Orthopaedic principles: fractures and dislocations

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Chapter 17 Orthopaedic principles

fractures and dislocations

John Raftos, Peter Locke

GENERAL PRINCIPLES

Resuscitation and detection of other injuries

Orthopaedic injuries often occur in multiply-injured patients. Resuscitation and identification and management of life-threatening injuries during the primary survey usually take precedence over the identification and management of orthopaedic injuries which should be identified and managed during the secondary survey once the patient has been stabilised. Exceptions include:

• major pelvic fractures—may cause life-threatening haemorrhage which must be controlled in the primary survey

• femoral shaft fractures—may involve 1–2 litres of blood loss and should be reduced and splinted during the primary survey.

Analgesia

(See also Chapter 13, ‘Pain management in the emergency department’.)

Most fractures and dislocations cause severe pain that requires urgent analgesia on presentation to the emergency department. Appropriate initial analgesia may include:

• inhaled nitrous oxide or methoxyflurane or intranasal fentanyl

• intravenous morphine (0.1 mg/kg for children, 2.5–5 mg aliquots for adults)

• oxycodone 5–10 mg orally

• compound oral analgesics (paracetamol plus codeine)—may be used but their efficacy is not proven

• immobilisation with a plaster slab, traction splint, Zimmer splint, sling etc

• regional anaesthesia (femoral nerve block for femoral shaft fracture).

Detection of associated injuries

A thorough knowledge of anatomy is necessary to suspect and detect injuries to tendons, nerves, blood vessels and other viscera that are commonly associated with bony injuries.

Early reduction of fractures

Some displaced fractures and dislocations should be reduced urgently to prevent serious permanent sequelae. These injuries (and their sequelae) include:

• traumatic hip dislocation (sciatic nerve injury, avascular necrosis, heterotopic calcification)

• true knee joint dislocation (popliteal artery injury with lower limb ischaemia, common peroneal nerve injury)

• supracondylar fractures of the elbow (median nerve, radial artery injury)

• elbow dislocation (ulnar nerve injury, heterotopic calcification)

• displaced pelvic fractures (ongoing haemorrhage)

• ankle fracture/dislocation (ischaemic necrosis of compressed skin, usually over one of the malleoli)

• shoulder dislocation (traction injury of the brachial plexus, axillary artery injury, recurrent dislocation).

Early reduction of dislocations

Joint dislocation causes injury to the structures supporting the joint. Prolonged dislocation increases the likelihood of recurrent dislocation. Early reduction reduces the risk of recurrent dislocation and is effective analgesia. Most patients require little or no analgesia once the dislocation has been reduced and their time in the emergency department is minimised with early reduction.

Procedural sedation for emergency department reduction of dislocations and fractures

(See also Chapter 2, ‘Securing the airway, ventilation and procedural sedation’.)

Performed by appropriately qualified emergency department specialists and registrars, procedural sedation is a safe technique for the reduction of most dislocations and the urgent reduction of some fractures in the emergency department. Ketamine is the preferred agent for use in children. A combination of propofol and fentanyl is ideal in adults because its short duration of action minimises the duration of altered consciousness and allows early discharge. Morphine plus midazolam is an adequate alternative in adults but has a longer duration of action.

Safe procedural sedation requires appropriate staffing with an airway-skilled doctor, other than the doctor who will perform the procedure, to perform the sedation and monitor the patient. ECG and oxygen saturation monitoring should be in place and advanced airway and resuscitation equipment should be at hand.

Appropriate consultation and referral

Each hospital has its own arrangements for referral of patients who need specialist orthopaedic assessment. If the patient needs orthopaedic assessment in the emergency department, then the orthopaedic registrar should be contacted. If outpatient orthopaedic referral is necessary, this is provided either at a hospital fracture clinic or in the rooms of the orthopaedic surgeon on call if there is no fracture clinic.

Injuries of the hand and wrist

(See also Chapter 18, ‘Hand injuries and care’.)

The management of hand injuries is the domain of specialist hand surgeons. Fractures of any of the bones of the hand or carpus should generally be reviewed by a hand surgeon as should any laceration of the hand or wrist with the potential for nerve or tendon injury, nail bed injuries, crush injuries, burns, hand infections and high pressure injection injuries. Arrangements for referral to a hand surgery unit will vary from hospital to hospital and should be clearly laid out in the emergency department.

UPPER LIMB INJURIES

Clavicle fracture

Assessment

• Clavicle fracture is most commonly caused by falls onto the outstretched hand, less commonly by direct force injury.

• Patients usually present with pain, tenderness and deformity, and are reluctant to move the affected arm.

• Fractures of the medial and middle thirds usually heal without sequelae. Fractures of the outer third may be complicated by delayed or mal-union.

• Plain X-rays usually adequately demonstrate clavicle fractures.

Management

Orthopaedic registrar assessment in the emergency department is necessary for:

• angulated or displaced fractures

• fractures of the outer third which may need open reduction and internal fixation.

Management of undisplaced fractures of the medial and middle thirds is:

1. a triangular sling or proprietary shoulder support

2. simple analgesia

3. referral to the fracture clinic or orthopaedic surgeon’s rooms.

Acromioclavicular (AC) subluxation/dislocation

Assessment

• This is most commonly caused by a fall onto the tip of the shoulder or an impact on the tip of the shoulder during contact sport.

• Subluxation of the AC joint is associated with rupture of the acromioclavicular ligament and generally requires symptomatic treatment only.

• Dislocation of the AC joint is associated with rupture of the acromioclavicular ligament and the stronger coracoclavicular ligament and may require open reduction and internal fixation, especially in sportspeople.

• Plain X-rays of the shoulder will show widening (subluxation) or displacement (dislocation) of the AC joint. Comparative X-rays of the normal side and weight-bearing views may help with diagnosis.

Management

• Symptomatic management (triangular sling/proprietary shoulder support, ice, simple oral analgesia) is appropriate for subluxation.

• Patients with dislocation should be referred to the fracture clinic or orthopaedic surgeon for consideration of open reduction and internal fixation.

Sternoclavicular subluxation/dislocation

Assessment

• Caused by:

• a direct blow to the sternum or medial clavicle or

• transmitted force from a blow to the posterolateral shoulder causing anterior dislocation of the clavicle or to the anterolateral shoulder causing posterior dislocation.

• Anterior dislocation of the medial clavicle causes pain and localised deformity.

• Posterior dislocation of the medial clavicle has the potential to injure or compress the trachea and the major vessels and nerves that underlie the sternoclavicular joint, causing dyspnoea, chest pain, altered sensation in the arm or vascular abnormality in the arm.

• Plain X-rays are not sensitive for sternoclavicular dislocation. CT scan should be performed for diagnosis and to detect any injury or compression of intrathoracic structures.

Management

1. All patients with sternoclavicular dislocation should be seen by the orthopaedic registrar in the emergency department.

2. Subluxations and some anterior dislocations may be treated symptomatically.

3. Posterior dislocations and most anterior dislocations will require reduction under general anaesthesia.

Anterior dislocation of the glenohumeral (shoulder) joint

Assessment

• The mechanism of injury is a forced abduction and external rotation of the arm at the shoulder or a fall onto the hand forcing the humeral head anteriorly. It occurs most frequently at sport or in the surf in young people and in falls in older people.

• Every dislocation damages the rotator cuff and/or bony structures of the shoulder and so recurrent dislocation is common. The incidence of recurrent dislocation after an initial dislocation is about 50% and increases after every subsequent dislocation, each of which tends to occur with decreasing force. The likelihood of recurrent dislocation is reduced by prompt reduction.

• The patient complains of pain in the shoulder and the arm is held immobile. Inspection usually reveals prominence of the tip of the shoulder and loss of the deltoid contour with an apparent hollow subacromially. Diagnosis may be difficult in obese individuals.

• Examine the patient for common complications of shoulder dislocation:

• circumflex axillary nerve injury with loss of sensation over the deltoid and loss of deltoid function (usually masked by pain pre-reduction)—test for sensation in the ‘nurse’s cape’ distribution over the deltoid

• fracture of the humeral head or neck—inspect the humeral head and neck and the greater tuberosity carefully on X-ray

• posterior cord brachial plexus injury with weakness of wrist extension through the radial nerve—test the function of the wrist and the hand, especially wrist extension

• axillary artery injury—palpate the radial pulse.

• Plain X-rays will identify the great majority of shoulder dislocations. The humeral head usually lies in the subcoracoid position. Look for avulsion fracture of the greater tuberosity and fracture of the humeral neck. Patients with greater tuberosity avulsion should have standard reduction. Patients with humeral neck fracture need orthopaedic consultation.

• Computerised tomography (CT) scan may be necessary for the patient with a painful immobile shoulder and inconclusive X-rays.

Management

Some emergency physicians may opt to reduce recurrent shoulder dislocations without preliminary X-rays but this cannot be regarded as standard practice.

1. Standard management for shoulder dislocation is prompt reduction in the emergency department. Reduction techniques that do not involve traction are preferred because they are said to reduce the likelihood of recurrent dislocation. Techniques include:

• The Spaso (after Spaso Miljesic) technique. With the patient supine the arm is lifted vertically with gentle traction and an assistant thumbs the humeral head while gentle external rotation is applied.

• The Stimpson technique. The patient lies prone on a bed with traction applied with weights to the extended arm.

• The Kocher manoeuvre. Countertraction is provided by an assistant with a towel in the axilla. The operator applies axial traction using the flexed forearm as a fulcrum, followed by external rotation to 90°, and then adduction of the upper arm across the chest wall and internal rotation.

• The Milch technique. With the patient supine on a bed, the arm is fully abducted and gentle external rotation is applied while an assistant thumbs the humeral head.

• The Hippocratic method. With the patient supine on a bed, place the stockinged foot in the axilla for countertraction, hold the arm at the wrist in both hands, and apply traction to the straight arm.

2. Reduction is usually heralded by a palpable ‘clunk’.

3. Once reduction has been achieved:

• Perform post-reduction X-rays to assess position and the possibility of bony injury.

• Re-examine for neurovascular injury.

• Immobilise the arm in a triangular sling/shoulder support.

• Advise the patient to avoid abduction for at least 1 week.

• Referral to the GP for follow-up is usually adequate if there is no evidence of associated fracture or neurovascular injury.

• Discuss referral to a specialist shoulder surgeon with patients with recurrent dislocation.

4. Successful reduction is generally a function of good technique and adequate sedation. The use of excessive force may result in humeral neck fracture, especially in older patients. If reduction is difficult, review the adequacy of sedation and/or seek orthopaedic assistance. Never apply excessive force.

Posterior dislocation of the glenohumeral (shoulder) joint

Assessment

• Posterior shoulder dislocation is uncommon (about 1% of all shoulder dislocations) and the diagnosis is often missed because the humeral head appears to be located on anteroposterior X-ray.

• The mechanism of injury is a forceful impact to the anterior aspect of the shoulder or tetanic muscle contraction during seizure or electric shock.

• The shoulder is painful and the patient is reluctant to move the arm which is held adducted and internally rotated.

• The shoulder joint may appear located on the anteroposterior X-ray but careful inspection will show the ‘light bulb sign’ (the usually asymmetrical appearance of the humeral head becomes symmetrical because of internal rotation) or the humeral head overlapping the glenoid. The lateral X-ray will show the head of the humerus posterior to the glenoid.

Management

Reduction under procedural sedation in the emergency department is usually successful—axial traction is applied while the arm is abducted to 90^o and then externally rotated.

Humeral head and neck fractures

Assessment

• The majority of fractures of the upper humerus occur in falls onto the outstretched hand in older patients.

• Fractures most commonly involve the surgical neck of the humerus but also involve the anatomical neck, the greater and lesser tuberosities, and the articular surface, all either alone or in combination.

• The history is usually of a fall onto the outstretched hand causing pain, swelling and later bruising about the shoulder. Bruising and/or reluctance to move the shoulder may be the only clinical features in older patients with dementia.

• X-rays of the shoulder are usually diagnostic. Look for associated shoulder joint dislocation, angulation, displacement, involvement of the articular surface and displacement of the greater tuberosity.

Management

• Most patients with upper humerus fractures should be reviewed by the orthopaedic registrar in the emergency department to determine appropriate treatment:

• Surgical treatment with replacement hemiarthroplasty should be considered for adults with significant intra-articular involvement.

• Surgical treatment with closed reduction or open reduction and internal fixation should be considered for younger patients with significant displacement or angulation and for displaced avulsion fractures of the greater tuberosity.

• Epiphyseal fractures in younger patients often require closed reduction under general anaesthesia.

• Uncomplicated fractures of the neck of humerus are treated conservatively in a triangular sling/shoulder support or in a collar and cuff if there is impaction requiring gravitational reduction.

• Older patients may be significantly disabled by immobilisation of one arm. Social work involvement is necessary to make appropriate care arrangements while the disability persists. Overnight admission allows analgesia to be optimised and social arrangements to be made.

Humeral shaft fractures

Assessment

• Humeral shaft fractures are caused by direct force injuries, torsion or falls onto the outstretched hand.

• The patient presents with upper arm pain and is reluctant to move the arm which is generally supported by the other hand.

• X-rays of the upper arm are usually diagnostic. Look for displacement, angulation, and the presence of a ‘butterfly’ fragment.

• The radial nerve may be contused in the radial groove in fractures of the middle third of the humerus—always test extension of the wrist and fingers. The injury is usually a neuropraxia which will recover over 6 weeks to 6 months. Vascular injury is uncommon.

Management

The orthopaedic registrar should review all humeral shaft fractures in the emergency department.

Management includes:

1. Standard management of humeral shaft fractures is immobilisation in a ‘hanging slab’. Apply ample padding, especially around the elbow, using an appropriate width plaster slab start in the axilla and continue the slab under the flexed elbow, over the outer surface of the upper arm and well onto the shoulder. Wrap with a gauze bandage, and support in a sling or collar and cuff.

2. Some humeral shaft fractures will require open reduction and internal nail fixation. These may include those with a butterfly fragment, those associated with multiple injuries.

3. Supply appropriate analgesia and arrange review at the fracture clinic or orthopaedic surgeon’s rooms.

Supracondylar fractures of the humerus

Assessment

• Supracondylar fracture is most common in children, with peak incidence at 8 years, and is usually caused by a fall onto the outstretched hand.

• The patient presents with a painful, swollen elbow and is reluctant to use the arm which is usually supported by the other hand.

• Assessment should include a full neurovascular examination of the hand looking for complications of the fracture:

• Brachial artery injury. The brachial artery may be compressed or, in severe cases, there may be intimal damage or rupture. Check the radial pulse and capillary refill in the fingers.

• Median nerve injury. Check sensation in the radial palmar 3½ fingers and motor function in the abductor pollicis.

• Increased tissue pressure/compartment syndrome. Haemorrhage and oedema around the fracture site may cause vascular compromise that is detected by regular vascular checks of the hand and forearm.

• Volkmann’s ischaemic contracture. A disabling ischaemic injury of the muscles and nerves of the forearm, this is caused by arterial injury or compartment syndrome following supracondylar fracture.

• X-rays will demonstrate a supracondylar fracture line. Look for displacement, angulation, comminution.

Management

• Urgent orthopaedic review is needed if there is evidence of vascular compromise.

• All supracondylar fractures should be reviewed by the orthopaedic registrar in the emergency department. Those with significant displacement or angulation will need closed reduction under general anaesthesia. Those with vascular compromise will need urgent reduction and vascular surgical assessment.

• Comminuted fractures in adults may require open reduction and internal fixation.

• Undisplaced fractures without significant swelling can be managed, after orthopaedic registrar review, with a collar and cuff, oral analgesia and referral to the fracture clinic or orthopaedic surgeon’s rooms.

Elbow dislocation

Assessment

• Elbow dislocation occurs in both children and adults, usually as the result of a fall onto the outstretched hand. The radius usually dislocates posteriorly in response to forced hyper-extension.

• The patient presents with a painful, swollen elbow and is reluctant to use the arm which is usually supported by the other hand.

• Assessment should include a full neurovascular examination of the hand looking for complications of the fracture:

• Ulnar nerve injury. Check sensation in the ulnar palmar 2½ fingers and motor function in adduction and abduction of the fingers.

• Brachial artery injury. The brachial artery may be compressed or, in severe cases, there may be intimal damage or rupture. Check the radial pulse and capillary refill in the fingers.

• Median nerve injury. Check sensation in the radial palmar 3½ fingers and motor function in the abductor pollicis.

• Increased tissue pressure/compartment syndrome. Haemorrhage and oedema around the fracture site may cause vascular compromise that is detected by regular vascular checks of the hand and forearm.

• X-rays usually demonstrate the dislocation clearly. Intra-articular bone fragments are common and their origin is often unclear. Look for these carefully—they may inhibit reduction.

Management

1. Elbow dislocations are generally reduced in the emergency department under procedural sedation. Most will reduce with axial traction on the forearm which is held in 30° flexion while the assistant thumbs the olecranon process. If this is not successful, then, with traction still applied, extend the elbow to unlock the coronoid process. An intra-articular bony fragment may prevent reduction—these patients will need open reduction.

2. Test range of elbow movement post-reduction—a full, smooth range suggests successful reduction, resistance to movement suggests intra-articular bone fragment or soft tissue entrapment.

3. Post-reduction X-rays are performed to show alignment and the position of any intra-articular fragment.

4. Repeat the neurovascular examination post-reduction to ensure that none of the nerves has been entrapped in the reduction.

5. Support the reduced elbow in a long arm plaster back slab and refer to the fracture clinic/orthopaedic surgeon’s rooms for review.

Olecranon fractures

Assessment

• These fractures are caused by either a fall onto the elbow or forcible contraction of the triceps.

• There is usually pain and swelling over the olecranon.

• X-rays clearly demonstrate the fracture in most cases. Look for displacement and the position of the fracture relative to the joint.

Management

• All olecranon fractures require orthopaedic registrar review in the emergency department.

• Management usually depends on the integrity of the extensor mechanism:

• If the mechanism is intact and the fracture undisplaced, treatment consists of immobilisation in a long arm slab supported in a sling/shoulder support and review at the fracture clinic or orthopaedic surgeon’s rooms.

• If the extensor mechanism is disrupted, then open reduction and internal fixation is usually necessary.

Pulled elbow

Assessment

• Occurs in children aged 1 to 6 years when the radial head slips out from under the annular ligament as a result of axial traction when there is a sudden tug on the arm by either child or parent while the parent is holding the child’s hand.

• The parent indicates that the child is not using the affected arm which is usually held limply by the side or semi-flexed. There is often, but not always, tenderness over the radial head.

• X-rays are not necessary when the history is clear.

Management

• Reduction is achieved without anaesthetic. The operator, having gained the child’s and parent’s confidence, holds the elbow in one hand with the thumb over the radial head while the other hand fully supinates and then flexes the forearm. Reduction is usually palpable.

• The child does not usually begin to use the arm again immediately. Review about 15 minutes post-reduction usually shows that full movement has returned. No follow-up is necessary.

Radial head and neck fracture

Management

• Undisplaced fractures of the radial head or neck are treated with triangular sling immobilisation and referral to the fracture clinic or orthopaedic surgeon’s rooms.

• Angulated fractures of the radial neck and displaced intra-articular fractures of the radial head should be reviewed by the orthopaedic registrar in the emergency department and considered for open reduction and internal fixation.

Radius and ulna shaft fracture

Assessment

• Isolated fracture of the shaft of one of the forearm bones is usually caused by direct force injury. Fractures of both bones are much more common and are caused by transmitted forces from falls onto the outstretched hand. The position of the hand and arm at the time of the fall will determine the pattern of the fractures.

• The patient presents with pain, swelling, deformity and limitation of movement of the forearm.

• X-rays will demonstrate the pattern of the fracture. Both bones are usually broken or there is a pattern of fracture of one bone with dislocation of the other (Monteggia, Galeazzi fracture/dislocations) so views that include the whole of the forearm including the elbow and wrist joints are essential. Look for angulation, displacement and comminution.

Management

• All fractures of the shaft of the radius and/or ulna should be reviewed by the orthopaedic registrar in the emergency department.

• Management depends on patient age, the site of the fracture and the degree of angulation and displacement.

• A significant proportion of radial/ulnar shaft fractures will require either closed reduction under general anaesthesia or open reduction and internal fixation.

Distal radius and ulna fracture

Colles’ fracture

Smith’s fracture

Assessment

• Defined as a full thickness fracture of the distal radius 1–2.5 cm from the wrist with volar displacement and angulation. Also known as a reversed Colles’ fracture.

• It is caused by falls onto the outstretched hand with forced supination and by injuries that cause forced hyperflexion at the wrist (fall onto the back of the hand, handlebar injuries).

• The patient presents with pain, swelling and deformity (often described as ‘garden spade’ deformity) of the wrist after a fall. There is tenderness over the distal radius.

• X-rays show a transverse fracture of the distal radius. Look for angulation, displacement, comminution, intra-articular involvement.

Management

All Smith’s fractures should be reviewed by the orthopaedic registrar in the emergency department and most will require closed reduction.

Barton’s fracture/dislocation

Assessment

• Barton’s fracture/dislocation is an intra-articular fracture of the distal radius in which impingement of the carpus causes displacement of either the volar (more common) or dorsal rim of the radius.

• X-ray shows an intra-articular fracture of the distal radius with either volar or dorsal displacement and angulation of the intra-articular rim of the radius, the carpus having been effectively driven into the distal radius.

Management

Closed reduction may be attempted but the carpus tends to hold the fragments apart, and so many of these fractures will require open reduction and internal fixation.

Scaphoid fracture

Assessment

• The scaphoid is the most frequently fractured carpal bone.

• Scaphoid fractures are usually the result of a fall onto the outstretched hand.

• About 70% of fractures involve the middle third (‘waist’) of the scaphoid, 10–20% involve the distal pole, and 5–10% involve the proximal pole.

• The patient presents with pain and perhaps swelling of the wrist after a fall. Presentation may be delayed days or weeks after an apparent ‘sprain’ does not resolve. Examination reveals tenderness in the anatomical ‘snuff box’ and pain on axial compression of the thumb.

• X-rays (with scaphoid views) usually reveal a transverse fracture of the scaphoid but may be normal. If clinical suspicion is high and the X-rays are negative, there are several options:

• Apply a scaphoid plaster and re-X-ray after 10–14 days.

• Perform a CT (or MRI) scan of the wrist.

• Perform a radionuclide bone scan of the wrist.

• The chosen option will depend on preference and availability of imaging.

Management

• All scaphoid fractures should be reviewed by the orthopaedic or hand surgery registrar in the emergency department to determine the need for internal fixation.

• Management is either immobilisation in a scaphoid plaster slab or open reduction and internal fixation. Fractures displaced by more than 1 mm are usually internally fixed. Some surgeons routinely internally fix proximal pole fractures because of their increased incidence of non-union and avascular necrosis.

• The main complications are:

• avascular necrosis—occurs in 15–30% of scaphoid fractures, most commonly in proximal pole fractures—the more proximal the fracture, the more likely is avascular necrosis

• delayed and non-union—is most common in proximal pole fractures

• osteoarthritis—results from avascular necrosis, mal-union and non-union and leaves the patient disabled with a painful, stiff wrist.

• Delayed diagnosis and immobilisation of scaphoid fracture significantly increases the likelihood of avascular necrosis and non-union. Obtain further imaging (CT, MRI, bone scan) for patients with snuff box tenderness but normal initial X-ray.

Gamekeeper’s/skier’s thumb

Also see a discussion of this topic in Chapter 18, ‘Hand injuries and care’.

Assessment

• This injury involves rupture of the ulnar collateral ligament of the thumb metacarpophalangeal (MCP) joint because of forced abduction and hyperextension of the thumb in motorcyclists, skiers and footballers.

• The patient presents with pain and swelling at the MCP joint and examination reveals laxity of the joint in abduction.

Management

Management is immobilisation in a thumb spica and referral to the fracture/hand clinic or orthopaedic/hand surgeon’s rooms for consideration for surgical repair.

Fifth metacarpal fracture

Also see a discussion of this topic in Chapter 18, ‘Hand injuries and care’.

Assessment

• The ‘boxer’s fracture’ is a fracture of the neck of the fifth metacarpal from punching a person or a wall or occasionally from a fall directly onto the fifth metacarpal knuckle.

• X-rays reveal a fracture of the neck of the metacarpal, usually with volar angulation.

• Test for rotational deformity by asking the patient to flex the fingers. If there is significant ulnar or radial deviation of the flexed little finger, reduction is necessary.

Management

1. Reduction is best performed with a proximal digital block.

2. Immobilisation is best maintained with a gutter slab that holds the wrist slightly extended, the MCP joint in 70–90° flexion, and the interphalangeal joints in extension (the ‘position of safe immobilisation’, POSI).

Punch injuries may also cause dislocation of the head of the fifth metacarpal which often requires reduction under general anaesthesia and internal fixation.

Metacarpal and phalangeal fractures

Management

• Isolated, uncomplicated metacarpal fractures with minimal angulation and displacement can be safely treated with immobilisation in a volar slab in the position of safe immobilisation:

• wrist slightly extended

• the MCP joint in 70–90° flexion

• the interphalangeal joints in extension.

• Refer to the fracture/hand clinic or orthopaedic/hand surgeon’s rooms.

• Isolated, uncomplicated phalangeal fractures with minimal angulation and displacement can be safely treated with immobilisation by ‘buddy-strapping’ and referred to the fracture/hand clinic or orthopaedic/hand surgeon’s rooms.

• Painful subungual haematoma should be treated by trephining the nail by gently pressing the tip of a red-hot paperclip onto the middle of the nail or drilling with a 21-G needle, over the haematoma.

• Angulated or displaced fractures, those with rotational deformity, open fractures and those complicated by tendon, nerve or nail bed injury need review in the emergency department by the orthopaedic or hand surgery registrar.

Dislocations of the interphalangeal and metacarpophalangeal joints

Assessment

• Dislocations of the finger joints are usually caused by forced hyperextension and the dislocation is usually dorsal.

• Always X-ray deformed fingers before attempting reduction because displaced fractures give a similar external appearance to dislocations.

Management

1. Most finger dislocations are easily reduced. Digital nerve block may be used but many dislocations can be reduced without anaesthesia. The technique involves applying axial traction to the distal part while pressing with the thumb of the other hand over the base of the dislocated bone.

2. Failed reduction may occur when the head of the proximal bone is ‘button-holed’ through the volar plate, necessitating open reduction.

3. Always obtain a post-reduction X-ray to exclude avulsion fractures.

4. Examine active movements of the finger post-reduction to detect rupture of the middle slip of the extensor tendon in distal interphalangeal dislocations.

5. Buddy-strap the reduced finger and encourage active movement.

Mallet finger

Assessment

• Mallet finger is caused by avulsion of the insertion of the extensor tendon mechanism from the dorsal base of the distal phalanx. It usually occurs in ball sports when the ball strikes the tip of the finger, forcing it into hyperflexion.

• The patient presents with pain and swelling at the distal interphalangeal joint and examination reveals weak or absent active extension.

• X-ray reveals a dorsal avulsion fragment. Look for the degree of separation and amount of joint surface involvement.

Management

• Definitive management depends on the degree of separation and joint surface involvement. The majority of patients are adequately treated with a mallet finger splint (splinting the joint in mild hyperextension) for 6–10 weeks.

• Apply a mallet finger splint and refer the patient for early review in the hand/orthopaedic clinic or the hand/orthopaedic surgeon’s rooms.

Boutonnière deformity

Assessment

• Boutonnière (‘button hole’) deformity results from avulsion of the central slip of the extensor tendon from the base of the middle phalanx. The lateral bands then migrate towards the volar surface causing flexion at the proximal interphalangeal joint and extension at the distal interphalangeal joint. The central slip disruption may be caused by laceration, dislocation of the interphalangeal joint or forced flexion of the extended finger.

• Most patients present with a tender, swollen proximal interphalangeal joint.

• X-rays may show an avulsion fragment adjacent to the dorsal base of the middle phalanx.

Management

All patients with boutonnière deformity should be referred urgently to the hand surgery/orthopaedic registrar for prompt surgical treatment.

Tendon injuries in the hand

Assessment

• The majority of tendon injuries in the hand are associated with skin lacerations.

• Tendon injury must be suspected with any hand or finger laceration and its presence must be confirmed/excluded according to the following:

• Test tendon function/finger movement.

• Carefully inspect the wound for signs of tendon injury. Remember that many tendon injuries are not visible in the wound because the injury has occurred with the finger in a different posture.

• If the laceration is in a position where tendon injury may have occurred and the laceration appears to extend past the deep fascia, tendon injury should be suspected.

• Be wary of partial tendon laceration which will go on to rupture.

Management

Urgently refer all patients with actual or possible tendon laceration to the hand/orthopaedic registrar for formal exploration with a bloodless field in the operating theatre.

PELVIC FRACTURES

Pelvic fractures occur in three broad settings:

1. As a result of simple falls from standing in older patients. These are usually undisplaced fractures of the pubic rami or acetabulum and usually do not require active treatment.

2. Avulsion fractures in adolescents and young adults.

3. As a result of major forces in young and old patients. Displaced pelvic fractures often cause life-threatening haemorrhage requiring urgent resuscitation and active definitive treatment.

Pelvic fractures in the elderly

Assessment

• These fractures occur as a result of falls from standing and include fractures of the pubic rami and undisplaced fractures of the acetabulum.

• The patient presents with hip pain, often localised to the groin in pubic ramus fractures, and is unwilling to bear weight.

• X-rays will often demonstrate undisplaced fractures of the pubic rami or acetabulum.

• CT imaging or radionuclide bone scan will detect occult fractures in patients who are unwilling to mobilise but have apparently normal X-rays.

Management

Management includes:

1. adequate analgesia

2. admission to hospital under the orthogeriatric or geriatric team

3. initial bed rest

4. prophylaxis against thromboembolic disease

5. early mobilisation

6. social work involvement to facilitate return to home

7. falls assessment.

Major pelvic fractures

Assessment

• These injuries occur as the result of major trauma:

• falls from heights

• motorcycle and motor vehicle accidents

• crush injuries

• industrial accidents.

• They may be complicated by:

• life-threatening haemorrhage from arteries and venous plexuses within the pelvis and sacrum

• bladder injuries

• urethral injuries

• gynaecological injuries

• rectal injuries

• neurological injury to the sacral nerves.

• A plain X-ray of the pelvis is a standard element of the primary survey for trauma management and will show most haemodynamically-significant pelvic fractures. Look for continuity of the three circles (pelvic inlet, two obturator foramens), sacral fracture, sacroiliac dislocation. Major pelvic fractures usually involve double breaks in the pelvic ring; if one is identified, look for the second.

• CT scan gives accurate visualisation of pelvic and sacral fractures but should not be performed if the patient is haemodynamically unstable.

LOWER LIMB INJURIES

Femoral neck fractures

Assessment

• These fractures are common in the elderly, most commonly caused by a simple fall from standing. They can occur with minimal or no apparent trauma in osteoporotic patients and as pathological fractures, especially with metastatic breast carcinoma.

• Most femoral neck fractures are clinically obvious. The patient is unable to stand or mobilise after a fall and there is characteristic shortening and external rotation of the affected limb. Be wary of the impacted fracture in which the limb may appear normal and the patient may be able to bear weight, albeit with pain and limp.

• X-rays will usually identify the femoral neck fracture. Look for position of the fracture, alignment, displacement, features of pathological fracture.

• When X-rays do not show an obvious fracture but there is pain or inability to mobilise, perform a CT scan or radionuclide bone scan to identify an occult fracture.

Management

• Patients with femoral neck fractures tend to be elderly with significant comorbidities. Many hospitals have joint orthopaedics/geriatrics (orthogeriatric) admission policies that provide thorough peri-operative medical assessment and management. Ensure that all comorbidities are identified, assessed and optimised pre-operatively by appropriate investigation and consultation.

• The management of femoral neck fracture is operative. Best mortality and morbidity outcomes are achieved with operation within 24 hours of injury.

Hip joint dislocation

Hip dislocation occurs in two circumstances.

Traumatic hip dislocation

Assessment

• Is a medical emergency because of risk of injury to the femoral head and sciatic nerve and requires urgent reduction.

• Usually caused by a high velocity impact on the flexed, abducted knee as in motorcycle accidents and impact from the dashboard in high speed motor vehicle accidents or in falls from significant heights.

• Is often associated with other injuries in the pelvis and knee with intra-abdominal and intrathoracic injuries.

• 80–90% of traumatic hip dislocations are posterior, 10% are anterior and the remainder are central.

• Major complications are:

• avascular necrosis of the head of the femur

• sciatic nerve injury

• myositis ossificans.

The likelihood of all of these complications is reduced by early reduction.

• The patient presents from a high velocity impact with a shortened, internally rotated and adducted leg.

• Urgent assessment should include:

• primary survey (ABCDE, resuscitation)

• looking for injuries in other organ systems

• examination of the knees and femoral shafts for associated injuries

• assessment of sciatic nerve function—test dorsiflexion and plantarflexion at the ankle and sensation over the lateral border of the foot

• palpate the arterial pulses of the leg and foot.

• X-rays usually demonstrate the dislocation adequately. Always obtain X-rays of the pelvis, femur and knee joint. Look for associated pelvic, femoral, patellar or tibial fractures.

Management

Reduction may be performed in the emergency department under procedural sedation if the patient is otherwise stable. In unstable patients, the dislocation is reduced in the operating theatre after life-threatening injuries have been controlled.

Prosthetic hip dislocation

Assessment

Does not cause sciatic nerve or femoral head injury but should still be reduced promptly to relieve pain.

Management

Usually reduced in the emergency department with procedural sedation. With the patient supine in bed, an assistant provides counter-traction to the pelvis while the operator stands on the bed and flexes the hip and knee to 90° and then applies vertical traction. X-ray to confirm successful relocation and re-check sciatic nerve and vascular function.

Femoral shaft fractures

Management

Urgent management should include:

1. primary survey (ABCDE, resuscitation)

2. looking for injuries in other organ systems

3. aggressive fluid resuscitation

4. urgent blood crossmatch

5. consider femoral nerve block for analgesia

6. early reduction and immobilisation in a traction splint to reduce pain and haemorrhage.

Most femoral shaft fractures in adults are treated with open reduction and internal fixation. Children are usually treated in gallows traction.

Distal femoral fractures

Assessment

• Includes supracondylar and condylar fractures. Occur with major trauma in motor vehicle accidents and falls and with minimal trauma in older and/or osteoporotic patients.

• Examination shows that the knee is swollen (with lipo-haemarthrosis in condylar fractures) and deformed with decreased range of movement.

• X-rays usually define these fractures well. Look for displacement, angulation and effusion and a blood/fat level in the knee joint.

Management

Give adequate intravenous analgesia and immobilise in a long leg plaster slab while awaiting urgent orthopaedic registrar review.

Patellar fractures

Assessment

• Caused by direct force injury to the patella in falls from standing and from the dashboard in motor vehicle accidents or from sudden forceful contraction of the quadriceps.

• The patient presents with a painful knee after the accident. Knee joint effusion is often, but not always, present.

• X-rays should include anteroposterior, lateral and ‘skyline’ views. Undisplaced linear fractures may be difficult to see on plain X-ray. Obtain a CT scan of the knee when there is significant pain but no evident fracture on plain X-rays. Look for a knee joint effusion with blood/fat level which is diagnostic evidence of a fracture.

• The orthopaedic registrar should review the patient in the emergency department.

Management

Management depends on patient age and the integrity of the quadriceps mechanism:

• If the mechanism is intact, management is usually with immobilisation in a Zimmer splint or long leg plaster.

• Open reduction and internal fixation is standard management if the mechanism is disrupted.

Patellar dislocation

Assessment

• Patella dislocation most commonly occurs in adolescent females but is also common in young males, especially during sport. Dislocation is usually lateral and is caused by either a force applied to the medial patella or forceful contraction of the vastus lateralis with the knee flexed. Congenital predisposition is present in more than 50% of cases, with excessive external rotation at the hip joint being the most common precipitant. Recurrent dislocation is common.

• The diagnosis is usually apparent with obvious lateral dislocation of the patella.

• Pre-reduction X-ray is not necessary when the diagnosis is clear.

Management

1. Reduction is often achieved without anaesthesia with the operator gently extending the knee fully while pressing on the lateral patella with the thumb. If the patient is reluctant to allow this, then procedural sedation should be used.

2. Post-reduction knee X-rays (anteroposterior, lateral, skyline) are performed to detect associated avulsion fractures.

3. The leg should be immobilised with the knee straight in a Zimmer splint for 3 weeks to allow the medial ligaments to heal. The patient is referred to the fracture clinic/orthopaedic surgeon’s rooms and to a physiotherapist for strengthening of the vastus medialis.

True dislocation of the knee

Assessment

• True dislocation of the knee is a medical emergency because it is commonly associated with popliteal artery injury and the risk of amputation.

• The mechanism of injury often involves significant force as in high speed motor vehicle accidents, pedestrian/car accidents and falls, but rotation on a planted foot at sport can cause dislocation, especially in heavy individuals.

• Associated injuries:

• Up to 30% of knee dislocations are open.

• Popliteal artery injury occurs in up to 79% of knee dislocations.

• Common peroneal nerve injury with foot drop occurs in up to 40%.

• Compartment syndrome occurs because of swelling around the knee joint and upper leg and its presence increases the risk of nerve and muscle ischaemia and amputation.

• The risk of amputation because of arterial injury increases if reduction is delayed.

• Three of the four major ligaments of the knee must be ruptured for the knee to dislocate.

• Examine for:

• distal pulses, capillary refill, colour, temperature

• common peroneal nerve injury—dorsiflexion of the foot and toes, sensation between the first and second toes dorsally

• increased compartment pressure.

• Urgent X-rays confirm the diagnosis of knee dislocation.

Management

Management should include:

1. primary survey (ABCDE, resuscitation)

2. looking for injuries in other organ systems

3. urgent orthopaedic registrar review in the emergency department

4. prompt reduction in the emergency department using procedural sedation

5. post-reduction immobilisation in a long leg plaster slab

6. urgent CT angiography and vascular surgery consultation in all cases.

If reduction is delayed for more than 8 hours, the likelihood of distal amputation is about 80%.

Tibial plateau fracture

Assessment

• Classically described as ‘bumper bar fractures’, these injuries are common in pedestrians struck by cars but also occur in falls from standing in the elderly and occasionally at sport. The causative force is usually applied to the knee laterally, driving the lateral femoral condyle into the lateral tibial plateau and opening the knee medially. The lateral tibial plateau is more frequently injured than the medial. Lateral tibial plateau fracture may be associated with medial collateral ligament (MCL) and anterior and posterior cruciate ligament (ACL, PCL) tears as the knee opens up from a laterally applied force.

• The patient complains of knee pain, usually has a knee joint effusion and is unable to bear weight.

• Tibial plateau fracture is easily missed on plain X-ray. Look for a knee joint effusion with a blood/fat level.

• CT scan of the knee should be performed on any patient with knee pain and inability to mobilise and will detect tibial plateau fractures that are poorly delineated on plain X-rays.

• Examine for popliteal artery and common peroneal nerve injury.

Management

• Management depends on patient age and degree of displacement.

• Immobilise the knee in a Zimmer splint or long leg plaster slab and obtain orthopaedic registrar review in the emergency department.

Acute knee pain

The cruciate ligaments (anterior and posterior, ACL and PCL), collateral ligaments (medial and lateral, MCL and LCL) and the medial and lateral menisci are frequently injured at sport and in accidents in which linear and/or torsional forces are applied to the knee. Injuries to the ACL, PCL and the menisci, along with fractures of the distal femur, proximal tibia and patella, will usually cause acute knee effusion (lipo-haemarthrosis). Acute inflammatory and infective monoarthropathies—gout, pseudogout, septic arthritis, are the most common—often also present with acute painful knee joint effusion.

Traumatic knee pain

Assessment

• All patients with acute knee injuries should have plain X-rays of the knee (anteroposterior, lateral, and skyline) to demonstrate fractures:

• tibial plateau fracture, femoral condyle fracture, patella fracture

• avulsion fractures:

º of the tibial spine in cruciate ligament injury

º avulsion flakes from the upper pole patella in quadriceps ligament rupture

º avulsion flakes from the femoral condyles in MCL and LCL injuries

º vertical avulsion flake from the proximal lateral tibia (Segond fracture, indicative of ACL tear).

• A careful history of the mechanism of the knee injury points to the probable derangement:

• A linear force applied to the lateral knee will open the joint medially and compress the bones laterally, resulting in, with increasing amount of force:

º MCL tear—the most common knee ligament injury. Occurs most frequently in football tackles, skiing. There will be tenderness over the MCL above and/or below the medial joint line. Test for laxity to valgus strain—grade 3 injuries involve complete rupture, cause medial joint laxity, and may require surgical repair. Grade 1 and 2 injuries are partial tears, there is no laxity, and they usually heal without surgery.

º MCL tear plus medial meniscus tear—also occurs most commonly at football and skiing. As well as features of an MCL tear, there will be a knee joint effusion and tenderness over the medial meniscus at the medial joint line. Usually requires arthroscopic repair of the medial meniscus.

º MCL tear plus medial meniscus tear plus ACL tear—also occurs most commonly at football and skiing. As well as the features of MCL and medial meniscus injury, there will be laxity to on anterior stress. Usually requires arthroscopic ACL reconstruction.

º Lateral tibial plateau fracture plus MCL tear.

• PCL tear is usually caused by hyperextension of the knee, most commonly at football or skiing. There will be a knee joint effusion and laxity to posterior strain.

• Rotational forces, as in changing direction on a planted foot, cause meniscal tears and cruciate ligament injuries.

• Examination of acute knee injury is often difficult because of pain and swelling but should always include:

1. Inspect for the presence and size of effusion. Compare with the other, normal knee; remember to milk the prepatellar bursa and test for patellar tap. Effusion suggests internal derangement and is unusual in isolated collateral ligament injuries.

2. Palpate for tenderness. Tenderness over the MCL and LCL above and below the joint line suggests collateral ligament injury. Tenderness in the joint line suggests internal derangement.

3. Test range of movement. A ‘locked’ knee is usually caused by acute or exacerbation of chronic meniscal tear.

4. Test for collateral ligament integrity. Laxity to valgus strain suggests MCL tear; laxity to varus strain suggests LCL tear.

5. Test for cruciate ligament integrity:

• Anterior drawer sign. Supine on bed, hip at 45°, knee at 90°, sit on patient’s foot and pull tibia forwards. Laxity suggests ACL tear.

• Lachman test. Supine on bed, knee flexed to 20–30°, tibia lifted upwards. Laxity suggests ACL tear.

• Posterior drawer sign. Supine on bed, knee at 90°, sit on patient’s foot and push tibia backwards. Laxity suggests PCL tear.

6. Test for meniscal injury:

• Apley grind test. Prone on bed, knee at 90°, apply axial force through leg and rotate.

• McMurray’s test. Patient supine on bed, knee at 90°, thumb over joint line, rotate lower leg. Pain and palpable click indicates meniscal injury.

Management

Initial management of knee ligament and meniscal injuries includes:

1. Give analgesia.

2. Consider aspirating a tense haemarthrosis for pain relief.

3. Immobilise in a Zimmer splint.

4. Refer to fracture clinic or orthopaedic surgeon’s rooms for further assessment and management.

Non-traumatic knee pain

• All patients with knee pain, effusion and no history of injury should have plain X-rays of the knee along with screening blood tests (blood count, erythrocyte sedimentation rate, C-reactive protein, urate).

• Aspiration of knee effusion fluid for microscopy, culture and crystals should always be performed to exclude a diagnosis of septic arthritis.

• Septic arthritis requires admission to hospital for urgent surgical lavage and intravenous antibiotics.

• Acute gouty arthritis should be treated with oral prednisone 1 mg/kg up to 50 mg daily for 3–4 days and a non-steroidal anti-inflammatory agent.

Isolated fibular fractures

Assessment

• These fractures are usually the result of direct force trauma but may be associated with diastasis of the tibio-fibular ligament, especially if the fibular fracture is at the neck of the fibula.

• X-rays of the tibia and fibula should always include the knee and ankle joints. Look carefully for evidence of tibio-fibular diastasis if an apparently isolated fibular fracture is present.

Management

Isolated fibular fractures may be treated with either a firm bandage or a short leg plaster slab and referral to the fracture clinic or orthopaedic surgeon’s rooms.

Ankle ligament injuries

Assessment

• Common cause of presentation to emergency departments.

• Usually caused by trips applying torsional force at the ankle joint. Inversion injury is the most common.

• The lateral ligament of the ankle comprises:

• anterior talofibular ligament

• posterior talofibular ligament

• calcaneofibular ligament.

• The medial (deltoid) ligament of the ankle consists of superficial and deep components.

• 75% of ankle injuries are ligament injuries without fracture and 90% of these involve the lateral ligaments. 90% of lateral ligament injuries involve its anterior talofibular portion.

• The great majority of ankle ligament injuries are partial (grade 1 and 2) tears which will heal to full strength with conservative treatment. Full (grade 3) tears of more than two ligaments often result in persistent ankle instability and so will often require surgical reconstruction. Assessment of instability is difficult at the acute presentation because of pain and swelling.

• The patient presents with a painful, often swollen ankle.

• The decision to image the ankle depends on the independently validated Ottawa ankle rules: if there is pain in the malleoli and any one of

• inability to bear weight both immediately and for four steps in the emergency department

• bone tenderness over the distal 6 cm of the fibula or the tip of the lateral malleolus

• bone tenderness over the distal 6 cm of the tibia or the tip of the medial malleolus,

plain anteroposterior and lateral X-rays of the ankle should be performed.

Ankle dislocation

Assessment

• This is a common injury and is usually associated with ankle fractures.

• The patient presents with pain, swelling and obvious deformity at the ankle joint.

• Distal neurovascular function is usually preserved but the skin is stretched tightly over one of the malleoli, and this may lead to ischaemic necrosis of the skin if reduction is delayed.

Management

Management should include:

1. Urgent reduction under procedural sedation in the emergency department, usually before X-rays have been performed. Most dislocations reduce easily with manual traction on the foot.

2. Immobilisation in a short leg plaster slab.

3. X-rays to reveal the associated fractures.

4. Urgent orthopaedic registrar review in the emergency department.

5. Associated fractures will usually require open reduction and internal fixation.

Ankle fractures

Management

• Stable fractures in anatomical position are usually treated conservatively in a short leg plaster slab with referral to the fracture clinic or orthopaedic surgeon’s rooms.

• Unstable fractures are usually treated with open reduction and internal fixation.

The orthopaedic registrar should review all ankle fractures in the emergency department.

Achilles tendon rupture

Assessment

• Achilles tendon rupture is usually a sporting injury and occurs in adults from the 20s with forceful contraction of the posterior compartment muscles, often when pushing off at tennis and squash and in sprinters.

• The patient reports a sudden severe pain at the base of the leg. There is often an audible snap and the patient describes feeling as though he or she has been hit in the calf and is unable to walk or stand on the toes.

• The Thompson test is usually diagnostic. The patient either lies prone or kneels on a chair facing away, the operator squeezes mid-calf—the foot plantarflexes with an intact Achilles tendon, does not move when the tendon is ruptured.

• Ultrasound confirms the diagnosis, demonstrates partial rupture and differentiates between Achilles tendon rupture and calf muscle tears.

Management

Management is surgical repair of the ruptured tendon.

Talus fractures

Assessment

• Flake avulsion fractures are common with ligamentous injury of the ankle and foot and are usually treated as ligamentous injuries.

• Fractures of the neck and body of the talus require substantial force (falls from a height, compression of the foot against the firewall in high speed motor vehicle accidents) and may lead to ischaemic necrosis of the talus.

• Most talus fractures will be visible on plain X-rays of the foot and ankle. CT scanning is indicated for patients with foot pain and swelling with apparently normal X-rays, e.g. talar dome fractures not visible.

Management

Patients with talar fractures should be reviewed by the orthopaedic registrar in the emergency department. Displaced fractures will require open reduction and internal fixation.

Calcaneus fractures

Management

• Calcaneus fractures should be reviewed by the orthopaedic registrar in the emergency department.

• Displaced and intra-articular fractures will need open reduction and internal fixation.

• Patients with bilateral fractures will need hospitalisation because they are unable to mobilise.

Major fracture/dislocations in the foot

Chopart fracture/dislocation

Assessment

• The Chopart fracture/dislocation is essentially a dislocation of the midfoot on the hindfoot. It is an uncommon injury, caused by major forces as in falls from a height or compression of the foot against the firewall in high speed motor vehicle accidents.

• There is fracture and dislocation about the talonavicular and calcaneocuboid joints.

• Plain X-rays may appear normal.

• CT imaging should be performed if there is pain and swelling of the foot with apparently normal X-rays. It will clearly identify the complex of injuries.

Management

• Urgent reduction is necessary if there are features of distal vascular compromise.

• The orthopaedic registrar should review all midfoot and hindfoot fractures in the emergency department.

• Management is by open reduction and internal fixation.

Lisfranc fracture/dislocation

Assessment

• The Lisfranc fracture/dislocation is essentially a dislocation of the forefoot on the midfoot. It is caused by major forces, as in a heavy weight falling on the foot or a trip off a gutter or step.

• The key to the injury is the articulation of the base of the second metatarsal with the midfoot, anchoring the forefoot and preventing lateral movement. Lisfranc fracture/dislocation occurs when lateral and rotational forces cause fracture of the base of the second metatarsal and disrupt Lisfranc’s ligament, allowing lateral dislocation of the forefoot.

• X-rays of the foot may appear normal. Look carefully for fracture of the base of the second metatarsal and lateral displacement of the metatarsals.

• CT imaging should be performed if there is pain and swelling of the foot with apparently normal X-rays.

Management

• Urgent reduction is necessary if there are features of distal vascular compromise.

• The orthopaedic registrar should review all midfoot and hindfoot injuries in the emergency department.

• Management is usually by open reduction and internal fixation.

Other metatarsal injuries

Stress fractures

• The second and third metatarsals are prone to stress fracture because they have little mobility in the forefoot.

• The patient will complain of persistent forefoot pain without history of injury.

• There is often a history of recent increase in walking or running.

• X-rays are often normal.

• Radionuclide bone scan will demonstrate these fractures.

• Advise rest and refer to the fracture clinic or orthopaedic surgeon’s rooms.

Phalangeal fractures in the foot

Assessment

Toe fractures are common and are caused by direct injury. The big toe and the little toe are the most exposed and the most frequently injured.

Management

1. Fractures are usually minimally displaced and are best treated by buddy-trapping.

2. Painful subungual haematoma should be treated by trephining the nail by gently pressing the tip of a red-hot paperclip onto the middle of the nail.

Open fractures of the toes require assessment in the emergency department by the orthopaedic registrar for lavage under general anaesthesia and intravenous antibiotics.

EDITOR’S COMMENT

These patients commonly present to the emergency department.

Respect pain and swelling—suspect fracture.

Remember: 1) you are not a radiologist; 2) not all fractures are visible even on good films.

Ensure the patient understands the need for follow-up, confirmation of a diagnosis/formal X-ray report, and the need for review if healing/pain/function is not to plan. Ignore this, and you will be sued.

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Orthopaedic principles: fractures and dislocations