Pocket Tutor Orthopaedics Nicola Blucher, Katherine Butler, Simon Platt
INDEX
Note: Page numbers in bold or italic refer to tables or figures respectively.
A
ABCDE approach, for trauma patients 345346
Abscesses 365366
Acetabular fracture 232236
anteroposterior radiograph 233, 234
CT scan 233
hip dislocation and 233
iliac view 233, 234
Judet–Letournel classification 233, 235
left 235
obturator view 233, 234
Acetabulum 222
Achilles tendon ruptures 271272, 297299
Acromioclavicular joint 90, 91
injuries 102103, 103
Acromioclavicular ligament 90, 91
Acromion 88, 90
Advance directive 9
Advanced Trauma Life Support (ATLS) 345346
Advance statement 8, 9
Amputation 54
Anatomical snuffbox 162, 163
Angulation 3
Ankle arthrodesis 288
Ankle–brachial pressure index (ABPI) 353
Ankle fracture 279285
bimalleolar fractures 281
Danis–Weber classification 281, 282, 283, 284
Lauge–Hansen classification 281282
mortise view radiograph 281, 281
open reduction and internal fixation 284, 285
Ottawa ankle rules 280, 280
stable fracture 282
trimalleolar fractures 281
Ankle sprains 289291
grading of ligamentous injuries 289, 289
MRI in 290, 290
radiographs in 290
RICE principles 290
Antalgic gait 29
Anterior cruciate ligament, injury to 263265, 264
Anterior drawer test 33, 34, 248
Anterior talofibular ligament 272
Anterior tibial artery 273
Antibiotics, use of 46
Apprehension test 107
Arthrocentesis see Joint aspiration
Arthrodesis 5152
Arthroplasty 5253
excision 52
hemireplacement 52
total replacement 5253
Articular fractures 23
Ataxic gait 29
Avascular necrosis 293294
Avulsion fractures 226 see also Pelvic fracture
Axillary artery 92, 92
Axillary nerve 86, 86, 92
Axonotmesis 14
B
Back pain 5556
Barton fracture 156
Base-of-thumb fractures 176178, 177
Bennett fracture 176, 177, 179
extra-articular fractures 176, 178
intra-articular fracture 176
Rolando fracture 176, 177
Beighton score for joint hypermobility 252, 253
Bennett fractures 176, 177, 179
Biceps tendon injuries 123124
Bisphosphonates 46
Bite injuries 371372
Blood tests 43, 4344
blood transfusion 4344
infection markers 44
microbiology 44
specific markers 44
Bone grafting 53
Bone healing 45
Bony Bankart lesion 108
Bouchard's nodes 22
Boutonnière deformity 23
Boxer's fracture 170
Brachial artery 128, 319
Brachial plexus 9293, 93
injuries 121123
Bruising 25
Bulbocavernosus reflex 66
Burst fractures, of lumbar spine 72, 72, 73
C
Cadaveric bone 53
Calcaneal fractures 294297
Böhler's angle 295, 296
classification 295
CT scans 295, 296
lateral radiograph 295, 296
Mondor's sign 295
Calcaneal gait 29
Calcaneofibular ligament 272
Calf squeeze test 34, 271
Capacity 7
assessment 8
in children 9
factors affecting 78
lack of 89
Capitellum fractures 139141, 141
anteroposterior radiograph 140, 141
classification 140
Caput ulna 23
Carpal bones 148, 148
Carpal keystone 166 see also Lunate dislocations
Carpometacarpal joints 148
Cauda equina 60
Cauda equina syndrome 56, 6770
atraumatic 67
blood tests 70
disc herniation and 67, 68
MRI scan 69, 69
surgical decompression 70
traumatic 67
Cellulitis 364365
Cervical spine injuries 73
C1 fractures 75, 75
C2 fractures 7576, 76, 77
compression injuries 74
extension injuries 74
flexion injuries 7374
flexion-with-rotation injuries 74
management 77
Chance fracture 7273
Chauffeur's fracture 156
Clavicle 87
Clavicular fractures 97, 99102
anteroposterior radiograph 100, 100
computerised tomography 100
group I 97
group II 97
group III 97
surgical management 100101, 101
tenting of skin 99, 99
Claw hand 22
Claw toes 23
Clostridial myonecrosis see Gas gangrene
Coccygeal fractures 238
Collateral ligament stability testing 246, 247
Colles fracture 156, 160
Compartment syndrome 171, 349352, 350
Complex regional pain syndrome type 1 160
Computerised tomography 3839
advantages/disadvantages 39, 39
principles 3839
terminology 39
Condylar fractures 322327
CRITOL (mnemonic) 325, 325
lateral condylar fractures 323, 323
medial epicondylar fracture 323, 324, 326
paediatric elbow, anatomy of 326
Consent 6
capacity to 79
expressed verbal 6
expressed written 6
implied 6
informed 7
voluntary 7
Conservative management 4546
Coracoclavicular ligament 90, 91
Coracoid processes 88, 90
Coronoid process fractures 144145
Cruciate ligament testing 246, 248
Cytotoxic drugs 46
D
Deep peroneal nerve 273, 276, 277, 277
Deformities 22, 2223
Deltoid ligament 272
Diagnostic categories 21, 21
Dislocation 34
elbow 131134, 132
hip 193197
knee 267269
patella 252253
shoulder 8587, 106111
Displacements 3
angulation 3
distraction and impaction 3
rotation 3
translation and shortening 3
Distal femoral fractures 259261, 260
Distal humerus fractures see Supracondylar fractures
Distal radioulnar joint (DRUJ) 160
injuries 160162, 161
ligaments of 161
Distal radius fractures 156, 156160, 157, 158, 159
classification of 156
fixation 159, 159
lateral radiograph 158
malreduced 160
posteroanterior radiograph 157
Drug history 19
E
Elbow 125, 127
articulations and ligaments 127, 127128
capitellum fractures 139141, 141
coronoid process fractures 144145
dislocations 131134, 132
examination 128130, 130
innervation 128, 129
lateral epicondylitis 126, 145146
medial epicondylitis 146
movements 130, 130
olecranon 127, 128
olecranon bursitis 145
olecranon fractures 137139, 138, 139
pain 125126
radial head and neck fractures 141144, 143
supracondylar fractures 134136, 135, 136
vascular supply 128
Epiphyseal fractures, in children 338
Erb–Duchenne palsy 122
Essex-Lopresti fracture 161
Examination
anatomical measurements 32, 3435, 35
beginning of 28
fracture and dislocation assessment 35
gait 28, 29
general examination 28
joint examination 2832, 3334
neurovascular status of limb 36
trauma assessment and management 3536
traumatic vs non-traumatic 28
F
Falls 19
Family history 20
Fasciotomy 352
Femoral head fractures 218
Femoral shaft fractures
anteroposterior radiograph 210
in children 335338, 337, 337
intramedullary nailing 211, 212
Fixed flexion 26
Fixed flexion deformities (FFD) 23, 2627
Flexor tendon sheath infection 182183
Foot and ankle 271
Achilles tendon ruptures 271272, 297299
ankle fracture 279285
ankle joint movement 278
ankle sprains 289291
bones and ligaments 272, 273, 274, 275
calcaneal fractures 294297
examination 274276
foot and toes movement 278
innervation 273, 276, 277, 277
Lisfranc injuries 300302
metatarsal fractures 303308
navicular fractures 310311
phalangeal fractures 308310
pilon fracture 285288
plantar fasciitis 311
surface anatomy 273, 274, 274, 275
talus fractures 291294
vascular supply 273, 276, 277
Foot drop 196
Foot ulcers 367369, 368
Foreign body, in foot 311
Fracture 1
articular vs nonarticular 23
closed vs open 12
dislocations 34
displacement 3
healing and complications 46
patterns 1, 2
simple vs comminuted 2
Fracture management 4651
devices for, use of 4951
local anaesthetic 51
questions in 4748
reduction and stabilisation 4849
stable fracture 48
G
Gait 21, 271
examination of 28
types of 29
Galeazzi fracture 144, 153, 160, 162
Gamekeeper's thumb 178
Gangrene 360362
dry 361
wet 361
Gas gangrene 361
Genu valgum 23
Genu varum 23
Gerber lift off test 96
Gillick competence 9
Glenohumeral joint 87, 90
Glenoid 88, 90
Golfer's elbow see Medial epicondylitis
Growth plate fractures 315319
anatomy of growth plate 315, 316
Salter–Harris classification 317, 317, 317
Salter–Harris type II fracture of distal tibia 317, 318
H
Haematoma 4
Hallux rigidus 23
Hallux valgus 23
Hamate fractures 186
Hammertoes 23
Hand see Wrist and hand
Hawkins–Kennedy test 96
Healing, fracture 4
and complications 56
stages of 45
Heberden's nodes 22
Heterotopic ossification 133
High-stepping gait 29
Hill–Sachs lesion 108
Hindfoot valgus 23
Hindfoot varus 23
Hip 187, 188
dislocations 193197
examination 190193
femoral head fractures 218
femoral shaft fractures 209212
femoral triangle 192
innervation 189, 191, 192, 193
joint anatomy 188, 190
movements 194
neck of femur fractures 197209
osteoarthritis 214217
Paget's disease of bone 217218
pain 187188
periprosthetic fractures 212214
prosthetic joint infection 218219
radiograph 189
surface anatomy 189, 189
vascular supply 188189, 190
Hip dislocation 193197
CT scan in 196
and fracture of femoral head/neck 194, 195
hip replacement and 194
posterior 195
radiographs in 196
Hip spica cast 336, 337
Histamine test 123
History taking 11, 12, 14
age 14, 15, 16
drug history 19
family history 20
history of presenting complaint 1819
medical and surgical history 19
occupation 1617
presenting complaint 1718
sex 16
social history 20
systems review 20
Horner's syndrome 122
Human bite injuries 371372
Humeral shaft fractures 118121
anterioposterior radiograph 119, 119
immobilisation methods 120
open reduction and internal fixation 120121
Humerus 87, 88
I
Imaging studies 3741
computerised tomography 3839
magnetic resonance imaging 40, 41
radiography 3738
ultrasound 41
Implied consent 6
Infections 355356
abscesses 365366
bite injuries 371372
causative organisms 355
cellulitis 364365
foreign bodies in tissues 369371
gangrene 360362
necrotising fasciitis 362363
neuropathic arthopathy 372374
osteomyelitis 358360
postoperative wound infections 363364
septic arthritis 356358
ulcers 367369
Informed consent 7
Infraspinatus 90, 91
Internal iliac artery 222
Intervertebral discs 5859
J
Jobe relocation test 96
Joint aspiration 4142, 42
diagnostic aspiration 4142
prosthetic joint and 43
therapeutic aspiration 42
Joint crepitus 26
Joint effusion 25
Joint examination 2832
feel 3132
look 2931
move 32
Joint posture 24
Joint stiffness 1213, 18
after injury 13, 13
Joint swelling 11, 18, 27
Jones fractures 304 see also Metatarsal fractures
K
Kanavel signs 182
Klumpke's palsy 122
Knee 239241
ACL rupture 239240
anterior view 241
bones and articulations 240
dislocation 267269
distal femoral fractures 259261, 260
examination 246247, 247, 248
injuries 239
innervation 245
lateral view 243
ligaments 243, 244
medial view 242
osteoarthritis 239, 265267, 267
patella 241242
patella dislocations 252253
patella fractures 248251, 249, 250, 251
Pellegrini–Stieda lesion 265, 266
quadriceps 242, 244
soft tissue injuries 263265
surface anatomy 246
tendon injuries 261263
tibial plateau fractures 253257, 256, 257, 258
tibial shaft fractures 257259
vascular supply 245, 245
Knee aspiration 41, 42
Knee brace 250
Kyphosis 30, 57
L
Lachman's test 33, 248
Lasègue's sign 56
Lateral epicondylitis 126, 145146
Leg length, equalisation of 53
Ligaments
elbow 127, 127128
foot and ankle 272, 273, 274, 275
knee 243, 244
spine 59, 59
wrist and hand 148, 148, 149, 152
Limb ischaemia 26
Limbs, measurement of 32, 3435
arm span 3435
calf and thigh circumference 34
true and apparent leg lengths 34, 35
Lisfranc injuries 300302
anteroposterior radiograph 300, 301
CT scan 301
oblique radiograph 300301, 302, 303
Lister's tubercle 168
Living will 9
Lordosis 30, 57
Loss of function 1314, 14
Lumbosacral plexus 222
Lunate dislocations 166169
Gilula's arcs 168, 169
Mayfield classification 167
M
Magnetic resonance imaging 40, 41
advantages/disadvantages 40
contraindications 41
principles 40
terminology 40
Maisonneuve fracture 279 see also Ankle fracture
Mallet finger 22, 180, 180
Mallet toe 23
March fractures see Stress fractures
Medial epicondylitis 146
Median nerve 128
Medications, use of 4546
Meniscal tears 263265
Metacarpal fractures 170173
acceptable angulation in 172, 172
operative treatment 172
5th metacarpal neck 170
Metaphyseal fractures, in children 338
Metatarsal fractures 303308
avulsion fracture to 5th metatarsal base 305, 305
mechanisms of injury 304, 304
Ottawa foot rules 307
stress fracture 304, 306
Mid-shaft fractures of forearm 153156
Mondor's sign 295
Mongolian blue spot 340
Monteggia fracture 144
Motion segment 59 see also Spine
Muscle atrophy 13
Muscle relaxants 46
Muscle wasting 24
N
Nail bed
anatomy of 184
injuries 183185
Navicular fractures 310, 310311
Neck movements 66, 67
Neck of femur fractures see Proximal femoral fractures
Necrotising fasciitis 362363, 363
Needle electromyelography 44
Neer's sign 96
Nerve conduction studies 44
Neurogenic shock 83
Neuropathic arthopathy 372374, 373
Neuropraxia 14
Neurotmesis 14
Neurovascular status, examination of 36
Nursemaid's elbow see Radial head subluxation
O
Oculosympathetic palsy 122
Odontoid peg, fractures of 75, 76, 77
Olecranon 127, 128
bursitis 145
fractures 137139, 138, 139
Open fractures 12, 346349
fracture patterns in 346
Gustilo–Anderson classification 347, 347
surgical management 348349
Osteitis deformans see Paget's disease of bone
Osteoarthritis, hip 214217
anteroposterior radiograph 215, 216
arthroplasty 216
primary 215
secondary 215
Osteoarthritis, knee 239, 265267
anteroposterior radiograph 266, 267
conservative management 266
joint replacement 267
Osteogenesis imperfecta 341342
Osteomyelitis 46, 358360
causative organism 358
radiographs in 359, 359
sequestrum 358
Osteotomy 51
P
Paediatric orthopaedics
child and adult bones, differences between 313
condylar fractures 322327, 323, 324, 325, 326
examination 315
femoral shaft fractures 335338, 337, 337
growth plate fractures 315319, 316, 317, 317, 318
non-accidental injury 339341
osteogenesis imperfecta 341342
Perthes' disease 333334, 334
principles of treatment 313
radial head and neck fractures 327329, 328, 329
radial head subluxation 329330
slipped upper femoral epiphysis 330332, 332
supracondylar humeral fractures 319322, 320, 321, 321, 322
tibial fractures 338339
transient synovitis 313315, 334335
Paget's disease of bone 217218
Pain 11, 1718
fracture 17
scale of severity of 17
SOCRATES mnemonic 17
Painful arc test 96
Paronychia 185
Parsonage–Turner syndrome 121
Passive range of movement 32
Patella 241242
bipartite 250, 251
dislocations 252253
fractures 248251, 249, 250, 251
tension band wiring of 250, 251
Patellar tap test, for knee effusion 246, 247
Patellar tendon injuries 261263, 262
Patellectomy 250
Pellegrini–Stieda lesion 265, 266
Pelvic binder 227
Pelvic fracture 221222, 226232
anterior posterior compression (APC) 228, 230
lateral compression (LC) 228, 230
open reduction and internal fixation 231, 232
radiographs in 227, 228
stable 226
unstable 226
vertical shear (VS) 228, 230
Young–Burgess classification 228, 229
Pelvis 221
anatomy 222224, 223, 224
examination 225
Perilunate dislocations 166169
anteroposterior radiograph 166
lateral radiograph 167
Peripheral nerve injury, Seddon classification of 14
Periprosthetic fractures 212214
at stress risers 213
Vancouver classification 212, 213
Perthes’ disease 333334, 334
Pes cavus 23
Pes planus 23
Phalangeal fractures 173176, 174, 308310
classification of 173
radiographs in 173174, 174
surgical management 175, 175
Phalen's test 33
Physiotherapy 45
Pilon fracture 285288
anteroposterior radiograph 286
distal tibia and 285, 286
external fixator application 286, 288
non-union 288
Pisiform fractures 186
Plantar fasciitis 311
Plaster of Paris 50
Popeye deformity 123
Popliteal artery, injury to 268
Posterior talofibular ligament 272
Prosthetic joint infection 218219
Proximal femoral fractures 197209
anteroposterior radiograph 199, 200, 201
classification 197
displaced fractures 206, 206207, 207
fall history 199
intertrochanteric fractures 207, 208
intracapsular fractures 203, 204, 204, 205, 205, 206, 207
minimally displaced fractures 205
risk factors 198
subtrochanteric fractures 207209, 208, 209
surgical management 201203, 202203
Proximal humeral fractures 114118
anatomy related to 115, 115
conservative management 116
displaced fracture radiograph 117
in elderly patients 116
hemiarthroplasty 116, 118
Neer classification 115
neurovascular anatomy 115, 116
open reduction and internal fixation 116, 117
Pubic rami fractures 231, 231
Pulled elbow see Radial head subluxation
Q
Quadriceps 242, 244
Quadriceps gait 29
Quadriceps tendon injuries 261263
R
Radial head and neck fractures 141144, 143
anteroposterior radiograph 142, 143
associated injuries 142
in children 327329, 328, 329
Mason classification 142
radioulnar joint, injury patterns of 142, 143
Radial head subluxation 329330
Radial nerve 128
Radiocapitellar line 328
Radiography 3738
advantages/disadvantages 38
principles 3738
rule of twos 38
terminology 38
Rashes 25
Restricted range of motion 27
Rolando fracture 176, 177
Rotation 3
Rotator cuff 9091, 91, 112
injuries 111114, 112
S
Sacral fractures 236238
CT scan 237, 238
radiographs in 237
Saphenous nerve 273, 277
Scaphoid fractures 162165, 163, 164
scaphoid views 164, 165
Scapula 87, 89
fractures 104106, 105
Y view 105
Scarf test 33, 96
Scars 24
Scissor gait 29
Scoliosis 22, 30
Segond fracture 263, 265
Septic arthritis 356358
causative organisms 357
Kocher's criteria 357
Shenton's lines 196
Short leg gait 29
Shoulder 85, 87
acromioclavicular joint injuries 102103
articulations 90, 91
biceps tendon injuries 123124
bones 87, 88, 89
brachial plexus injuries 121123
clavicular fractures 97, 99102
dislocations 8587, 106111
examination 96, 9697, 98
humeral shaft fractures 118121
movements 98
proximal humeral fractures 114118
rotator cuff 9091, 91
rotator cuff injuries 111114
scapular fractures 104106
surface anatomy 93, 94, 95
vascular supply and innervation 9193, 92, 93, 93
Shoulder dislocations 8587, 106111
anterior dislocations 107109, 108
apprehension test 107
conservative management 109111
inferior dislocation 106
open procedure 111
posterior dislocation 106, 109, 109, 110
right 107
Y view radiographs 108
Signs, in orthopaedic examination 22
asymmetry 24
bruising 25
colour 25
crepitus 26
deformities 22, 2223
fixed flexion 2627
heat/warmth in joint 27
joint posture 24
muscle wasting or weakness 24
rashes 25
restricted range of motion 27
scars 24
swelling 25, 27
tenderness 22
wounds 26
Simmonds' test see Calf squeeze test
Skier's thumb 178
Slipped upper femoral epiphysis 330332, 332
frog-leg view of pelvis 332
operative management 331, 332
Trethowan's sign 332
Smith fracture 156
Social history 20
Speed's test 96
Spinal anomolies 28, 30
Spinal cord 5960, 5963, 61, 62
grey matter 5960, 61
injuries 7880
levels of 60, 62
meninges 60
sensory and motor tracts 6063, 61
vascular supply 63
white matter 60
Spinal fractures 7071
burst fractures 72, 72, 73
Chance fracture 7273
dislocation 73
wedge fracture 71, 71
Spinal metastases 8083
MRI scan 81, 82
pathological wedge fracture 80, 81
radiography 80, 81, 82
radiotherapy 8384
surgical management 84
winking owl sign of pedicle loss due to 82
Spinal shock 66, 83
Spine 55, 56
anterior column 57
cross-section of 58
examination 6364, 66, 67, 68
intervertebral discs 5859
ligaments 59, 59
middle column 58
movements 68
posterior column 58
regions 5657, 57
spinal cord 5963, 61, 62
surface anatomy 63, 64, 65
vertebrae 56, 58, 58
Stiff hip gait 29
Stiff knee gait 29
Straight leg raise test 56
Stress fractures 304, 306 see also Metatarsal fractures
Subscapularis 90, 91
Subungual haematomas 184, 309
Superficial peroneal nerve 273, 276, 277, 277
Supracondylar fractures 134136
CT scan 135, 135
plate fixation 136, 136
radiographs 135
Supracondylar humeral fractures 319322
Gartland classification 320, 321, 321
Kirschner wires for stabilisation 322, 322
type I fractures 320
type II fractures 322
type III fractures 322
Suprapatellar bursa 241
Supraspinatus 90, 91
Sural nerve 273, 276, 277, 277
Swan neck deformity 23
T
Talus fractures 291294
and avascular necrosis 293294
Hawkins classification 292, 292, 293
Hawkins’ sign 293, 293
lateral process fractures 294, 294
radiographs in 292, 293
Tendon injuries, of hand 178182, 181
extensor tendon injuries 178
splinting 181
tendon reconstruction 181
zones of flexor tendon injury 178, 181
Tendon surgeries 53
Tennis elbow see Lateral epicondylitis
Tension band wiring 139
Teres minor 90, 91
Terrible triad fracture 133
Thomas splint 5051
Thomas's test 33
Thompson's test see Calf squeeze test
Tibial fractures, in children 338339
Tibial nerve 273, 276, 277, 277
Tibial plateau fractures 253257, 257, 258
CT scan in 255
and meniscal injuries 255
plate fixation 258
Schatzker classification 255, 256
Schatzker type II fracture 257, 258
Tibial shaft fractures 257259
Toddler's fracture 339
Torticollis 22
Transient synovitis 313315, 334335
Translation 3
Trauma 18, 343345
assessment and management 35
compartment syndrome 349352, 350
open fractures 346349
primary survey (ABCDE approach) 345346
vascular injuries 352354, 354
Trendelenburg gait 29
Trendelenburg's test 33
Triquetral fractures 185186
Tumour excision 5354
U
Ulcers 367369, 368
in bed-bound patients 369
in diabetic patients 368
in vascular patients 368
Ulnar deviation of fingers 23
Ulnar nerve 128
Ultrasound 41
V
Vascular injuries 352354, 354
Vertebrae 56, 58, 58, 64
Volkmann's ischaemic contracture 319
W
Wedge fracture, of lumbar vertebrae 71, 71
Winging of scapula 22
Wound infections, postoperative 363364
Wounds 26
Wrist and hand 147
base-of-thumb fractures 176178, 177
bones and ligaments of 148, 148, 149, 152
distal radioulnar joint injuries 160162, 161
distal radius fractures 147148, 156, 156160, 157, 158, 159
examination 151, 153
flexor tendon sheath infection 182183
hamate fractures 186
hand movements 154
innervation 150, 150
lunate and perilunate dislocations 166, 166169, 167, 167, 169
metacarpal fractures 170, 170173, 172
mid-shaft fractures of forearm 153156
nail bed injuries 183185, 184
paronychia 185
phalangeal fractures 173176, 174, 175
pisiform fractures 186
prayer sign 155
scaphoid fractures 162165, 163, 165
surface anatomy 149, 151, 152
tendon injuries 178182, 181
thumb movements 155
triquetral fractures 185186
vascular supply 150
wrist movements 153
×
Chapter Notes

Save Clear


General principleschapter 1

 
1.1 Fractures and dislocations
A fracture is a break or loss of continuity in a bone. They are either open or closed, and may involve a joint surface (see below). The mechanism of injury (e.g. pathological, stress, periprosthetic) should be sought because it will give a clue as to the nature of the fracture. There is always a significant soft tissue component of fractures that requires consideration as part of the pattern of injury.
 
Types
Fractures are described by (Figure 1.1):
  • Skin being intact (closed) or not (open)
  • How many pieces of bone: two (simple) multiple (comminuted)
  • Fracture pattern, e.g. oblique, tranverse, spiral, greenstick
  • Anatomical location in the bone, i.e. diaphysis, metaphysis
  • Joint involvement (articular) or not (nonarticular)
  • Displacement. If displaced, the fracture will be any combination of: translation, angulation, rotation, shortening, distraction
 
Closed vs open fracture
An open (compound) fracture is one that communicates with an opening (break) in the skin. Any fracture that involves a body cavity which communicates with the skin, e.g. a pelvic fracture involving the rectum or vagina is also an open fracture.
Open fractures have more complications and are often caused by high-energy trauma. They can involve skin loss, injury to nerves and blood vessels, and be contaminated by 2debris (e.g. soil). All open fractures require prompt assessment and management to reduce the risks of complications.
zoom view
Figure 1.1: Fracture patterns.
 
Simple vs comminuted fracture
A simple fracture is a fracture consists of two parts of bone; fractures with more than two parts are comminuted.
 
Articular vs nonarticular fracture
Articular fractures involve the surface of a joint; nonarticular fractures do not. Articular fractures require careful management 3because of the risk of post-traumatic arthrosis, which can occur even after effective treatment.
 
Fracture displacement
Displacements are bone deformities caused by a fracture. They are described as the position of the distal fragment relative to the proximal and are usually categorised using radiographs.
Angulation Angulation describes the angle that the bone is left at after the fracture. It is given in degrees in either the coronal plane (varus v valgus) and/or the sagittal plane (anterior v posterior).
Rotation Rotation describes the angle a bone twists after fracture. It is difficult to determine accurately from a radiograph and is usually more obvious clinically.
Translation and shortening Translation is the displacement of the fracture parts away from each other. This distance is estimated and often described using the bone as a reference, e.g. ‘translated 50% of the width of the bone’. If the bones are also left overlapping, the length of this overlap is estimated and referred to as shortening.
Distraction and impaction Distraction and impaction refer to the distance or overlap, respectively, of two parts of bone after fracture if they are not displaced (i.e. still aligned).
 
Dislocations
Dislocations are described by:
  • Direction of displacement
  • Associated fractures
  • Associated injuries, e.g. vascular, neurological
Any joint can be dislocated either by an indirect or direct force. Where there is no congruity between the joint surfaces the joint is dislocated; where there is partial congruity the joint is subluxed.
Neighbouring structures such as ligaments, nerves and blood vessels can all be injured by a dislocation. In some cases the blood vessels are kinked or stretched, compromising the 4blood supply distally. This is common in ankle fracture dislocations, but reducing the dislocation restores the blood supply promptly.
 
Healing and complications
Most fractures heal without complications or significant loss of function. However, complications, which can arise early or late, have the potential to cause both local and systemic problems.
The risk of complications is determined by many factors, both fracture-specific and patient-specific. Fracture-specific factors include open fractures, comminution, intra-articular involvement, soft tissue injury and dislocation. Patient-specific factors include age, weight and comorbidities.
 
Bone healing
Bone generally takes 6–8 weeks to heal. The process may take over a year for full fracture healing and remodelling, but clinically the patient will be asymptomatic. In general terms, most fractures heal well.
Fracture healing occurs in an environment that encourages the process. The more that environment is respected, the greater the likelihood of healing.
Stages of healing Fracture healing begins with development of a haematoma and then proceeds in three stages:
  • Inflammation
  • Repair
  • Remodelling
To optimise healing, there needs to be good anatomical reduction (good bony contact and alignment), immobilisation and no infection. In other words, the environment for fracture healing has to be correct, taking into account all these factors. The amount of new bone formed, known as callus, is inversely proportional to the amount of movement across the fracture site.
The haematoma provides haemopoietic cells, which secrete the necessary growth factors and initiate the inflammatory stage. Within 2 weeks, primary callus is formed, which is then 5converted to hard callus. When the bone ends are not in contact, bridging callus is formed.
In the final stage, the newly formed bone is remodelled to restore the bone's prefracture ability to bear physiological load.
 
Local complications
General complications to the site of the fracture occur immediately, early in the healing process (within days) or late (after 6 weeks). Early complications are:
  • vascular injury
  • soft tissue injury
  • compartment syndrome
  • infections
  • nerve injury
Late complications are:
  • delayed union
  • non-union
  • malunion
  • implant complications: infection, prominence, breakage
  • joint stiffness
  • avascular necrosis
  • osteomyelitis
  • growth disturbance or arrest
  • osteoarthritis
  • contractures
  • complex regional pain syndrome
  • heterotopic ossification
 
Systemic complications
General systemic complications affect the body more widely and, like local complications, occur either early or late in the healing process. Early complications are:
  • thromboembolism
  • pneumonia
  • acute respiratory distress syndrome
  • acute renal failure
  • fat embolism6
  • shock
  • multiorgan failure
Late complications are:
  • sepsis
  • pressure sores
  • muscle wasting
  • reduced mobility
 
1.2 Consent
Consent is the permission granted by a patient for a medical procedure, including surgery, to be performed. A surgeon is liable if a patient's consent is not obtained correctly before a procedure is carried out.
Consent must also be obtained for any adjunctive procedures. The patient must be advised of alternate treatment options and the consequences of not undergoing treatment. The complications of, and recovery from, the procedure must be explained and documented. Ideally, consent for the procedure should be taken at the time of admission.
 
Types of consent
There are different types of consent.
  • Implied consent is presumed for minor procedures, such as radiography and phlebotomy
  • Expressed verbal consent is normally adequate for simple procedures with minimal risk of harm, for example insertion of a nasogastric tube
  • Expressed written consent is required for all surgical procedures; written consent is not legal proof that adequate consent has been obtained, but rather proof that a discussion has taken place outlining the specifics of the procedure, risks and benefits, along with the other aspects discussed below7
For any consent to be valid, it must be voluntary and informed, and the patient giving it must have capacity.
 
Voluntary
The decision to give consent should be the patient's alone; there should be no coercion or pressure from family, friends or medical staff.
 
Informed
The patient should be given all the information about the procedure:
  • the reason for carrying out the procedure
  • what it involves
  • the benefits of the procedure
  • the risks of the procedure in terms of possible complications
  • other treatment options
  • the possible consequences if the procedure is not carried out
The patient needs to be fully informed, i.e. no information should be withheld from them.
 
Capacity
To give consent, a patient must have capacity, i.e. the ability to make decisions regarding their care. They must be able to:
  • understand the information they are given about the procedure
  • retain the information
  • weigh the risks and benefits of the procedure in order to make a decision whether to agree to it
  • communicate their decision
All adults are assumed to have capacity unless there is significant evidence against this. Factors that reduce capacity are:
  • dementia
  • acute confusion
  • mental illness8
  • intellectual disability
  • drug or alcohol intoxication
  • use of certain medications
  • fatigue
 
Capacity assessment
Capacity can change, so it is assessed at the time that consent is required. This is usually at admission for an emergency and at outpatient listing for an elective case. Capacity can be rechecked at any time during the patient's stay. Consent is usually checked verbally at multiple times prior to the patient's procedure.
A patient may have capacity to consent to one procedure but not another. For example, a patient with intellectual disability may be able to give consent for a blood test but may lack the capacity to consent to a procedure with longer term consequences, such as an operation.
If a patient makes a decision that you consider irrational, their decision will stand as long as they have capacity.
 
Lack of capacity
If a patient lacks capacity, decisions about their treatment depend on whether:
  • they have made an advance statement or an advance decision to refuse treatment
  • they have conferred a lasting power of attorney on another person, giving that person the authority to make decisions on their behalf, should they lose capacity
  • an independent mental capacity advocate has been assigned to represent and support the patient
If none of these conditions apply, decisions must be made on behalf of the patient by the doctor responsible for their care.
Any decision made on a patient's behalf must be in their best interests, considering their preferences, wishes, beliefs and 9values. Whenever possible, the views of the family and friends of the patient should be sought when making such decisions.
 
Capacity in children
In most countries, as in the UK, over 16s are regarded as adults and have capacity by default. Under 16s can give consent on their own behalf if they are judged to understand what a treatment involves and its possible consequences (termed Gillick competence).
A child's decision to refuse a treatment, unlike that of an adult, can be overruled by a person with parental responsibility or a court if treatment is deemed to be in the child's best interests.10