4: Orthopaedic Emergencies

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Section 4 Orthopaedic Emergencies

Edited by Anthony F.T. Brown, Anne-Maree Kelly

4.1 Injuries of the shoulder 154
4.2 Fractures of the humerus 157
4.3 Dislocations of the elbow 161
4.4 Fractures of the forearm and carpal bones 163
4.5 Hand injuries 168
4.6 Pelvic injuries 174
4.7 Hip injuries 178
4.8 Femur injuries 182
4.9 Knee injuries 184
4.10 Tibia and fibula injuries 190
4.11 Ankle joint injuries 193
4.12 Foot injuries 197

4.1 Injuries of the shoulder

Anne-Maree Kelly

Essentials

1 Most clavicular fractures heal despite displacement, therefore reduction is not necessary.
2 Injuries to the shoulder region may also involve injury to local neurovascular structures.
3 Acromioclavicular joint injuries and fractures of the scapula are usually treated conservatively.
4 Posterior sternoclavicular dislocations require reduction.
5 In dislocation of the shoulder, careful examination of the axillary (circumflex) nerve, brachial plexus and axillary artery is mandatory both before and after reduction.
6 In anterior dislocation of the shoulder, surgical repair of the capsule is recommended for recurrent dislocators and first-time dislocators who are young and engaged in high-risk sports.

Fractures of the clavicle

Fractures of the clavicle account for 2.6–5% of all fractures and usually result from a direct blow on the point of the shoulder, but may also be due to a fall on the outstretched hand. The most common site of fracture is the middle third of the clavicle, which accounts for 69–82% of clavicular fractures. There are varying degrees of displacement of the fracture ends, with overlapping fragments and shortening being common. Owing to the strategic location of the clavicle, injury to the pleura, axillary vessels and/or brachial plexus is possible, but fortunately these complications are rare.

The clinical signs of clavicular fracture are a patient supporting the weight of their arm at the elbow and local pain and tenderness, often accompanied by deformity.

In non-displaced or minimally displaced fractures, treatment consists of an elbow-supporting sling (e.g. broad arm sling) for 2–3 weeks. For comfort, this may be worn under clothes for the first few days. The sling may be discarded when local tenderness has subsided. Note that clinical union precedes radiological union by weeks. Early shoulder movement should be encouraged within the limits of pain. Non-union is rare.

Midshaft fractures with complete displacement, comminution or fractures in the elderly or women with osteoporosis, have a higher rate of non-union and poorer functional outcome. Recent evidence suggests that this group may benefit from surgical stabilization with either plate-and-screw fixation or intramedullary devices. Fractures of the outer third of the clavicle may involve the coracoclavicular ligaments. If so, surgical management should be considered. This may be performed by open or arthroscopic techniques.

Late complications include shoulder stiffness and a local lump at the site of fracture healing, which is rarely of cosmetic significance.

Acromioclavicular joint injuries

Acromioclavicular (AC) joint injuries usually result from a fall where the patient rolls onto his/her shoulder. The degree of the injury relates to the number of ligaments damaged. The clavicle is attached to the scapula by acromioclavicular, trapezoid and conoid ligaments. In sprains and subluxations, only the AC ligament is damaged; in dislocations, the conoid and trapezoid ligaments are also ruptured and displacement may be severe.

On clinical examination of the standing patient, the outer end of the affected clavicle may be prominent and there will be local tenderness over the AC joint. The degree of damage can be ascertained by taking standing X-rays of both shoulders with the patient holding weights in both hands (stress X-rays) and by ultrasound. Stress X-rays may be normal in mild strains, but dynamic ultrasonographic techniques may better define the injury.

Treatment is with a broad arm sling. For minor sprains 1–2 weeks is usually sufficient; dislocations may require 4–6 weeks of immobilization. If there is gross instability, surgery should be considered.

Sternoclavicular subluxation and dislocation

Sternoclavicular injuries are uncommon and usually due to a fall on the outstretched hand or a blow to the front of the shoulder. Subluxation is more common than dislocation, with the affected medial end of the clavicle displaced forwards and downwards. Dislocations may be anterior or, rarely, posterior. In the latter case, the great vessels or trachea may be damaged.

Clinical features include local tenderness and asymmetry of the medial ends of the clavicles. The diagnosis is essentially clinical. X-rays can be difficult to interpret. They are not necessary for subluxations, but may be helpful to confirm major dislocations. CT scanning may assist in identification.

Subluxations should be treated in a broad arm sling for 2–3 weeks. Anterior sternoclavicular joint instability should also be treated conservatively; however, there is a significant risk of ongoing instability that is usually well tolerated and of little, if any, functional impact. For patients with posterior dislocation expeditious diagnosis and treatment are important. Closed reduction, performed under general anaesthesia, is usually stable and the joint can then be managed in a brace or sling for 4–6 weeks. Operative stabilization is required if closed reduction is unsuccessful or there is persistent instability.

Fractures of the scapula

Fractures of the scapula are uncommon, accounting for less than 1% of all fractures. They typically occur after high-energy trauma, and up to 90% of patients have other associated injuries.

Fractures of the blade of the scapula are usually due to direct violence. Clinical features are local tenderness, sometimes with marked swelling. Healing is usually rapid, even in the presence of comminution and displacement, with an excellent functional outcome. Treatment is non-operative, with a broad arm sling and early mobilization.

Fractures of the scapula neck are often comminuted and may involve the glenoid. Swelling and bruising of the shoulder may be marked. Clinical examination and X-rays should ensure that the humeral head is enlocated. Computed tomography (CT) scans may be useful in defining the anatomy and the degree of involvement of the glenoid, including any steps in the articular surface. Surgery is often indicated for fractures involving the scapular neck or glenoid.

The ‘floating shoulder’ is an uncommon injury pattern. Although it is usually defined as an ipsilateral fracture of the clavicle and scapular neck, recent studies suggest that ligamentous disruption associated with a scapular neck fracture can give the functional equivalent of this injury pattern, with or without an associated clavicle fracture. Because the degree of ligament disruption is difficult to assess, indications for non-surgical and surgical management are not well defined. Minimally displaced fractures typically do well with conservative management. The degree of fracture displacement and ligament disruption that results in poor outcome with conservative management is not well defined and the indications for surgery are controversial, as is choice of surgical technique. Options include fixation of the clavicular fracture, which often indirectly reduces the scapular fracture, or fixation of both fractures.

Rotator cuff injuries

Rotator cuff injuries become more common with advancing age as degeneration weakens the cuff. Indeed, the presence of asymptomatic partial or complete tears identified on ultrasound or MRI may be as high as 40% in patients aged over 50.

Symptomatic injuries may follow minor trauma or the sudden application of traction to the arm. Many are acute on chronic in nature, rather than truly acute, and this can be defined with ultrasound or MRI if required. The clinical features of a strain include a painful arc of abduction centred at 90° of abduction, and tenderness under the acromion. If the tear is complete, no abduction at the glenohumeral joint will occur, although some abduction to 45–60% is possible by scapular rotation. In both cases there is a full passive range of abduction.

Treatment of rotator cuff strains is conservative, usually including analgesia and physiotherapy. Local injection of hydrocortisone may be useful if symptoms persist. Treatment of rotator cuff tears is controversial, with no clear evidence guiding the choice of operative versus non-operative therapy or the components or duration of non-operative treatments. Most experts would still recommend a trial of non-operative therapy before considering surgery. An exception to this may be the patient with a previously asymptomatic shoulder who sustains trauma with resultant weakness (after the pain from the injury subsides) in whom imaging studies indicate an acute full-thickness tear.

Dislocation of the shoulder

Dislocation of the shoulder results in the humeral head lying anterior, posterior or inferior to the glenoid. Of these, anterior dislocation is the most common.

Anterior dislocation

Anterior dislocation of the shoulder is most often due to a fall resulting in external rotation of the shoulder, for example the body rotating internally over a fixed arm. It is most common in young adults, often being related to sports. There is inevitable damage to the joint capsule (stretching or tearing), and there may be associated damage to subscapularis and the greater trochanter of the humerus. Complications may include damage to the axillary (circumflex) nerve (resulting in inability to contract deltoid and numbness over the insertion of deltoid) and, rarely, the axillary vessels and the brachial plexus.

Clinical features include severe pain, reluctance to move the shoulder, and the affected arm being supported at the elbow, often in slight abduction. The contour of the shoulder is ‘flattened off’ and there is a palpable gap just under the acromion where the humeral head usually lies. The displaced humeral head may be palpable anteriorly in the hollow behind the pectoral muscles. Dislocation is confirmed by X-ray. The dislocation may be evident on the AP film but cannot be ruled out on a single view. Additional views (e.g. an axial lateral, translateral, tangential lateral) are required. These may reveal an associated fracture of the greater trochanter, but this does not influence initial management.

The principles of management are the provision of adequate analgesia as soon as possible (ideally, this should take the form of titrated intravenous opioid), reduction of the dislocation, and immobilization followed by physiotherapy. There are more than 20 described methods for the reduction of anterior dislocations, with reported success rates ranging from 60% to 100%. These include the Spaso technique, the modified Kocher’s manoeuvre, the Milch technique and scapular rotation techniques. There is no high-quality evidence to assist in selecting the most effective. That said, the Hippocratic method is not recommended as the traction involved may damage neurovascular structures. Gravitational traction, having the patient lie face down with a weight strapped to the limb, is occasionally successful and may be worthwhile if there will be a delay until reduction by another method. All reduction methods require adequate analgesia. Intra-articular local anaesthetic may also be useful. Sedation, in an appropriately controlled environment, may be of assistance in augmenting analgesia and providing a degree of muscle relaxation and amnesia. Failure of reduction under analgesia/sedation is rare and mandates reduction under general anaesthesia.

Spaso technique

The patient is placed in the supine position. The affected arm is held by the forearm or wrist and gently lifted vertically, applying slight traction. While maintaining vertical traction, the shoulder is externally rotated, resulting in reduction.

Modified Kocher’s manoeuvre

While applying traction to the arm by holding it at the elbow, the shoulder is slowly externally rotated, pausing if there is muscle spasm or resistance. External rotation to about 90° should be possible, and reduction often occurs during this process. The elbow is then adducted until it starts to cross the chest, and then internally rotated until the hand lies near the opposite shoulder.

Scapular rotation

This technique is traditionally performed with the patient prone, but can be performed on a seated patient. For both variations, the scapula is manipulated by adducting (medially displacing) the inferior tip using thumb pressure while stabilizing the superior aspect with the other hand.

Post-reduction X-rays confirm reduction, and neurovascular status must be rechecked. The arm should be immobilized in a sling under clothes for several days and the patient advised not to abduct or externally rotate the arm. This should be followed by an external broad arm sling and physiotherapy. The duration of immobilization and the timing of physiotherapy are controversial.

If there is an associated fracture of the greater trochanter, it usually reduces when the shoulder is reduced. If it remains displaced, open reduction and internal fixation may be required.

Primary surgery, usually by arthroscopic techniques, is recommended for patients having suffered recurrent dislocations and should be considered for first-time dislocators, especially those who are young, as surgery has been shown to significantly reduce the risk of recurrent dislocation.

Recurrence is rare in the elderly, but approaches 50% in younger patients.

Posterior dislocation

Posterior dislocation is frequently mentioned in medicolegal reports as it is easy to miss, especially in the unconscious. It may result from a fall on the outstretched or internally rotated hand, or from a blow from the front. It is also associated with seizures and electrocution injuries, where it is not uncommonly bilateral. The dislocation is usually not apparent on an AP film, so additional views are required. Reduction is performed by traction on the limb in the position of 90° abduction, followed by external rotation. Aftercare is the same as for anterior dislocation.

Posterior dislocation is prone to recurrence. Good functional outcomes are associated with early detection and treatment, a small osseous defect, and stability following closed reduction. Poor prognostic factors include late diagnosis, a large anterior defect in the humeral head, deformity or arthrosis of the humeral head, an associated fracture of the proximal part of the humerus and the need for an arthroplasty. The indications for surgery are controversial.

Inferior dislocation

This type of dislocation is rare and usually obvious, as the arm is held in abduction. Neurovascular compromise is a significant risk requiring careful examination and prompt reduction. Reduction is by traction in abduction followed by swinging the arm into adduction. Aftercare is the same as for anterior dislocation.

Controversies

• The role of surgery for midshaft clavicular fractures.
• Timing of mobilization after dislocation of the shoulder.
• The role of surgery in rotator cuff tears.
• The best technique for reduction of anterior dislocation of the shoulder.
• Surgery for first dislocations of the shoulder.

Further reading

Bicos J, Nicholson GP. Treatment and results of sternoclavicular injuries. Clinical Journal of Sport Medicine. 2003;22:359-370.

Canadian Orthopaedic Trauma Society. Non-operative treatment compared with plate fixation of displaced midshaft clavicular fractures. A multi-center randomized clinical trail. Journal of Bone and Joint Surgery. 2007;89A:1-10.

Kuhn JE. Treating the initial anterior shoulder dislocation – an evidence-based medicine approach. Sports Medicine and Arthroscopy Review. 2006;14:192-198.

Miljesic S, Kelly AM. Reduction of anterior dislocation of the shoulder: the Spaso technique. Emergency Medicine. 1998;10:173-175.

Oh LS, Wolf BR, Hall MP, et al. Indications for rotator cuff repair: a systematic review. Clinical Orthopaedics and Related Research. 2007;455:52-63.

Zlowodzki M, Bhandari M, Zelle BA, et al. Treatment of scapula fractures: systematic review of 520 fractures in 22 case series. Journal of Orthopaedic Trauma. 2006;20:230-233.

4.2 Fractures of the humerus

Timothy Rainer, Raymond Chi Hung Cheng

Essentials

1 Fractures of the proximal humerus occur primarily in the elderly, whereas distal humerus fractures occur more often in children.
2 Falls producing fractures in elderly patients are often precipitated by an underlying medical problem that should be sought and managed.
3 Most proximal humeral fractures do not require surgical intervention.
4 The aim of treatment is to minimize pain, to maximize the return of normal function as soon as possible, and to achieve acceptable cosmesis.
5 Humeral shaft fractures, displaced distal humeral fractures and fractures associated with neurovascular compromise require early orthopaedic review.
6 Low-force fractures, especially in the elderly, suggest the presence of osteoporosis. ‘At-risk’ patients not already identified as having osteoporosis should be referred for bone density scans and vitamin D testing and treatment.

Introduction

The function of the upper limb depends on an intact shoulder girdle that is in turn affected by the integrity of muscles, tendons and ligaments, bones, joints, blood vessels and nerves. Fractures of the humerus severely limit efficient function of the upper limb, and may be divided into proximal (neck), middle (shaft) and distal (supracondylar) segments.

Fractures of the proximal humerus

Patterns of injury

Fractures of the proximal humerus represent 5% of all fractures presenting to emergency departments (ED) and 25% of all humeral fractures. The fracture typically occurs as a result of an indirect mechanism in elderly, osteoporotic patients who fall on their outstretched hand with an extended elbow. These injuries are important to understand, as the majority do not require surgical intervention and may initially be treated in the ED. A subset with non-viable humeral head requires early surgical intervention, and it is therefore important to identify this group. Fractures of the humerus may also occur in patients with multiple injuries or in the elderly with associated fractures of the neck of femur.1

Clinical assessment

History and examination

Patients typically present soon after injury holding their arm close to the chest wall. They complain of pain, and exhibit swelling and tenderness of the shoulder and upper arm. Although crepitus and bruising may occur, the former should not be elicited because it causes excessive and unnecessary pain. Bruising is usually delayed, occurring several days after injury. It appears around the lower arm rather than at the fracture site as a result of gravity and blood tracking distally.

A neurovascular examination is essential as the axillary nerve, brachial plexus and/or axillary artery may be damaged. The axillary nerve is the most commonly injured, and presents with altered sensation over the badge area (insertion of the deltoid) and reduced deltoid muscle contraction (which may be hard to assess because of pain). The axillary artery is the commonest vessel to be injured and may present with any combination of limb pain, pallor, paraesthesia, pulselessness, poor limb perfusion and paralysis.

As these injuries frequently occur in elderly patients, careful attention must be paid to the reason for the fall, as an underlying acute medical condition may have precipitated the event and require management in its own right.

Investigations

Three radiographic views – anteroposterior, lateral and axillary – will allow most proximal humeral fractures to be correctly diagnosed.

Fracture classification

Although the majority of these fractures are easily managed in the ED, the challenge is to differentiate these from the minority that require orthopaedic intervention.

Neer classification system

In this system, fractures are classified first according to four anatomical sites (anatomical and surgical necks, greater and lesser tuberosities); second, according to the number of fragments (one to four parts); and third, according to the degree of fracture displacement, defined as 1 cm separation or >45° angulation (Figs 4.2.1 and 4.2.2).

image

Fig. 4.2.1 Neer classification with two-part fractures of (a) the anatomical neck, (b) the surgical neck, (c) the greater tuberosity and (d) the lesser tuberosity.

image

Fig. 4.2.2 Neer classification with three-part fractures of (a) the greater tuberosity and anatomical neck, (b) the lesser tuberosity and anatomical neck, and (c) four-part fracture involving the anatomical neck, greater tuberosity and lesser tuberosity.

One-part fracture

One-part fractures account for 80% of proximal humeral fractures. Any number of fracture lines may exist, but none are significantly displaced.

Two-part fracture

Two-part fractures account for 10% of proximal humeral fractures, and usually one fragment is significantly displaced. Two-part fractures of the humerus may involve the anatomical neck (Fig. 4.2.1a), the surgical neck (Fig. 4.2.1b), the greater tuberosity (Fig. 4.2.1c) or the lesser tuberosity (Fig. 4.2.1d).

Three- and four-part fracture

Three- and four-part fractures account for the remaining 10% of proximal humeral fractures, with two or three significantly displaced fragments (Fig 4.2.2a–c).

Management

One-part fractures (both displaced and undisplaced) and undisplaced two-part fractures can be treated with a collar and cuff sling, adequate analgesia and follow-up. Early mobilization is important, and the prognosis is good.

Definitive management of displaced two-part fractures may include open (intraoperative) or closed reduction depending upon neurovascular injury, rotator cuff integrity, associated dislocations, likelihood of union and function. Early orthopaedic assessment is recommended.

For undisplaced three- and four-part fractures, the consensus is for open reduction and internal fixation. However, recent reviews suggest that there is little evidence that surgery is superior to the non-operative approach.2

For displaced proximal humeral fractures, surgical management remains varied and controversial.3 Small randomized controlled trials suggest that external fixation may confer some benefit over closed manipulation,4 and that conservative treatment is better than tension band osteosynthesis.5 A recent study shows that the decision should be made according to the viability of the humeral head. Locking plate technology may also provide better outcomes in patients with unstable displaced humeral fractures having a viable humeral head.6 Other small-scale studies suggest that some bandaging styles may be better than others,7 that early physiotherapy may improve functional outcome, but that pulsed high-frequency electromagnetic energy gives no additional benefit.8

Special cases

Fracture of the anatomical neck and articular surface

Fractures at these sites are uncommon, but are important to recognize as they have a high incidence of compromised blood supply to the articular segment, may result in avascular necrosis and may require a humeral hemiarthroplasty.

Fracture dislocations

Fractures of the greater tuberosity accompany 15% anterior glenohumeral dislocations and may be associated with rotator cuff tears. Although the fracture may be grossly displaced, reduction of the dislocated shoulder usually also reduces the fracture. In patients who require the full range of movement of their shoulders, surgical repair of the cuff may be required.

Fractures of the lesser tuberosity are associated with posterior glenohumeral dislocations.

Disposition

Most patients with undisplaced one- and two-part fractures may be discharged from the ED with a collar and cuff sling, analgesia, early mobilization and appropriate follow-up. High-risk cases, including displaced three- and four-part fractures, all open fractures, and the special proximal humeral fractures described above, require orthopaedic consultation and admission, as do those with medical problems requiring investigation or treatment.

Low-energy fractures, especially in the elderly, suggest the presence of osteoporosis. ‘At-risk’ patients not already identified as having osteoporosis should be referred for bone density scans and vitamin D testing and treatment.

Fractures of the shaft of humerus

Patterns of injury

Fractures of the humeral shaft commonly occur in the third decade (active young men) and in the seventh decade of life (osteoporotic elderly women). The commonest site is the middle third, which accounts for 60% of humeral fractures. The close proximity of the fracture to the radial nerve and brachial artery commonly leads to neurovascular deficits.

Direct blows tend to produce transverse fractures, whereas falls on the outstretched hand produce torsion forces and hence spiral fractures. Combinations of the two mechanisms may produce a butterfly segment. Pathological fractures are also common, most resulting from metastatic breast cancer.

The angle and degree of displacement of the fracture depends on the site of injury and its relationship to the action and attachment of muscles on either side of the injury (Fig. 4.2.3).

image

Fig. 4.2.3 Relationships between humeral fracture site and the actions of inserting muscles determine bony angulation and displacement.

Clinical assessment

History and examination

Patients typically present complaining of pain and supporting the forearm of the injured limb, flexed at the elbow, held close to the chest wall. Examination of the limb reveals tenderness, swelling, shortening and possibly deformity. The skin should be assessed for tension or disruption, and particular attention should be paid to the shoulder and elbow regions for associated fractures or dislocations. Initial and post-reduction assessments of the brachial artery and vein, and ulnar, median and radial nerves are essential.

The commonest complication is radial nerve injury resulting either from injury or reduction of the fracture, and evidenced by wrist drop and altered sensation in the first dorsal web space. A recent systemic review reported that radial nerve injury occurs in 11% of mid-shaft humerus fractures.9

Investigations

Two radiographic views – anteroposterior and lateral – will allow the correct diagnosis in most cases.

Fracture management and disposition

Uncomplicated, closed fractures account for the majority of injuries and may be treated by immobilization, analgesia, a functional brace such as a hanging or U-shaped cast (Fig. 4.2.3), and a broad arm or collar and cuff sling. The acceptable deformity is 20° anterior/posterior angulation, and 30° valus/valgus deformity.10 The union rate is usually higher than 90%. Early specialist follow-up is recommended.

Some departments may prefer a humeral brace rather than U-shaped plaster for immobilization, as the former may permit greater functional use without affecting healing or fracture alignment.11 For oblique/spiral fractures some orthopaedic surgeons prefer an operative approach for a better functional outcome.12

Open fractures and complications affecting the vessels require surgical repair. Although the majority of radial nerve injuries are neuropraxia and recover without surgical intervention, each case should be considered individually by an orthopaedic surgeon with a view to possible operative exploration.

Fractures of the distal humerus

Classification and patterns of injury

Unlike in children, fractures of the distal humerus in adults are very uncommon and patterns of injury tend to reflect the anatomical two-column construction (condyles) of the humerus. Several classification methods have been used, such as the Riseborough and Radin, Mehne and Matta classifications, but the simplest and most commonly used are the AO/ASIF classifications.13 These classify injuries into three categories: type A are extra-articular fractures, type B are partial articular, and type C are complete articular fractures. Practically, distal humeral fractures may be classified into supracondylar, intercondylar and other types. Supracondylar fractures lie transversely, whereas intercondylar T or Y fractures include an additional vertical extension between the condyles.

Mechanisms of injury usually involve a direct blow to the flexed or extended elbow. In the former, the olecranon is driven upwards, thereby either splitting the condyles apart producing a T or a Y pattern, or shearing off one condyle.

Clinical assessment

History and examination

Patients typically present with a swollen, tender, deformed elbow. As very little subcutaneous or other tissue separates the bone from skin, any disruption of the skin should be carefully examined for the possibility of a compound fracture. Distal neurological and vascular injury must be assessed carefully, as the possibility of nerve injury has been reported to be as high as 12–20%.14

Investigations

Two radiographic views – anteroposterior and lateral – should be obtained. Some authors suggest that an internal oblique view may improve the diagnostic accuracy.15 Pain and inability to extend the elbow often result in poor-quality radiographs. Although high-quality radiographs are essential for operative planning, repeat films should not be attempted in the ED as they rarely provide the desired result. When there is any suspicion of severe injury, either from the history or from gross soft tissue swelling, early CT scanning should be considered to give better detail, especially of intra-articular fractures.

Undisplaced fractures may not be visible on radiography but may be suggested by posterior or anterior fat pad signs, which result from fat displaced by an underlying haemarthrosis. Ultrasonography, CT and MRI may all improve diagnostic precision. They alter management and improve outcome in patients with occult fractures, mostly of intra-articular type.

Fracture management and disposition

Uncomplicated, undisplaced, closed fractures with minimal swelling should be immobilized for 3 weeks in 90° flexion with an above-elbow cast and a broad arm sling, followed by active mobilization.

Patients with severe swelling, compound fractures, displaced fractures or neurovascular compromise require orthopaedic intervention.

Controversies

Guidance for management is based primarily on experience rather than rigorous research evidence.

• For humeral shaft fractures, it is unclear whether hanging plasters are better than U-shaped plasters for pain relief, fracture healing and position.
• Small-scale studies suggest that bracing may yield better functional results than U-shaped plaster immobilization for fractures of the humeral shaft.
• Low-intensity pulsed ultrasound may be useful in the treatment of non-union. Whether it may enhance normal fracture healing is not known.16
• The role of magnetic resonance imaging in the diagnosis of bone bruising and humeral fracture has not been studied.

References

1 Mulhall KJ, Ahmed A, Khan Y, Masterson E. Simultaneous hip and upper limb fracture in the elderly: incidence, features and management considerations. Injury. 2002;33:29-31.

2 Handol HHG, Madhok R. Interventions for treating proximal humeral fractures in adults. Cochrane Database Systematic Review. (4):2003. CD000434. DOI: 0.1002/14651858.CD000434

3 Weber E, Matter P. Surgical treatment of proximal humerus fractures – an international multicenter study [In German]. Swiss Surgery. 1998;4:95-100.

4 Kristiansen B, Kofoed H. Transcutaneous reduction and external fixation of displaced fractures of the proximal humerus. A controlled clinical trial. Journal of Bone and Joint Surgery. 1988;70:821-824.

5 Zyto K, Ahrengart L, Sperber A, Tornkvist H. Treatment of displaced proximal humeral fractures in elderly patients. Journal of Bone and Joint Surgery. 1999;79:412-417.

6 Vallier HA. Treatment of proximal humerus fractures. Journal of the Orthopaedic Trauma. 2008;21(7):469-476.

7 Rommens PM, Heyvaert G. Conservative treatment of subcapital humerus fractures. comparative study of the classical Desault bandage and the new Gilchrist bandage. Unfallchirurgie. 1993;19:114-118.

8 Livesley PJ, Mugglestone A, Whitton J. Electrotherapy and the management of minimally displaced fracture of the neck of the humerus. Injury. 1992;23:323-327.

9 Shao YC, Harwood P, Grotz MRW, et al. Radial nerve palsy associated with fractures of the shaft of the humerus: A systematic review. Journal of Bone and Joint Surgery. 2005;87-B:1647-1652.

10 Klenerman L. Fractures of the shaft of the humerus. Journal of Bone and Joint Surgery. 1966;48B:105-111.

11 Camden P, Nade S. Fracture bracing the humerus. Injury. 1992;23:245-248.

12 Ring D, Chin K, Taghinia AH, Jupiter JB. Nonunion after functional brace treatment of diaphyseal humerus fractures. Journal of Trauma. 2007;62:1157-1158.

13 Diana JN, Ramsey ML. Decision making in complex fractures of the distal humerus: current concepts and potential pitfalls. Orthopaedic Journal. 1998;11:12-18.

14 Ramachandran M, Birch R, Eastwood DM. Clinical outcome of nerve injuries associated with supracondylar fractures of the humerus in children, the experience of a specialist referral centre. Journal of Bone and Joint Surgery. 2006;88B:90-94.

15 Song KS, Kang CH, Min BW, et al. Internal oblique radiographs for diagnosis of nondisplaced or minimally displaced lateral condylar fractures of the humerus in children. Journal of Bone and Joint Surgery. 2007;89A:58-63.

16 Nolte PA, van der Krans A, Patka P, et al. Low-intensity pulsed ultrasound in the treatment of nonunions. Journal of Trauma. 2001;51:693-702.

Further reading

McRae R, editor. Practical fracture treatment. Churchill Livingstone, Edinburgh, 1994, 99-127.

Uehara DT, Rudzinski JP. Injuries to the shoulder complex and humerus. In: Tintinalli JE, Kelen GD, Stapczynski JS, editors. Emergency medicine. A comprehensive study guide. New York: McGraw-Hill; 2000:1783-1791.

Willet K. Upper limb injuries. In: Skinner D, Swain A, Peyton R, Robertson C, editors. Cambridge textbook of accident and emergency medicine. Cambridge: Cambridge University Press; 1997:601-617.

4.3 Dislocations of the elbow

Raymond Chi Hung Cheng, Timothy Rainer

Essentials

1 Elbow dislocations are the third most common large joint dislocation.
2 Surgical intervention is rarely required for simple elbow dislocations.
3 Surgical intervention may be required when fractures of the radius, ulnar and humerus are associated with elbow dislocation, or when neurovascular injury occurs.
4 The commonest neurovascular complication involves the ulnar nerve.
5 After reducing elbow dislocations, it is important to reassess joint stability and potential neurovascular complications.

Introduction

Elbow dislocation, along with glenohumeral and patellofemoral joint dislocations, is one of the three most common large joint dislocations.1 The elbow joint is a hinge-like articulation involving the distal humerus and proximal radius and ulna. Owing to its strong muscular and ligamentous supports, the joint is normally quite stable and rarely requires operative intervention, even for acute instability after dislocation.

Elbow dislocations can be classified as either anterior or posterior. Posterior dislocation is the most common type and can be further divided into posteromedial or posterolateral. It usually results from a fall on the outstretched hand with some degree of flexion or hyperextension at the elbow. The radius and ulna commonly dislocate together. Similarly, anterior dislocation can also be divided into anteromedial or anterolateral. This type is less common and is usually due to a direct blow to the dorsal side of the elbow.

Uncommonly, the radius or ulna alone may dislocate at the elbow. In such cases there is always a fracture of the other bone. One common example is in Monteggia fractures, where anterior or posterior radiohumeral dislocation occurs alongside a fracture of the ulna shaft (Fig. 4.3.1). A rarer example is a posterior ulna–humeral dislocation with fracture of the radial shaft. So, although elbow dislocations may appear to be isolated, it is essential to look for associated intra-articular or shaft fractures.

image

Fig. 4.3.1 Monteggia fracture dislocation. Fracture of the ulnar shaft may be associated with (a) anterior radiohumeral dislocation or (b) posterior radiohumeral dislocation.

Clinical assessment

History and examination

Patients typically present holding the lower arm at 45° to the upper arm and with swelling, tenderness and deformity of the elbow joint. The three-point anatomical triangle of olecranon, medial and lateral epicondyles should be assessed for abnormal alignment, as this strongly suggests dislocation.

The commonest neurovascular injury involves the ulnar nerve, reported in 10–15% of elbow dislocations,2 but the median and radial nerves, and the brachial artery may also be affected.

The differential diagnosis is a complex distal humerus fracture which, in a swollen elbow, may be hard to differentiate clinically from an elbow dislocation.

Investigations

Anteroposterior and lateral radiographic views should be obtained and scrutinized for associated fractures of the coronoid process, radial head, capitellum and olecranon.

Magnetic resonance imaging (MRI) characterizes bony injury more accurately than radiography in children with elbow injuries, but its potential role for diagnosis and guiding management in adults has not been well evaluated.3 Duplex Doppler ultrasound can be use to identify early brachial artery injury.4

Management

Simple dislocation can be reduced using a closed method. With adequate sedation, gentle traction and counter-traction, the joint relocates quite easily. Medial and posterolateral dislocations may also require sideways correction. Dislocation of the stable elbow joint produces severe soft tissue injury and resultant instability, therefore, after reduction, signs and symptoms of compartment syndrome should be sought along with an assessment of joint instability. The reduced elbow joint should move smoothly. Any crepitation or resistance, particularly during the mid-range, suggests incongruent reduction or soft tissue interposition, which is commonly associated with coronoid process or epicondylar fractures. Inability to fully flex or extend the elbow suggests a loose bone or cartilaginous fragment, or a capsular tear. Post-reduction films should be assessed, not only for correct joint relocation, but also for associated fractures. After successful reduction the elbow should be placed in a posterior plaster slab in 90° of flexion. Cylinder casts are contraindicated because of the likelihood of severe soft-tissue swelling.

There is little evidence that surgical intervention improves outcome in patients with medial or lateral elbow instability after dislocation. One small randomized controlled trial showed no evidence that surgical ligamentous repair produced better results than conservative management.5 Another small study, a case series of patients with humeral medial condyle fracture, suggested good results after surgical management using absorbable implants compared to removal of the bony fragment.6 Current practice is to treat all Monteggia fractures by early reduction and stabilization of the ulnar facture. The majority could be treated very well with close reduction and percutaneous intramedullary K-wire fixation of the ulnar fracture.7 All late cases require open reduction and internal fixation; 45% of these cases are associated with complications and poor long-term functional outcome.8

Ulnar nerve injuries can occur both before and after closed reduction. The reported rate varies between 10% and 15%. Most of them are neuropraxia and will recover with conservative measures. The most sensitive sign and symptoms are numbness over the little fingers.

Compound fracture dislocation should be reduced by the open method.

Patients with irreducible dislocations, neurovascular complications, associated fractures or open dislocations require orthopaedic intervention.

Disposition

Current practice is that most patients may be discharged from the emergency department (ED) with analgesia, plaster slab support and a broad arm sling with appropriate follow-up. A recent prospective, randomized French study9 suggested that early mobilization is superior to plaster immobilization in terms of functional recovery, without any increased instability or a recurrence of dislocation for patients with uncomplicated posterior dislocations, so the duration of immobilization is controversial. Patients with irreducible dislocations, neurovascular complications, associated fractures or open dislocations require admission.

Controversies

• There are no large-scale randomized studies comparing operative and non-operative management of elbow dislocation. It is therefore unclear whether one method may produce better outcomes than another.
• Early mobilization may be superior to plaster immobilization after reduction of uncomplicated posterior dislocations.
• The epidemiology of elbow injury including dislocation in patients presenting to emergency departments has not been well described, and requires further studies.
• Roles for ultrasound, computerized tomography and magnetic resonance imaging in evaluating elbow injury and influencing management require further study.

References

1 Uehara DT, Chin HW. Injuries to the elbow and forearm. In: Tintinalli JE, Kelen GD, Stapczynski JS, editors. Emergency medicine. A comprehensive study guide. New York: McGraw-Hill; 2000:1763-1772.

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2 Robert S, David R. Current concepts review: the ulnar nerve in elbow trauma. Journal of Bone and Joint Surgery. 2007;89A:1108-1116.

3 Griffiths JF, Roebuck DJ, Cheng JCY, et al. Comparison of radiography and magnetic resonance imaging in the detection of injuries after paediatric elbow trauma. American Journal of Roentgenology. 2001;176:53-60.

4 Ergunes K, Yilik L, Ozsoyler I, et al. Traumatic brachial artery injuries. Texas Heart Institute Journal. 2006;33:31-34.

5 Josefsson PO, Gentz CF, Johnell O, Wendeberg B. Surgical versus non-surgical treatment of ligamentous injuries following dislocation of the elbow joint. A prospective randomized study. Journal of Bone and Joint Surgery. 1987;69:605-608.

6 Partio EK, Hirvensalo E, Bostman O, Rokkanen P. A prospective controlled trial of the fracture of the humeral medial epicondyle – how to treat? Annales Chirurgiae Gynaecologiae. 1996;85:67-71.

7 Lam TP, Ng BKW, Ma RF, Cheng JCY. Monteggia fractures in children a review of 30 cases. Journal of the Japanese Pediatric Orthopedic Association. 2004;13:193-195.

8 Reynders P, De Groote W, Rondia J, et al. Monteggia lesions in adults. A multi-centre Bota study. Acta Orthopaedica Belgica. 1996;62:78-83.

9 Rafai M, Largab A, Cohen D, Trafeh M. Pure posterior luxation of the elbow in adults: immobilization or early mobilization. A randomized prospective study of 50 cases. Chirurgie de la Main. 1999;18:272-278.

Further reading

McRae R. Practical fracture treatment. Edinburgh: Churchill Livingstone, 1994.

Willet K. Upper limb injuries. In: Skinner D, Swain A, Peyton R, Robertson C, editors. Cambridge textbook of accident and emergency medicine. Cambridge: Cambridge University Press; 1997:601-617.

4.4 Fractures of the forearm and carpal bones

Peter Wright

Essentials

1 Forearm fractures are among the most common fractures seen in the ED.
2 When assessing the need for, or success of, reduction the external appearance of the limb is a key feature.
3 Median nerve function must be assessed before and after reduction of all distal radial fractures.
4 Splinting or functional bracing may be sufficient for stable fractures. Early movement and load bearing aids functional recovery.
5 General indications for orthopaedic referral include fractures which are compound, unstable, associated with intra-articular or neurovascular injury, and those that have failed reduction in the ED.
6 Displaced, isolated fractures of the ulna or radius may be associated with a dislocation of the radius or ulna respectively (Monteggia and Galeazzi fracture-dislocations). These should be carefully sought, as there is high risk of long-term disability.
7 Significant or persistent symptoms with the absence of a visible fracture on plain X-ray may be due to an undetected fracture or significant soft-tissue injury. A high index of suspicion and review in 1 or 2 weeks are recommended. Further investigation with CT, MRI or repeat X-ray may be indicated.

Radial head fractures

Clinical features

History

Patients have usually had a fall onto their outstretched hand or received a direct blow to the lateral side of the elbow, and present with pain and restricted movement at the elbow.

Examination

Usually there is swelling and tenderness over the radial head. Sometimes, with more subtle injuries, rotating the forearm while palpating the radial head may be necessary to elicit tenderness. Elbow extension and forearm rotation are limited. Severely comminuted fractures may have proximal displacement of the radius, which can be associated with disruption of the interosseous membrane and subluxation of the distal radioulnar joint (Essex–Lopresti fracture-dislocation).

Imaging

Anteroposterior (AP) and lateral X-rays of the elbow are required. A radiocapitellar view may be necessary if the fracture is subtle. The presence of an anterior fat pad sign alone on X-ray is associated with an underlying radial head or neck fracture in up to 50% of patients. In this case a fracture should be assumed to be present if there is an appropriate mechanism and local signs. A follow-up X-ray or CT scan is indicated only in the presence or persistent pain, stiffness or locking.

Classification

Radial head fractures may be described as hairline, marginal (displaced and undisplaced), segmental (displaced and undisplaced) or comminuted. They may also be classified into four types (Fig. 4.4.1). Fractures of the radial neck may be undisplaced or have various degrees of lateral tilting.

image

Fig. 4.4.1 Mason–Hotchkiss classification of radial head fractures.

Management

Type I and minor type II radial head fractures without mechanical block may be managed with a bandage and sling. If there is severe pain, aspiration of the fracture haematoma, intra-articular bupivacaine or a back slab may be useful. Mobilization can occur after 1–2 days depending on symptoms. Prognosis is good, but full extension may not be possible for many months.

All type III and those type II fractures with the presence of a mechanical block to movement require surgical intervention. Mechanical block can be difficult to assess acutely due to pain. Intra-articular injection of bupivacaine may assist early assessment, or assessment may be deferred until pain has settled. Surgical options include open reduction and internal fixation, and excision of the radial head with or without implantation of a prosthesis.

Radial neck fractures with up to 20° tilts can be managed conservatively. More severe tilt can be reduced using intra-articular bupivacaine. The forearm is pronated until the most prominent part of the radial head is felt. Then traction is applied to the forearm and pressure applied to the radial head. Open reduction is indicated if closed methods fail or displacement is gross.

Complications

Neurovascular complications and compartment syndrome are uncommon. Most complications relate to disturbance of the relationships of the proximal radioulnar and radiocapitellar articular surfaces causing limitation of movement. This is uncommon with minor fractures and often responds to radial head excision.

Shaft fractures

History

This type of injury requires great force, typically from a motor-vehicle accident, a fall from a height or a direct blow. These fractures are commonly open and nearly always displaced.

Examination

The forearm is swollen and tender and may be angulated and rotated. Examination looking for an open wound, local neurovascular compromise, compartment syndrome or musculotendinous injury is required. Given the mechanism of injury, other injuries should also be sought.

Imaging

AP and lateral X-rays of the forearm, including the wrist and elbow joints, are needed. Displacement and angulation are easily determined, but torsional deformity may be subtle. Because the ulna and radius are rectangular in cross-section rather than circular, a change in bone width at the fracture site indicates rotation. The radial and ulnar styloid processes normally point in opposite directions to the bicipital tuberosity and coronoid process, respectively. A change in this alignment also suggests torsion.

Management

Adult forearm fractures are less stable than those in children, and lack of remodelling limits tolerance to incomplete reduction. Undisplaced fractures may be managed with an above-elbow cast, but must be reviewed at 1 week for displacement and angulation. Most fractures, however, are displaced and require open reduction and internal fixation.

Complications

Early complications include wound infection, osteomyelitis, neurovascular injury and compartment syndrome. Later, non-union, malunion, reduced forearm rotation and reflex sympathetic dystrophy are possible complications.

Isolated fracture of the ulnar shaft

These fractures are due to a direct blow to the ulna, often when raised in defence; hence they are also known as ‘nightstick’ fractures. Patients present with localized pain and swelling. AP and lateral X-rays delineate the location of the fracture and degree of angulation. Look for associated dislocation of the radial head if displacement is present (Monteggia fracture-dislocation).

Fractures displaced less than 50% of the ulna width heal well with a non-union rate of 0–4%. Traditional treatment involves fixing the forearm in mid-pronation with a plaster cast, extended above elbow if the middle or proximal thirds of the ulna are fractured. The cast is removed once union occurs, usually in 6–8 weeks. Other proven options include a below-elbow plaster (BEPOP) for proximal fractures, early mobilization with bandage after 1–2 weeks in BEPOP, or functional bracing after 3–5 days, which allows movement at wrist and elbow.

Fractures with more than 10° of angulation or displaced more than 50% of the diameter of the ulna require surgical intervention.

Monteggia fracture-dislocation

This is a rare fracture of the proximal ulna with dislocation of the radial head. It occurs either through a fall onto the outstretched hand with hyperpronation or through a force applied to the posterior aspect of the proximal ulna. Patients present with pain, swelling and reduced elbow movement. The forearm may appear shortened and the radial head may be palpable in the antecubital fossa. Associated posterior interosseous nerve injury is common.

On X-ray the fracture is obvious, but the dislocation is commonly missed. Check that a line through the radial shaft bisects the capitellum on both views. Dislocation is anterior in 60%, but may be anterolateral or posterolateral.

All Monteggia fractures require open reduction and internal fixation. Common complications include malunion and non-union of the ulnar fracture and an unstable radial head.

Isolated radial shaft fracture

Isolated fractures of the proximal two-thirds of the radial shaft are uncommon and are usually displaced. Rare undisplaced fractures can be treated similarly to isolated ulnar shaft fractures. Displaced fractures require open reduction and internal fixation.

Galeazzi fracture-dislocation

Fractures of the distal third of the radial shaft occur as a result of a fall onto the outstretched hand or a direct blow. There may be an associated subluxation or dislocation of the distal radioulnar joint (DRUJ), known as the Galeazzi fracture-dislocation. Patients have pain and swelling at the radial fracture site. Those with a Galeazzi injury will also have pain and swelling at the DRUJ and a prominent ulnar head.

X-rays show the radial fracture, which is tilted ventrolaterally. Widening of the DRUJ space on the AP and dorsal displacement of the ulnar head on the lateral are seen (Fig. 4.4.2). An ulnar styloid fracture is seen in 60% of cases.

image

Fig. 4.4.2 The Galeazzi fracture-dislocation.

All Galeazzi fracture-dislocations require surgical management. Complications include malunion or non-union of the radial fracture and subsequent instability of the DRUJ.

Fractures of the distal radius and ulna

Fractures of the distal radius and ulna are common, particularly in children, young men and elderly women. Fractures in the latter group are indications for evaluation of bone-mineral density.

Clinical features

History and examination

Fractures usually occur after a fall onto the outstretched hand resulting in bending, shearing or impaction forces being applied to the distal metaphysis; or from a direct blow. Patients present with pain, tenderness and variable degrees of swelling and deformity. It is important to examine for associated injuries to carpals, radial and ulnar shafts, elbow and shoulder joints, for median nerve injury, vascular compromise, and for extensor tendon injury.

Imaging

Anteroposterior and lateral X-rays of the wrist demonstrate most injuries. For patients with significant symptoms or signs and a normal X-ray, consider an occult undisplaced fracture or ligamentous injury.

Although this chapter uses eponymous names, it is important to be aware that orthopaedic circles have moved to more formal classification systems for distal radial fractures. Several have been proposed and are beyond the scope of this text. The author recommends being familiar with anatomical descriptions and fracture features associated with need for reduction, instability of reduction, and indications for operative intervention.

Management

Prompt attention to analgesia, splinting and elevation is essential while awaiting X-rays.

Reduction is indicated in the following circumstances to improve long-term function:

• Visible deformity of the wrist.
• Loss of volar tilt of the distal radial articular surface beyond neutral.
• Loss of >5° of the radial inclination of the distal radius (normally approximately 20°).
• Intra-articular step of >2 mm.
• Radial shortening >2–3 mm.

Greater deformity can be accepted in low-demand, elderly patients.

Anaesthetic options for reduction include intravenous anaesthesia with Bier’s block, haematoma block, and procedural sedation. Reduction is traditionally maintained with an encircling plaster cast moulded to oppose displacement forces from volar metacarpal crease to proximal forearm for 6 weeks. Displaced or comminuted fractures at high risk of swelling, especially in the elderly or coagulopathic patients, are immobilized with non-encircling splints.

Factors associated with instability of the distal fragment and failure to maintain reduction include:

• Comminution > two-thirds to three-quarters of metaphyseal width on lateral X-ray.
• Shearing fractures (Barton-type).
• The magnitude of the initial displacement.

Weekly X-rays for 2–3 weeks with orthopaedic follow-up are recommended for all displaced fractures, those with intra-articular extension and potentially unstable fractures.

Stable, undisplaced, extra-articular fractures can be managed more conservatively with splinting and referral to a family doctor for early mobilization after 4 weeks.

Indications for operative management are debated, but should be considered for:

• Comminuted, displaced, intra-articular fractures.
• Open fractures.
• Associated carpal fractures.
• Associated neurovascular or tendon injury.
• Failed conservative treatment (failed reduction or unstable after reduction).
• Bilateral fractures/impaired contralateral extremity.

Complications

Median nerve injury may occur acutely due to the injury, as a result of reduction, or later due to pressure effects from the plaster. Median nerve function must be documented before and after reduction.

Loss of reduction may require delayed surgical intervention.

Malunion with chronic wrist pain, arthritis and secondary radioulnar and radiocarpal instability are associated with intra-articular extension of the fracture.

Delayed ruptures of the extensor pollicis longus can occur.

Colles’ fracture

First described in 1814, the Colles’ fracture is a metaphyseal bending fracture. The wrist has a classic ‘dinner-fork’ appearance, often with significant swelling of the soft tissues.This appearance is reflected in the radiographs (Fig. 4.4.3). There is often associated damage to the radioulnar fibrocartilage. There may be comminution, commonly dorsally, which can extend into the radiocarpal or radioulnar joints.

image

Fig. 4.4.3 Colles’ fracture. A fracture of the distal radial metaphysis with six classic deformities. The lateral view shows anterior angulation, dorsal displacement and impaction. The AP view reveals radial displacement, ulnar angulation and an ulnar styloid fracture.

Management

The aim of reduction is to restore radial length, volar tilt and radial angulation. A minimum of 0° tilt is acceptable if full reduction is not possible. Reduction is achieved by first disimpacting the fracture with traction in the line of the forearm. If this fails, traction in extension or hyperextension should be tried. Volar tilt is then restored with volar pressure over the dorsum of the distal fragment while traction is maintained. Lastly, correct radial tilt and radial displacement with ulnar pressure over the radial side of the distal fragment. Reduction is successful in 87%, but almost two-thirds lose reduction over 5 weeks, most of this occurring during cast immobilization.

The commonly accepted cast immobilization position is with the wrist joint in 10° flexion, full ulnar deviation and pronation. However, some evidence suggests better outcomes are achieved with the wrist in dorsiflexion and mid-supination. The cast must be carefully moulded over the dorsum of the distal fragment and the anteromedial forearm. Functional bracing allowing wrist movement has also shown good outcomes.

Smith’s fracture

This metaphyseal bending fracture of the distal radius occurs through a direct blow or fall onto the back of the hand or a fall backward onto the outstretched hand in supination.

AP and lateral X-rays of the wrist show a ‘reverse Colles’ fracture′ with a similar AP appearance, but with volar displacement and tilt on the lateral X-ray view.

Closed reduction to achieve anatomical radial length and volar tilt should be attempted. Traction is first applied to restore length, followed by dorsal pressure over the volar surface of the distal radius to reverse displacement and angulation. A full above-elbow cast is applied with the wrist in supination and fully dorsiflexed to prevent loss of reduction.

Barton’s fracture

Barton’s fractures are dorsal or volar intra-articular fractures of the distal radial rim (Fig. 4.4.4). The mechanisms of injury are similar to those seen with Colles’ and Smith’s fractures, respectively. There is often significant soft-tissue injury and the carpus is usually dislocated or subluxed along with the distal fragment. These fractures are complicated by arthritis of the radiocarpal joints and carpal instability.

image

Fig. 4.4.4 Barton fractures demonstrated on lateral views of the wrist.

Minimally displaced fractures involving less than 50% of the joint surface and without carpal displacement may be reduced along the lines of a Colles’ or Smith’s fracture. Immobilization should occur with wrist flexed for dorsal Barton’s and extended for volar Barton’s. However, most fractures are unstable and potentially disabling, requiring early operative management, especially in younger patients. Early orthopaedic follow-up is mandatory.

Radial styloid (Hutchison or chauffeur’s) fracture

This oblique intra-articular fracture of the radial styloid is caused by a direct blow or fall onto the hand. Displacement is associated with carpal instability and long-term arthritis. The fracture is seen best on AP X-rays of the wrist (Fig. 4.4.5). Undisplaced fractures can be treated with a cast for 4–6 weeks. Displaced fractures should be referred to an orthopaedic surgeon for anatomical reduction and fixation.

image

Fig. 4.4.5 Radial styloid (Hutchison or chauffeur) fracture.

Ulnar styloid fracture

An isolated fracture can occur through forced radial deviation, dorsiflexion, rotation, or a direct blow. If displaced there may be associated damage to the triangular radioulnar fibrocartilage with subsequent DRUJ instability. Fractures should be treated with a splint or cast with the wrist in ulnar deviation, and referred to an orthopaedic surgeon to assess DRUJ stability.

Carpal fractures and dislocations

Carpal fractures account for 18% of hand fractures. The bones in the proximal carpal row are more commonly involved (scaphoid 70%, triquetral 14%). Isolated fractures of other carpal bones are rare. Management depends on the degree of displacement and damage and stability. Generally, undisplaced fractures with minimal comminution can be managed by cast immobilization. Given the importance of wrist function, early orthopaedic review should be sought for patients with displaced or comminuted fractures, or where instability or an associated carpal dislocation is suspected.

Scaphoid fracture

The most common mechanism of injury is a fall on the outstretched hand. Clinical features include wrist pain and local tenderness over the scaphoid, palpated dorsally or via the anatomical snuffbox. Imaging with AP, lateral and scaphoid views will often identify the fracture.

Fractures of the scaphoid are classified by their location (proximal third, waist, distal third or tubercle) and by their stability. Stable fractures are undisplaced with little comminution, and unstable fractures are displaced with considerable comminution. Stable fractures are treated with a below-elbow cast for 10–12 weeks. Unstable fractures require surgical intervention. Complications include non-union and avascular necrosis of the proximal segment.

A cohort of patients have clinical features suggestive of scaphoid fracture without confirmatory X-ray evidence. In the past, cast immobilization for 1–2 weeks followed by repeat X-ray was advocated. Although this is still advocated by some, a number of alternative approaches have been suggested, including bandaging with clinical review at 7–10 days followed by CT if clinical features persist or early primary CT. Both have been shown to be effective and avoid the wrist stiffness that often results from casting. MRI is advocated as an additional imaging modality if required.

Dislocations of the wrist

Dislocations involving the wrist usually result from high-energy falls on the outstretched hand (such as from a height) that result in forced hyperextension. The distal row of carpal bones is commonly displaced dorsal to the proximal row as a result of a scaphoid fracture, a scapholunate dislocation, or a perilunate dislocation. Trans-scaphoid perilunate fracture-dislocation is slightly more common than perilunate dislocation. Clinical features include mechanism of injury, wrist pain, swelling and tenderness, and possibly reduced grip strength. Imaging requires PA and lateral X-rays. The normal PA view should show two rows of carpal bones in a normal anatomic position with uniform joint spaces of no more than 1–2 mm. No overlap should be seen between the carpal bones or between the distal ulna and the radius. On the lateral film, a longitudinal axis should align the radius, the lunate, the capitate, and the third metacarpal bone.

Radiographic features include:

• Lunate dislocation: On the usual PA image, the lunate has a triangular shape rather than its usual trapezoidal shape. On the lateral film, the lunate has a ‘C’ or ‘half-moon’ shape. The rest of the carpal bones are in a normal anatomic position in relation to the radius.
• Perilunate dislocation: On the lateral film, the lunate is in a normal anatomic position with respect to the radius with and the rest of the carpal bones displaced dorsally. On the PA film crowding is evident between the proximal and distal carpal bones.
• Scapholunate dislocation: On a PA radiograph, the scapholunate space is greater than 4 mm (also known as the Terry-Thomas sign). The scaphoid rotates, producing the classic signet-ring sign. Associated carpal fractures, especially of the scaphoid, may be evident. All wrist dislocations require orthopaedic consultation and prompt reduction.

Controversies

• Optimal immobilization for distal radial fractures.
• The role of splints and functional braces versus traditional plaster casts.
• Duration of immobilization for undisplaced fractures.
• Operative versus non-operative management of distal radial fractures, particularly in the elderly.
• Optimal management strategy for suspected scaphoid fracture with normal initial X-rays.

Further reading

Barton’s fracture/dorsal shearing fracture. Wheeless CRIII, editor. Wheeless’ textbook of orthopaedics, 2008. Accessed Jan http://www.wheelessonline.com/ortho/dorsal_bartons_fracture_dorsal_shearing_frx

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Connolly JF. Nonoperative fracture treatment. In Bucholz RW, Heckman JD, Court-Brown C, et al, editors: Rockwood and Green’s fractures in adults, 6th edn, Baltimore: Lippincott Williams & Wilkins, 2005.

Geiderman JM, Magnusson AR. Humerus and elbow. Rosen P, Barker. Emergency medicine, 4th edn, St. Louis: Mosby-Year Book, 1998.

Closed reduction of distal radius fractures. Wheeless CRIII, editor. Wheeless’ textbook of orthopaedics, 2008. Accessed Jan http://www.wheelessonline.com/ortho/closed_reduction_of_distal_radius_fractures

Cruikshank J, Meakin A, Braedmore R, et al. Early computerized tomography accurately determines the presence or absence of scaphoid and other fractures. Emergency Medicine of Australasia. 2007;19:223-228.

de Beaux AC, Beattie T, Gilbert F. Elbow fat-pad sign: implications for clinical management. Journal of the Royal College of Surgeons of Edinburgh. 1992;37:205-206.

Distal Radial Frx: position of immobilization. Wheeless CRIII, editor. Wheeless’ textbook of orthopaedics, 2008. Accessed Jan http://www.wheelessonline.com/ortho/distal_radius_frx_position_of_immobilization

Eisenhauer MA. Wrist and forearm. In Rosen P, Barker R, editors: Emergency medicine, 4th edn, St. Louis: Mosby-Year Book, 1998.

Ferris BD, Thomas NP, Dewar ME, Simpson MA. Brace treatment of Colles’ fracture. Acta Orthopaedica Scandinavica. 1989;60:63-65.

Hanel DP, Jones MD, Trumble TE. Wrist fractures. Orthopaedic Clinics of North America. 2002;33:35-57.

Irshad F, Shaw NJ, Gregory RJ. Reliability of fat-pad sign in radial head/neck fractures of the elbow. Injury. 1997;28:433-435.

Kouros GJ, Schenck RR, Theodorou SJV. Carpal fractures, 2008. Accessed Jan http://www.emedicine.com/orthoped/topic36.htm

Kuntz DGJr, Bararz ME. Fractures of the elbow. Orthopaedic Clinics of North America. 1999;30:37-61.

Mackay D, Wood L, Rangan A. The treatment of isolated ulnar fractures in adults: a systematic review. Injury. 2000;31:565-570.

McRae R, editor. Practical fracture treatment, 3rd edn, London: Churchill Livingstone, 1994.

Uehara DT, Chin HW. Injuries to the elbow and forearm. In Tintinalli JE, Kelen GD, Stapcznski JS, et al, editors: Emergency medicine, 5th edn, New York: McGraw Hill, 2000.

Radial inclination of distal radius frx. Wheeless’ Textbook of Orthopaedics, 2008. Accessed Jan http://www.wheelessonline.com/ortho/radial_inclination_of_distal_radius_frx

Ruch DS. Fractures of the distal radius and ulna. In Bucholz RW, Heckman JD, Court-Brown C, et al, editors: Rockwood and Green’s fractures in adults, 6th edn, Lippincott Williams & Wilkins: Baltimore, 2005.

Sarmiento A, Latta L. The evolution of functional bracing for fractures. Journal of Bone and Joint Surgery. 2006;88B:141-148.

Barton’s fracture/dorsal shearing fracture. Wheeless CRIII, Wheeless CRIII, editors. Wheeless’ textbook of orthopaedics, 2008. Accessed Jan http://www.wheelessonline.com/ortho/smiths_fracture

Szabo RM. Extra-articular fractures of the distal radius. Orthopaedic Clinics of North America. 1993;24:229-237.

Uehara DT, Chin HW. Wrist injuries. In Tintinalli JE, Kelen GD, Stapczynski JS, et al, editors: Emergency medicine, 5th edn, New York: McGraw Hill, 2000.

Van Glabbeek F, Van Riet R, Verstreken J. Current concepts in the treatment of radial head fractures in adults. A clinical and biomechanical approach. Acta Orthopaedica Belgica. 2001;67:430-441.

Villarin LAJr, Belk KE, Freid R. Emergency department evaluation and treatment of elbow and forearm injuries. Emergency Medicine Clinics of North America. 1999;17:843-858.

Volar Barton’s fracture. Wheeless CRIII, editor. Wheeless’ Textbook of Orthopaedics, 2008. Accessed Jan http://www.wheelessonline.com/ortho/volar_bartons_fractures

4.5 Hand injuries

Peter Freeman

Essentials

1 A comprehensive knowledge of hand anatomy and function is essential for appropriate initial management of the injured hand.
2 Hand injuries are common and most carry a good prognosis if treated early and competently.
3 Aftercare and rehabilitation are essential for return to normal function.

Introduction

Five to 10% of emergency department (ED) attendances involve injury to the hand. Presentations may be due to wounds (∼35%), contusions (∼20%), fractures (∼20%), sprains (∼10%) or infections (∼5%).1 Males injure their hands more than females. The effect of hand injury on an individual cannot be overestimated. Apart from the initial pain and trauma, occupational and psychological concerns play a major role in the aftermath of these injuries. Even a relatively minor fingertip injury can result in an individual being away from work for several days, with consequent loss of earnings and concerns for long-term function and appearance. It is therefore essential that initial assessment and management are appropriate. Complications of traumatic wounds account for the highest number of medicolegal actions against emergency physicians in the United States.

Clinical features

History

Time taken eliciting an accurate history of the mechanism of injury is never more important than in cases of hand injury. Key questions include: When did the injury occur? What was the position of the hand at the time? Was the hand injured with a sharp implement such as glass, or crushed in a machine? Incised wounds caused by sharp implements tend to damage structures such as nerves and tendons, whereas crush injuries may cause fractures and lacerations. Was there brisk bleeding, and does any part of the hand feel numb? These symptoms are important, as in the fingers the digital arteries lie adjacent to the nerves. What was the environment of the injury? Is it likely that the wound is contaminated or contains foreign material? Glass is radio-opaque to a varying degree, and if there is any doubt it is best to assume the wound contains glass and X-ray will confirm or otherwise. Is the patient right or left handed, and what are their occupation and leisure activities? It is also important to ascertain medications and allergies, to guide analgesia and antibiotic choice and tetanus prophylaxis status.

Examination

The injured hand must be examined in a well-lit area. Temporary dressings may need to be soaked off if they have been allowed to dry out and become adherent. At triage an initial moist dressing is ideal, with firm pressure and elevation if there is significant haemorrhage.

Hand and finger injuries are painful and suitable analgesia must be given to allow full examination. Local infiltration of lignocaine without epinephrine (adrenaline) around a wound or as a digital nerve block will allow examination of all aspects except sensation, which must be tested and recorded prior to anaesthesia. A wrist block is useful when some or all of the hand needs to be anaesthetized (Fig. 4.5.1), and longer-acting local anaesthetic is generally used to prolong the effect.

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Fig. 4.5.1 Palmar wrist block.

(Reproduced with permission from American Society for the Surgery of the Hand. The hand, 2nd edn. Boston, MA: Churchill Livingstone, 1990.)

Testing sensation is achieved by light touch or two-point discrimination in the distribution of the three main nerves that supply the hand (Fig. 4.5.2). The median nerve supplies the palmar aspect of the thumb, index, middle and half of the ring finger, extending to supply the fingertip and nailbed. The ulnar nerve supplies both palmar and dorsal aspects of the other half of the ring finger and the little finger. The radial nerve supplies the radial dorsum of the hand, thumb, index, middle and radial aspects of the ring finger. If the patient is unable to describe sensation because they are too young or unconscious, it is useful to remember that the digital nerves also carry the sympathetic supply to the fingers, and that division will cause a dry finger in the distribution of the digital nerve.

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Fig. 4.5.2 The nerve supply to hand.

The hand examination should be holistic and not just concentrate on the obvious injury. Inspection of the hand will provide information about the perfusion of the tissues, local swelling and position of wounds. The resting position of the hand may be a clue to tendon injury, as the normal uninjured position is held with the fingers in increasing flexion from the index to the little finger (Fig. 4.5.3a). A pointing finger may indicate a flexor tendon injury (Fig. 4.5.3b). Obvious bone or joint deformity should be recorded.

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Fig. 4.5.3 The normal resting hand (a). The pointing finger (b).

(Reproduced with permission from American Society for the Surgery of the Hand. The hand, 2nd edn. Boston, MA: Churchill Livingstone, 1990.)

Palpation of the hand will elicit any local tenderness, and the metacarpals and phalanges are all easily palpable subcutaneously.

Functional testing should be performed for all injured hands. Tendon function is tested by asking the patient to perform specific movements. Some tendon injuries may be obvious, such as mallet finger injuries and the pointing finger; however, two flexor tendons supply each finger, and simply asking the patient to flex the finger will not exclude a divided flexor digitorum superficialis tendon. The profundus tendon flexes the distal interphalangeal joint and is tested by asking the patient to flex the tip of each finger in turn while the examiner holds the proximal interphalangeal joint. The superficialis tendon is tested by asking the patient to flex each finger individually, while the examiner holds the other fingers straight. The extensor tendons to the fingers are tested by asking the patient to extend the fingers as much as possible. It is important to remember that the interconnections between the extensor tendons make it possible to extend to near neutral in the presence of a divided tendon. Partial tendon injuries may still exist despite normal functioning of the fingers. The functioning hand should allow full extension of all fingers and comfortable flexion of the fingers into the palm.

Displaced fractures or dislocations may be apparent as deformity. More subtle rotational deformity will be detected by a finger crossing its neighbour when flexed.

Investigations

Most information will be obtained from a full history and examination. Radiology of the hand and fingers will be necessary if bone/joint deformity or tenderness is elicited. Dislocations should always be X-rayed prior to manipulation, however trivial they may seem. Radiography can also reveal radio-opaque glass in a wound. Organic foreign bodies and infections can often be detected by ultrasound imaging using a small-parts soft tissue probe.

Blood investigations are rarely of use in the acutely injured hand.

Magnetic resonance imaging (MRI) is useful in selected injuries as it shows the soft tissues of the hand clearly, but it is relatively unavailable acutely and should be reserved for conditions where clinical examination requires supplementary information about the integrity of the soft structures in the hand, e.g. tendon injury.

Treatment

Appropriate analgesia should be provided as previously described. Rings should be removed from injured fingers to prevent subsequent compromise of circulation as the finger swells. Elevation is essential after hand injury to reduce swelling. Minor injuries can be successfully managed in the ED, but more significant injuries usually require specialist repair.

Fingertip injuries

The fingertips have an excellent blood supply and will usually heal if given the correct environment. Fingertip avulsions are classified as type A when the skin loss is oblique dorsal, type B when the loss is transverse, and type C when the loss is oblique volar (Fig. 4.5.4).

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Fig. 4.5.4 Classification of fingertip amputations.

The most complex to manage is type C, as there is loss of palmar skin. When there is a type A or B injury involving less than 50% of the nailbed, conservative treatment is often the best option. Care of the fingertip initially is likely to require haemostasis followed by an occlusive dressing. There is good evidence that this kind of dressing promotes healing by being non-adherent and allowing fast re-epithelialization of the fingertip.2 The dressing is also quick to apply, easily removed, and comfortable for the patient. Most other dressings adhere to the wound and pull epithelial cells off when removed. Alternatives to conservative dressings include skin grafts to the fingertips, advancement flaps and cross-finger flaps. These should be performed by surgeons trained in the specialist techniques, and reserved for injuries involving large areas of skin loss.

Major amputations of the fingertip or crush injuries may require terminalization of the finger. This should be fully discussed with the patient, who may be prepared to forgo finger length in exchange for early healing. Small tuft fractures of the underlying terminal phalanx are stable and will be supported by the dressing or nailbed repair.

Occasionally patients will bring amputated pieces of the injured fingertip with them into the ED. This tissue may be useful for harvesting full-thickness skin and must be thoroughly defatted before use. No attempt should ever be made to resuture avascular tissue. If there is any doubt about the viability of fingertip tissue the patient should be referred to a specialized hand service.

Digital nerve injuries

Nerve repairs distal to the distal interphalangeal joint are rarely rewarding. More proximal injuries may be repaired under magnification by an experienced surgeon. Salvage of the digital nerve will depend on the extent of local tissue damage.3 Good results are achieved with early repair of digital nerves when the ends can be approximated without tension using a fine (>8/0) suture. The return of protective sensation depends on the level of repair and axon regeneration.

Nailbed injuries

These injuries are frequently underestimated, often because of a reluctance to remove the nail. An underlying fracture or growth-plate slip of the terminal phalanx will usually be associated with nailbed disruption. A subungual haematoma larger than 25% of the area of the nail mandates removal of the nail itself. Small painful subungual haematomas can be released using a hot paperclip or trephine burr. Often damage to the nailbed results in spontaneous separation of the nail, preceded by new nail growth which pushes the damaged nail off. Assuming the nail root is intact, a new nail will grow back at a rate of 1 mm per week; thus full growth of a new nail takes approximately 80 days. Removal of the damaged nail is achieved under digital nerve block using blunt dissection with a pair of fine forceps or scissors. The nail should be retained for use as a dressing later. Underlying fractures should be reduced with pressure, and fracture haematoma irrigated away to achieve anatomical approximation of the bone ends. Fractures distal to the insertion of the profundus tendon are stable. Repair of the fragmented nailbed should be performed with fine (6/0 or 7/0) absorbable suture on an atraumatic needle. Care needs to be taken not to cut out with the needle as the nailbed is extremely friable. Haemostasis can be achieved with the prior application of a finger tourniquet or firm pressure. Ideally, the nail is trimmed and reapplied as an organic splint and dressing.

Terminalization

Terminalization of a finger is sometimes necessary when fingertip damage precludes reconstruction. Occupation and leisure activities must be considered before embarking on this course, and informed patient consent obtained. This procedure can be performed under digital nerve/ring block anaesthesia, but requires skill as removal of the nail root and fashioning of the stump are vital for a good cosmetic result.

The terminal phalanx should be nibbled down short enough to allow loose closure. Ideally, the insertion of the profundus tendon into the base of the terminal phalanx should be preserved, but often this needs to be sacrificed to achieve skin closure. Terminal vessels and digital nerves should be cauterized with bipolar diathermy. Loose closure of the skin should be performed with 5/0 or 6/0 non-absorbable monofilament suture, being careful to avoid ‘dog-ears’. The skin flaps must be observed to ensure adequate perfusion. Postoperatively the hand should be elevated and analgesia provided.

Distal interphalangeal joint injuries

Acute flexion injuries of the terminal phalanx may either rupture the extensor tendon at the level of the distal interphalangeal (DIP) joint or avulse its insertion into the terminal phalanx. This produces an acute flexion deformity of the DIP joint, known as a mallet finger. An X-ray of the finger should be taken, as an intra-articular fracture involving more than one-third of the joint surface may require internal fixation. Small avulsion fractures and tendon ruptures are best treated by the application of a correctly fitting mallet splint, which should not be removed for 8 weeks. Persisting mallet finger deformity after treatment or late presentations is often best treated conservatively as the finger is still functional despite the deformity.

Avulsion fractures resulting from hyperextension of the fingertip are unstable owing to the detachment of the profundus tendon and require internal fixation.

Simple dislocations of the distal interphalangeal joint are easily reduced and rarely cause long-term instability. However, prior radiography should be performed to differentiate dislocation from the more complicated intra-articular fractures.

Middle phalangeal injuries

The middle phalanx takes the insertion of the superficialis tendon slips through which passes the profundus tendon. Fracture of the middle phalanx can disrupt the fibrous tunnel of the profundus tendon and cause adhesions. These fractures need to be accurately reduced and may require internal fixation. They are usually unstable owing to the pull of the tendons. Palmar wounds at this level are likely to divide the profundus tendon or digital nerves and should be explored by a specialized hand service if these injuries are suspected on clinical grounds.

Proximal interphalangeal joint injuries

This is the joint that causes most long-term complications, owing to stiffness and joint contracture. The proximal interphalangeal (PIP) joint is mechanically complex and is supported dorsally by the extensor apparatus, whereas on the palmar aspect is the strong fibrous volar plate. Lateral stability is provided by the collateral ligaments. Rupture of either the volar plate or the extensor apparatus will result in joint instability and potential long-term disability. Tears in the extensor apparatus may result from relatively minor trauma. Dislocations of the proximal interphalangeal joint invariably displace both structures. Occasionally, the central slip of the extensor tendon or the volar plate avulses a small fragment from the middle phalanx which will be visible on lateral finger X-ray. Reduction of dislocations should be followed by extension splinting and early follow-up. The boutonnière deformity (flexion of the PIP joint accompanied by hyperextension of the DIP joint) is a hand surgeon’s nightmare and ideally should be prevented, as long-term results from reconstructive surgery are poor. These injuries should not be underestimated, and ultrasound can be used to aid in early diagnosis.

Proximal phalangeal injuries

Both flexor tendons pass along the palmar aspect of the proximal phalanx, and therefore fractures of this bone tend to be unstable. Rotational deformity is particularly disabling and may not be noticeable with the finger held straight. These fractures usually require internal fixation. The lateral X-ray will often be the most useful in determining the degree of angulation or displacement. Wounds may damage digital nerves or either or both of the flexor tendons. Examination of the finger should detect these injuries, and referral to a specialized hand service will be required.

Metacarpophalangeal joint injuries

Subluxation of the metacarpophalangeal (MCP) joint may occur in the older patient after relatively minor trauma. The clinical appearances are subtle and the injury is easy to miss on X-ray. The clue is the inability of the finger to extend fully. In recent injuries reduction is achieved by traction on the finger, although once the displacement is established reduction becomes difficult even with open procedures.

MCP joint injuries relating to forced contact between a fist and a tooth are common and should be assumed to be infected. The extensor tendon may be divided and X-ray may show fracture of the metacarpal head. These injuries should be treated aggressively by joint irrigation, splinting and antibiotics.

The ulnar collateral ligament rupture (gamekeeper’s or skier’s thumb) results from an abduction injury of the thumb and, when complete, results in MCP joint instability. The ligament when completely ruptured may become folded back outside the adductor aponeurosis. X-rays must be taken to identify avulsion fractures of the base of the proximal phalanx. Stress X-ray views will confirm joint instability. Early repair gives superior results to conservative splinting when complete rupture is diagnosed.

Metacarpal injuries

These injuries are caused by punching, crush injury or falls on to the closed fist. The commonest injury is fracture of the neck of the fifth metacarpal, which is usually best treated conservatively. Correction of significant angulation will only be achieved by open reduction and internal fixation. Spiral fractures of the shaft of a metacarpal will result in shortening of the bone and loss of the contour of the knuckle. Conservative management of these fractures should involve splinting the hand in intrinsic plus (Fig. 4.5.5) with the metacarpophalangeal joint flexed to 70%. The fingers must be splinted straight, with support to the fingertip. Abduction injuries of the thumb may cause a Bennett’s fracture, which is an intra-articular fracture of the base of the thumb metacarpal. Bennett fractures, when displaced, should be referred for internal fixation.

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Fig. 4.5.5 Intrinsic plus – recovery position.

(Reproduced with permission from American Society for the Surgery of the Hand. The hand, 2nd edn. Boston, MA: Churchill Livingstone, 1990.)

Dorsal hand injuries

Wounds on the dorsum of the hand may divide the extensor tendons, which are relatively superficial. Division may be apparent by loss of full extension, but the extensor tendons have extensive cross-insertions, and therefore visualization of the intact tendon throughout its range of movement is the only safe way to exclude damage. Repair of these tendons is relatively straightforward, if there are suitable facilities and equipment. Good exposure of the tendon is required, and haemostasis may be achieved using an ischaemic arm block. Good approximation of the tendon ends is required, using interrupted slowly absorbable sutures. Splinting of the hand in extension will be required for 3 weeks, followed by guarded active flexion. Aftercare must be provided, with access to occupational therapy or physiotherapy during rehabilitation.

Palmar hand injuries

Penetrating wounds on the palm of the hand are likely to divide flexor tendons or main digital nerves. These injuries should be detected by examination. Briskly bleeding wounds proximal to an area of anaesthesia are a clue to digital nerve injury because of coexisting damage to both neurovascular structures. Neurovascular and tendon damage will require referral for specialist repair.

Foreign bodies in the hand can be notoriously difficult to find, and damage to other structures can result from injudicious exploration. The best results are achieved in a bloodless field with full anaesthesia. Nail-gun injuries require an X-ray prior to removal of the nail to establish its location with respect to bone, and to see whether the nail has barbs that will make removal difficult. High-pressure grease- or paint-gun injuries result in extensive tissue penetration and should never be underestimated. Wide exposure and decompression of the tract will require the care of a specialist hand service.

Disposition

Many hand injuries can be well managed in an appropriately equipped ED ambulatory care area. No attempt should be made to operate surgically on a hand without good instruments, adequate lighting and assistance, and fine sutures. After treatment the hand should be elevated in a high arm sling and suitable analgesia provided. Some injuries will require access to a specialized plastic or orthopaedic hand service. When in doubt, early consultation with a specialist hand service is mandatory.

Prognosis

Hand injuries recover best with early definitive treatment, as badly managed injuries can be very difficult to salvage at a later date. Stiffness and loss of function can be avoided if good surgical principles of wound management are adhered to. Appropriate initial splinting and guarded mobilization are the cornerstones of rehabilitation. The injured hand recovers best when splinting has been in a functional position. Whenever possible, the hand should be immobilized with the fingers straight and the MCP joints flexed to 70°. This can be achieved in even the most swollen hand by careful application of a volar plaster slab. Early referral for definitive surgery and subsequent rehabilitation will be essential for severe or complicated injuries. An explanation to the patient of the need to prevent joint stiffness is important when the finger requires dressings for more than 3 weeks.

Prevention

Hand and finger injuries can be prevented. Strategies for prevention involve providing data for public awareness, identifying strategies (e.g. safety equipment, machinery modification) to prevent occupational injuries, and lobbying officials to legislate for sensible measures to prevent injury.

Controversies

• Emergency physicians should keep an open mind to new dressings. There is good evidence that a sterile moist environment for wound healing is beneficial and promotes re-epithelialization. There is no doubt that dressings that adhere to wounds are uncomfortable to remove, damage new epithelial cells, and delay healing.
• Emergency departments have long used sterile solutions to cleanse wounds. There is no evidence that using tap water results in more infected wounds and is cost effective.
• Foreign body removal from the hand can range from being entirely straightforward to being excessively difficult and damaging. A judgement needs to be made on the likely ease of removal and the facilities available. The first attempt is usually the easiest. Wood and glass can be very difficult to find in the tissues without precise localization and a bloodless field.
• To suture or not? Injudicious suture of an acutely injured finger can compromise circulation and confer a secondary injury. Skin closures may be used to bring the skin edges together or, where there is gross swelling, dressings may be used to maintain the anatomy of the finger. The application of a non-adherent dressing may be sufficient or allow secondary closure a few days later.
• Antibiotics have no role in the initial management of hand injuries. The exception to this is the grossly contaminated injury and those known to be caused by bites. Open fractures of the hand bones will need to be admitted for surgical debridement.

References

1 Angermann P, Lohmann M. Injuries to the hand and wrist. Journal of Hand Surgery. 1993;18B(5):642-644.

2 de Boer P, Collinson PO. The use of silver sulphadiazine occlusive dressings for fingertip injuries. Journal of Bone and Joint Surgery. 1981;63B(4):545-547.

3 Jabaley M. Technical aspects of peripheral nerve repair. Journal of Hand Surgery. 1984;9:9-14.

Further reading

American Society for the Surgery of the Hand. The Hand – primary care of common conditions, 2nd edn. Boston, MA: Churchill Livingstone, 1990.

Atasoy E, Ioakimidis E, Kasdan ML, et al. Reconstruction of the amputated finger tip with a triangular volar flap. Journal of Bone and Joint Surgery. 1970;52A:921-926.

Hart RG, Kleinert HE. The hand in emergency medicine. Emergency Medicine Clinics of North America. 1993;11:755-756.

Quinn J, Cummings S, Callaham M, Sellers K. Suturing versus conservative management of lacerations of the hand (RCT). British Medical Journal. 2002;325:299-300.

Stewart C. Hand injuries. Emergency Medicine Reports. 1997;18:223-234.

4.6 Pelvic injuries

Michael Cadogan

Essentials

1 Pelvic fractures constitute 3% of skeletal fractures.
2 Understanding the mechanism of injury and observing the pelvic fracture pattern on X-ray provides insight into the potential for complications such as associated neurovascular or urogenital injuries.
3 Fractures are either stable or unstable. Unstable fractures are associated with considerable mechanical forces and result in concomitant injuries, with a significant overall mortality.
4 Isolated stable pelvic fractures are usually treated conservatively.

Anatomy

The pelvic ring is formed by the two innominate bones and the sacrum. The innominate bones are made up of the ileum, ischium and pubis, and are joined anteriorly at the symphysis pubis and posteriorly at the left and right sacroiliac joints.

The lateral surface of the innominate bone forms a socket, the acetabulum, contributed to by the ileum, ischium and pubis. Stability of the pelvic ring is dependent on the strong posterior sacroiliac, sacrotuberous and sacrospinous ligaments. Disruption of the ring can result in significant trauma to the neurovascular and soft tissue structures it protects.

Classification of pelvic fractures

Pelvic fractures may be open or closed, major or minor, stable or unstable depending on the degree of ring disruption, and may be associated with haemodynamic compromise and/or hollow viscus injury.

The Young and Resnik classification outlined in Chapter 3.8 classifies pelvic fractures by the mechanism of injury and the direction of the causative force. It does not include isolated fractures outside the bony pelvic ring, or acetabular fractures, which are discussed later in this chapter.

Young and Resnik pelvic fracture classification

Most pelvic fractures result from lateral compression, anteroposterior compression or vertical shear forces. These injuries may be suggested by the history and are confirmed radiographically.

Lateral compression injuries

Lateral compression accounts for 50% of pelvic fractures and commonly occurs when a pedestrian or motor vehicle occupant is struck from the side. Most of these injuries are stable, but as a result of the considerable forces involved there is a high potential for associated injuries. This mechanism of injury can produce several fracture patterns involving anterior and posterior pathology.

Anteriorly there is always a transverse fracture of at least one set of pubic rami. These fractures can be unilateral or bilateral, and may include disruption of the pubic symphysis. The posterior element of lateral compression fractures is important, but may be overlooked by the emergency physician concentrating on the anterior findings. However, it is critical in determining the functional stability of the pelvic ring and defining associated injuries.

Type 1 fractures

Type 1 fractures are the most common, and involve a compression injury to the sacrum posteriorly and oblique pubic rami fractures anteriorly. These injuries occur on the side of impact and are usually stable, involving impaction of the cancellous bone of the sacrum without ligamentous disruption. X-rays confirm discontinuity of the sacral foramina posteriorly.

Type 2 fractures

Type 2 fractures result from greater lateral compressive forces. The iliac wing is fractured posteriorly, with the fracture line often extending to involve part of the sacroiliac joint. This leaves part of the ileum firmly attached to the sacrum. Anteriorly there are associated fractures of the pubic rami. Stability is determined by the degree of sacroiliac joint disruption, and mobility of the anterior hemi-pelvis involved. These fractures are usually stable to external rotation and vertical movement, but are more mobile to internal rotation.

Type 3 fractures

Type 3 fractures usually occur when one hemi-pelvis is trapped against the ground and a lateral force rolls over the mobile hemi-pelvis. This produces a lateral compression injury to the side of primary impact and an unstable anteroposterior compressive injury to the contralateral sacroiliac joint.

Anteroposterior compression injuries

Anteroposterior compression injuries of the pelvis account for 25% of pelvic fractures. They result from anterior forces applied directly to the pelvis or indirectly via the lower extremities to produce an open-book type injury.

Type 1 injuries

Type 1 injuries result from low-energy forces that stretch the ligamentous constraints of the pelvic ring. The pubic symphysis is disrupted anteriorly, but with less than 2.5 cm diastasis observed radiographically. These fractures are stable and there is usually no significant posterior pelvic injury.

Type 2 injuries

Type 2 injuries classically cause an open-book fracture. They involve rupture of the anterior sacroiliac, sacrospinous and sacrotuberous ligaments posteriorly and disruption of the pubic symphysis anteriorly. There is widening of the anterior sacroiliac joint with diastasis of the pubic symphysis by more than 2.5 cm on radiology, and occasionally avulsion of the lateral border of the lower sacral segments. Considerable force is involved to disrupt these ligaments, and neurovascular injuries and complications are common. The pelvis is unstable to external rotation, and external compression will ‘spring’ the pelvis.

Type 3 injuries

Type 3 injuries occur when an even greater force is applied and involve disruption of all the pelvic ligaments on the affected side. Rupture of the posterior sacroiliac ligaments leads to lateral displacement and disconnection of the affected hemi-pelvis from the sacrum. They are completely unstable and are associated with the highest rate of neurovascular injury and haemorrhage (see Fig. 4.6.1).

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Fig. 4.6.1 ‘Open-book’ pelvic fracture, with pubic symphysis diastasis and sacroiliac disruption, following an anteroposterior compression injury.

Vertical shear injuries (Malgaigne fracture)

These injuries account for only 5% of pelvic fractures. They usually occur following a fall from a height or during a motor vehicle accident when the victim reflexly extends their leg against the brake pedal before impact. These mechanisms force the hemi-pelvis in a vertical direction and result in complete ligamentous or bony disruption, with cephaloposterior hemi-pelvis displacement.

Anterior disruption occurs through the pubic symphysis or pubic rami. Posteriorly, dissociation usually occurs through the sacroiliac joint, but may occur vertically through the sacrum. These fractures are usually unilateral, but may be bilateral and may be associated with significant intra-abdominal injury.

Clinical assessment

It is essential that a standard trauma management protocol is adhered to in the multitrauma patient, with attention being paid initially to the airway, breathing and circulation (ABCs) in the primary survey and resuscitation phases of care.

General examination

The back is examined to assess for injury to the lumbar spine, sacroiliac regions and coccyx. Abdominal, rectal, vaginal and perineal examinations are required. The rectal examination includes observation for fresh blood, assessment of anal sphincter tone, and the position and tenderness of the prostate. A thorough neurovascular examination must be performed.

The pelvis is examined during the secondary survey phase. The suprapubic, pelvic and urogenital regions are examined for signs of bruising, abrasions, open wounds and obvious deformity. In males the urethral meatus is inspected for the presence of frank blood and the scrotum for bruising. Flank bruising may indicate retroperitoneal haemorrhage.

Palpation of the pelvic ring

Palpation of the pelvis commences at the anterior superior iliac spines. Evidence of internal rotation is assessed by compressing the spines towards each other, and external rotation is tested by pulling both the spines outwards. The pelvic compression test does not always correlate with the significance of the injury, and in the haemodynamically unstable patient this examination should only be performed once, to avoid exacerbating haemorrhage by dislodging any clots.

Radiology

The AP pelvic X-ray will usually reveal anterior fractures, although posterior fractures are often difficult to visualize. Further plain X-rays or a CT scan may be warranted.

Injuries associated with pelvic fractures

Haemorrhage

Haemorrhage is the most significant complication of pelvic fractures. It may result from bleeding at fracture sites, local venous or arterial tears, and disruption of major vessels. Catastrophic bleeding may result from disruption of the internal iliac arteries, their tributaries and accompanying veins as they pass over the anterior aspect of the sacroiliac joint.

Severe hypovolaemia due to persistent haemorrhage without major vessel disruption is a significant cause of mortality. Up to 4 L of blood can be lost into the retroperitoneal space before tamponade occurs. Anteroposterior type 3 injuries and vertical shear injuries disrupt the sacroiliac joint and are associated with significant haemorrhage.

Treatment to minimize or stop the haemorrhage associated with pelvic fractures requires urgent interventional radiology with angiography and embolization, external fixation, and/or open reduction with internal fixation. A multidisciplinary team approach is essential.

Genitourinary and bladder injuries

Pelvic fractures are associated with injury to the lower urinary tract in up to 16% of cases. They are more prevalent in males, who sustain a much higher rate of urethral injury. Pelvic trauma may also result in bladder rupture. The bladder is normally protected by the pelvis, and rupture usually indicates significant disruption of the pelvic ring.

Almost 90% of blunt trauma patients with bladder rupture have an associated pelvic fracture. Patients are usually hypotensive with frank haematuria, although gross haematuria is a non-specific sign of genitourinary trauma, and is not necessarily indicative of bladder rupture. Therefore, a retrograde urethrogram is performed to delineate any urethral trauma prior to performing retrograde cystography.

Urethral and genital injuries

Urethral rupture is rare in females. Rupture of the urethra secondary to blunt trauma commonly occurs in the anterior bulbous urethra just distal to the urogenital diaphragm. It is associated with bilateral fractures of the pubic rami, pubic symphysis disruption and vertical shear injuries.

Suspect a urethral rupture in the adult male with a pelvic fracture, blood at the urethral meatus, a high-riding prostate, perineal haematoma and urinary retention. However, not all these ‘classic’ signs may be present. A retrograde urethrogram is diagnostic, and must be performed prior to urethral (Foley) catheterization when indicated clinically.

Injury to the female genitalia is uncommon but often overlooked. Vaginal lacerations are associated with pelvic fractures in 4% of cases. They normally present with bleeding, but may be occult. A bimanual pelvic examination is necessary in women with a pelvic fracture. This may necessitate anaesthesia because of patient discomfort. Complications such as abscess formation and sepsis can be severe.

Management of unstable pelvic fracture

The mainstay of pelvic fracture management in the ED is to identify and assess the degree of pelvic injury, provide adequate fluid resuscitation to minimize life-threatening haemorrhage, and provide pain relief. Early identification of the potential for major pelvic trauma with mobilization of general surgical, orthopaedic, vascular, interventional radiology and intensive care specialists is essential.

Fluid resuscitation

Start fluid resuscitation with intravenous crystalloid in the hypotensive patient with pelvic trauma using two large-bore peripheral intravenous cannulae. Include blood products if the patient remains hypotensive despite intravenous fluids. The average blood transfusion requirement for anteroposterior compression fractures is 15 units, for vertical shear injuries is 9 units, and for lateral compression injuries is 3.5 units.

Pelvic immobilization

Pelvic sling or sheet

Immobilization of the pelvis with attempted reapproximation of the bony fragments creates a tamponade effect that reduces the risk of continuing haemorrhage prior to definitive treatment. This may be achieved initially by simply bracing the pelvis in a sheet and supporting it laterally with sandbags. Alternatively, use a proprietary radiolucent pelvic sling device with a pulley mechanism to effectively apply compression pressure.

Pneumatic anti-shock garment

The efficacy of the pneumatic anti-shock garment (PASG) in the ED is unproven, but they may still be used in the pre-hospital setting to provide stabilization and immobilization during transport. The PASG reduces haemorrhage from anteroposterior compression fractures, but conversely may increase fracture displacement with lateral compression injuries. Other complications of their use include catastrophic hypotension on sudden injudicious removal, compartment syndrome, and reduced access to the lower limbs.

External fixation

External fixation is a rapid and simple procedure designed to stabilize and immobilize the pelvis in the ED to reduce pelvic haemorrhage prior to definitive treatment. Three pins are placed through each iliac crest and then clamped to an external frame to reduce the displaced pelvic ring injury. The advantages of external fixation are that it is quick, effective, and can proceed in the ED without delaying the continued management of the multiply injured patient. The disadvantages include the lack of support for the posterior component of the pelvic ring fracture, difficulty of placement in the obese patient, and reduced pelvic surgical access in the event of laparotomy being required.

Embolization

Life-threatening arterial haemorrhage is estimated to occur in 5–20% of patients with blunt pelvic fracture. Emergency angiography is both diagnostic and therapeutic to control primary haemorrhage. Early recognition of this subset of patients, organizing transfer to a hospital with angiography capabilities and mobilizing an interventional radiologist, reduces mortality but is logistically challenging. The procedure is operator dependent, time-consuming, and does not address venous blood loss, which still requires appropriate replacement of blood and blood products.

Open pelvic fractures

Open pelvic fractures are rare and associated with increased morbidity and mortality. Open fractures with pelvic ring disruption lose any tamponade effect by virtue of an enclosed space and can result in massive and fatal haemorrhage.

Management

Control of haemorrhage is a priority in open pelvic injury, with attempts to avoid early infection. Sterile gauze packed into the wounds applies a direct pressure tamponade. Urgent operation to repair associated open bowel and bladder injuries and to debride bleeding wounds is paramount, with stabilization of the pelvic fracture as the last step in treatment.

Stable fractures of the pelvis

Isolated avulsion fractures

These are often sustained by young adults following acute stress to the muscular and ligamentous insertions onto the bony pelvis. They include anterior superior iliac spine fracture, anterior inferior iliac spine fracture and ischial tuberosity fracture.

Anterior superior iliac spine fracture

The anterior superior iliac spine may be fractured in jumping activities due to powerful contraction of the sartorius muscle. Such injuries cause pain on weightbearing, with local tenderness and swelling at the fracture site. Active flexion and abduction of the thigh reproduces the pain. There is usually minimal displacement of the avulsed fracture on the AP film of the pelvis.

Anterior inferior iliac spine fracture

Forceful contraction of the rectus femoris muscle in sports that involve kicking may avulse the anterior inferior iliac spine. These patients complain of a sharp pain in the groin and are unable to actively flex the hip. The fracture is usually evident on plain AP pelvic views, with the fragment being displaced distally.

Ischial tuberosity fracture

Fracture of the ischial tuberosity is rare and occurs with forceful contraction of the hamstrings, usually in young adults whose apophyses are not fully united. They are associated with hurdling and other jumping activities. Pain may be reproduced by local palpation and by active flexion of the hip with the knee extended. Plain X-rays of the pelvis reveal minimal displacement of the apophysis from the ischium.

Isolated pubic ramus fractures

These injuries are commonly seen in the elderly with direct trauma following a fall. The patient has difficulty in weightbearing, and local pain and tenderness in the groin. They should be carefully looked for in any patient unable to bear weight with a suspected hip fracture, when X-ray of the hip is normal.

Pain is usually reproduced with the FABER test. The ipsilateral foot is placed on the contralateral knee, forcing the ipsilateral hip to be Flexed, ABducted and Externally Rotated, causing typical pain to exacerbate. Pelvic radiographs confirm non-displaced isolated fractures of the pubic rami.

Iliac wing fracture (Duverney fracture)

Direct lateral trauma may result in an isolated iliac wing fracture. Patients complain of severe pain on weightbearing and walk with a waddling gait. Localized tenderness and bruising occur over the site of injury, associated with abdominal guarding, ileus, and lower quadrant tenderness. These fractures are usually minimally displaced, rarely comminuted, and are easily visualized on AP pelvic X-rays.

Coccyx fractures

These fractures are more frequent in women and are caused by a falls onto the buttocks with both hips flexed. Patients have difficulty in mobilizing and have local pain, swelling, bruising and tenderness over the lower sacral region. Radiographic confirmation is unnecessary if physical examination confirms an isolated injury.

Management of isolated stable fractures

Avulsion fractures, pubic ramus fractures and iliac wing fractures are treated conservatively with non-steroidal anti-inflammatory drugs (NSAIDs) and non-weightbearing crutches for 10 days. Slow mobilization and physiotherapy allow resumption of normal activities in 3–4 weeks. Coccygeal fractures require rest, analgesia and stool softeners. Sitting is painful, and a doughnut-ring foam cushion is helpful.

Acetabular fractures

Acetabular fractures account for 20% of pelvic fractures and are usually associated with lateral compression forces. They also occur with posterior forces applied distally through the femur. Their classification is complex.

Clinical features

Acetabular fractures are caused by direct impaction of the femoral head that may be associated with a central hip dislocation. These fractures are associated with sciatic and femoral nerve injury, depending on the position of the hip dislocation. A thorough neurovascular examination is mandatory. In addition, these fractures are often associated with other pelvic injuries, knee injury, hip fractures and dislocations, which should all be looked for separately.

Management

Standard radiographs of the hip and pelvis are useful in defining the fracture, but a CT scan is essential to show the anterior and posterior fragments and the involvement of ilioischial and iliopubic columns. All fractures should be referred for inpatient orthopaedic management.

Controversies

• Optimal multidisciplinary management in the emergency department of the hypotensive pelvic trauma patient; who to call and when; and who takes charge.
• The role of external pelvic fixation devices in the emergency department.
• The optimum timing of embolization to control primary haemorrhage.

Further reading

Blackmore CC, Cummings P, Jurkovich G, et al. Predicting major hemorrhage in patients with pelvic fracture. Journal of Trauma. 2006;61:346-352.

Burgess AR, Eastridge BJ, Young JW, et al. Pelvic ring disruptions: effective classification system and treatment protocols. Journal of Trauma. 1990;30:848-856.

Dalal SA, Burgess AR, Siegel JH, et al. Pelvic fracture in multiple trauma: classification by mechanism is key to pattern of organ injury, resuscitative requirements, and outcome. Journal of Trauma. 1989;29:981-1002.

Fallon B, Wendt JC, Hawtrey CE. Urological injury and assessment in patients with fractured pelvis. Journal of Urology. 1984;131:712-714.

Gokcen EC, Burgess AR, Siegel JH, et al. Pelvic fracture mechanism of injury in vehicular trauma patients. Journal of Trauma. 1994;36:789-796.

Kellam JF. The role of external fixation in pelvic disruptions. Clinical Orthopaedics and Related Research. 1989;241:66-82.

Mattox KL, Bickell W, Pepe PE, Mangelsdorff AD. Prospective randomized evaluation of antishock MAST in post-traumatic hypotension. Journal of Trauma. 1986;26:779-786.

Pennal GF, Tile M, Waddell JP, et al. Pelvic disruption: assessment and classification. Clinical Orthopaedics and Related Research. 1980;151:12-21.

Rothenberger DA, Velasco R, Strate R, et al. Open pelvic fracture: a lethal injury. Journal of Trauma. 1978;18:184-187.

Sarin EL, Moore J, Moore E, et al. Pelvic fracture pattern does not always predict the need for urgent embolization. Journal of Trauma. 2005;58:973-977.

4.7 Hip injuries

Michael Cadogan

Essentials

1 Trauma to the hip is a major cause of morbidity and mortality, with a huge impact on healthcare and resources.
2 Hip injuries are frequently a pathological disease of the elderly. However, there has been an increased incidence of hip fractures and dislocations in young people sustaining high-energy trauma.
3 Avascular necrosis of the femoral head is a complication of intracapsular femoral neck fractures.
4 Extracapsular neck of femur fractures are associated with significant haemorrhage.
5 The hip joint is least stable when flexed and adducted and prone to dislocation. Posterior hip dislocations are an orthopaedic emergency as they are associated with sciatic nerve injury and avascular necrosis.
6 Anterior hip dislocations are associated with femoral neurovascular injury and occult hip joint fractures.

Anatomy

The hip joint is a large ball and socket articulation encompassing the acetabulum and proximal femur. The hip joint provides a high degree of stability and mobility.

Blood supply

The head and intracapsular portion of the femoral neck receive the majority of their blood supply from the extracapsular arterial ring, the trochanteric anastomosis, with a minor supply arising from the obturator artery via the ligamentum teres, known as the foveal artery. Retinacular arteries from the extracapsular ring pass under the reflection of the hip capsule to supply the femoral neck and head in a retrograde manner. Intracapsular fractures disrupt this ‘distal to proximal flow’ and so may result in avascular necrosis of the femoral head.

Avascular necrosis (AVN)

Avascular necrosis in the context of hip injuries refers to ischaemic bone death within the femoral head following compromise to its blood supply. Increased bone density of the femoral head is the radiographic feature of AVN, but may take up to 6 months to become manifest.

AVN results primarily from the disruption of the trochanteric anastomosis in femoral neck fractures, and is the commonest early complication of these fractures.

Traumatic haemarthrosis, with or without a fracture, may result in intracapsular tamponade. AVN can occur if the intracapsular pressure exceeds the diastolic blood pressure.

The risk of AVN with posterior dislocations is related to the degree of trauma and the length of time the femoral head is out of the joint. Early management is an orthopaedic emergency.

Chronic pancreatitis, alcohol abuse, sickle cell anaemia, vasculitis, irradiation, decompression illness (DCI) and the prolonged use of corticosteroids may also result in AVN.

Classification of hip fractures

Hip fractures are either intracapsular or extracapsular. Intracapsular fractures involve the femoral neck or head. Extracapsular fractures include intertrochanteric, trochanteric and subtrochanteric types, and are four times more common than intracapsular fractures.

The incidence of hip fractures increases exponentially with age, as the fracture rate doubles for every decade over 50 years. Hip fractures occur most frequently in white postmenopausal women, as 50% of 65-year-old women, and 100% of women over the age of 85, have a bone mineral content below fracture threshold level.

Intracapsular fractures

Femoral head

Femoral head fractures are uncommon and are usually associated with dislocations of the hip. They often occur in young patients, 75% of cases being associated with motor vehicle accidents.

Classification

Fractures of the superior aspect of the femoral head are usually associated with anterior dislocations, whereas inferior femoral head fractures occur with posterior dislocations. Fractures may involve a single fragment (type 1) or comminution (type 2).

Clinical evaluation

The symptoms and signs of femoral head injuries are usually those of the associated dislocation rather than the fracture itself. Femoral head fractures are not always picked up on initial X-rays. In the absence of abnormality on plain radiographs further radiological imaging with CT should be performed in the presence of persistent pain following reduction of a hip dislocation.

Management

Orthopaedic consultation is essential as prompt reduction of the dislocation and appropriate stabilization of the fracture reduce the risk of AVN, increasing the chances of a full return of mobility. The prognosis is related to the severity of the initial trauma, time to definitive reduction, and the number of failed closed relocation attempts.

Complications

AVN occurs in 15–20% of cases, post-traumatic arthritis in 40%, and myositis ossificans in 2%.

Femoral neck fractures

Intracapsular fractures are four times more common in females than males. There are four main causes of this type of injury:

• Elderly, with minimal trauma following a fall onto the greater trochanter (pathological fracture).
• Elderly, with torsion or twisting injury prior to fall (pathological fracture).
• Young persons involved in high-energy trauma (excessive loading).
• Repetitive stress or cyclical loading injuries (stress fracture).

Classification

The Garden classification system is commonly used to describe intracapsular neck of femur fractures.

Garden I

Incomplete, impacted or stress fractures that are stable. Trabeculae of the inferior neck are still intact and, although they may be angulated, they are still congruous.

Garden II

Undisplaced fracture across the entire femoral neck. The weightbearing trabeculae are interrupted, without displacement. These fractures are inherently unstable and must be fixed.

Garden III

Complete femoral neck fracture with partial displacement. There is associated rotation of the femoral head, with non-congruity of the head and acetabular trabeculae.

Garden IV

Complete subcapital fracture with total displacement of fracture fragments. There is no congruity between proximal and distal fragments, but the femoral head maintains a normal relationship with the acetabulum.

These fractures may be further simplified into non-displaced (Garden I and II) and displaced (Garden III and IV).

Clinical assessment and management

Non-displaced fractures

Non-displaced fractures include stress fractures, Garden I and Garden II fractures. Stress fractures are usually the result of repetitive abnormal forces on normal bone in fit, active young people such as military recruits or marathon runners, but may occur with repetitive normal stresses on abnormal bones, such as in rheumatoid arthritis or patients taking long-term steroids.

They present with pain that is gradual in onset and worse after activity, radiating from the groin to the medial aspect of the knee. Patients walk with a limp and often present late. Physical examination reveals no obvious deformity, although there is mild discomfort on passive movement at the extremities of motion and percussion tenderness over the greater trochanter.

Additional radiological examination with a bone scan and/or MRI is indicated when initial X-rays are normal but there is persistent pain. MRI is the investigation of choice, being more sensitive than bone scans in the first 24 hours, but is of similar accuracy to bone scans in fracture assessment at 72 hours.

Stress fractures and Garden I impacted fractures are considered stable and may be treated conservatively under close orthopaedic supervision. Garden II fractures, although non-displaced, are inherently unstable and must be fixed internally.

Displaced fractures

Elderly patients with displaced fractures usually present with pain in the hip area and markedly reduced hip movement. The lower limb is shortened, abducted and externally rotated distal to the fracture, albeit less than with intertrochanteric fractures. X-ray reveals the fracture and the degree of posterior comminution of the proximal fragment. Systemic analgesia and a femoral nerve block reduce discomfort. Skin traction will also reduce pain and helps preserve femoral head vascularity.

Traumatic femoral neck fractures in the young adult are uncommon and usually involve normal bone. These fractures are outside of the Garden classification. They follow a large degree of force and have up to a 35% risk of AVN and up to a 57% risk of non-union.

Complications

Mortality

Femoral neck fractures are associated with a mortality of 14–36% in the first year after injury, the rate returning to the pre-fracture level after this. Mortality is increased threefold in those who were institutionalized prior to the fracture, with risk factors of male gender, increased age, malnutrition, multiple medical problems and end-stage renal failure also increasing the mortality.

Morbidity

AVN is the most common complication despite optimal treatment. Non-union, postoperative infection and osteomyelitis are also common.

Extracapsular femur fractures

Intertrochanteric femur fractures

Fractures of the proximal femur that occur along a line between the greater and lesser trochanters are referred to as intertrochanteric. They are usually pathological, occur in the elderly, and have a female preponderance.

Mechanism

A simple fall with a direct force applied to the greater trochanter in the elderly is enough to cause an intertrochanteric femoral fracture. In young adults they are associated with high-speed motor vehicle accidents or falls from a height.

Clinical assessment

Patients sustaining an intertrochanteric fracture are unable to bear weight and have significant pain on hip movement. There is often a large haematoma overlying the greater trochanter, owing to the highly vascular bone that has been fractured without any intracapsular containment. Examination reveals a markedly shortened, abducted, significantly externally rotated lower limb.

X-ray confirms the fracture in most cases. However, internal rotation of the hip on the AP view prevents rotation of the greater trochanter, which may obscure the fracture. The lateral view depicts the size, location and degree of comminution of the fracture fragments and determines stability.

Classification

Numerous classification systems are available for intertrochanteric fractures, the simplest of which is by Evans. This divides intertrochanteric fractures into stable and unstable. However, for the emergency physician an anatomical description of the fracture detailing the degree of comminution, subtrochanteric extension and the presence of displaced posterior fragments is adequate (Fig. 4.7.1).

image

Fig. 4.7.1 Unstable comminuted intertrochanteric fracture with subtrochanteric extension.

Management

A complete evaluation is essential to formulate an early treatment plan, as intertrochanteric fractures occur most frequently in the elderly. Patients may lose up to 1.5 L of blood from comminuted fractures and are often dehydrated, malnourished and in significant pain on arrival in the emergency department (ED). Systemic analgesia and fluid resuscitation are important in preparation for theatre.

Skin traction or immobilization with sandbags prevents further soft tissue damage and bony comminution, and reduces blood loss. Full preoperative evaluation requires a search for associated injuries such as rib fractures, distal radial fractures and vertebral compression fractures at the level of T12 and L1.

An ECG, bloods, and chest X-ray help to elucidate the cause of the fall and may indicate the need for associated medical treatment.

Treatment aims to return the patient to their pre-fracture status. Open reduction with internal fixation (ORIF) produces better anatomical alignment, a shorter hospital stay, and improved function with reduced mortality than does conservative management.

Complications

Survival is directly related to the patient’s age and pre-existing medical factors.

Greater trochanteric fracture

Mechanism

Isolated fractures of the greater trochanter are uncommon. They usually occur between 7 and 17 years of age and involve true epiphyseal separation secondary to indirect trauma. Forceful muscular contraction by the gluteus medius causes avulsion of the apophysis. The displaced, non-comminuted fragment may be separated by up to 6 cm.

Greater trochanteric fractures in adults are rare and usually result from direct trauma, causing a comminuted fracture whose fragments are rarely displaced and usually involve only part of the trochanter.

Clinical assessment

Patients with a greater trochanter injury are tender to palpation over the area of avulsion or comminution, but bruising is uncommon. There is often an associated flexion deformity of the hip as a result of pain and muscle spasm, and weightbearing produces a limp.

Management

The prognosis after these fractures is good. Most are treated with bed rest for 3 days, followed by non-weightbearing crutches for 4 weeks. Open reduction and internal fixation are needed when there is marked separation of the bony fragment.

Lesser trochanteric fracture

Isolated fractures of the lesser trochanter usually occur in children and young athletes, with 85% occurring before the age of 20.

Mechanism

Lesser trochanter fractures are usually an apophyseal avulsion secondary to the forceful contraction of iliopsoas.

Clinical assessment

Patients complain of pain on flexion and internal rotation of the hip. Examination reveals tenderness in the femoral triangle. The patient is unable to flex the hip and raise the foot off the ground in a seated position (Ludloff sign).

Radiology is often inconclusive, as there may not be complete separation of the bony fragment and comparison views may be required.

Management

Ten days of bed rest and slow mobilization result in a full recovery. Open reduction and internal fixation are not indicated, even with wide apophyseal separation.

Subtrochanteric femoral fractures

The subtrochanteric region of the femur lies between the lesser trochanter and a point 5 cm distally. Fractures in this region are termed subtrochanteric. They account for 11% of hip fractures and occur in the elderly with osteoporosis, bone metastases or end-stage renal failure. High-energy injuries in young adults with normal bone are less common.

Mechanism

Ninety per cent of these fractures are as a result of blunt trauma, either from a simple fall in the elderly or following a high-speed MVA or fall from a height in young adults. In the USA up to 10% are due to high-energy gunshot wounds.

Classification

A variety of classification systems are available, but none is widely used. As with intertrochanteric fractures, it is best to describe the location, presence of comminution and the position of the lesser trochanter proximal or distal to the fracture line.

Clinical assessment

In the elderly subtrochanteric fractures are usually isolated. However, as substantial force is required, in young adults the presence of other injuries must be actively sought. The limb distal to the fracture is usually held in abduction, flexion and external rotation. Haemorrhage from a comminuted subtrochanteric fracture may be up to 2 L. Assess the patient’s circulatory status and commence fluid resuscitation to prevent hypovolaemic shock.

Management

The affected limb should be immobilized in a splint following parenteral analgesia. Suitable splints include proprietary splints such as the Donway or Hare, and fluid resuscitation started as required. The older, more laborious Thomas splint is rarely now used. Orthopaedic referral is necessary for open reduction and internal fixation of these fractures.

Complications

There is up to a 20% mortality associated with these fractures in the first year, mainly in the elderly. Subtrochanteric bone is cortical, unlike the cancellous bone involved in intertrochanteric fractures, therefore these fractures often lack the vascularity for adequate new bone growth and repair. They are associated with a higher rate of non-union and implant failure. The further down the shaft of femur the fracture line is located, the greater the degree of non-union and implant failure.

Hip dislocation

The hip joint is inherently stable and considerable force is required to produce a dislocation. Associated injuries must always be sought.

Hip dislocations are classified anatomically into anterior and posterior, depending on the final position of the femoral head relative to the acetabular rim.

Non-prosthetic hip dislocations are an orthopaedic emergency, as the femoral head’s blood supply is precarious, and also because of the proximity of the sciatic nerve. Failure to reduce a hip dislocation within 6 hours dramatically increases the risk of AVN and sciatic nerve ischaemia.

Posterior dislocation

Mechanism

Posterior dislocations represent 85–90% of traumatic hip dislocations. Classically, a direct distal force applied to the flexed knee, with the hip in varying degrees of flexion, causes a posterior dislocation of the hip, as when seated in the front of a car. The hip and knee are usually flexed to 90° and the hip adducted, which is the least stable position for the hip to be in. The force applied by the dashboard in a head-on collision to a seated individual may produce a simple posterior dislocation.

The abducted and partially flexed hip in the same scenario is more stable, and if the force of impact is great enough will result in a posterior dislocation with displaced acetabular fracture.

Clinical assessment

Examination of the affected limb will reveal shortening, adduction, internal rotation and some degree of flexion. A single AP pelvis radiograph is usually adequate to confirm a posterior dislocation. However, as up to half of these dislocations are associated with an acetabular, femoral head or femur fracture, further radiological imaging is essential. Judet views, AP hip with internal rotation and AP and lateral femoral views will reveal these associated fractures.

Neurological examination is important in posterior dislocations, particularly with marked internal rotation, which may compress the sciatic nerve and its branches. This results in neurological deficits, particularly in the peroneal nerve distribution. Associated injuries such as ipsilateral knee ligament disruption with a posterior cruciate rupture must be looked for at the same time.

Management

The orthopaedic team should be consulted early. A thorough search for associated periarticular and distal limb injuries, neurological evaluation and adequate imaging are essential in the ED.

Closed reduction

Closed reduction of posterior hip dislocations may be performed in the ED under procedural sedation, unless there is immediate access to an operating theatre (see Chapter 22.3).

There are numerous methods of relocation, many requiring significant physical strength. The most common is the Allis manoeuvre, whereby the patient lies supine with assistants on either side stabilizing the pelvis with downward pressure on anterior superior iliac spines. The operator forcefully distracts the lower leg with the hip and knee in 90° of flexion. Other techniques include the lateral traction–countertraction method and the Whistler technique.

Complications

The risk of developing AVN is directly proportional to the length of time the hip remains dislocated, and increases dramatically if the dislocation is not reduced within 6 hours of injury. Sciatic nerve neuropraxia may occur in 15% of cases but is usually relieved by reduction. Permanent ischaemic changes with neurological deficit secondary to pressure necrosis have been reported in up to 3% of cases, usually in the peroneal nerve distribution. Missed knee injuries occur in up to 15% of cases, as well as patellar, tibial plateau and posterior cruciate injuries.

Anterior dislocation

Anterior dislocations account for 10–15% of traumatic hip dislocations, and are associated with femoral neurovascular injury and occult hip joint fractures. They usually result from a direct blow to the abducted and externally rotated hip. When the hip is in abduction, the femoral neck or greater trochanter impinges on the rim of the acetabulum. A direct force applied distally can lever the head out of the acetabulum and tear the anterior capsule of the hip.

Classification

Anterior dislocations may be superior or inferior. Type I or superior dislocations occur when the hip is extended at the time of injury. These are also known as iliac dislocations. Type II or inferior dislocations occur when the hip is flexed at the time of injury, and are also known as obturator dislocations. They may be further subclassified as simple dislocation, associated femoral neck fracture, or associated acetabular fracture.

Clinical assessment

The superior type of injury causes an extended, externally rotated and slightly abducted distal limb. The distal limb in the inferior type of dislocation is externally rotated, abducted, and in flexion. The femoral head may be palpated around the anterior superior iliac spine in superior types and in the obturator foramen in inferior types.

A neurovascular examination is essential in anterior dislocations, particularly the superior type, where trauma to the femoral artery, vein and nerve is common. Hip and pelvis radiographs must be studied carefully for associated fractures of the acetabulum and femoral head. Further imaging with CT is indicated for persistent post-reduction pain.

Management

A thorough general examination looking for associated life-threatening injuries is essential, as these injuries are usually associated with high-energy trauma. Orthopaedic consultation is mandatory because of the high probability of vascular injury and the need for closed reduction under general anaesthesia.

Complications

Early complications in superior dislocations result from direct pressure on the femoral vessels, with the potential for distal neurovascular compromise. Late complications include post-traumatic arthritis and AVN. Recurrent dislocation is common when anterior capsular healing is incomplete following inadequate immobilization after reduction.

Controversies

• The efficacy of applying skin traction and immobilization to reduce extracapsular femoral fractures in the emergency department.
• The early use of CT and MRI to evaluate the reduced non-prosthetic hip may reduce (missed) associated morbidity.
• Whether the hip reduction should take place in the emergency department or in the operating theatre, as it is essential to treat hip dislocations early.

Further reading

Dahners LE, Hundley JD. Reduction of posterior hip dislocations in the lateral position using tractioncountertraction: safer for the surgeon? Journal of Orthopaedic Trauma. 1999;13:373-374.

Garden RS. The structure and function of the proximal end of the femur. Journal of Bone and Joint Surgery. 1961;43B:576-589.

Hirasawa Y, Oda R, Nakatani K. Sciatic nerve paralysis in posterior dislocation of the hip. Clinical Orthopedics. 1977;126:172-175.

Holmberg S, Conradi P, Kalen R, Thorgren KG. Mortality after cervical hip fracture: three thousand two patients followed for six years. Acta Orthopaedica Scandinavica. 1986;57:8-11.

Jazayeri M. Posterior fracture dislocations of the hip joint with emphasis on the importance of hip tomography in their management. Orthopedic Review. 1978;7:59-64.

Keller CS, Laros GS. Indications for open reduction of femoral neck fractures. Clinical Orthopedics. 1980;152:131-137.

Walden PD, Hamer JR. Whistler technique used to reduce traumatic dislocation of the hip in the emergency department setting. Journal of Emergency Medicine. 1999;17:441-444.

4.8 Femur injuries

Michael Cadogan

Essentials

1 Early femoral fracture reduction and immobilization in traction reduces mortality.
2 Haemorrhagic shock is a major complication, with a closed femoral fracture having an average blood loss of 1200 mL.
3 Femoral shaft fractures are associated with other significant injuries, which should be sought.

Femoral shaft fracture

Mechanism

Considerable force is required to break the adult femur in the absence of a pathology such as osteoporosis or metastatic disease. The majority of femoral shaft injuries occur in young adults following road traffic accidents, falls from a height or gunshot wounds.

Classification

The description of a femoral shaft fracture is important, but no universally accepted classification system exists. A precise description of the fracture provides the orthopaedic specialist with an indication of the potential for blood loss and the urgency of definitive management.

Femoral fractures are either open or closed and may be transverse, oblique, spiral or segmental. They may occur within the proximal third, midshaft or distal third of the femur. The degree of fracture comminution, soft tissue involvement and neurovascular status should also be described.

The majority of fractures occur in young adults with healthy bones and are transverse fractures. Greater mechanical force usually results in comminution (Fig. 4.8.1). Minimal force with pathological bone tends to produce metaphyseal fractures with propagation into the shaft.

image

Fig. 4.8.1 Comminuted femoral fracture.

Stress fractures of the femoral shaft are becoming increasingly common. They occur when repetitive mechanical forces are applied to the femur, such as in marathon running or military recruits. They are associated with pain in the mid-thigh and apparently normal X-rays, although a bone scan will detect the fracture, and low-impact training such as cycling is used in rehabilitation. They are rarely displaced.

Clinical evaluation

The clinical diagnosis of femoral shaft fracture is usually straightforward. The thigh is shortened and externally rotated, with the hip held in slight abduction. Palpation reveals tenderness over the fracture site and extreme pain on attempted movement. Neurovascular injuries are rare, but the distal pulses, capillary refill and distal sensation must be carefully examined.

Vascular damage is usually limited to rupture of the profunda femoris perforating branches in closed fractures. The resulting tense, swollen haematoma is limited to the thigh and is not associated with distal circulatory compromise. However, penetrating trauma and open fractures may cause femoral artery disruption with distal circulatory compromise, so repeated vascular evaluations are important. Any evidence of an expanding haematoma or diminished distal pulses requires further investigation with Doppler imaging or arteriography.

Associated injuries

Commonly associated injuries include fractures of the pelvis, the femoral head and neck, dislocation of the hip, and soft tissue disruption of the knee. Up to 50% of closed femur injuries are associated with meniscal and collateral ligament injuries in the knee, although it is usually impossible to evaluate these injuries reliably in the acute setting. Up to 1.5 L of blood may extravasate into the surrounding soft tissues.

Management

The treatment of any associated head, neck, thoracic or pelvic injury must take priority in the setting of multiple trauma. The administration of analgesia, fluid resuscitation and femoral shaft fracture reduction and immobilization are indicated prior to X-ray of the lower limb.

Analgesia

Adequate pain relief is essential in the ED. Intravenous opioid analgesia is necessary, titrated to effect. A femoral nerve block is an important adjunct that should be considered prior to fracture reduction (see Chapter 22.2).

Reduction and immobilization

Early fracture reduction and immobilization in traction reduces overall mortality and pain, limits blood loss and reduces the risk of fat embolism. Fractures are reduced to near anatomic alignment using longitudinal traction, following appropriate analgesia with the knee in extension.

Proprietary splints such as the pneumatic Donway or Hare traction splints have replaced the skin traction Thomas splint in the ED. These provide smooth and gentle traction with minimal discomfort to the patient, and have the additional benefit of reducing blood loss by direct pressure and tamponade of haematoma formation.

Traction is only an interim procedure prior to definitive management, as it cannot maintain a constant force of sufficient magnitude to maintain the length and alignment of adult femur fractures.

Fluid resuscitation

Haemorrhagic shock is a major complication with an average blood loss from a closed femoral fracture of 1200 mL. All patients must be resuscitated with intravenous fluid, cross-matched for blood, kept fasted, and an indwelling catheter inserted to monitor fluid balance.

Orthopaedic management

Early operative fixation is indicated in adults within 8 hours, typically intramedullary nailing. Open fractures require immediate operative debridement with antibiotic cover, followed by delayed intramedullary nailing.

Complications

Complications include fat embolus syndrome, haemorrhagic shock and adult respiratory distress syndrome, with a higher incidence in comminuted fractures. Long-term complications of shortening, malalignment and non-union may result in post-traumatic arthritis. Early mobilization following intramedullary nailing greatly reduces those complications associated with prolonged immobilization. Patients older than 60 years with closed femoral fractures have a mortality rate of 17% and a complication rate of 54%.

Controversies

• Indications for arteriography, particularly in distal third femoral fractures following proximity penetrating trauma, even in the absence of initial vascular compromise.

Further reading

Provost R, Morris J. Fatigue fracture of the femoral shaft. Journal of Bone and Joint Surgery. 1969;51A:487-498.

Russell RH. Fracture of the femur. A clinical study (Abridged by Peltier LF). Clinical Orthopedics. 1987;224:4-11.

Taylor M, Banerjee B, Alpar E. Injuries associated with a fractured shaft of the femur. Injury. 1994;25:185-187.

Vanganess C, DeCampos J, Merritt P. Meniscal injury associated with femoral shaft fractures. An arthroscopic evaluation of incidence. Journal of Bone and Joint Surgery. 1993;75:207-209.

West H, Turkovich G, Donnell C. Immediate prediction of blood requirements in trauma victims. Southern Medical Journal. 1989;82:186-189.

4.9 Knee injuries

Michael Cadogan

Essentials

1 The knee is the most commonly injured joint in the body.
2 Knee injuries often occur in the young, usually associated with sport.
3 The mechanism of injury is an essential part of the history, and examination must include the hip and ankle joint.
4 Anterior cruciate ligament disruption is associated with meniscal and collateral ligament injuries in 50% of cases.
5 Lateral tibial plateau fractures are associated with anterior cruciate and medial collateral ligament disruption, whereas medial tibial plateau fractures are associated with posterior cruciate and lateral collateral ligament disruption.
6 Knee dislocations require urgent reduction followed by angiography, and so represent time-critical orthopaedic emergencies.

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