Teach Me Surgery Ortho

Question 1

Acetabular fracture
Type of injury
Clinical features
Investigation
Management
Complications

Answer 1

High energy - eg road traffic collision, significant fall from height

Clinical Features
Pain, swelling, inability to weight bear.
Associated injuries eg hip dislocations or femoral neck fractures.
Morel Lavallée Lesion - internal degloving injury, where the skin and subcutaneous tissues separated from the underlying fascia due to trauma. A potential space is produced that is then filled with fluid. Can become encapsulated and persistent.

Investigation
Gold standard = CT scan

Management
Any associated hip dislocation should be reduced
Undisplaced or minimally displaced acetabular fractures can be managed conservatively with protected weight bearing for 6-8 weeks.
Surgical if displaced

Complications
Secondary osteoarthritis
VTE
Nerve injury

Question 2

Distal femur fractures
Definition
Classification
Clinical features
Investigation
Management

Answer 2

Fractures from the distal metaphyseal-diaphyseal junction of the femur to the articular surface of the femoral condyles.

Classification
extra-articular (type A), partial articular (type B), and complete articular (type C).
Partial articular fractures can be further classified into sagittal fractures of lateral condyle, sagittal fractures of medial condyle, and coronal fractures.

Clinical Features
After trauma. Severe pain in the distal thigh and an inability to weight bear.
Obvious deformity, swelling and ecchymosis of the distal thigh. If fracture extends into intra-articular, then a knee effusion.

Investigations
Urgent bloods, coagulation, Group and Save.

Imaging
AP and lateral X-rays of the knee and entire femur
If there is any intra-articular extension, then CT imaging.

Management
Realignment in A&E (with analgesia / sedation) and then immobilised using skin traction.

Majority - surgery unless minimal displacement/very co-morbid patient
Retrograde nailing or open reduction internal fixation (ORIF) (for more distal and complex).

Complications
Malunion (more common for fractures that have been plated), non-union, and secondary OA.

Question 3

Femoral shaft fractures
Mechanism
Clinical features
Investigation
Management
Complication

Answer 3

Commonly seen in:
High-energy trauma
Fragility fractures
Pathological fractures
Bisphosphonate-related fractures

Clinical Features
After trauma
Pain or swelling in the thigh, hip and/or knee pain, and unable to weight bear.
Obvious deformity will be apparent from the end of the bed.
The proximal fragment is pulled into flexion and external rotation (by iliopsoas and gluteus medius & minimus, respectively).
Tenting of skin.

Investigations
Routine urgent bloods, including a coagulation and Group and Save.
AP and lateral of the entire femur, including the hip and knee
Further imaging via CT scanning

Management
A to E
Opioid analgesia +/- regional blockade (such as a fascia iliaca block).
Immediate reduction and immobilisation - Traction splints (not used for any other fracture) should be changed to skin traction by an orthopaedic specialist as soon as possible.
Most surgery unless undisplaced/unsuitable - then long leg cast
Fixed within 24-48 hours
Antegrade intramedullary nail (common) / External fixation (unstable polytrauma).

Complications
Nerve injury or vascular injury - pudendal
Mal-union (or rotational mal-alignment), delayed union, or non-union
Infection
Fat embolism
VTE
More long-term problems include hip flexor or knee extensor weakness, limb stiffness, or re-fracture.