T&O

Question 1

Septic Arthiritis

Answer 1

Risk factors: Age >60
Pre existing joint disease - OA, Gout, Pseudogout, RA
Prosthetic joint
DM
IVDU, Immunosupression

Causes: Trauma, Haemotogenous spread, Introduction of infection from joint aspiration/corticosteroid
Iatrogenic

Common pathogenic organisms: S Aureus, Strep Penumoniae, Neisseria Gonorrhoea

Clinical features: Warm/Hot to touch, swollen, tender, painful on movement, restricted range of movement/inability to weight bear

Ddx: Gout/Pseudogout, RA, OA, Intraarticular fracture, Bursitis,

Ix: Joint aspiration - synovial fluid (test for gram stain, crystals, WCC)

Bloods: FBC, UE, CRP, Blood culture

X ray of joint

Septic screen if patient unwell

Question 2

Ankle fractures

Answer 2

Presentation: fall, twisting injury to ankle, painful and unable to weight bear
Urgent reduction if fracture dislocation of ankle obvious

Important points from hx: Fitness for op, Hx of diabetes, pre-injury mobility, smoking status

Examination: Neurovascular status of the limb, Soft tissue injury
Deep peroneal nerve: 1st dorsal webspace
Superficial peroneal nerve: Dorsum of the foot
Sural nerve: Lateral border of the foot
Saphenous nerve: Medial aspect of the foot

Invesigation: Bloods, ECG,
X ray: AP, Lat, Mortise view, Need radiographs pre and post reduction (after application of back slab)
CT scan

Classification: Webber A- Below level of syndesmosis
B- Level of syndesmosis
C- Above level of syndesmosis

Mx: Analgesia, Reduction of fracture in A&E, aim is to reduce deformity at the ankle, post reduction need repeat xray

Weber A- Non operative tx. Place the foot in a black boot and bring them back to fracture clinic

Weber B- Undisplaced: Place in backslab - new x rays to check position/remains undisplaced - keep NBM (non weight bearing) and book into fracture clinic

Displaced: Need reduction and application of back slab in ED and surgical stabilisation - admit and optimise for theatre + consent

Weber C- Ankle fractures - unstable and require surgical fixation.
Place in a back slab, Check x ray after application of plaster
Admit and optimise for theatre and consent

Consent: Ankle Open reduction internal fixation (ORIF)

Intended benefits of operation- reduce and stabilize fracture, aid n healing, improve function

Risks: Bleeding, infection, anaesthetic risks, DVT and PE, nerve/blood vessel/tendon injury, stiffness, metalwork issues, wound breakdown, non union, loss of reduction, on going pain, need for further surgery

Question 3

Cauda equina

Answer 3

Incomplete: altered urinary sensation, decreased desire to void
Complete: urinary retention

Risk factors: Hx of spinal stenosis, prev spinal surgery, degenerative joint disease, trauma injury, infection, tumour,

Common causes:
Lumbar intervertebral disc herniation/prolapse: Prev disc herniation/prev spinal surgery
Epidural haematoma: following recent spinal surgery, epidural trauma
Infection: IVDU, recent surgery
Trauma: spinal fracture/dislocation
Tumour: metastatic

Clincal features: SPINEE
Saddle anaesthesia - altered sensation over buttocks, perineum (S3-S5)
Pain - Lower/lumbar back pain
Incontinence/retention- Bowel/ bladder dysfunction
Neurological dysfunction - Bilateral sciatica/ altered power and sensation in the lower limbs
Erectile dysfunction

Examination: Document findings on ASIA chart
L2 - S1. Score sensory and motor function

Sensory - 0 = no sensation
1 = altered sensation
2 = normal sensation

Motor. 0 no power
1- flicker of muscle movement
2- gravity taken out/some movement
3- movement against gravity
4- some resistance
5- full power

Reflexes: Knee (L3/4), Ankle (S1/2), Plantars

Clonus - rapid dorsiflexion of the ankle. Looking for more than 5 beats (<5 normal)

DRE: Test perianal sensation and anal tone

Investigations: Ask nurses to conduct a pre void and post void bladder scan. A significant amount of urine present in bladder after voiding warrants hx/exam to rule out CES

MRI lumbar spine

If saddle anaesthesia/ urinary or bowel dysfunction present urgent senior discussion

Mx: Optimise for theatre
Analgesia
Bloods- FBC, UE , CRP , G&S
IVI, Catheter
NBM
Uregent discsussion with spinal surgeon on call
Consent
If CE confirmed - post lumbar decompression. Discectomy, laminectomy +/- intrumenation
Drainage/decompression of haematoma/collection

Question 4

Shoulder relocation

Answer 4

Consent:
Benefits- Relief of symptoms, improve function
Risks- pain, fracture, nerve injury, failure, requiring GA for further reduction, open reduction

Traction - counter traction
Hippocratic method
1) assistant places sheet in the axilla for counter traction
2) surgeon - hold distal forearm/wrist and gradually apply traction to the arm, holding it for around 2-5 mins, then begin gentle external rotation (internal for posterior) of the shoulder
3) Should feel clunk/joint reduce

Following attempt: Is the shoulder reduced ?. Pain relief. Are range of movements easier and pain free for the patient
Check NV status and document.
Check Xray
Follow up- Polysling, fracture clinic follow up

If unsuccessful in closed reduction - Was analgesia and sedation adequate. Does the patient need to go to theatre

Question 5

Ankle fracture reduction

Answer 5

Requirements: A&E doctor/Anaesthetist to administer sedation, assistant to apply plaster, assistant to keep knee flexed whilst performing reduction
Review X rays pre reduction to plan reduction
Keep patient supine. Have assistant hold the knee flexed to relax the gastrocnemius

Reduction - Aim is to reduce the deformity at the ankle
Normally the foot is displaced laterally within the mortise and externally rotated. To reduce:
1) Hold heel with one hand/outside hand
2) place other hand over medial distal tibia
3) Push heel/foot medially whilst internally rotating and dorsi-flexing and push distal tibia laterally
4) Reduce the fracture - often will feel a clunk when bone reduces.

Apply the plaster whilst holding the big toe. Once backslab applied repeat the reduction manoeuver and hold until plaster hardens moulding around the ankle joint.
Post reduction need repeat radiographs to confirm reduction

Question 6

Wrist fracture reduction

Answer 6

This can be done with a combination of a haematoma block and entonox
Preparation is important
Ideally requires 3 people
One to provide traction, one assistant will provide counter traction and third to apply back slab

Haematoma block: Insert needle into dorsal aspect of wrist aiming to be in the fracture site (where haematoma is)
Aspirate- ensure you get blood in the syringe. This confirms your in the haematoma. Infiltrate LA
Ask pt to utilise the entonox

Traction- Hold the first three digits and provide longituidinal traction (with elbow in flexion)
Counter traction - ask assistant to hold arm above the elbow and pull opposite direction.
Maintain traction for around 1-2 mins
Exagerate fracture then longitudinal traction to re align fracture
If fracture is dosally angulated then place wrist in volar angulation with backslab on the dorsum of the hand
If fracture in volar angulation then place wrist in dorsal angulation with backslab over the volar aspect of the hand

Check X ray in backslab - AP and lateral views
If position satisfactory then patient can return to fracture clinic

Question 7

Joint aspiration

Answer 7

Native joint- Ensure no overlying cellulitis. If so then consider alternative diagnosis/treat with IV Abx. For superficial infection and review within 24hrs. Cellulitis/Bursitis

Knee aspiration- Patient sat at 45deg upright in bed, with knee in extension.
Obtain procedural pack. Spray affected joint above and below. Use green needle attached to syringe. Lateral approach. Identify most fluctuant area. Identify supra-patellar pouch
Use straight/horizontal needle
Aspirate the joint
Place aspirate into sterile bottle. Place aspirate into blood cultures bottle
Cover wound with dressing

Elbow joint aspiration
Locate three anatomical points. Radial head, olecranon, lateral epicondyle
Same as above. Aseptic technique. Aim for middle of the anatomical triangle

Investigations
Contact micro and inform you are sending for - Gram staining, crystals, WCC, MC&S

Consent for prosthetic knee joint in theatre
Benefits- Aid in diagnosis and further mx
Risks- pain, bleeding, infection, damage to nerves and blood vessels, DVT/PE, failure to make diagnosis, further procedures

Question 8

Paediatric distal radius fractures

Answer 8

Buckle (Torus fracture) - Incomplete fracture of bone
1 side is crumpled whilst the opposite side is intact. Typically see a bulging of the cortex
These fractures are undisplaced/minimally displaced and treated non operatively

Greenstick fracture
Incomplete fracture of the bone. 1 side has failed under tension whilst opposite cortex is simply bent, overall the bone appears bent
Mx is determined by degree of angulation, age of child and how close the fracture is to the joint

Fractures through growth plates
Salter harris system
1- physial separation
2- fracture passes through physis and exits the metaphysis of the bone
3- fracture through physis and exits into epiphysis of bone
4- passes through metaphysis, physis and epiphysis of he bone
5- Physis is crushed

Mx: Closed reduction and application of cast. Can be done in A&E or under GA
Potentially unstable fractures requiring MUA and K wire stabilisation or open reduction and internal fixation with plates include both off ended fractures and volarly displaced fractures

Paediatric forearm fractures
Common mechanism FOOSH. Present with trauma hx. Painful arm with clinical deformity

Galeazzi fracture- Fracture of distal radius with associated dislocation of distal radio ulnar joint
Tx- normally with MUA and above elbow cast, with screening of the DRUJ after reduction. Occasionally open reduction and internal fixation is required

Monteggia fracture
Fracture of the ulnar with associated dislocation of the radial head.
Tx normally with MUA and plaster with anatomical reduction of the ulnar. The radial head spontaneously reduces. Occasionally open reduction and internal fixation is required.

Operative treatment
1- MUA and application of plaster
2- Flexible elastic nailing of forearm fractures +/-open reduction
3- ORIF

Consent
Benefits- relief of symptoms, aid in healing, reduce deformity
Risks- Anaesthetic risks, mal/non union, limb deformity, growth plate arrest (if physis involved), re displacement of fracture, need for open surgery, nerve/blood vessel/tendon injury, loss of movement, need for further surgery

Question 9

Pre op tips

Answer 9

1) Fascia iliaca nerve block in A&E (24hr delay in patients on Warfarin/NOACs)
2) Paracetamol and Oramorph (5mg BD)
3) Do NOT stop rate control meds (e.g Beta blockers, digoxin, diltiazem)
4) No NSAIDs (inc risk of bleeding and affects bone healing
5) Withold ACEi and diuretics
6) 10 hrly maintenance fluids
7) Check bloods and correct abnormalities. Repeat bloods to ensure adequate correction
8) Resuscitation fluids (500ml over 20min, repeat till 1.5 L given )
9) Catheterise in patients with AKI, AKI on CKD and fluid balance chart
10) Dalteparin 5000 units SC. Cant be given within 6hrs of surgery

Question 10

Pre op tips

Answer 10

Warfarin- Stop warfarin and administer 5mg IV Vit K if INR >1.5 or INR not known

Recheck INR at 6hrs. if INR <1.5 proceed to surgery. Pt can have spinal

If INR > 1.5. Repeat 5mg IV Vit K and re check in 6-12hrs. If INR >1.5 after second vit K hen repeat/discuss with haem/ortho geri

Antiplatelet
SIngle - Clopidogrel/Aspirin then continue and no reason to delay surgery or avoid spinal

Dual. Stop Clopidorel and aspirin. Surgery 24hrs after last dose. GA not spinal. If spinal required then discuss with Haem/Ortho geri

DOAC
xaban - Stop. Confirm time of last dose. Surgery 24hrs after last dose. Patient can have spinal if required
If creatnine clearance <30ml/min. Surgery 48hrs after last dose. GA not spinal. If spinal required then discuss with Haem/Ortho geri

Thrombin inhibitors (Dabigatran) Stop and give pracbind. Patient can have spinal if required

Consider bridging if required
Within 3months - Embolic stroke, systemic embolism, coronary stent, VTE
Mech mitral valve, mech aortic valve and high stroke risk , AF and high risk of stroke, Previous VTE during interruption of anticoagulation

Question 11

Post op tips

Answer 11

Day 1 post op review

Wound (dry/ooze/blood) look at dressing
NEWS and Bloods
E&D
PU and BO
AMTS and orientated
Mobility status documented
VTE prophylaxis prescribed
Pain managed
Check Xray for hemi and THR arranged ?
NOK up date

If patient on DOAC/Warfarin then generally hold for 24-48hrs post op then if happy wound isn’t bleeding then restart.
Clinical criteria for stepping down femoral fracture patients over the weekend from post OP day 2
1) News scoring 2 or less
2) Post op Hb 90 or above
3) Surgical wound healthy. Post op Xray done and T&O follow up if required
4) No acute signs of delirium
5) Post op bloods are actioned (i.e treat for sepsis/AKI)
6) Physio have assessed the patient and happy to stepdown
7) Resuscitation decision made and treatment escalaion plan completed with family informed.

Question 12

On call

Answer 12

Tips from induction booklet and videos

Question 13

Distal radius fractures

Answer 13

Distal radius fractures
Hx: Mechanism of injury- Typically FOOSH
Any other injuries- Head, Elbow, Shoulder, Hip ?
Paraesthesia ?/ Numbness (if so where)
Colour of hand.
Occupation
Obtain a full medical hx, PMHx, Drug Hx

Examination- Angulation of deformity. Dorsal – is there a dinner fork deformity (Colles fracture)
Volar Angulation- Smiths fracture
Sensation – Is it intact over the hand ?
Median- lateral 3.5 digits - Touch the index finger and lateral edge of ring finger
Radial nerve – Touch the dorsal aspect of the 1 st web space (dorsal web-space of the thumb)
Ulnae nerve – Touch the little finger
Motor function – Medial is palmer abduction of the thumb, Anterior interosseous nerve – OK sign.
Posterior interosseous nerve Thumbs up.
Ulnar nerve – Ask them to spread their fingers against resistance and cross fingers

Investigations
X ray wrist – AP and Lateral views, Check angulation of fracture, Intra articular extension of fracture
– Does the fracture extend into the joint ?
Bloods – If fracture requires MUA +/- ORIF (FBS, U&Es)

Management
Review of X ray. Manipulation under sedation
If the fracture is displaced will need to be reduced. Usually under haematoma block.
If intraarticular fracture then operative mx. If reduction is inadequate then surgery considered.
If concerned about NV status then admit to ward and elevate in a bradford sling and reassess pt overnight

Consent
Bedside procedure. You should also explain this may only be temporary measure. Patient may
require further manipulation. Possible need for surgery – ORIF of distal radius fracture.

Question 14

Paediatric supracondylar fracture

Answer 14

Presentation- Painful swollen elbow – unwilling to move arm
FOOSH
Eamination- ATLS protocol – Any other injury
Soft tissue status of the arm- swelling, bruising, puckering of skin around elbow
Clearly document NV status
Sensation – Is it intact over the hand ?
Median- lateral 3.5 digits - Touch the index finger and lateral edge of ring finger
Radial nerve – Touch the dorsal aspect of the 1 st web space (dorsal web-space of the thumb)
Ulnae nerve – Touch the little finger
Motor function – Medial is palmer abduction of the thumb, Anterior interosseous nerve – OK sign.
Posterior interosseous nerve Thumbs up.
Ulnar nerve – Ask them to spread their fingers against resistance and cross fingers
Vascular status (Radial pulse, CRT)
If hand is white and no pulse present this needs CEPOD and vascular team ASAP
Pink pulseless hand suggests adequate collateral supply and should be discussed with senior

Investigation – radiographs (AP and Lat view)
If undisplaced fracture then post fat pad sign may be only clue

Classification- Gartland 1- undisplaced with intact anterior humeral line
2 – Displaced by >2mm. Hinged on intact post cortex
3- Displaced injury. Both ant and post cortices have fractured
4- Type 3 with rotational displacement

Management
Immediate – Paracetamol, Ibuprofen, Oramorph, Above elbow backslab. If vascular/ neuro injury
present or type 3 or 4 displacement then keep NBM and discuss with senior
Undisplaced type 1 fractures can be treated non operatively with cast immobilisation (elbow at
90deg and forearm in neutral) and follow up in fracture clinic
Displaced fractures require opeative stabilisation with K wires following reduction and are then
immobilised in cast

Consent - Manipulation under anaesthetic and K wire stabilisation +/- open reduction
Benefits; Reduction and stabilisation of fracture
Risks: Anaesthetic risks, infection especially of pin sites, nerve or blood vessel injury, loss of
reduction requiring further surgery, removal of wires, stiffness with reduced range of movement of
elbow

Question 15

Shoulder dislocation

Answer 15

Presentation- Trauma – FOOSH, blunt force/injury to shoulder, seizure
95% + are ant dislocation
Examination – Pain, Squaring of shoulder, Empty glenoid, Shoulder position – Ant (external rotation)
Post ( adduction internal rotation)
Neurology – Document regimental badge sensation (axillary nerve), radial, median and ulnar nerve
motor and sensory function pre and post reduction

Investigations
X ray AP and Y Views: Ensure to get 2 views

Classification
Ant – Subcarocoid, subglenoid, subclavicular head medial to coracoid, inferior,
Post – if any doubt then discuss for CT
Hill sachs (impaction fracture humeral head against glenoid), Bony bankart lesion (ant inf glenoid
fracture)
Fracture greater tuberosity/ neck

Management
Analgesia
Have A&E tried then consider discussing with trauma theatre to consider doing this under GA
If there is a tuberosity/neck fracture – discuss with senior for reduction in theatre.

Question 16

Neck of femur fractures

Answer 16

History of fall and inability to weight bear
Complain of painful hip/groin/thigh on affected side.

Need to elicit – Cause of fall (was it a simple fall/ medical reason)
Any medical co-morbidities
Any other injuries e.g fractured wrist/humerus/ribs
Function pre-fall: Any limitations to walking/any walking aids/ any preceeding hip pain (will influence
type of operation)
Perform a AMTS
Clinical examination: Reveal painful movements of hip, inability to straight leg raise
If medical cause then refer to medics to investigate
When there is a painful hip but no obvious fracture on x ray. Conduct a focussed examination:
Can they straight leg raise
Is there pain on pin rolling
Is there pain on pill rolling
Is there pain on axial loading (when pushing against the hip using the knee or foot)
Pain on internal and external rotation of the hip

Investigations
Bloods – FBC (transfuse pre op if Hb <100), U&E, LFT< Bone profile, CK, 2x G&S,
ECG
Radiology – AP pelvis and lat of affected hip
CXR
Full length femur (AP and Lat) if planning an intramedullary nail / hx of cancer to suggested
metastatic lesion.

Classification
Intracapsular NOF fracture
Extra capsular/Per-trochanteric femoral fracture: need to define number of parts and obliquity of
fracture
Sub trochanteric femoral fracture
Immediate management
Analgesia, IV fluids, Consider a fascia iliac block. Treat medical problems and optimise for surgery
Intracapsular – Completely undisplaced- closed reduction with cannulated hip screws/ DHS fixation

Displaced – Hip hemiarthroplasty or if high functioning and low ASA score THR NB also consider THR
in RA
Extracapsular NOF
DHS for majority unless reverse obliquity, highly Comminuted or pathological fracture. For these
patients safest to consent for DHS/IM nail
Subtrochanteric femoral fracture
IM femoral nail
Consent
Benefits – relief of symptoms: aid in healing (not for hemiartroplasty), improve function
Risks/caution: Bleeding, infection, anaesthetic complications, DVT, PE, MI, CVA, need for catheter,
loss of function/mobility, NV injury leading to numbness +/- paralysis of part or whole of limb

Specific risks - DHS (cut out of screw, AVN, need for revision surgery)
Cannulated screw fixation (Failure of metalwork, AVN, need for revision surgery)
IM femoral nail fixation – failure of metal work, periprosthetic fracture, perf of bone, AVN fem head,
further surgery
Hip hemiarthoplasty or THR – dislocation, leg length discrepancy, periprosthetic fracture, metalwork
failure, metalwork infection, need for revision surgery

Question 17

Acute compartment syndrome

Answer 17

Clinical features- Pain out of proportion to injury. Passive movements will cause pain.
Ongoing/increasing use of analgesia with no relief
Tense painful swelling, paraethesia (late finding), absent peripheral pulses (late), Paralysis (late)

DDx: Compartment syndrome, DVT, Nec fasciitis

Investigations/initial management
Remove/release circumferential dressings/Bi-valving of cast
Cut bandages/cast and elevate limg to heart level
Ensure analgesia
Re-evaluate symptoms in 30mins if still no improvement inform senior for facsciotomy
Mx: Leg – 2 longitudinal incisions, 4 compartment decompression
Forearm - 2 longitudinal incisions

Optimise patient for theatre
Bloods- FBC, UEs, CRP, COAG, G&S, CK, X ray, senior review, anaesthetic review
Consent – Benefits/reason- relief of symptoms, salvage limb aid in healing, improve function
Side effects/risks of op –pain, bleeding, infection, blood vessel damage, nerve damage, loss of limb
function, no improvement, loss of limb/amputation, further procedures, DVT/PE, anaesthetic risks

Question 18

Clavicle fractures

Answer 18

Clavicle fracture
Common after a fall onto the shoulder. Fractures over middle third more common (80%), lateral third (15%), Medial third (5%). Lateral third have high risk of non union and medial third have high risk of brachial plexus/ lung injury

Ix: X ray AP view and 30deg cephalad

Tx: Most cases conservatively managed with collar and cuff for 4-6 weeks and mobilisation as tolerated. Indications for surgery include open fractures, tenting/comprimise of skin/ NV injury. Lateral third fractures can be managed surgically due to high risk of non union expecially if they extend into acromioclavicular joint.
Fractures that are highly comminuted have higher risk of non union

Question 19

Acute rotator cuff tear

Answer 19

Acute rotator cuff tear
Acute tear presents with new onset weakness and pain. Chronic tear in elderly due to gradual degeneration of the tendons and may be associated with arthiritis
Examine all movements of the cuff looking for focal weakeness. Comparing the opposite side. MRI/ USS confirms diagnosis. Tx is repair of the tendons can be arthroscopically

Question 20

Proximal humerus fractures

Answer 20

Proximal humerus fractures
Falling onto an outstretched hand may result in fracture of proximal humerus, especially in elderly with osteoporosis.
Three types of fracture
1) Avulsion of greater tuberosity caused by pulling of supraspinatus
2) Fracture of surgical neck
3) Comminuted fractures in which head and tubersities are separated

Tx:
Isolated tuberostiry fractuers can be managed conservatively in broad arm sling if undisplaced. If displaced then fixed

Minimally displaced surgical neck fractures treated conservatively in a collar and cuff

Comminuted fractures involving the head of the humerus. If head is split or fragments widely displaced high risk of non union/ AVN or late arthiritis. Fracture is then either fixed with plate/screws or whole head is replaced with hemiarthoplasty

Question 21

Humerus shaft fractures

Answer 21

Most commonly occur due to direct trauma to upper limb, characteristically resulting in transverse fracture. Torsional injuries result in spiral fracture.

AP and lateral x rays required. Describe fractures as proximal, middle or distal third. Ensure x ray include shoulder and elbow joints.

Hx: Mechanism of injury, limb dominance, occupation
Smoking?, Any numbness/altered sensation/weakness in arm

OE: Inspect for open wounds. Examination of radial nerve. A spiral fracture of distal 1/3 is commonly associated with radial nerve neuropraxia.

Mx: Early immobilsation with low collar and cuff (wrist at the level of umbilicus) along with analgesia
If wrist drop then place wrist in a splint.
If humeral brace available this should be fitted with collar and cuff
Repeat x ray after placing in collar and cuff/humeral brace

Operative fixation if:
Vascular injury, Open fracture, Ipsilateral forearm fracture, Pathological fractures/segmental fractures and fractures in presence of poly trauma
Radial nerve palsy

Question 22

Distal humerus fractures

Answer 22

Distal humerus is composed of medial and lateral condyles. Fractures of the condyles may occur after a fall on the arm. As with all joints, perfect anatomical alignment is essential for elbow to remain functional. Condylar fractures are therefore normally treated with open reduction and internal fixation using specially designed plates

Radiological imaging include AP and lateral x rays. Typically 3 patterns of injury

Supracondylar, condylar, complex intra-articular

Hx
Mechanism of injury, limb dominance, occupation, smoking, numbness, altered sensation, weakness in arm,
OE: Exclude open wounds and assess NV status

Mx
Early analgesia and cast immobilisation with above elbow backslab supported by collar and cuff. Position arm at 90deg in the cast.
If undisplaced or minimally displaced supracondylar or extra articular condylar fractures there is a role for non operative mx.
Can be brought back to fracture clinic for review in a week
Displaced fractures and or intraarticular fractures may need operative mx

Question 23

Olecranon fractures

Answer 23

Posteriorly the olecranon provides insertion for triceps tendon. Can fracture if elbow is forcibly flexed in a fall or direct blow to olecranon. Usual best method is either wire fixation (tension band wiring) or plate if the fracture is comminuted

OE: Exclude open wounds and assess NV status
Assess active extension of elbow before the plaster backslab is applied. Inability to do suggests discontinuity of the triceps extensor mechanism and that surgical fixation may be necessary

Mx: Early pain mx and a broad arm sling/poly sling given to patient
Admission/early surgery if: Open fracture, dislocated elbow, NV injury

Question 24

Elbow dislocation

Answer 24

Most common type is a posterior dislocation which occurs after a fall onto a hyper extended outstretched arm. Anterior, medial and lateral dislocations may occur as well as rotational forces through the elbow joint or varus/valgus forces exerted on the elbow.

Need AP and Lateral x ray. Terrible triad pattern. Look carefully to see if any fractures associated with dislocation. Terrible triad include post dislocation, coronoid fracture, radial head fracture. Making joint unstable so may need operative intervention

Hx: Any other injury, Any numbness, paraethesia or weakness

Mx: Analgesia and sedation should be administered and patient should be monitored in a bed before any reduction attempted.
Assess and document NV status pre and post
Place patient in an above elbow backslab with a collar and cuff to support the arm. Post reduction x ray

Simple and uncomplicated dislocations the patient should be able to go home and return to fracture clinic in a week

Question 25

Forearm fractures

Answer 25

Commonly fractured after fall/direct blow. Careful examination of NV status is essential. Median, radial and ulnar nerves can all be damaged.
Check radial and ulnar pulses and perform an Allens test.

AP and lateral X rays are essential. Ensure elbow and wrist joints are imaged.

Hx: Mechanism, limb dominance and occupation
Smoking hx, Numbness/altered sensation/weakness

OE: Wounds/NV status

Mx: Analgesia, Above elbow back slab.
Undisplaced or minimally displaced fractures (<50% displacement and < 10 deg angulation) conservative mx in a backslab for a week, followed by a full cast for a further 5 weeks.

For both bone fractures/grossly displaced/Monteggia/Open fractures/injuries with NV insult operative tx is necessary

Both bone fractures: If both radius and ulna fractured then alignment must be restored and maintained. Undisplaced can be managed in above elbow cast.
Displacement indication for surgery. Adults ORIF with plates and screws

Nightstick fracture: Isolated ulnar fractures

Galeazzi fracture- Isolated fracture of distal radius shaft with disruption or DRUJ. DRUJ assessed on lateral.
Radius must be fixed with ORIF and plate and the DRUJ stability assessed intraoperatively. Persistent instability mandates temporary K wire fixation to hold it reduced

Monteggia fracture
Isolated proximal third fracture with dislocation of the radial head is called monteggia fracture. Reduction and fixation of the ulnar fracture restores alignment of radiocapitellar joint

Question 26

Scaphoid fractures

Answer 26

Pain on radial side of wrist. Tenderness max in the anatomical snuff box.
Request scaphoid views. Displaced fractures treated with screw fixation.
Undisplaced may be treated in plaster but slow healing. If plaster to be used then below elbow cast.

Question 27

Lunate/Perilunate dislcocation

Answer 27

Usually occurs after a fall onto a dorsiflexed wrist. Disruption of the carpal ligaments results in carpus dislocating. If lunate dislocates and carpus remains in place then it’s a lunate dislocation

Question 28

Base of thumb fractures

Answer 28

Most injuries caused by axial force transmitted through the thumb normally after a fall on an outstretched arm.
Rolando fracture- 3 part of T shaped intra articular
Bennet: Intraarticular 2 part fracture
Extra articular

AP and lateral view radiographs

Hx: Limb dominance, age, occupation

OE: Thumb usually swollen and tender on palpation. If clinical deformity of thumb consider a fracture dislocation

Mx: Fracture/fracture dislocation can be reduced under LA and sedation. Longitudinal traction and pronation of the thumb with pressure applied to base commonly reduces fracture which should be placed in plaster of paris thumb spica
For fractures that fail to reduce or intra articular in nature. Need operative fixation.

Question 29

Boxer fracture

Answer 29

Little finger metacarpal neck fracture
Commonly occur after a fall onto an outstretched hand or from punching. When fractures affect the neck of the metacarpal, subtle tilting of distal fragment cause rotational deformity of the finger and occasional prominent and uncomfortable palmar lumb in hand.

AP, Lateral and oblique view radiographs to assess fracture

OE: Look for rotational deformity of little finger. Ask patient to make a fist and observe scissoring of the digit compared to contralateral little finger

Management
Closed reduction in the ED with a haematoma block. Traction of the metacarpal with the MCP flexed to 90 and direct pressure on the distal fragment may reduce fracture. Held in an ulnar gutter plaster with MCP flexed at 90 and wrist hyperextended.
Majority managed non operatively but significant angulation or rotational deformities may require operative fixation.

Question 30

Femoral shaft fractures

Answer 30

Usually high energy traumatic injuries. Low energy femoral fractures should raise suspicion of pathological fractures

Obtain AP pelvic, AP and Lat X ray whole femur. AP and Lateral of ipsilateral hip and knee. If suspicion of pathological fracture then ? CT

OE: ATLS initially. NV status of limb especially function of branches of sciatic nerve.

Mx: ATLS, Analgesia, Investigate cause of fall, monitor patient,
Treatment usually surgical although definitive fixation may be delayed if patient is unstable. External fixator applied as interim measure

Traction: Temporariliy reduce pain and bleeding. E.g Thomas splint. This provides traction to the foot with counter traction via a post in the groin (ambulance service may provide this but don’t leave on for more than a few hours)

IM nailing: Antegrade most common. Retrograde for low lying femoral shaft fractures

Plate fixation: ORIF with plate if segmental fractures

Question 31

Hip dislocation

Answer 31

High energy trauma. A dislocation following THR or Hemi is far more common than native.

AP and Lat of pelvis requested to confirm. 90% posterior and 10% ant

Look for fractures femoral neck, head and acetabulum. If any doubt then CT

Hx: Details injury, numbness of foot (sciatic nerve injury)

OE: Wounds. Vascularity (Femoral, politeal, Tib Ant and post, Dorsalis pedis)
Neurological exam.

Internally rotated and adducted then posterior
Abducted and externally rotated then anterior

Mx: ATLS, Analgesia, Relocate hip. NV assessment prior. Closed reduction under sedation in ED should be attempted followed by full GA with paralysis in theatre if initial unsuccessful. Contrainidicated in presence of femoral neck fracture
NV assessment afte reduction. Sciatic nerve can get trapped.
If reduction not achieved immediately then consider skin traction. Recheck NV status following traction/splint

Native need to be reduced asap but prosthesis can wait until morning

Question 32

Distal femoral fractures

Answer 32

Distal femur comprises 2 condyles, which articulate with the tibia. If above condyle then supracondylar. If between condyles then intercondylar. Mechanism usually axial load combined with varus/valgus stress.

Undisplaced fractures may be treated in above knee cast but these fractures usually displace due to pull of gastrocnemeus

Displaced fractures require surgery to restore alignment of the fragments and anatomical reduction of the joint surface. A plate and screws is most commonly used fixation device. Retrograde IM nailing may be used or external fixatior in polytrauma/open injuries.

Question 33

Tibial plateau fractures

Answer 33

Periarticular fractures of the proximal tibia often associated with soft tissue knee injuries and occasionally NV injuries

AP and lateral x ray of knee with consideration of an AP and Lat of tibia if distal extension is present. Lipohaemarthoris is an indication of an occult intra-articular injury
Most of these injuries require surgical intervention and CT for operative planning

Schatzer classification used

OE: Knee swelling and tense painful effusion common. Palpate distal pulses and CRT. Increased incidence of popliteal artery injury in displaced plateau fractures. Assess NV status of the limb especially the function of the brances of the sciatic nerve (tibial and peroneal) as they divide around popliteal region.

Mx: Above knee POP, repeat NV, Non operative treatment for non mobile elderly and undisplaced lateral plateau fracture
Surgical treatment to restore joint line. Acheived with plate fixation. Areas of joint depression are elevated and may need to use bone graft/cement to prevent recurrent depression

Question 34

Tibial shaft fractures

Answer 34

Most common long bone fracture. May occur either as direct blow or result of twisting (torsion) injury. High incidence of open fractures.

AP and lateral of Tibia, knee, ankle. Lipohaemarthrosis is indication of an occult intra-articular injury.

OE: NV assessment. Inc deep peroneal nerves, sural nerve, saphenous nerve, tibial nerve, parasthesia or weakness raises suspicion of nerve injury

Mx: Undisplaced can be managed conservatively. Initially with above knee cast. After 6-8 weeks this can be converted to below knee cast for further 6-8 weeks.
Displaced fractures require reduction and stabilisation.
IM nailing most commonly used.

Plate and screws may be used if fracture extends into knee/ankle.
Open fractures or in cases where soft tissues are swollen, external fixator may be applied. This is usually temporary solution as a precursor to nailing once tissues allow.

Question 35

Tibial plafond fractures

Answer 35

Pilon fractures. Severe axial load may result in comminuted intra-articular fractures of distal tibia.
Check NV status and splint the limb in a backslab. Grossly displaced or dislocated ankles need urgent reduction. Often they are unstable and external fixator may be required to maintain alignment.
Soft tissue injury is extensive and may not develop fully for several days. High elevation and ice reduce swelling.
Definitive treatment is plate fixation or circular external fixator frame.

Question 36

Tarsometatarsal fracture dislocation

Answer 36

Midfoot articulation is between bases of the metatarsals distally and cuneiforms and cuboid bones proximally. Joint is kept in alignment by Lisfranc ligamant. Runs betwen base of second metatarsal and medial cuneiform. Twisting or crush injuries to foot may result in disruption of lisfranc ligament often associated with fractures to one or more metatarsal bones

Clinically foot will be swollen with severe midfoot pain and brusing to sole

If Dx unclear weightbearing AP and oblique views of the foot. Treatment usually surgical

Question 37

Metatarsal fractures

Answer 37

5th Metatarsal being the most common. 2nd Metatarsal most commonly involved in stress fractures. Mechanism direct cruch, indirect twisting of the forefoot onto hindfoot or stress fracture.

AP, lateral and oblique x rays. Review alignment of metatarsals looking at location of fracture (Type of fracture) amount of displacement and angulation and any articular involvement

OE: Swelling and pain. Inability to weight bear. Vascularity of foot

Mx: Analgesia, No splints neccessary initially, elevation and icing is key.
If pain then below knee backslab
Mostly treated with stiff insole or a boot weight bearing as tolerated. More caution and follow up required for displaced base of 5th Metatarsal fracture due to risk of non union.

Question 38

Cervical spine trauma

Answer 38

Injuries to C spine can occur after high energy or with low energy mechanisms in elderly. All trauma patients should be assumed to have cervical injury until proven otherwise. Apply triple immobilisation - rigid cervical collar, 2 sandbags 2 lengths of tape across stretcher

Indications- Over 65, high risk mechanism, neurological symptoms or inability to move neck freely
Lateral, AP and open mouth view

Interpretation - Whole C spine must be visible from C1 down to C7/T1 junction. Count vertebra to ensure this is the case.

Alignement- Trace 4 lines looking for a step
Bones- Trace cortex of each bone looking for a breach/step. Assess facet joints for alignment
Cartilage- Look at disc spaces, are they equal
Dens- Look at Dens (peg) of C2. Is it broken
Everything else - look for soft tissue swelling. May represent fracture haeamatoma

Clinical examination- Neurological exam of upper and lower limbs. With patient lying still, gently remove tape and sandbags. Open collar and palpate in midline for bony tenderness.
Patient must fulfil all this criteria before collar removed:
No neurological deficit, No midline tendernes, No intoxication/reduced GCS, No distracting injury

Remove the collar and ask the patient to slowly turn their head to either side and put chin on their chest. If painful or neuro symptoms occur then stop and replace collar.
Finish the exam by palpating for midline tenderness along rest of thoracolumbar spine

Question 39

Specific cervical spine injuries

Answer 39

C1 Burst fracture
C1 (Atlas) bears the weight of the head. Axial loading can fracture C1 in a burst pattern. Treatment is surgical, either to fuse the skull to the spine, or to immobilise the cervical spine with halo brace

C2 Peg fracture
The atlas rotates around a peg of bone arising from C2. Hyperextension of neck may result in fracture of the peg. Common injury in elderly who fall from standing, hitting their chin on the floor and forcing neck into extension. Most cases are treated with collar for 8 weeks, but if fracture is displaced or non healing, screw fixation is possible

Hangman’s fracture
Combined distraction and extension as with hanging may result in fracture of C2 pedicles and disruption of soft tissues between C2 and C3. Risk of spinal cord injury and quadriplegia is high. Treat with surgical stabilisation. It is a bilateral fracture of the pars interarticularis

Facet joint dislocation
The facet joints are obliquely orientated joints towards the posterior part of the vertebra. They allow movement to occur between adjacent vertebra. Adjacent facet joints are normally congruent and aligned parallel. On true lateral the left and right facet joints directly overlie each other. Distraction and flexion may result in dislocation of facet joints. Lateral x ray demonstrates one vertebra is subluxed anterior to the other and congruence of facets lost. Double shadow
Treatment is reduce and stabilise dislocation.

Body fracture
Hyperflexion combined with axial load may reuslt in fracture of anterior aspect of vertebral body. Teardrop fracture. If force sufficient posterior elements of spine may be distracted, rendering spine unstable. Surgical fixation is in form of ant approach, combined with bone grant fusion

Question 40

Thoracolumbar spine trauma

Answer 40

There are 12 thoracic and 5 lumbar vertebra. Junction between these 2 segments is most common site of fracture

Stability of spinal fractures
Unstable fractures may collapse, creating or worsening neurological injury and exacerbating deformity. 3 Column theory

1) Ant column is ant half of the vertebral body along with ant ligaments
2) Middle column is post half of vertebral body and posterior ligaments
3) Posterior column is everything behind the vertebral body, including the pedicles, facet joints, laminae and spinous processes

If one column then stable whereas 2 involved is unstable

Question 41

Specific thoracolumbar spine trauma

Answer 41

Wedge compression fracture - frequent affect elderly woman who are osteoporotic. A simple fall from standing height onto bottom is classic way. Red flag symptoms, absence of fall, involvement of multiple vertebra or past hx of cancer should prompt consideration of bony metastases.
Only the anterior column is involved. The posterior border of the vertebral body is intact. This is a stable injury without risk of neuro injury as spinal canal not compromised. Treatment is conservative with analgesia and gentle mobilisation.
Corset style brace may be used to reduce pain. Surgery if fracture fails to heal (common in pathological fractures) or severe kyphosis

Burst fracture
Involves 2 columns. Anterior and middle column are both fractured. Spinal canal iscompromised as posterior wall of vertebra is involved. Risk of neurological injury. Further imaging. Treatment may be conservative in brace. If neuro symptoms or deformity then surgery is indicated to stabilise spine and decompress cord

Chance fracture
Extreme flexion combined with distraction results in burst fracture to anterior and middle columns, combined with distraction fracture to posterior column. These fractures are highly unstable. Surgical stabilisation is necessary

Transverse process fractures
Large muscles inc trapezius and psoas originate from transverse process. Avulsion fractures common when these muscles contract. Often stable and heal without intervention but other spinal/pelvic fractures may co exist.