurovascular status, particularly following reduction and immobilisation Manage infection including tetanus prophylaxis IV broad spectrum antibiotics for open injuries As a general principle all open fractures should be thoroughly debrided ( and internal fixation devices avoided or used with extreme caution) Open fractures constitute an emergency and should be debrided and lavaged within 6 hours of injury

Answer 105

Early plain x-ray changes in Perthes Disease: Widening of the joint space. Sub chondral linear lucency. This is a typical presentation for Perthes disease. X-ray may show flattening of the femoral head or fragmentation in more advanced cases. Developmental dysplasia of the hip Usually diagnosed in infancy by screening tests. May be bilateral, when disease is unilateral there may be leg length inequality. As disease progresses child may limp and then early onset arthritis. More common in extended breech babies. Splints and harnesses or traction. In later years osteotomy and hip realignment procedures may be needed. In arthritis a joint replacement may be needed. However, this is best deferred if possible as it will almost certainly require revision Initially no obvious change on plain films and USS gives best resolution until 3 months of age. On plain films Shentons line should form a smooth arc Perthes Disease Hip pain (may be referred to the knee) usually occurring between 5 and 12 years of age. Bilateral disease in 20%. Remove pressure from joint to allow normal development. Physiotherapy. Usually self-limiting if diagnosed and treated promptly. X-rays will show flattened femoral head. Eventually in untreated cases the femoral head will fragment. Slipped upper femoral epiphysis Typically seen in obese male adolescents. Pain is often referred to the knee. Limitation to internal rotation is usually seen. Knee pain is usually present 2 months prior to hip slipping. Bilateral in 20%. Bed rest and non-weight bearing. Aim to avoid avascular necrosis. If severe slippage or risk of it occurring then percutaneous pinning of the hip may be required. X-rays will show the femoral head displaced and falling inferolaterally (like a melting ice cream cone) The Southwick angle gives indication of disease severity

Answer 106

The radial nerve supplies the extensor muscle group. Radial nerve Continuation of posterior cord of the brachial plexus (root values C5 to T1) Path In the axilla: lies posterior to the axillary artery on subscapularis, latissimus dorsi and teres major. Enters the arm between the brachial artery and the long head of triceps (medial to humerus). Spirals around the posterior surface of the humerus in the groove for the radial nerve. At the distal third of the lateral border of the humerus it then pierces the intermuscular septum and descends in front of the lateral epicondyle. At the lateral epicondyle it lies deeply between brachialis and brachioradialis where it then divides into a superficial and deep terminal branch. Deep branch crosses the supinator to become the posterior interosseous nerve. ``` Regions innervated Motor (main nerve) Triceps Anconeus Brachioradialis Extensor carpi radialis Motor (posterior interosseous branch) Supinator Extensor carpi ulnaris Extensor digitorum Extensor indicis Extensor digiti minimi Extensor pollicis longus and brevis Abductor pollicis longus Sensory The area of skin supplying the proximal phalanges on the dorsal aspect of the hand is supplied by the radial nerve (this does not apply to the little finger and part of the ring finger) ``` Muscular innervation and effect of denervation Anatomical location Muscle affected Effect of paralysis Shoulder Long head of triceps Minor effects on shoulder stability in abduction Arm Triceps Loss of elbow extension Forearm Supinator Brachioradialis Extensor carpi radialis longus and brevis Weakening of supination of prone hand and elbow flexion in mid prone position

Answer 107

It's an easy question really, we just made the wording difficult (on purpose). It is asking about the branches of the axillary artery and knowledge of the fact that there is an extensive collateral network around the shoulder joint. As a result, the occlusion of the proximal aspect of the circumflex humeral inflow (from the axillary artery) ceases and there is then retrograde flow through it from collaterals. The circumflex scapular artery is a branch of the subscapular artery and normally supplies the muscle on the dorsal aspect of the scapula. In this instance, flow is reversed in the circumflex scapular and subscapular arteries forming a collateral circulation around the scapula. The axillary artery extends from the outer border of the first rib to the lower border of teres major, where it becomes the brachial artery. The vessel is subdivided into three zones; the first part lies above pectoralis minor, the second part is behind the muscle and the third part lies inferior to it. First part Together with the axillary vein, the artery is enclosed within the cords of the brachial plexus. Both vessels are contained within the axillary sheath, a prolongation of the prevertebral fascia. Posteriomedial to the sheath lies the first intercostal space, the superior aspect of the serratus anterior and the long thoracic nerve. Within the sheath, the medial cord of the brachial plexus lies behind the artery. Anteriorly lies the clavipectoral fascia. Superolaterally, lie the lateral and posterior cords of the brachial plexus. Inferomedially lies the axillary vein. Second part Posterior to the second part lies the posterior cord of the brachial plexus and the subscapularis muscle. Anteriorly, lie pectoralis minor and major. The lateral cord of the brachial plexus lies laterally. Medially, lies the medial cord of the brachial plexus, here it separates the artery from the vein. Third part Posterior to the artery lie suscapularis, latissimus dorsi and teres major. Interspersed between the vessel and subscapularis are the axillary and radial nerves. Anterior to the vessel is the medial root of the median nerve. Laterally, the lies the median and musculocutaneous nerves and coracobrachialis. The axillary vein is related medially. ``` Branches of the axillary artery Highest thoracic artery Thoraco-acromial artery Lateral thoracic artery Subscapular artery Posterior circumflex humeral artery Anterior circumflex humeral artery ```

Answer 108

The cutaneous branch of the obturator nerve is frequently absent. However, the obturator nerve is a recognised contributor to innervation of the medial thigh and large pelvic tumours may compress this nerve with resultant pain radiating distally. The obturator nerve arises from L2, L3 and L4 by branches from the ventral divisions of each of these nerve roots. L3 forms the main contribution and the second lumbar branch is occasionally absent. These branches unite in the substance of psoas major, descending vertically in its posterior part to emerge from its medial border at the lateral margin of the sacrum. It then crosses the sacroiliac joint to enter the lesser pelvis, it descends on obturator internus to enter the obturator groove. In the lesser pelvis the nerve lies lateral to the internal iliac vessels and ureter, and is joined by the obturator vessels lateral to the ovary or ductus deferens. Supplies Medial compartment of thigh Muscles supplied: external obturator, adductor longus, adductor brevis, adductor magnus (not the lower part-sciatic nerve), gracilis The cutaneous branch is often absent. When present, it passes between gracilis and adductor longus near the middle part of the thigh, and supplies the skin and fascia of the distal two thirds of the medial aspect. Obturator canal Connects the pelvis and thigh: contains the obturator artery, vein, nerve which divides into anterior and posterior branches.

Answer 109

Partial denervation of flexor digitorum profundus Injury to the ulnar nerve in the mid to distal forearm will typically produce a claw hand. This consists of flexion of the 4th and 5th interphalangeal joints and extension of the metacarpophalangeal joints. The effects are potentiated when flexor digitorum profundus is not affected, and the clawing is more pronounced.More proximally sited ulnar nerve lesions produce a milder clinical picture owing to the simultaneous paralysis of flexor digitorum profundus (ulnar half). This is the 'ulnar paradox', due to the more proximal level of transection the hand will typically not have a claw like appearance that may be seen following a more distal injury. The first dorsal interosseous muscle will be affected as it is supplied by the ulnar nerve. Ulnar nerve Origin C8, T1 ``` Supplies (no muscles in the upper arm) Flexor carpi ulnaris Flexor digitorum profundus Flexor digiti minimi Abductor digiti minimi Opponens digiti minimi Adductor pollicis Interossei muscle Third and fourth lumbricals Palmaris brevis ``` Path Posteromedial aspect of upper arm to flexor compartment of forearm, then along the ulnar. Passes beneath the flexor carpi ulnaris muscle, then superficially through the flexor retinaculum into the palm of the hand Branch Supplies Muscular branch Flexor carpi ulnaris Medial half of the flexor digitorum profundus Palmar cutaneous branch (Arises near the middle of the forearm) Skin on the medial part of the palm Dorsal cutaneous branch Dorsal surface of the medial part of the hand Superficial branch Cutaneous fibres to the anterior surfaces of the medial one and one-half digits Deep branch Hypothenar muscles All the interosseous muscles Third and fourth lumbricals Adductor pollicis Medial head of the flexor pollicis brevis Effects of injury Damage at the wrist Wasting and paralysis of intrinsic hand muscles (claw hand) Wasting and paralysis of hypothenar muscles Loss of sensation medial 1 and half fingers Damage at the elbow Radial deviation of the wrist Clawing less in 4th and 5th digits.

Answer 110

Complete loss of wrist flexion Loss of the median nerve will result in loss of function of the flexor muscles. However, flexor carpi ulnaris will still function and produce ulnar deviation and some residual wrist flexion. High median nerve lesions result in complete loss of flexion at the thumb joint. Median nerve The median nerve is formed by the union of a lateral and medial root respectively from the lateral (C5,6,7) and medial (C8 and T1) cords of the brachial plexus; the medial root passes anterior to the third part of the axillary artery. The nerve descends lateral to the brachial artery, crosses to its medial side (usually passing anterior to the artery). It passes deep to the bicipital aponeurosis and the median cubital vein at the elbow. It passes between the two heads of the pronator teres muscle, and runs on the deep surface of flexor digitorum superficialis (within its fascial sheath). Near the wrist it becomes superficial between the tendons of flexor digitorum superficialis and flexor carpi radialis, deep to palmaris longus tendon. It passes deep to the flexor retinaculum to enter the palm, but lies anterior to the long flexor tendons within the carpal tunnel. ``` Branches Region Branch Upper arm No branches, although the nerve commonly communicates with the musculocutaneous nerve Forearm Pronator teres Flexor carpi radialis Palmaris longus Flexor digitorum superficialis Flexor pollicis longus Flexor digitorum profundus (only the radial half) Distal forearm Palmar cutaneous branch Hand (Motor) Motor supply (LOAF) Lateral 2 lumbricals Opponens pollicis Abductor pollicis brevis Flexor pollicis brevis Hand (Sensory) Over thumb and lateral 2 ½ fingers On the palmar aspect this projects proximally, on the dorsal aspect only the distal regions are innervated with the radial nerve providing the more proximal cutaneous innervation. ``` Patterns of damage Damage at wrist e.g. carpal tunnel syndrome paralysis and wasting of thenar eminence muscles and opponens pollicis (ape hand deformity) sensory loss to palmar aspect of lateral (radial) 2 ½ fingers Damage at elbow, as above plus: unable to pronate forearm weak wrist flexion ulnar deviation of wrist Anterior interosseous nerve (branch of median nerve) leaves just below the elbow results in loss of pronation of forearm and weakness of long flexors of thumb and index finger

Answer 111

Hypoglossal nerve Nerves at risk during a carotid endarterectomy: Hypoglossal nerve Greater auricular nerve Superior laryngeal nerve During a carotid endarterectomy the sternocleidomastoid muscle is dissected, with ligation of the common facial vein and then the internal jugular is dissected exposing the common and the internal carotid arteries. The nerves at risk during the operation include: Hypoglossal nerve Greater auricular nerve Superior laryngeal nerve The sympathetic chain lies posteriorly and is less prone to injury in this procedure. Internal carotid artery The internal carotid artery is formed from the common carotid opposite the upper border of the thyroid cartilage. It extends superiorly to enter the skull via the carotid canal. From the carotid canal it then passes through the cavernous sinus, above which it divides into the anterior and middle cerebral arteries. ``` Relations in the neck Posterior Longus capitis Pre-vertebral fascia Sympathetic chain Superior laryngeal nerve Medially External carotid (near origin) Wall of pharynx Ascending pharyngeal artery Laterally Internal jugular vein (moves posteriorly at entrance to skull) Vagus nerve (most posterolaterally) Anteriorly Sternocleidomastoid Lingual and facial veins Hypoglossal nerve ``` ``` Relations in the carotid canal Internal carotid plexus Cochlea and middle ear cavity Trigeminal ganglion (superiorly) Leaves canal lies above the foramen lacerum ``` Path and relations in the cranial cavity The artery bends sharply forwards in the cavernous sinus, the aducens nerve lies close to its inferolateral aspect. The oculomotor, trochlear, opthalmic and, usually, the maxillary nerves lie in the lateral wall of the sinus. Near the superior orbital fissure it turns posteriorly and passes postero-medially to pierce the roof of the cavernous sinus inferior to the optic nerve. It then passes between the optic and oculomotor nerves to terminate below the anterior perforated substance by dividing into the anterior and middle cerebral arteries. ``` Branches Anterior and middle cerebral artery Ophthalmic artery Posterior communicating artery Anterior choroid artery Meningeal arteries Hypophyseal arteries ```

Answer 112

The head of the radius articulates with the capitulum of the humerus. The radius is one of the two long forearm bones that extends from the lateral side of the elbow to the thumb side of the wrist. It has two expanded ends, of which the distal end is the larger. Key points relating to its topography and relations are outlined below; Upper end Articular cartilage- covers medial > lateral side Articulates with radial notch of the ulna by the annular ligament Muscle attachment- biceps brachii at the tuberosity ``` Shaft Muscle attachment Upper third of the body Supinator Flexor digitorum superficialis Flexor pollicis longus Middle third of the body Pronator teres Lower quarter of the body Pronator quadratus Tendon of supinator longus ``` ``` Lower end Quadrilateral Anterior surface- capsule of wrist joint Medial surface- head of ulna Lateral surface- ends in the styloid process Posterior surface: 3 grooves containing: 1. Tendons of extensor carpi radialis longus and brevis 2. Tendon of extensor pollicis longus 3. Tendon of extensor indicis ```

Answer 113

Sibson's fascia overlies the apices of both lungs The suprapleural fascia (Sibson's fascia) runs from C7 to the first rib and overlies the apex of both lungs.It lies between the parietal pleura and the thoracic cage. The suprapleural fascia (Sibson's fascia) runs from C7 to the first rib and overlies the apex of both lungs.It lies between the parietal pleura and the thoracic cage. The right lung is composed of 3 lobes divided by the oblique and transverse fissures. The left lung has two lobes divided by the oblique fissure.The apex of both lungs is approximately 4cm superior to the sterno-costal joint of the first rib. Immediately below this is a sulcus created by the subclavian artery. Peripheral contact points of the lung Base: diaphragm Costal surface: corresponds to the cavity of the chest Mediastinal surface: Contacts the mediastinal pleura. Has the cardiac impression. Above and behind this concavity is a triangular depression named the hilum, where the structures which form the root of the lung enter and leave the viscus. These structures are invested by pleura, which, below the hilum and behind the pericardial impression, forms the pulmonary ligament Right lung Above the hilum is the azygos vein; Superior to this is the groove for the superior vena cava and right innominate vein; behind this, and nearer the apex, is a furrow for the innominate artery. Behind the hilum and the attachment of the pulmonary ligament is a vertical groove for the oesophagus; In front and to the right of the lower part of the oesophageal groove is a deep concavity for the extrapericardiac portion of the inferior vena cava. The root of the right lung lies behind the superior vena cava and the right atrium, and below the azygos vein. The right main bronchus is shorter, wider and more vertical than the left main bronchus and therefore the route taken by most foreign bodies. Left lung Above the hilum is the furrow produced by the aortic arch, and then superiorly the groove accommodating the left subclavian artery; Behind the hilum and pulmonary ligament is a vertical groove produced by the descending aorta, and in front of this, near the base of the lung, is the lower part of the oesophagus. The root of the left lung passes under the aortic arch and in front of the descending aorta. ``` Inferior borders of both lungs 6th rib in mid clavicular line 8th rib in mid axillary line 10th rib posteriorly The pleura runs two ribs lower than the corresponding lung level. ```

Answer 114

Psoas major inserts onto the lesser trochanter. Femur Extends from a rounded head, which articulates with the acetabulum down to the knee joint where the two large condyles at it's inferior aspect articulate with the tibia. The superior aspect comprises a head and neck which pass inferolaterally to the body and the two trochanters. These lie at the junction between the neck and the body. The neck meets the body of the femur at an angle of 125o. Developmentally, the neck is part of the body but is demarcated from it by a wide rough intertrochanteric crest, this continues inferomedially as a spiral line that runs below the lesser trochanter. Medially, the intertrochanteric line gives attachment to the inferior end of the iliofemoral ligament. The neck is covered by synovial membrane up to the intertrochanteric line. The posterior aspect of the neck is demarcated from the shaft by the intertrochanteric crest and only it's medial aspect is covered by synovium and the joint capsule. The greater trochanter has discernible surfaces that form the site of attachment of the gluteal muscles.Laterally, the greater trochanter overhangs the body and this forms part of the origin of vastus lateralis Viewed anteriorly, the body of the femur appears rounded. Viewed laterally, it has an anterior concavity which gives fullness to the anterior thigh. Posteriorly, there is a ridge of bone, the linea aspera. The surface of the anterior aspect of the body forms the origin of the vastus intermedius. More medially, it forms the origin of vastus medialis. The upper and middle aspects of the linea aspera form part of the origin of the attachments of the thigh adductors. Inferiorly, it spans out to form the bony floor of the popliteal fossa. At the inferior aspect of the popliteal surface the surface curves posteriorly to form the femoral condyles. The structures that are attached to the inferior aspect of the linea aspera split with it as it approaches the popliteal fossa. Thus the vastus medialis and adductor magnus continue with the medial split and the biceps femoris and vastus intermedius along the lateral split. Blood supply The femur has a rich blood supply and numerous vascular foramina exist throughout it's length. The blood supply to the femoral head is clinically important and is provided by the medial circumflex femoral and lateral circumflex femoral arteries (Branches of profunda femoris). Also from the inferior gluteal artery. These form an anastomosis and travel to up the femoral neck to supply the head.

Answer 115

The terminal part of the thoracic duct crosses anterior to it to insert into the right subclavian vein - FALSE Internal jugular vein Each jugular vein begins in the jugular foramen, where they are the continuation of the sigmoid sinus. They terminate at the medial end of the clavicle where they unite with the subclavian vein. The vein lies within the carotid sheath throughout its course. Below the skull the internal carotid artery and last four cranial nerves are anteromedial to the vein. Thereafter it is in contact medially with the internal (then common) carotid artery. The vagus lies posteromedially. At its superior aspect, the vein is overlapped by sternocleidomastoid and covered by it at the inferior aspect of the vein. Below the transverse process of the atlas it is crossed on its lateral side by the accessory nerve. At its mid point it is crossed by the inferior root of the ansa cervicalis. Posterior to the vein are the transverse processes of the cervical vertebrae, the phenic nerve as it descends on the scalenus anterior, and the first part of the subclavian artery. On the left side its also related to the thoracic duct.

Answer 116

In the middle of the forearm, the artery is overlapped by the flexor carpi ulnaris and on the flexor retinaculum it is covered by a superficial layer from that structure. In its distal two-thirds, flexor digitorum superficialis lies on its radial side, and the ulnar nerve is situated on its ulnar side. Ulnar artery Path Starts: middle of antecubital fossa Passes obliquely downward, reaching the ulnar side of the forearm at a point about midway between the elbow and the wrist. It follows the ulnar border to the wrist, crossing over the flexor retinaculum. It then divides into the superficial and deep volar arches. Relations Deep to- Pronator teres, Flexor carpi radialis, Palmaris longus Lies on- Brachialis and Flexor digitorum profundus Superficial to the flexor retinaculum at the wrist The median nerve is in relation with the medial side of the artery for about 2.5 cm. And then crosses the vessel, being separated from it by the ulnar head of the Pronator teres The ulnar nerve lies medially to the lower two-thirds of the artery Branch Anterior interosseous artery

Answer 117

The radial nerve lies in this groove and may be compromised by fractures involving the shaft. Humerus The humerus extends from the scapula to the elbow joint. It has a body and two ends. It is almost completely covered with muscle but can usually be palpated throughout its length. The smooth rounded surface of the head articulates with the shallow glenoid cavity. The head is connected to the body of the humerus by the anatomical neck. The surgical neck is the region below the head and tubercles and where they join the shaft and is the commonest site of fracture. The capsule of the shoulder joint is attached to the anatomical neck superiorly but extends down to 1.5cm on the surgical neck. The greater tubercle is the prominence on the lateral side of the upper end of the bone. It merges with the body below and can be felt through the deltoid inferior to the acromion. The tendons of the supraspinatus and infraspinatus are inserted into impressions on its superior aspect. The lesser tubercle is a distinct prominence on the front of the upper end of the bone. It can be palpated through the deltoid just lateral to the tip of the coracoid process. The intertubercular groove passes on the body between the greater and lesser tubercles, continuing down from the anterior borders of the tubercles to form the edges of the groove. The tendon of biceps within its synovial sheath passes through this groove, held within it by a transverse ligament. The posterior surface of the body is marked by a spiral groove for the radial nerve which runs obliquely across the upper half of the body to reach the lateral border below the deltoid tuberosity. Within this groove lie the radial nerve and brachial vessels and both may be affected by fractures involving the shaft of the humerus. The lower end of the humerus is wide and flattened anteroposteriorly, and inclined anteriorly. The middle third of the distal edge forms the trochlea. Superior to this are indentations for the coronoid fossa anteriorly and olecranon fossa posteriorly. Lateral to the trochlea is a rounded capitulum which articulates with the radius. The medial epicondyle is very prominent with a smooth posterior surface which contains a sulcus for the ulnar nerve and collateral vessels. It's distal margin gives attachment for the ulnar collateral ligament and, in front of this, the anterior surface has an impression for the common flexor tendon.