ORTHOPAEDIC TRAUMA

Lecture Notes

Department of Orthopaedics
School of Clinical Medicine
University of KwaZulu-Natal
Table of Contents
Extremely Page
Important
Topics
General Topics 4
Orthopaedic nomenclature 5
Fracture patterns and description + 8
Principles of fracture management + 11
Open fractures + 12
Compartment syndrome + 13
Fat embolism syndrome + 14
Polytrauma + 16

Specific Injuries 21
Middle 1/3rd clavicle fracture 22
Lateral 1/3rd clavicle fracture 22
Acromioclavicular joint dislocations 23
Scapula fractures 23
Shoulder dislocation + 23
Proximal humerus fractures 24
Humerus shaft fractures + 25
Distal humerus fracture 26
Elbow dislocations 26
Radial head fractures 27
Olecranon fractures 27
Radius and ulna shaft fractures 28
Montegia fractures 28
Galeazzi fractures 28
Nightstick fractures 29
Distal radius fractures + 29
Perilunate injuries 31
Scaphoid fracture 34
Metacarpal fractures 34
Phalanx fractures 36
Fingertip injuries 37
Hand lacerations 37
Peripheral nerve injuries + 38
Spinal cord injury + 41
Cervical spine Injuries + 43
Thoracolumber spine injuries + 44
Pelvis fractures + 45
Acetabulum factures 47
Hip dislocations + 47
Femur neck fractures + 48
Intertrochanteric femur fractures 50
Subtrochanteric femur fractures 50
Femur shaft fracturs 51
Distal femur fractures 51
Patella fractures 52
Patella dislocation 53

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Knee dislocations + 53
Tibial plateau fractures 53
Tibia shaft fractures 54
Tibial plafond fractures 54
Ankle fractures + 55
Lateral ankle ligament injuries + 59
Calcaneus fractures 60
Talus fractures 60
Lis Frank injuries 61
Metatarsal fractures 62
Toe fractures 63

Paediatric orthopaedic trauma 64

Unique paediatric fracture type 65
Salter-Harris injury 66
Supracondylar humerus fractures + 67
Lateral condyle fractures 69
Forearm fractures 70
Distal radius fractures 70
Femur fractures 71

Nov 2018

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General Topics

4
Orthopaedic Nomenclature

Pathology

- Sprain: An injury to a ligament ligament. First-degree injuries involve

microscopic tearing. Second-degree injuries involve a partial tear of the and
third-degree injuries involve a complete disruption of the ligament.
- Strain: An injury to an muscle. (Grading similar to sprains)

- Subluxation: Partial dislocation of the articular surfaces of a joint

- Dislocation: Complete disassociation of the articular surfaces of a joint.

- Osteoarthritis = Degenerative condition that causes inflammation, breakdown

of synovial fluid, and destruction of the articular cartilage with resultant
abnormal new bone formation
- Osteochondritis dissecans: Injury (often traumatic) to the joint surface of bone
that involves detachment of the subchondral bone and its overlying articular
cartilage. Commonly affected sites include the knee (femur), elbow (ulna), and
ankle (talus).
- Apophysitis: Repetitive stress injury with inflammation in the growth plate of a
bony prominence such as the point of insertion of a tendon (tuberosity).
Commonly affected sites include the knee (tibial tubercle [Osgood-Schlatter
disease] and elbow).

- Tendinitis: Acute inflammation of a tendon. Symptoms are typically present for

several (1 to 3) weeks. Com- monly affected sites include the shoulder (rotator
cuff tendons), knee (patellar tendon), elbow (extensor tendon), and heel
(Achilles tendon).
- Tendonosis/tendonopathy: Degenerative breakdown of the tendon and
abnormal vascularization due to chronic, repetitive stress. Symptoms are often
present for several weeks to months.
- Tenosynovitis: Inflammation of the sheath surrounding a tendon. This can
occur concomitantly with tendon involvement or independently.
- Bursitis: Inflammation of the synovial sac (bursa) that protects the soft-tissue
structures (muscles, tendons) from underlying bony prominences. Common
areas of involvement include the shoulder (subacromial bursa), knee
(prepatellar bursa), elbow (bursa of olecranon bursa), and hip (trochanteric
bursa).

- Spondylolisthesis: The abnormal translation of one vertebra with respect to

another.
- Spondylolysis: A fracture of the pars inter-articularis of the vertebra. This injury
is usually caused by repetitive stress and most commonly affects the lower
lumbar vertebrae.
- Spondylosis: Osteoarthritis of the spine

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Movement

- Abduction: Movement away from the body’s midline

- Adduction: Movement toward the body’s midline

- Eversion: Rotation of the foot and ankle outward

- Inversion: Rotation of the foot and ankle inward
-
- Pronation: Rotary movement described at the forearm, where the palm of the
hand rotates from a superior facing position to one facing inferiorly.
- Supination: Rotary movement described at the forearm, where the palm of the
hand rotates from an inferior facing position to one facing superiorly.

- Range of motion description: All joints are at zero degrees in the anatomical
position.

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Deformity

- Varus: Deformity where the distal portion is angulated toward the midline (i.e.
apex lateral), for example, bowlegs = genu varus
- Valgus: Deformity where the distal portion is angulated away from the midline
(i.e. apex medial), for example, knock knees = genu valgus
-

- Procurvatum: Deformity where the distal segment angulates posteriorly (i.e.

apex anterior)
- Recurvatum: Deformity where the distal segment angulates anteriorly (i.e.
apex posterior)

Procedures

- Debridement: Surgical removal of all contamination, ischemic/necrotic tissue

and irrigation to decrease bacterial load (“solution to pollution is dilution”)

- Arthrocentesis: Aspiration of synovial fluid from a joint with a needle.

- Arthroscopy: A surgical technique that uses a small camera (endoscope) in a
joint space for the diagnosis and treatment of joint-related conditions
- Arthrotomy: Surgical incision into a joint through the joint capsule.
- Arthrodesis: Surgical fusion of a joint

- Open reduction: Surgical incision with physical visualisation of the fracture site
or joint.
- Closed reduction: Reduction of fracture with surgery, may be done under x-ray
imaging.

- Internal fixation: Surgical stabilization devices (implants) placed internally,

directly on or in the bone.
- External fixation: Bulk of stabilization device outside of soft tissues and skin.
Connected to bone with pins or wires.

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Fracture Patterns and Description

Diaphyseal fracture patterns:

(Taken from: Orthopaedic Trauma Association And AO Foundation. Fracture and Dislocation
Classification Compedium – 2018. J Orthopaedic Trauma 2018;32:Suppl1)

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X-ray description

1. Name, age, gender

2. What is depicted in the x-ray (i.e. AP and Lateral view of the left tibia)

3. Side (left or right)

4. Is the x-ray adequate?

- 2 Views (i.e AP and LAT)?

- 2 Joints (i.e. joint above and below the injury)?
- 2 Sides (sometimes necessary, i.e. in children for example image left
and right side to compare)

5. Soft tissues

6. Bone/s involved

7. Which part of the bone is involved?

- Diaphysis / Metaphysis / Epiphysis / Physis (growthplate)

8. Is a joint involved?

- Check for subluxation/dislocation of joint above and below

- Intra-articular fracture?

9. Fracture pattern

- Incomplete or complete
- Transverse
- Oblique
- Spiral
- Wedge (butterfly fragment)
- Segmental
- Greenstick or Taurus (kids)
- Avulsion

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10. Deformity (NB)

- Angulation
i. Coronal plane (i.e. AP view)
ii. Sagital plane (i.e. LAT view)
- Translation (also called displacement)
i. Coronal plane (i.e. AP view)
ii. Sagital plane (i.e. LAT view)
- Shortening or lengthening
- Rotation

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Principles of fracture management

NB - Indication for Open Reduction and Internal Fixation:

- Open Fractures (sometimes external fixaxtion used but always requires

surgery)
- Intra-articular fractures
- Diaphyseal fractures of long bones (Femur, Tibia, Radius/Ulna, Humerus)
- Fractures in polytrauma patients
- Fracture-dislocation of joints (dislocations associated with a periarticular
fracture)

Types of ORIF

- K-wires
- Interfragmentary screws
- Tension band wires (Olecranon or patella)
- Plates and screws
- Intra-medullary nails (Femur, Tibia, Humerus)
- Pin-and-Plate (Intertrochanteric proximal femur fractures)

How long should fractures be immobilized in cast etc., when being managed non-
operatively?

- United fracture = Bone healing with restoration of the bone tissue to the extent
that it can withstand normal physiological loads without deformation or
refracture.
- Not possible to give an exact time for each fracture, every patient and fracture
is different
- Bottomline: Each fracture needs to be immobilized until it is clinically and
radiologically united:
o Clinical union (you have to remove the cast to assess this) = No pain
and no movement on physical manipulation of the fracture site.
o Radiological union = Callus bridging at least three of the four cortices
(i.e., anterior, posterior, medial and lateral cortices)

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Open fractures (NB)

Definition
- Any fracture where the fracture haematoma is communicating with the
external environment

Management

- ATLS principles in polytrauma patients

- Examination:
o Neurovascular examination
o Classify the open fracture: Gustillo-Anderson classification

Soft tissue Bone Contamination

Wound <1cm, minimal soft
Type I and Simple fracture pattern and No contamination
tissue damage
Wound >1cm, mild soft
Type II and Simple fracture pattern and No contamination
tissue damage, and
Extensive soft tissue High energy; complex
Type IIIA and/or and/or Contaminated
damage fracture pattern
Extensive soft tissue
Type IIIB any any
damage with soft tissue loss
Vascular injury that requires
Type IIIC any any
repair

- Specific treatment:
o Analgesia: Morphine IV
o Anti-tetanus: Tetanus prophylaxis
o Antibiotics:
§ Gustillo-Anderson I and II: Cefazolin 2 gram stat IV
§ Gustillo-Anderson III: Cefazolin 2 gram stat IV plus Gentamycin
240mg stat IV (plus PenG or metronidazole of “Farm Yard” / soil
contamination with concerns about Clostridium sp.)
o Inspect wound (classify) and remove any gross contamination
o Irrigate wound with saline (at least 3 litres)
o Apply sterile gauze dressing (DO NOT SUTURE and do not expose the
wound multiple times)
o Align the limb (perfect reduction not necessary)
o Apply backslab
o Consent for surgery
o Contact orthopaedic surgeon for urgent debridement in theatre

Factors that decrease infection rate in open fractures:

- Quality of debridement
- Timing of debridement (should be within 24 hours of injury)
- Timing of soft tissue closure (should be within 5 days of injury)
- Timing of initiation of antibiotics (delay increases infection)

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Compartment syndrome (NB)

Pathogenesis:
- Pressure in soft tissue compartment exceeds capillary pressure (30 mmHg)

Diagnosis:
- Clinical diagnosis based on the presence of the following:
o Pain out of proportion to the injury not responding to analgesia
o Pain on passive stretch of the muscles in the affected compartment
o Parasthesia followed by anaesthesia
o A tensely swollen soft tissue compartment

NOTE: Pulselessness, Palor, Poikilothermia, Paralysis is signs of arterial injury NOT

compartment syndrome.

- In patients with decreased consciousness intra-compartmental pressures can

be monitored through:
o Commercially available compartment pressure monitors
o Whiteside’s technique

Management of compartment syndrome:

- Pre-operative
o Fluid resuscitation to maintain prefusion pressure
o Remove constrictive bandages / split plaster
o Elevate limb to level of the heart
o Prepare patient for theatre
- Surgery
o Fasciotomy of all compartments in the involved segment
o Immobilize fracture with external fixator

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Fat embolism syndrome (NB)

Definition:
- Clinical syndrome caused by inflammatory response to embolized fat globules,
characterized by:
o ARDS (Acute respiratory distress syndrome)
o Encephalopathy
o Petchia
o DIC (Diffuse intravascular coagulopathy)

Pathogenesis:
- Two theories regarding the causes of fat embolism include
o Mechanical theory = embolism is caused by droplets of bone marrow
fat released into venous system
o Metabolic theory = stress from trauma causes changes in chylomicrons
which result in formation of fat embolism

Diagnosis:
- Clinical diagnosis
o Single or multiple long bone fractures (especially femur), typically young
active patients (10-40 yrs of age), typically (12-72 hours after fracture or
fracture-fixation)
o Hypoxia (tachypnoea and eventually full-blown ARDS)
o CNS depression (confusion)
o Petechial rash (Conjunctival and skin of the axilla or upper trunk)

Special investigations
- Lab tests
o Arterial blood gas is the most important special investigation (other
adjunctive role only). PaO2<60mmhg, PaCO2 initially decreased due
to tachypnoea later increases
o Trombocytopenia (late)

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 - Radiological imaging
o X-ray changes are only seen late = “snowstorm” appearance or non-
specific infiltrates bilateral

o CT chest
o MRI brain confirms diagnosis

Management:
- Start treatment based on clinical suspicion (special investigations only adjunct
role)
- Treatment basically supportive (no specific treatment available)
- Immediate transfer to High-care or ICU
- Fluid resuscitation
- Supplemental oxygen or mechanical ventilation
- Immobilize/stabilize fracture

NB = Prevention:
- Early fracture immobilization and stabilization
- Adequate fluid resuscitation
- Adequate pain relief

(the aim is to decrease severity of the inflammatory response as a result of the

fracture)

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Approach to Orthopaedic Polytrauma Patient

Initial assessment and management = ATLS principles:

- Primary survey and Resuscitation

o Airway Maintenance with cervical spine protection
§ Assess = Airway patency
§ Manage = Establish Airway
§ Maintain cervical spine in neutral position and instate c-spine
immobilization

o Breathing: Ventilation and oxygenation

§ Assess = Resp rate, Tracheal deviation, chest movement, resp
distress, percuss, auscultate, SaO2
§ Manage = O2, Ventilate, Intercostal drain

o Circulation with Haemorrhage control

§ Assess = sources of external/internal haemorrhage, pulse, blood
pressure, signs of shock

§ Manage = Direct pressure to external bleeding, Surgical consult

for internal haemorrhage, Two large bore IV catheters, type &
crossmatch for possible transfusion, Warmed crystalloid fluids
and blood replacement

o Disability: Brief neurological Examination

§ Assess = GCS, Pupils, Spinal Cord injury

o Exposure/Environmental control
§ Undress patient but prevent hypothermia

- Adjuncts to primary survey, consider

o Arterial blood gas
o ECG
o Urinary catheter plus monitor urine output
o NGT
o AP X-ray Chest and Pelvis
o FAST or DPL

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- Reassess ABCDE

- Secondary survey
o History
§ AMPLE
§ Mechanism of injury
o Head and maxillofacial
o Cervical spine and neck
§ c-spine clearance, see figure below)

o Chest
o Abdomen
o Spine
§ Logroll
§ Inspect and palpate the thoracic and lumbar spines for evidence
of blunt and penetrating injury, including contusions, lacerations,
tenderness, deformity, and sensation.
§ Obtain x-rays of any suspicious area
§ Routine x-ray of spine with fall from a height
o Pelvis/perineum/rectum
§ Pelvis x-ray
§ Pelvis = pelvic stability (press on the ASIS on posterior direction
to check if pelvis opens up [open book injury]; press on iliac
wings in medial direction [lateral compression type injury])
§ Check skin for open wounds or haematomas
§ Perineum = look for lacerations, contusions/haematomas
§ Urethral bleeding = if positive do Urethrogram/cystogram
§ Rectal examination = Sphincter tone, voluntary contraction,
rectal blood, prostate position, bony fragments, rectal laceration
§ Vaginal examination = look for vaginal lacerations

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18
 o Musculoskeletal examination
§ Inspect the upper and lower extremities for evidence of blunt and
penetrating injury, including contusions, lacerations, and
deformity.
§ Palpate the upper and lower extremities (ALL the bones from
proximal to distal) for tenderness, crepitation, movement, and
sensation.
§ Ask patient to actively move ALL joint of upper and lower limb (if
possible) and test passive motion of all joints
§ Palpate all peripheral pulses for presence/absence and equality.
§ Obtain x-ray films of suspected fracture sites as indicated.

o Neurologic secondary survey

§ Test motor function of all nerves:
• Axillary: shoulder abduction
• Musculocutaneous: elbow flexion
• Ulnar: abduction of fingers
• Median: OK sign
• Radial: Thumb extension
• Femoral: knee extension
• Posterior tibial: ankle plantarflexion
• Deep peroneal: ankle dorsiflexion or big toe dorsiflexion
§ Check dermatomes and myotomes:
• Elbow flexion: C5
• Wrist extension: C6
• Elbow extension: C7
• Grip: C8
• Finger abduction: T1
• Nipple level sensation: T4
• Umbilical level sensation: T10
• Hip flexion: L2
• Knee extension: L3
• Ankle dorsiflexion : L4
• Big toe dorsiflexion: L5
• Ankle plantarflexion: S1

- Adjuncts to secondary survey, consider

o Pelvis -ray
o Spine x-rays
o X-rays of suspected fractures or dislocations
o CT head, c-spine, chest, abdomen, pelvis
o Urethrogram/cystogram

- Ongoing post-resuscitation monitoring & reevaluation

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- Definitive care and transfer
o Orthopaedic management:

OR = Operating Room (theatre)

ETC = Early Total Care: defined as complete, primary, definitive fracture stabilization within
the first 24–48 h of injury.
DCO = Damage Control Orthopaedics: Phase I consists of control of hemorrhage,
debridement of open wounds and temporary stabilization of fractures, Phase II by
resuscitation in the ICU, and Phase III by the conversion to definitive fixation of fractures and
closure of wounds.

- Tertiary survey
o Repeat primary and secondary examination within 24 h to prevent
missed injuries and confirm adequate resuscitation

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Specific Injuries

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Middle 1/3rd clavicle fracture

Associations (i.e. look out for):

- Brachial plexus injuries
- Blunt chest trauma

Management:
- Controversial: non-operative (Triangle bandage) vs operative treatment (ORIF ie.
Open Reduction and Internal Fixation)
- Similar functional outcome
- Decreased non-union rate and earlier return to function with operative treatment
- Less re-operations with operative treatment
- Recommended treatment: non-operative

Lateral 1/3rd clavicle fracture

Associations:
- Risk of non-union
Management:
- Non-operative for stable fracture patterns (Types I, III) and children (Type IV)
- Operative treatment preferred for unstable fracture patterns (Type II and V)

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Acromioclavicular joint dislocations

Management:
- Non-operative for pure superior displacement of lateral end of clavicle
- Refer to Orthopaedic surgeon for surgery if distal end of clavicle displaced in any
other direction

Scapula fractures

Associations:
- Blunt chest trauma, lung contusion
- Brachial plexus injuries:
- Shoulder (gleno-humeral) dislocation

Management:
- May be difficult to evaluate on X-rays; CT scan advisable
- ORIF may be required if associated with possible shoulder instability
- Orthopaedic specialist opinion required

Shoulder dislocation

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Associations:
- Axillary nerve injury
- Greater Tuberositas fractures
- Rarely brachial plexus injuries
- Bankart lesion – glenoid sided labrum, capsule and ligament avulsion
o High risk for recurrence of dislocation
o 1st dislocation at age < 20yrs results in > 90% chance of recurrence

Management:
- Urgent closed reduction required (in emergency department)
o Explain to patient what you are going to do
o Extremely important that patient relaxes the muscles around his shoulder
during the reduction procedure.
o Conscious sedation and analgesia: Dormicum and Morphine, but remember
you need a cooperative patient that relaxes muscles
o 1st line: Cunningham technique
o 2nd line: Modified Hippocratic Method
o 3rd Line: General anaesthetic and Modified Hippocratic Method
o Sling post-reduction X 4 weeks
o All young (<30Yr) active patients with first time traumatic dislocation to be
referred to orthopaedic surgeon for MRI and ?Bankart repair

Proximal humerus fractures

Anatomical neck fracture

Surgical neck fracture (2 part)

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Surgical neck fracture (3 part)

Surgical neck fracture (4 part)

Management:
- Depends on type of fracture, functional demand of patient and presence of shoulder
dislocation:
o Anatomical neck fracture = ORIF
o Two-part surgical neck fractrure = Non-operative treatment (Barford-Jones
sling until union)
o Three- or Four-part surgical neck fracture = Refer to Orthopaedic surgeon
(may be treated non-operatively or operatively)
o Surgical neck fracture with dislocated gleno-humeral joint = ORIF

Humerus shaft fractures

Associations:
- Radial nerve injury (check extension of thumb and wrist)
- Blunt chest trauma (lung contusion, cardiac contusion)

Management:
- ORIF generally preferred due to increased risk of non-union with non-operative
treatment

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Distal humerus fracture

Management:
- Intra-articular fracture= ORIF indicated with early post-operative mobilization to regain
elbow ROM (Range of Motion)

Elbow dislocations

Associations:
- Elbow dislocation, radial head fracture and coronoid fracture = Terrible Triad (Very
Unstable)
- Ulnar nerve injury

Management:
- Urgent closed reduction required
o Check x-ray carefully for the presence of fractures
o Explain procedure to patient
o Conscious sedation and analgesia (Morphine and Dormicum)
o Reduction Technique (for posterior dislocation)
§ 30 degree flexion of elbow and Supinate forearm (disengage the
coronoid)
§ Correct varus/valgus angulation at elbow
§ Apply constant axial traction with one hand (An assistant can apply
counter-traction to humerus)
§ While maintaining traction with your one hand and slowly flexing the
elbow use your other hand as follows: Fingers of other hand on
anterior aspect of distal humerus while your thumb is on olecranon.

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 Push olecranon anteriorly with your thumb, while your push distal
humerus posteriorly with your fingers.
o If no fractures on initial x-rays (i.e. pure dislocation) test stability: Extend the
elbow slowly to about 30 degrees flexion of elbow – If it does not redislocate it
is considered stable.
§ If stable: Above elbow backslab x 3 weeks
§ If unstable: Refer to orthopaedic surgeon
o Control x-ray post reduction – Check again for any fractures (No matter how
small the fragment is)
- Dislocation associated with fractures
o For example: Terrible Triad or Olecranon fracture associated elbow
dislocation
o Requires ORIF - Refer to orthopaedic surgeon

Radial head fractures

Associations:
- Elbow dislocations, terrible triad injuries

Management
- Undisplaced fractures = Non-operative treatment (Barford-Jones sling for 3 weeks
and early pro-/supination ROM excercises)
- Displaced = Refer to Orthopaedic surgeon (May require excision of radial head, ORIF
or replacement)
- If associated with elbow dislocations or other fractures around the elbow = refer to
orthopaedic surgeon

Olecranon fractures

Management:
- Undisplaced and extensor mechanism intact (i.e. patient can actively extend the
elbow against gravity) = non-operative treatment (Sling for 3 weeks)
- Displaced fractures and / or extensor mechanism not intact = ORIF with tension band
wire

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Radius and ulna shaft fractures

Management:
- All displaced fractures = ORIF (plate and screws)

Galeazzi fractures

Definition:
- Radius shaft fracture associate with distal radio-ulnar joint (DRUJ) dislocation
Management:
- ORIF of radius and closed reduction of DRUJ

Monteggia fractures

Definition:
- Ulna shaft fracture associate with radial head dislocation

- Note: Normally (i.e. radial head not dislocated) a line through the centre of the radius
shaft will transect the centre of the capitellum on both the AP and LAT views

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Management:
- ORIF of ulna and closed reduction of radial head

Nightstick fractures

Definition:
- Isolated fracture of the shaft of the ulna resulting from a direct blow.
- No radius fracture and no joint dislocations.

Management:
- Below elbow backslab or cast typically sufficient until facture clinically united.

Radial styloid (shear) fracture (a.k.a. Chauffeur’s fracture)

Management: ORIF (it is an intra-articular fracture that tends to displace due to the shear
force)

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Dorsal Barton (shear)distal radius fracture

Management: ORIF (it is an intra-articular fracture that tends to displace due to the shear
force)

Extra-articlular (metaphyseal bending) distal radius fracture

Associated injuries:
- Median nerve injury
- Scapho-lunate ligament injury

An example of this type of fracture is a Colles fracture, which is characterized by the

following:
- Extraarticular metaphyseal bending fracture of the radius
- Dorsal angulation and translation (displacement)
- Radial angulation
- Impaction/shortening of the radius
- Always in osteoporotic bone (i.e. patients 50yrs of age)

Management:
- No osteoporosis/young patient:
o Tend to re-displace following closed reduction, therefore operative treatment
generally preferred in young patients.
o Discuss with orthopaedic surgeon.
- Osteoporosis/older patient (i.e. Colles fracture):
o Closed reduction under conscious sedation or Bier’s Block

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 o Well-moulded below-elbow cast with three-point pressure and slight flexion
and ulnar deviation of hand.

Intra-articular distal radius fractures

Management:
- Requires orthopaedic consultation
- Undisplaced fracture (with less than 2 mm step) can be treated non-operatively
- Displaced fractures: ORIF

Perilunate injuries

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Normal wrist x-rays:

Scapho-lunate dissociation:

- Separation of the scaphoid and the lunate due to ligamentous injury

- Diagnosis: Gap between scaphoid and lunate > 3-5mm (compare to normal side) on
AP x-ray (= Terry Thomas sign)
- Associations:
o Scaphoid or radial styloid fracture
- Management:
o Refer to Orthopaedic surgeon for ORIF

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Peri-lunate dislocation:

- Diagnosis: Capitate displaced dorsally of lunate (which is in its normal position)

- Associations:
o Scaphoid fracture
- Management:
o ORIF

Lunate dislocation:

- Diagnosis: Lunate dislocated volarly and not articulating with radius anymore
- Associations:
o Median nerve injury
o Scaphoid fracture or Radial Styloid fracture
- Management:
o ORIF

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Scaphoid fracture

Associations:
- Perilunate injuries
- Distal radius fractures
Diagnosis:
- Scaphoid views (x-rays)
- CT Scan
Management:
- Displaced: ORIF
- Undisplaced: Below-elbow cast x 3 months

Metacarpal fractures

- Undisplaced =
o 2nd metacarpal = no rotation and/or < 10° degrees apex volar angulation
o 3rd metacarpal= no rotation and/or < 20° degrees apex volar angulation
o 4th metacarpal = no rotation and/or < 30° degrees apex volar angulation
o 5th metacarpal = no rotation and/or < 40° degrees apex volar angulation

- Displaced =
o 2nd metacarpal = rotation and/or > 10° degrees apex volar angulation
o 3rd metacarpal= rotation and/or >20° degrees apex volar angulation
o 4th metacarpal = rotation and/or > 30° degrees apex volar angulation
o 5th metacarpal = rotation and/or > 40° degrees apex volar angulation

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Management:
- Undisplaced 4th or 5th metacarpal = Buddy strap 2 fingers plus ulnar gutter slab

- Undisplaced 2nd or 3rd metacarpal = Buddy strap 2 fingers plus radial gutter slab

- Displaced = ORIF

Boxer’s fracture = fracture of the 5th metacarpal typically due to the patient punching
something (or someone)

Management: Buddystrap ring and little finger plus ulnar gutter slab

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Bennet’s fracture = Base of 1st metacarpal fracture with subluxation 1st carpo-metacarpal
joint

Definitive management:
- Operative treatment for displaced fractures

Phalanx fractures

Management (closed fractures)

- Closed reduction under ringblock if displaced
- Buddy strap finger to adjacent uninjured finger

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 - Burkhalter type cast (with Metacarpophalangeal joint in 90° flexion) for 2-3 weeks
then buddy strap only

Fingertip injuries

Associations:
- Nailbed lacerations (which can later lead to nail deformities)
- Distal phalanx fractures

Management:
- Refer to orthopaedic surgeon for surgical repair of nailbed and soft tissues

Hand lacerations and tendon injuries

Initial management:
- Theoretically all deep hand lacerations needs to be explored in theatre and vitals
structures (tendons and nerves) repaired.
- Clean wound adequately with Aqueous Hibitane (1% solution) following local
anaesthetic. Remove all contamination and copious irrigation with saline.
- Dress the wound with sterile qauze and bandages.
- Refer to Orthopaedic Surgeon.

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Peripheral nerve injuries

Median nerve:
- Screening test: “OK” sign FPL and FDL index finger

Normal Abnormal

- Motor test : Power of abductor polices brevis

- Sensation test

- Median nerve palsy on inspection= Benediction sign

38
Ulnar nerve:
- Screening test: adduction and abduction of fingers

Normal Abnormal

- Motor: Froment’s test

- Sensation

- Ulnar nerve palsy on inspection= Ulnar claw hand

39
Radial nerve:

- Screening test: “Thumbs-up” Sign = thumb extension (EPL)

Normal Abnormal

- Motor: wrist extension

- Sensation

- Radial nerve palsy on inspection= Drop wrist

40
Spine Injuries
- The spine is composed of the vertebral column consisting of the osseous structures,
the intervertebral discs, ligaments and facet joints and the neural structures.
- The nerves are either the spinal cord (upper motor neurons) or nerve roots (lower
motor neurons).
- Injury to the neural elements is unlikely in the presence of stable vertebral column
injuries.

Spinal cord injuries (SCI)

Definitions:
- SCI = Damage to any part of the spinal cord or nerves at the end of the spinal canal
(cauda equina)
- Neurological level of injury (NLI) = Most caudal (inferior) segment of the cord with
normal sensation and ³ grade 3 muscle power.

Classification:
- Paraplegia vs Tetraplagia
o Paraplegia = only lower extremities involved
o Quadriplegia = upper and lower extremities involved

- Complete vs Incomplete
o Complete = no spared motor or sensory function below the affected level. I.e.
No voluntary anal contraction + absent sensation in S5 + patient out of spinal
shock (therefore bulbocavernosus reflex has returned)
o Incomplete = some preserved motor or sensory function below the injury level.
Different types of incomplete spinal cord injuries
§ Brown-Sequard syndrome
§ Central cord syndrome
§ Anterior cord syndrome
§ Posterior cord syndrome
§ Conus medullaris syndrome
§ Cauda Equina syndrome

- ASIA grading scale

o A = Complete
o B = Sensory incomplete
o C = Motor incomplete (muscle power grade < 3)
o D = Motor incomplete (muscle power grade ³ 3)
o E = Normal

Examination (please see examination techniques lecture notes)

- Muscle power grading scale:
o 0 = total paralysis
o 1 = visible contraction
o 2 = active full ROM (range of movement) with gravity eliminated
o 3 = active full ROM against gravity
o 4 = active full ROM against moderate resistance
o 5 = normal

41
 - Sensory function grading scale:
o 0 = absent sensation
o 1 = altered or decreased
o 2 = normal
- Spinal shock
o Temporary loss of spinal cord function and reflex activity below the level of the
SCI
o Characterized by flacid paralysis with absent reflexes including the
bulbocavernosus reflex (reflex characterized by anal sphincter contraction in
response to squeezing the glans penis or tugging on an indwelling Foley
catheter)
o Duration = End of spinal shock indicated by return of the bulbocavernous
reflex. Variable, usually within 48 hours
o Cause = neurons become hyperpolarized and unresponsive to stimuli from
brain
o Why is it important? Because one cannot evaluate neurologic deficit until
spinal shock phase has resolved
- Neurogenic shock
o Part of spinal shock. Circulatory collapse due to loss of sympathetic reflexes
and tone.
o Characterized by = Hypotension with or without Bradicardia
o Why is it important? Potentially fatal

Management:
- Prevent further damage to the cord: Spine immobilization (hard collar for cervical
injuries) and log-roll patient
- ATLS approach
- Primary survey
o Airway and Breathing: SCI above C5 may need intubation
o Circulation: Treat neurogenic shock. IV Fuid resuscitation, Vasopressor
(adrenalin), careful haemodynamic monitoring, NB = urine output (and CVP if
possible).
o Disability: Determine level, ASIA grade, complete vs incomplete
o Exposure: Warm patient
- Secondary survey
o Full head to toe examination to exclude other injuries (remember patient can’t
feel pain)
- Urgent reduction of spine injury = consult orthopaedic surgeon stat
o Cervical facet dislocations = require immediate closed reduction with cones
callipers

o Thoraco-lumbar injuries = requires surgical reduction

42
Cervical spine Injuries

- Bifacet dislocations are characterized by approximately 50% translation of vertebral

body and is often associated with neurological compromise.

- Unifacet dislocations are characterized by approximately 25% translation of vertebral

body and clinical (cockrobin) & radiological (spinous process asymmetry) signs of
rotation.

- Lateral, AP and open mouth xray views are required to visualise the spinal column.
- If the C7/T1 junction cannot be visualised on the lateral xray, a swimmers view should
be requested.
- Failing adequate visualisation on the swimmers view, a CT scan should be obtained.

Clearing a lateral cervical spine xray:

- Visualise down to the C7/T1 junction

- Soft tissue shadow not increased
- Anterior vertebral body line in tact
- Posterior vertebral body line in tact
- Spinolaminar line (junction of spinous process and lamina) in tact
- No splaying of spinous processes
- Individual vertebrae not fractured, including atlanto-dens interval < 3-5 mm.

43
Thoraco-lumber spine injuries

The vertebral column is divided into an anterior column (anterior half of disc and vertebral
body and anterior longitudinal ligament), middle column (posterior half of the disc and
vertebral body and posterior longitudinal ligament) and posterior column (pedicles, lamina,
spinous processes and interspinous ligaments). A 3 column injury is usually unstable and
requires surgical fixation.

Wedge compression fracture (stable)

Posterior vertebral body intact and compression of superior
(usually) endplate

Burst fracture (potentially unstable)

Posterior vertebral body affected/injured. One or both endplates
injured, but spinous process and interspinous ligaments not
affected.

Chance fracture (unstable)

Flexion distraction type injury with centre of rotation anterior to the
vertebral body. Minimal compression of vertebral body. Variants
include soft tissue and combined chance injuries.

Dislocation/Fracture-Dislocation/Shear injury (Unstable)

Translation in the coronal or sagittal plane across the
injury site. Often associated with

44
Pelvis fractures

Anterior-Posterior compression (open book injuries)

Lateral compression injuries

Vertical shear injuries

45
Pelvis Fractures associated injuries:
- Bleeding
- Bowel (rectal lacerations)
- Bladder/urethral rupture or vaginal lacerations

Initial management for patients with unstable pelvis fracture:

- ATLS approach
- Reduce haemorrhage - Bind pelvis with sheet over greater trochanters

- Resuscitate – Blood products preferred (Packed cells, Fresh Frozen Plasma,

Platelets)
- If patient remains haemodynamically unstable despite resuscitation:
o FAST ultrasound or DPL (diagnostic peritoneal lavage) to exclude intra-
abdominal bleeding:
§ If FAST or DPL positive (free fluid present in abdomen) = Emergency
laparotomy indicated
§ If FAST or DPL negative but patient remains hemodynamically =
Emergency surgery (pre-peritoneal packing) and ? external fixation of
pelvis
- If patient becomes haemodynamically stable after resuscitation:
o CT scan abdomen and pelvis with IV contrast to look for occult bleeding or
organ damage

Definitive management of pelvis fractures:

- Inlet and outlet x-ray views ± CT scan
- Consult orthopaedic surgeon
- Mostly non-operative (bed-rest until severe pain subsides then mobilize with crutches)
- Indications for surgery:
o Pubic diastasis >2.5cm or more then 50% superior translation of one
hemipelvis at the symphysis
o > 1cm displacement of fractures
o Complete SI joint separation (i.e. anterior, middle and posterior ligament
disrupted)
o Acetabulum fractures (if displaced)

46
Acetabulum factures

Diagnosis:
- May be difficult to see on normal AP pelvis X-ray: Ask for Judet views if uncertain

Associations:
- Hip dislocation (i.e. hip fracture dislocation)
- Sciatic nerve injury

Initial management:
- Reduce hip dislocation (see hip dislocations)
- Apply skin or skeletal traction

Definitive management:
- CT scan required
- Indications for surgery
o Displaced fractures (more than 2mm step or 5mm gap)
o Associated hip instability (subluxation or dislocation)
o Bone fragment in joint

Hip dislocations

Types:
- Posterior
o Most common
o Leg appears shortened and hip held in adduction and internal rotation
o Femoral head appears to have move superiorly on AP pelvis x-ray
- Anterior
o Rare

47
 o Leg does not appear shortened and hip held in abduction and external
rotation
o Femoral head appears to have moved inferiorly on AP pelvis x-ray)
- Central (Infrequent, femoral head has gone through the medial wall of the pelvis,
always associated with acetabulum fracture)

Associations:
- Sciatic nerve injury
- Acetabulum fractures
- AVN of the femoral head (up to 40%)
o Risk of AVN 5 x higher (odds ratio5.6) if hip not reduced within 12 hours
- OA hip (up to 60%)
Initial treatment:
- Emergency reduction in emergency department
- Conscious sedation (Dormicum and Morphine IV)
- Allis manoeuvre

- Confirm stable reduction (Hip in 90° flexion and 10° adduction apply slight postiorly
directed force on the femur to see if it re-dislocates)
- Repeat x-ray
- Repeat neuro-vascular examination
Definitive treatment:
- CT Scan to exclude fragments in the joint and confirm concentric reduction
- Mobilize toe-touch with crutches x 6 weeks

Intracapsular femur neck fractures

Associations:
- Initially patients present with dehydration and pre-renal failure
- Avascular necrosis of femoral head (30%)
- Non-union of fracture in fixation attempted (30%)
- Delay in prompt (<24-48 hours) surgical treatment increases morbidity and mortality:
o Bedsores
o Pneumonia
o UTIs
o DVT and pulmonary embolism
o Dehydration and electrolyte disturbances
o Myocardial infarcts
(Therefore, these fractures are never managed non-operatively)

48
Diagnosis:
- Clinically = Groin pain, leg shortened and externally rotated
- Radiologically = Hip x-ray (AP And LAT). Displaced fractures will show break in
Shenton’s line

-
Initial Management:
- Fluid resuscitation, check renal function, monitor urine output
- NO skin traction in bed (support leg with pillows in comfortable position)
- Prepare patient for theatre (within 48 hours)

(a) Undisplaced

Definitive Management:
- Urgent internal fixation

(b) Displaced

Definitive Management:
- Patients < 60 years = ORIF
- Patients 60-70 years (high demand and generally well) = Total hip replacement
- Patients >70 years (low demand and/or significant medical comorbidities) =
Hemiarthroplasty of hip

49
Intertrochanteric femur fractures

Associations:
- As for intra-capsular femur neck fractures
Definitive Management:
- Urgent internal fixation (dynamic hip screw or intra-medullary nail)

Sub-trochanteric femur fractures

Associations:
- High energy injury (typically younger patients) – look for other injuries (intrabdominal,
chest, spine, head, etc)
- Compartment syndrome of the thigh
- Fat embolism
Definitive Management:
- Urgent internal fixation (intra-medullary nail)

50
Femur shaft fractures

Associations:
- High energy injury (typically younger patients) – look for other injuries
(intrabdominal, chest, spine, head, etc)
- Compartment syndrome of the thigh
- Fat embolism syndrome
- Knee ligament injuries
- Femur neck fractures
Initial management:
- ATLS principles
- Fluid resuscitation
- Pain relief (IV Morphine)
- Thomas splint and skin traction
Definitive management:
- Intra-medullary nail

Distal femur fractures

Associations:
- Watch out for femoral or popliteal artery injury in young patients with high energy
trauma
- Also common in osteoporotic patients
Initial management:
- As for femur shaft fractures
Definitive management:
- ORIF (nail or plate)

51
Patella fractures

Definitive treatment:
- If undisplaced and active knee extension intact = non-operative treatment
- If displaced and/or active knee extension lost = operative treatment

Patella dislocations

Associations:
- Hyperlaxity
- Recurrent dislocations (15-40%)
- Patello-femoral OA on long term

Management:
- Reduce patella by extending knee and applying medial pressure on patella
- MRI recommended to exclude osteochondral or meniscal injuries
- Above-knee backslab in 20 degrees of flexion for 2-3 weeks
- Weightbearing mobilization with crutches
- Start mobilizing knee with physiotherapy as soon as pain allows (with patella-
stabilizing brace)
- Surgery should be consider if bony avulsion fragment visible on x-rays

52
Knee dislocations

Associations:
- Always multiple ligaments (ACL/PCL/MCL/LC) ruptured
- NB = very high risk of popliteal artery injury
- Peroneal nerve injury
- Tibial plateau fractures (Fracture-dislocations)
- Compartment syndrome in lower leg
Initial treatment:
- Immediate closed reduction in casualties

- Above knee backslab

- Urgent CT angiogram of leg and vascular surgery consult
Definitive treatment:
- Refer to orthopaedic surgeon for ligament reconstruction (within 3 weeks)

Tibial Plateau fractures

Associations:
- Knee ligament or meniscus injury
- Knee dislocation
- In high energy injuries:
o Compartment syndrome

53
 o Open fractures
o Arterial injury
- If mechanism of injury = Fall from a height
o Calcaneus or talus fracture
o Tibial plafond fractures
o Acetabulum fractures
o Thoraco-lumbar fractures
o Intra-abdominal injuries
Initial management:
- Below knee skin traction (or above knee backslab)
- Elevation and Ice
Definitive management:
- Discuss with orthopaedic surgeon
- CT scan
- All displaced fractures treated operatively (intra-articular fracture in weightbearing
joint)
- Operative treatment generally delayed until soft tissues

Tibia shaft fractures

Associations:
- Most common open fractures
- Compartment syndrome in closed fractures
Initial management:
- As for open fracture if open
- Above knee back slab
- Monitor closed fractures for compartment syndrome
Definitive management:
- Intramedullary nail (operative)

Tibial plafond fractures

54
Associations:
- Severe soft tissue swelling
- If mechanism of injury = Fall from a height
o Calcaneus or talus fracture
o Tibial plafond fractures
o Acetabulum fractures
o Thoraco-lumbar fractures
o Intra-abdominal injuries
- Long-term: post traumatic osteoarthritis
Initial management:
- Back slab
- Elevation and ice
Definitive management:
- Discuss with orthopaedic surgeon
- CT scan
- All displaced fractures treated operatively (intra-articular fracture in weightbearing
joint)

Ankle fractures

Danis-Weber classification of ankle fractures:

Type A: Fibula fracture below the level of the syndesmosis

Type B: Fibula fracture at the level of the syndesmosis

Type C: Fibula fracture above the level of the syndesmosis

55
Nomenclature:
- Medial malleolus fracture =

- Lateral malleolus fracture =

- Posterior malleolus fracture =

- Bimalleolar fracture = Medial + Lateral malleolus fracture

- Trimalleolar fracture = Medial + Lateral + Posterior malleolus fracture

- Fracture-subluxation = Any displaced ankle fracture with partial loss of articulation

between tibia and talus

- Fracture-dislocation = Any displaced ankle fracture with complete loss of articulation

between tibia and talus

56
Initial management:
- NB: If ankle subluxed/dislocated– emergency closed reduction in casualties
o Conscious sedation
o Closed reduction technique
§ The typical displacement in most ankle fractures is posterior and
lateral, usually with the foot externally rotated

§ Correct lateral displacement

§ Correct posterior displacement

57
 § Apply below knee backslab with POP slabs on 3 sides (posteriorly,
medially and laterally)

§ Apply three-point pressure to maintain reduction

§ Avoid placing the ankle in equines position

- Three X-ray views: AP, Lateral and Mortis view

- Elevation

58
Definitive management:
- The only fracture that can be treated non-operatively = Isolated, undisplaced (<2 mm
displacement) lateral malleolus fracture
o 6 weeks in below knee cast
o limited (non or partial) weightbearing
o Strict follow-up @ 1, 2, 4 AND 6 weeks
§ Check if POP loose or worn – if it is, replace it
§ Repeat X-ray at each visit to make sure fracture has not displaced
§ If fracture displaces at any point - ORIF required
- All other ankle fractures need surgery (ORIF) once soft tissue swelling subsided
(including all bimalleolar fractures)

Lateral ankle ligament injuries

Classification:
- Grade 1 = Anterior Talofibular Ligament (ATFL) injury only
- Grade 2 = Anterior Talofibular Ligament (ATFL) injury and partial Calcaneofibular
ligament (CFL) injury
- Grade 3 = Anterior Talofibular Ligament (ATFL) injury and complete rupture of
Calcaneofibular ligament (CFL)

Diagnosis:
- Distinguish grade 1 from grade 2 by: Absence of tenderness directly inferior of tip of
lateral malleolus (i.e. Over CFL)
- Distinguish grade 2 from grade 3 with: Clinically (grade has marked swelling and
ecchymosis), Ultrasound (or stress views)

Management:
- X-rays indicated if: (Ottowa ankle rules)
o Bone tenderness of the lateral malleolus / fibula, or
o Bone tenderness of the medial malleolus, or
o An inability to bear weight both immediately and in the emergency department
for four steps

(Note: this only applicable in isolated injuries in fully awake and cooperative
patients)

59
 - Phase 1 = RICE and immobilization
o Duration =
§ Grade 1 or 2 = 1-3 days
§ Grade 3 = 7-10 days
o RICE
§ Rest (Non weightbearing)
§ Ice
§ Compression
§ Elevation
o Immobilization
§ Grade 1 or 2 = Lace up ankle brace with rigid collateral support
§ Grade 3 = “Mooonboot” or backslab

- Phase 2 = Functional rehabilitation

o Physiotherapy: restoring range of motion, strength and flexibility.
Propriocepttive retraining
- Phase 3 = Gradual return to activity
o Lace up ankle brace with rigid collateral support during high risk activities

Talus neck fractures

Associations:
- Avascular necrosis
- Subtalar joint ± Ankle joint ± Talonavicular joint subluxation or dislocation
Definitive management:
- Urgent referral to orthopaedic surgeon if associated with adjacent joint dislocation
- ORIF for all displaced fractures (CT scan required)

Calcaneus fractures

60
Associations:
- Severe soft tissue swelling
- Compartment syndrome of the foot
- Post-traumatic OA of the subtalar joint
Initial management:
- Strict bedrest, elevation and ice packs
Definitive management:
- Undisplaced fractures = non-operatively = Below knee cast non-weightbearing 6-12
weeks
- Displaced fractures controversial, therefore has to be discussed with an orthopaedic
surgeon
o Displaced tongue type fractures generally need surgical management
o For displaced joint depression type fractures: Evidence currently shows no
advantage in surgical management, therefore non-operative management
preferred.

Tarso-metatarsal fracture dislocation (Lisfranc injuries)

Diagnosis:
- AP, Lateral and oblique views of the foot
- Compare with normal foot – look for
o Metatarsal and tarsal bones should normally line up

o Widening of the space between 1st and 2nd metatarsal base = abnormal
o Avulsion fracture and medial corner of the base of the 2nd metatarsal
o Dorsal displacement of metatarsal bases on lateral view

61
 o Weightbearing views and stress views (pro-/supination of forefoot) helps for
subtle injuries
Associations:
- Metatarsal fractures
- Severe soft tissue swelling
- Compartment syndrome of the foot
- Post-traumatic OA
Definitive management:
- If no displacement on stress views = Below knee cast for 8 weeks
- Displaced or unstable (displaces on stress views = operative treatment (once swelling
subsides)

Metatarsal fractures

Associations:
- Lisfranc injuries
Definitive management:
- Non-operative (stiff soled shoe or moonboot with weight bearing as tolerated):
o Undisplaced 1st metatarsal fracture
o Isolated fractures of 2nd to 4th metatarsals
o Undisplaced or minimally displaced fractures 2nd to 4th
o Stress fractures
o Base 5th metatarsal fracture
- Operative
o Displaced 1st metatarsal fractures
o Multiple fractures 2nd to 4th metatarsals
o 2nd to 4th metatarsals with > 10 degrees of plantar/dorsal angulation
o Zone 2 and 3 base 5th metatarsal fracture if no signs of healing after 6 weeks
of non-operative treatment

62
Toe fractures

Definitive treatment:
- Generally non-operative (except open fractures of course)
o Strap forefoot (not toes, as the metatarsals splay during weightbearing)
o Heel-walking shoe

63
Paediatric Orthopaedic Trauma

64
Unique paediatric fracture types:

Children’s bone is different from adult bone. It is more likely to fracture incompletely when the
load exceeds the strength of the bone. Three common patterns occur:

1. Greenstick fracture: one cortex fails in tension and the opposite remains intact

2. Torus or buckle fracture: one cortex fails in compression and the opposite remains
intact

3. Plastic deformity: a child’s long bone under load may exceed the range of elastic
deformation and deform permanently without breaking. This commonly happens in
the ulna and may be associated with a dislocation of the radial head/capitellum
articulation. This is a variation of the Monteggia-fracture. Corrective osteotomy and
reduction of the radial head is indicated

65
Growthplate injuries (Salter-Harris injuries)

Injuries to the physis are classified according to the Salter-Harris classification. If the fracture
extends through the whole growth plate (Types 3 to 5) it is likely that future growth will be
affected. The most common is type 2, often seen in the distal radius.

Specific injuries around the distal tibia in adolescents:

1. Juvenile Tillaux fracture is a Salter-Harris type 3 of the anterolateral distal tibial

epiphysis

2. Triplanar fracture is a complicated fracture pattern that appears as a type 3 on the

AP and a type 2 on the lateral

66
Growth centres around the elbow
It is important to know the secondary ossification centres around the elbow and when they
appear. Both to estimate the skeletal age of the child and to avoid misdiagnosing a fracture.
They can easily be remembered by the mnemonic CRITOE

Supracondylar Humerus fractures

Classification:

Grade 1 (undisplaced) = “fat pad sign”

67
Grade 2 (partially displaced)

Grade 3 (displaced)

Associate injuries:
- Median (anterior interosseous) nerve injury > ulnar nerve injury
- Brachial artery injury
- Compartment syndrome (forearm)
- Distal radius fracture

Initial Management:
- Check median nerve function
- Check Peripheral perfusion (compare to normal side)
o Temperature of hand
o Radial pulse
o Capillary refill
o Colour of palm of hand
o Classify into three groups according to perfusion status

Group Hand Capillary refill Radial pulse Management

I Warm <4sec Intact Urgent reduction
II Warm <4sec Absent Urgent reduction (<6-8hrs)
III Cool >4sec Absent Emergent reduction (1-2hrs), if no
return of circulation, anterior
approach and vascular repair by
micro vascular surgeon with
fasciotomy if >6 hrs. to surgery.

68
 - If signs of impaired perfusion = group 3
o Immediate closed reduction in casualty department
o Oral analgesia (paracetamol and Valoron (tilidine) drops)
o Closed re-alignment of the fracture (does not have to be anatomical reduction,
you just need to reduce the pressure on the artery i.e. reduce the severe
angulation):
§ Axial traction
§ Supinate the forearm
§ Correct varus or valgus
§ Push olecranon anterior with thumb while pushing the humerus shaft
posterior, while flexing the elbow
§ Immobilize the elbow in slight flexion 60-90 degree and check that
pulse/perfusion returns.
§ If it remains cool and pulseless helicopter transfer required to access
microvascular service.

Definitive treatment:
- Grade 1 = Above elbow backslab in >90 degree flexion for 3-4 weeks
- Grade 2 = Closed reduction and above elbow backslab for for 3-4 weeks in
approximately 120 degree flexion if vascular status allows (refer to orthopaedic
surgeon, may need closed reduction and K-wires)
- Grade 3 = Closed reduction and K-wires (refer to orthopaedic surgeon)

Lateral condyle fractures

Frequently missed injury – Therefore maintain high index of suspicion and always compare
x-rays to normal side

Definitive treatment:
- Refer to orthopaedic surgeon – requires open reduction and internal fixation

69
Forearm shaft fractures

Angulation will correct (to some extent) due to remodelling that occurs in children

Indication for reduction

- Patients < 8 year =
o > 15 degree angulation
o Any loss of radial bow
o (note: complete displacement (translation) still acceptable)

- Patient ³ 8 years =
o > 10 degree angulation
o Any loss of radial bow
o (note: complete displacement (translation) still acceptable)

Definitive treatment:
- If fracture deformity as stated above – open reduction and internal fixation

Distal radius fractures

70
Indication for Closed reduction and K-wires ( Degrees = Angulation in sagittal plane)

Age Boys Girls

14 0° 0°
13 10° 0°
12 15° 0°
11 20° 10°
10 25° 15°
9 30° 20°
8 30° 25°
7 30° 30°
6 30° 30°
5 30° 30°
4 30° 30°
3 30° 30°
2 30° 30°
1 30° 30°

Femur Fractures

Femoral shaft fractures in children are common.

There is a bimodal incidence with the first peak in early childhood (generally low energy and
isolated injury) and the second in mid-adolescence (associated with MVA). In reality these
two groups overlap and young paediatric patients with polytrauma are not uncommonly seen.
Diagnosis is not difficult in isolated injuries due to extreme pain, deformity and inability to
walk.

71
Mechanism of injury ranges from a simple fall while running to falls from height and non-
accidental injury. The highest incidence of NAI in children presenting with a femur fracture
occur in those that are unable to walk.

In all patients open fracture; vascular injury and compartment syndrome must be excluded.
Fat embolism syndrome is often subclinical in children and a high index of suspicion for
respiratory and neurological impairment must be maintained.

Associated injuries in any child presenting with a femur fracture should be actively excluded:
specifically head and spinal injuries, thoraco-abdominal injuries and pelvic fractures.
Systematic and complete head to toe examination is essential in the patient with multiple
injuries

Initial management:
- ATLS principles: Primary and Secondary survey
- IV Fluid and opiate analgesia
- Splinting of the femur (Thomas splint – convert to balanced traction in the ward or
spica cast)

Definitive management:
- Patients younger than 24 months with low energy fractures and minimal soft tissue
injury may be treated with immediate spica cast. Exclude NAI prior to discharge.

- <24mo
o <10kg with soft tissue injury or associated injury: admit for Gallows traction
and conversion to spica cast once associated injuries appropriately managed.
o >10kg with soft tissue injury or associated injury: admit for Thomas splint (if
appropriate size available, otherwise fashion plaster or fiberglass splint from
iliac crest to ankle)

- 2 – 5 yr
o <1,5cm of shortening and no severe soft tissue injury or associated injury may
be treated with immediate spica casting either in the emergency department
or in the operating theatre. Exclude NAI prior to discharge.
o >1,5cm of shortening and associated injury: admit with Thomas splint and
balanced traction for delayed conversion to spica cast.

- 6-10 yr
o Appropriate resuscitation, rule out associated injuries
o Admit for Thomas splint and balanced traction
o Operative vs non-operative treatment individualized
o TENS for length stable fractures only
o Consider plating or external fixation

72
 - 10-12 yr +
o Appropriate resuscitation, rule out associated injuries
o Admit for Thomas splint and balanced traction
o Pediatric lateral trochanteric entry locked intra-medullary nailing
o Consider plating or external fixation

Acceptable Angulation
Age (years) Varus/Valgus Anterior/Posterior Shortening (mm)
(deg) (deg)
0–2 30 30 15
2–5 15 20 20 (due to
overgrowth)
6 – 10 10 15 15
11 – adult 5 10 10

Pitfalls:
- Exclude associated injuries, especially lung contusion. Pediatric rib fractures are rare
due to bone plasticity. Absence of rib fractures does not exclude lung contusion.
Diagnosis is essential to ensure High-care/ICU admission and appropriate care.
- Exclude Non-accidental injury or bone softening conditions such as Osteogenesis
Imperfecta

73