Chapter 17 Orthopaedic principles
fractures and dislocations
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:
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
• true knee joint dislocation (popliteal artery injury with lower limb ischaemia, common peroneal nerve injury)
Procedural sedation for emergency department reduction of dislocations and fractures
(See also Chapter 2, ‘Securing the airway, ventilation and procedural sedation’.)
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.
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.
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.
Sternoclavicular subluxation/dislocation
Assessment
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
• 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.
Management
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.
3. Once reduction has been achieved:
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.
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.
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.
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.
Management
The orthopaedic registrar should review all humeral shaft fractures in the emergency department.
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.
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.
Management
• 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.
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.
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.
Olecranon fractures
Assessment
Management
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.
Radial head and neck fracture
Assessment
• These structures may be injured by direct force but the most common mechanism of injury is a fall onto the outstretched hand.
• The patient presents with pain in the elbow and pain on movement. Supination and pronation are usually limited by pain. Firm palpation over the radial head reveals tenderness.
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.
• 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.
Distal radius and ulna fracture
Colles’ fracture
Assessment
• Colles’ fracture, first described by Abraham Colles in 1814, is defined as a fracture of the distal radius within 2.5 cm of the wrist joint with dorsal and radial angulation and dorsal displacement.
