Orthopaedics

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CHAPTER 17 Orthopaedics

Fractures

A fracture is a complete or partial break in the continuity of a bone. There are several ways of classifying fractures, e.g. according to causation, according to configuration of fracture or according to their relation to surrounding tissues.

Causation

Trauma

The fracture occurs in a normal bone as a result of trauma. The pattern depends upon the direction of the force. Direct force usually results in a transverse fracture. Indirect force, e.g. a twisting injury, usually results in a spiral or oblique fracture. Axial compression results in a comminuted, crush or burst fracture. An avulsion fracture is caused by traction, usually a tendon or ligament tearing off a bony fragment, e.g. patellar fracture with a sudden contraction of quadriceps.

Stress fractures

The bone is fatigued by repetitive stress and resembles the fatigue fractures that occur in metals. This type of fracture occurs in individuals undertaking increased amounts of often unaccustomed exercise, e.g. ‘march’ metatarsal fractures in soldiers.

Pathological fractures

These occur in bones already compromised by underlying disease. The trauma may be quite minimal. Common underlying causes include osteoporosis and metastases.

Pattern (→ Fig. 17.1)

Figure 17.1 Types of fracture.

Transverse fracture

This is caused by direct force.

Spiral or oblique fracture

This is caused by force transmitted from a distance often in a twisting motion.

Crush fracture

This is caused by direct compression in cancellous bone.

Burst fracture

This is caused by strong axial compression of a short bone, e.g. vertebrae.

Avulsion fracture

This is caused by sudden, strong traction by a tendon or ligament avulsing a bony fragment.

Fracture–dislocation

This occurs when there is fracture of a bone involved in a joint with complete loss of congruity of the joint surfaces. Partial loss of congruity is a fracture subluxation.

Greenstick fracture

An incomplete paediatric fracture in which the bone buckles and cortical continuity is lost only on one side of the bone.

Comminuted fracture

One in which the bone is broken into more than two fragments.

Relation to surrounding structures

Closed fracture

There is no skin or body cavity wound communicating with the site of fracture.

Open fracture

There is communication between the site of fracture and the skin or body cavity wound, e.g. fractured tibial shaft protruding through the skin.

Intra-articular fracture

The fracture involves an articular surface.

Complicated fracture

There is associated damage to nerves, blood vessels or internal organs.

Symptoms and signs

History to assess mechanism of injury. Pain. Loss of function. Loss of sensation or paralysis. Tenderness. Deformity. Swelling. Crepitus. Abnormal mobility. Discrepancy in length of limbs, associated nerve and vascular injuries. Examine for any associated injuries. Wound associated with open fracture.

Investigations

Radiographs: in two planes at right angles. With long bones include joints at either end. Normal side for comparison. Radiograph – confirms the diagnosis, accurately localizes it, demonstrates the type (e.g. spiral, comminuted, etc.), shows any displacement, shows any pre-existing disease (e.g. pathological fracture through a metastasis), may show foreign body in open fracture, may show associated joint problem. Occasionally a fracture may not be apparent on initial radiograph (e.g. stress fracture, scaphoid fracture) and further radiographs may be required later when callus or late radiolucent line associated with healing is apparent. Further imaging may be required to assess associated damage, e.g. arteriography.

Principles of fracture treatment

First aid

Follow Advanced Trauma Life Support (ATLS) principles (→ Ch. 4). Ensure clear airway. Ensure adequate breathing. Stop bleeding. Splintage to prevent further damage by movement of fragments. If open fracture, cover with Betadine-soaked gauze, administer prophylactic antibiotics and check tetanus status.

Treatment of shock

Considerable blood loss can occur with fractures – 1.5 L can be lost with a femoral shaft fracture. Multiple fractures can lead to considerable blood loss. Ensure adequate treatment of shock with blood or plasma expanders before investigation and treatment.

The fracture itself

1. Reduction, i.e. the restoration of the displaced fragments to their anatomical position

2. Stabilization, i.e. keeping the bony fragments in the reduced position until union occurs

3. Rehabilitation starts as soon as possible after the injury. It is aimed initially at maintaining the function of the uninjured parts and, once the fracture is united, restoring function of the injured parts.

Reduction

Is reduction necessary?

Small displacements in extra-articular fractures may be acceptable, although joint surfaces should be anatomically reduced. Initially, reduction is the best form of pain relief. Indications for reduction include functional impairment if not reduced, deformity, interference with blood supply, and interposition of soft tissue between bone ends.

How should it be done?

Reduction may be either closed or open.

Closed reduction

This may be by manipulation or traction, the latter being applied via the skin or skeleton. This must be done under anaesthesia, local, regional or general.

Open reduction

This allows accurate alignment of fragments but carries the risk of infection. It is carried out in the following circumstances:

• Reduction cannot be obtained by closed manipulation, e.g. because of soft tissue interposition

• There is inability to maintain reduction – maintenance of reduction requires internal fixation

• Where early mobilization may be appropriate, encouraging rehabilitation and avoiding joint stiffness.

How is reduction held?

Some fractures are intrinsically stable and require no additional stabilization. Others require external or internal fixation.

Types of stability

Absolute stability

Fracture fragments are held rigidly together by compression allowing bone healing by remodelling. Little or no external callus forms, e.g. ankle fracture fixation.

Relative stability

Fracture fragments are held approximately opposed without compression. Micromovement occurs at the fracture site and abundant bridging callus forms, e.g. forearm fracture stabilized with a cast.

Methods of stabilizing a fracture

External

Plaster of Paris (or synthetic materials)

This may be used for splints, casts or jointed casts. It is usually applied over a layer of wool. Where there is excessive swelling, a slab may be used initially, a full cast being applied at a later date. The cast is radiolucent and the position of the bone should be checked by radiograph after the plaster has been applied. The distal circulation should be observed because a tight plaster may interfere with blood flow. All plasters should be checked 24 h after application. Cast-bracing involves the use of hinged and jointed casts – various segments are connected by specially designed hinges. This allows joint mobility and fracture stability, as well as patient mobility.

Traction

This is used to overcome the powerful pull of muscles, which may cause shortening or angulation. Traction may be fixed, e.g. a Thomas splint for femoral shaft fractures, or sliding (balanced) where the patient’s weight is balanced against an applied load. The patient’s weight and friction forces counter the applied traction. The patient can move the limb or can move about the bed while traction continues to act in the desired direction. Traction may be applied to the skin via adhesive tape or to bone via pins or wires. Skull traction can be effected by securing a pair of tongs to the skull and applying traction in the longitudinal axis of the neck. Tongs are now used less due to ‘halo’ traction.

Internal fixation

Wires

Kirschner (K) wires may be used to internally splint a fracture fragment in two separate planes, e.g. distal radial fracture or used with a figure of 8 tension band wire, e.g. fractures of the olecranon.

Screws

Stainless steel or titanium alloy screws are used. May be used to attach small bony fragment, e.g. fractures of malleoli or to lag two fragments in compression.

Plating

A plate is fastened to both fragments by screws (→ Fig. 17.2). Plates can be designed to compress a fracture, neutralize (support) a fracture compressed by lag screws or bridge a comminuted fracture.

Figure 17.2 A fracture of the radius and ulna fixed with plates and screws. The radial fracture is comminuted.

Intramedullary nail

A rod is passed along the medullary cavity of a long bone across the fracture and locked with transverse locking screws. It is used mainly for long bone fractures, e.g. femoral shaft fractures.

External fixation devices

The fragments are transfixed by pins or wires, which are then held in an external fixation device to immobilize the fragments. Difficult, comminuted fractures can be reduced and immobilized by this method. The fracture can be held while surgery for associated injuries, e.g. skin, vascular or nerve, is carried out.

Indications for internal fixation

• Failure to maintain adequate reduction by external methods

• Intra-articular fractures to secure good alignment of joint surfaces and prevent later osteoarthritis

• Need to avoid long periods of immobilization, e.g. elderly patient with fracture of femoral neck

• Patients with multiple injuries where internal fixation may facilitate nursing and patient mobility

• Where damage to other structures, e.g. vessels and nerves, requires stability for good results following repair

• Pathological fractures.

Open fractures

Principles of management of open fractures include:

• First aid: adequate splintage plus coverage with a clean dressing

• Treatment of shock: bleeding may be external as well as internal

• Antibiotic therapy: as soon as diagnosis is made, large doses of antibiotics are given i.v. (benzylpenicillin 1.2 g 6-hourly and flucloxacillin 1 g 6-hourly)

• Tetanus prophylaxis: ± immunoglobulin

• Photograph wound

• Treatment of the wound and fracture:

— Clean the wound removing any foreign bodies and all devitalized tissue. A minimum of 6 L of saline washout should be used.

— Repair any damage to blood vessels.

— Mark the ends of any nerves that have been severed to facilitate identification for delayed repair.

— Fracture stabilization, usually by external fixation as internal fixation may be associated with increased rates of infection. However, if adequate debridement is carried out, intramedullary nailing may be appropriate, particularly if plastic surgery is required as internal fixation facilitates easier skin cover.

— Clean wounds may be closed primarily.

— Contaminated wounds older than 6 h, or dirty wounds, are further debrided and washed in 48 h.

— Massive wounds may require early free tissue flap coverage.

— If Plaster of Paris is applied a window may be cut in it so the wound can be observed and infection excluded.

— Plastic surgeons should be involved early.

Rehabilitation

The aims should be the restoration of function of the injured part and rehabilitation of the patient as a whole. Specific advice includes: suitable exercises; active use as much as compatible with fracture healing; active exercises; physiotherapy; occupational therapy; advice from social worker; employment advice.

Complications of fractures

Immediate (at time of fracture)

• Haemorrhage: may be internal or external. Internal haemorrhage can be considerable at the fracture site, i.e. up to 1.5 L with a fractured femoral shaft

• Injury to nerves and vessels

• Injury to underlying structures, e.g. brain damage with skull fractures, splenic rupture with left lower rib fractures, urethral trauma with pelvic fractures.

Early (during the period of initial treatment)

Local

• Gangrene due to vessel damage or tight plaster casts

• Nerve palsies from tight plaster casts, or involved in callus, or iatrogenic injury

• Wound infection or wound dehiscence

• Loss of position

• Pressure sores.

General

DVT

This can occur with fractured neck of femur or generalized immobility in bed. Prophylaxis should be given.

Acute urinary retention

Always exclude the possibility of bladder or urethral injury.

Pneumonia

Fat embolism

This usually complicates fractures of a major long bone at 3–10 days post-injury. Embolization of the pulmonary and systemic microvasculature with lipid globules occurs. The exact source of the fat is controversial. Originally it was thought to be due to fat release from bone marrow adipocytes at the site of the fracture; it is now thought to be more likely to be an abnormal response of fat metabolism to trauma. The main effects are on the brain and lung. The patient may suddenly become drowsy, pyrexial and tachycardic. A petechial rash may appear on the upper trunk. Coma and death may result. With lung involvement the patient develops confusion, breathing difficulties, cyanosis. PO₂ down. Radiograph appearance is similar to ARDS. Renal problems may occur with excretion of lipid droplets. Diagnosis may be confirmed by finding lipid globules in urine or sputum. Treatment is by oxygen therapy, ventilation and renal support. Early operative immobilization of fractured long bones may reduce incidence.

Compartment syndrome

This is elevation of interstitial pressure in a closed fascial compartment that results in microvascular compromised. It may occur with or without arterial injury. Muscle swells and compartment pressure rises. Ischaemia results from pressure on surrounding small arteries. Distal pulses may still be palpable and the diagnosis therefore missed. Awareness of the possibility of the diagnosis is important, particularly when the pain is out of all proportion to the injury. In the lower limb, the posterior compartment (flexors of the ankle), anterior compartment (extensors) or peroneal compartment (evertors) may be involved. The anterior compartment is most commonly involved. Treatment is by prompt fasciotomy, which allows the muscle to expand and relieves the pressure on the vessels.

Crush syndrome

This is due to extensive crushing of muscle or extensive muscle necrosis, e.g. with ischaemia due to arterial injury. Myoglobin is released into the circulation. Myoglobinuria and renal failure may ensue. Oliguria with dark brownish red urine should suggest the diagnosis. Prompt treatment with an osmotic diuretic may prevent renal failure. Removal of all dead muscle, possibly by amputation of the limb, may be required. Dialysis is required for established ARF, which usually recovers.

Late (after the period of initial treatment)

Delayed union

The fracture does not heal in the expected time. Absence of callus and mobility at the fracture site are features.

Non-union

The fracture remains un-united. Non-union may be hypertrophic (due to excessive movement) or atrophic due to poor blood supply, infection or pathological fracture. A pseudarthrosis (false joint) may result. Hypertrophic produces non-bridging callus. Atrophic produces no callus. Treatment is with rigid stabilization, bone grafting, intramedullary bone reaming or pulsed electromagnetic stimulation.

Mal-union

Healing has resulted in a deformed position. This may be because of shortening, mal-rotation, or angulation. Treatment depends on the degree of deformity and the age of the patient. In children considerable remodelling may occur resulting in correction of the deformity. In recent fractures, manipulation, or wedging of the plaster cast, may suffice. In older fractures osteotomy may be required. Deformity may put strain on adjacent joints, resulting in osteoarthritis.

Complex regional pain syndrome (causalgia, reflex sympathetic osteodystrophy, Sudeck’s atrophy)

The limb becomes painful, swollen and stiff with a reddened, smooth, shiny appearance to the skin. Radiograph shows patchy porosis of the bone. It may be seen after a Colles’ fracture, in which case the symptoms affect the hand and wrist. Physiotherapy is required over a prolonged period of weeks or months. The prognosis is usually good.

Avascular necrosis of bone

Part of a bone necroses when its blood supply is interrupted by the fracture. Common sites are:

• The head of the femur is intracapsular where retinacular and intramedullary vessels supplying the femoral head are disrupted.

• The proximal part of the scaphoid bone in fractures across the waist; the blood supply enters from the distal end.

Diagnosis is by radiograph, the avascular fragment being more dense and sclerotic. Early diagnosis may be made by MRI. Osteoarthritis may result.

Myositis ossificans

Calcification with subsequent ossification occurs in a haematoma associated with either stripping of the periosteum and release of osteoblasts into the surrounding muscle and tissue or reactive proliferation in soft tissues causing ectopic calcification. It is most common in injuries around the elbow and those involving quadriceps femoris. Initially treatment involves strict rest, NSAIDs and avoidance of passive movements. When radiographs show that the shadow of calcification has been replaced by a clear outline of ossification, exercise may be reinstituted. Occasionally surgical excision of the ossification is necessary but only when the bone is mature.

Osteoarthritis (OA)

This may result from misaligned fractures putting strain on joints, or after intra-articular fractures.

Post-traumatic stress disorder

Compensation neurosis and malingering may occur.

Spinal trauma

The incidence in the UK of spinal injuries is about 15 per million of the population per year. RTAs account for over 50%, the remainder being due to accidents in the home, industrial accidents, sports injuries and assault. Many patients have associated head, chest and abdominal injuries. The correct management of spinal injuries is essential at every stage to prevent the continuing risk to the spinal cord. Ideal management involves immediate evacuation from the scene of the accident to a centre where care can be supervised by specialists in spinal injuries. A wide spectrum of spinal trauma ranging from minor whiplash injuries to cord transection may occur. All patients complaining of neck/back pain must be thoroughly assessed. All unconscious patients must be assumed to have a spinal injury until proved otherwise.

Management of spinal injuries

Scene of the accident

1. Keep the head and neck in neutral position. Avoid any unnecessary movement. Summon help. Do not remove a crash helmet.

2. Medical, paramedical or ambulance personnel. Ensure a clear airway. Apply a collar in suspected cervical injury or a spinal board with an integral head and neck splint prior to extraction from the scene of the accident.

3. Ventilation may be impaired with cervical and upper thoracic injuries. Intubate if necessary with extreme care.

4. Avoid oropharyngeal suction in tetraplegic patients. It may stimulate the vagal reflex, aggravate the pre-existing bradycardia and precipitate cardiac arrest.

5. The casualty who is trapped should be carefully removed and if conscious or intubated placed supine on a stretcher. A ‘scoop’ stretcher may be fitted together around the casualty on the ground. Unconscious patients who are not intubated are at risk of passive gastric regurgitation and aspiration of vomit if they are nursed on their backs. If intubation is not performed, the patient should be ‘log rolled’ into a modified lateral position supporting the head in the neutral position. Log rolling should be performed by four people in a coordinated manner ensuring that unnecessary movement does not occur in any part of the spine.

6. Keep the patient warm. Hypothermia may occur owing to paralysis of the sympathetic system.

Initial management at the receiving hospital

1. Follow Advanced Trauma Life Support (ATLS) principles for emergency management.

2. Take a brief history during the primary survey with a more detailed history at the end of the secondary survey.

3. At the start of the secondary survey while removing the spinal board, assess the spine. ‘Log roll’ for a proper and safe examination of the back. Look for localized bruising and tenderness. Spinal deformity – gibbus or interspinous gap. Assess for other injuries.

4. Full neurological examination to assess the level and the extent of cord damage. Record pin-prick sensation (spinothalamic tracts); fine touch and joint position sense (posterior columns); power of muscle groups according to Medical Research Council Scale (corticospinal tracts); reflexes – limbs, abdominal, anal, and bulbocavernous. Cranial nerves. Priapism indicates a high lesion. A neurological examination should be repeated following the period of potential spinal shock.

5. Radiological investigation: a lateral C-spine radiograph will reveal 85% of cervical spine fractures. However, this is no longer an essential part of the primary ATLS survey, especially if the C-spine is scanned during a trauma CT scan. A CT neck should be requested if the C7/T1 junction is not easily visualized on a lateral radiograph. A C-spine radiograph series comprises an anteroposterior (AP), lateral and odontoid peg view. Unstable fractures include: fracture-dislocations of the cervical, thoracic and lumbar spine; burst fractures (sometimes); fractures of atlas and axis. CT scan may give clearer view of the damage. MRI shows cord compression and soft tissue damage more clearly.

6. Initial assessment should define two aspects. First, is there a cord injury and is it complete or incomplete (distal sparing easiest to demonstrate as motor activity)? Second, is there a significant spinal injury and is it stable or unstable? Note that these two aspects of the injury can be quite independent (e.g. central cord syndrome after a forced extension injury in a spondylitic patient with no spinal fracture).

Whiplash injuries

Car struck from behind. Neck extends with sudden acceleration and then flexes forward with sudden deceleration. Usually ligamentous and soft tissue damage only, although there may be pain and paraesthesia in the arms and hands. Radiographs are normal or show mild pre-existing degenerative changes.

Treatment

Rest followed by physiotherapy. Prognosis is variable, some patients recovering while others have prolonged symptoms that may be permanent and require a collar. (In some patients, symptoms settle miraculously after awards of compensation!)

Fractures and dislocations of the spine

Classification by mechanism of injury

• Compression: burst fracture (usually stable)

• Flexion compression: anterior wedge fracture. Possible disruption of posterior ligaments

• Flexion rotation: shearing of all restraining ligaments. Unifacet or bifacet dislocations. These fractures are the commonest cause of neurological damage

• Hyperextension: disruption of the anterior structures. These fractures may cause momentary cord compression leading to ‘central cord syndrome’.

Cervical spine fractures and dislocations

Injuries most often occur because of RTAs or sport. A fall on the head with the neck forcibly bent, e.g. flexion and rotation. Subluxation or dislocation occurs with disruption of disc. Forced extension, e.g. a fall on the face or forehead, may occur resulting in cervical spine injury. If a cervical spine injury is suspected the first move should be to safeguard the cord by controlling neck movements. Do not allow the head to flex forward, and do not hyperextend the neck. Keep in a neutral position.

Symptoms and signs

Often associated head injury so patient may be unconscious. Assume cervical spine injury. Conscious patient may have pain, muscle spasm and localized tenderness. Pain may radiate down arms. Look for neurological signs. The patient with damage above C4 is unlikely to survive because of paralysis of all respiratory muscles. Transection above sympathetic outflow causes bradycardia and hypotension.

Investigations

Radiographs

• Lateral to show C1–T1. May need CT scan

• AP through open mouth to show odontoid

• 30° oblique for facet joints (rarely done now because of CT)

• Flexion and extension views to assess stability

Treatment

Fractures of the atlas

These are usually fractured as a result of vertical compression force breaking the ring into four pieces. Inherently unstable, requiring halo jacket immobilization and fusion if non-union occurs.

C1–C2 subluxation

This is due to failure of the transverse ligament. Treatment is by initial traction in extension then posterior fusion.

Odontoid peg fracture

It is uncommon and easily missed. All but the rare apical avulsion type require traction followed by a halo jacket with posterior fusion for non-union.

Burst fractures

These may be stable, in which case treatment is by halo jacket. If unstable, traction followed by a halo jacket is required. Decompression of the cord and fusion may be necessary.

Anterior wedge fractures

These may be stable (treatment in a collar) or unstable with opening of the posterior elements (halo jacket or posterior fusion).

Facet joint dislocations

They are always unstable. Treatment is by reduction and posterior fusion following MRI to check for sequestrated disc.

Isolated spinous process avulsion

These are stable and require treatment in a collar.

Thoracic spine

Flexion injuries result in crush or wedge fractures, which are usually stable. Such fractures may occur with minimal trauma if the vertebral body is weakened, e.g. osteoporosis or secondary deposits. Fracture-dislocations tend to occur at the thoracolumbar junction and are caused by flexion and rotation injuries, e.g. a fall from a height on to the shoulders or a heavy load falling on the flexed back. If the disc and posterior ligaments are disrupted the injury is unstable. Paraplegia is common in fracture-dislocations.

Symptoms and signs

History of fall from height on shoulder or heavy weight falling on flexed back. Pain over spine. Bruising or abrasions over shoulders. Palpable gap along spinous processus with unstable fracture-dislocations. Associated injuries. Neurological deficit.

Investigations

AP and lateral spine radiographs.

Treatment

Simple flexion injuries with crush or wedge fractures are treated by bed rest and analgesia followed by mobilization when pain allows, occasionally in a plaster or polythene jacket. If trauma is minimal an underlying pathological cause should be sought. Fracture-dislocations may be treated conservatively or operatively. Conservative management includes careful nursing with regular turning on a special spinal bed until core stability returns followed by thoracolumbar support (TLS) orthosis for 3 months. Spontaneous interbody fusion usually occurs. If there is paraplegia, care is as for the paraplegic patient. To offset the problem of long-term bed rest, operative treatment may be undertaken. The fracture may be stabilized by internal fixation.

Lumbar spine

Compression fractures are the most common and may result from a fall from a height on to the heels. With a burst fracture a fragment of bone may be displaced posteriorly and cause damage to the cord or cauda equina syndrome.

Symptoms and signs

History of fall from height on to heels. Pain over lumbar spine. Pain and spasm in paravertebral muscles. Look for associated os calcis fractures or hip injury. Paraplegia.

Investigations

AP and lateral radiograph of lumbar spine (→ Fig. 17.3).

Figure 17.3 Lateral radiograph of the thoracolumbar spine. There is an anterior wedge fracture of the body of the 1st lumbar vertebra.

Treatment

Where there is no neurological damage and the fracture is not comminuted, immobilization in a moulded plastic or plaster jacket will suffice until union occurs. Pathological fractures will require fixation.

Fractures of the transverse processes

The most common are in the lumbar region. It may result from direct violence in a crushing injury or violent muscular contraction. Treatment is symptomatic. There is often severe soft tissue trauma and associated haematoma; prolonged pain may occur. Fractures of L5 transverse process suggestive of pelvic trauma.

Fractures of sacrum and coccyx

This may accompany fractures of the pelvis or occur as isolated fractures due to direct violence. Undisplaced linear fractures are treated symptomatically. Displaced fractures may injure sacral nerves with consequent neurological deficit.

Coccydynia

This causes chronic pain in the coccygeal region. It may follow a fall on the buttocks. The pain interferes with sitting. Treatment is by injection of LA and depot steroid or manipulation under anaesthesia (if fracture-dislocation). If conservative management fails excision of the coccyx may be required.

Spinal cord injury

Management and complications of cord injury

Respiratory

Impairment of respiratory function is common after injury to the cervical spine. This may relate to partial phrenic nerve palsy, intercostal paralysis, inability to expectorate, and a ventilation-perfusion disorder. Associated chest injuries may be present. Monitor by CXR and ABG. Ventilation and bronchoscopy may be needed.

Cardiovascular

Bradycardia and hypotension may occur owing to damage to sympathetic outflow. Excessive i.v. fluids to attempt to correct hypotension may cause pulmonary oedema. Avoid pharyngeal suction as it may potentiate bradycardia via a vagal reflex and lead to cardiac arrest.

Urinary tract

Insert catheter to avoid overdistension of an atonic bladder. If potential urethral injury (perineal bruising or pelvic fracture) perform retrograde urethrogram. Suprapubic or intermittent self-catheterization may be required later. Stasis in the urinary tract combined with hypercalciuria due to immobilization may lead to repeated UTIs and stone formation. Urinary catheter should be changed frequently.

Gastrointestinal

Paralytic ileus follows a few days after injury. Avoid oral fluids. i.v. fluids and NG suction will be required until bowel sounds return. Beware stress ulceration with perforation. Signs may be lacking. Shoulder tip referred pain may be the only clinical indication.

Hypothermia

Hypothermia may occur owing to paralysis of the sympathetic nervous system. The patient should be kept warm.

Thromboembolism

The incidence of DVT and PE is high. Start subcutaneous low molecular weight heparin 6 h after injury. Continue until the patient is mobile in a wheelchair.

Pressure sores

These form as a result of pressure ischaemia, particularly over bony prominences. Regularly turning in bed every 2 h is essential. The patient’s bottom should be lifted off a wheelchair seat every 15 min for a similar reason. Established sores require aggressive treatment with plastic reconstruction if necessary.

Long-term management of spinal trauma

Nursing care

Good nursing care is essential and should always be in a specialized spinal unit. Objectives include: prevention of secondary complications; facilitation of maximum functional recovery; support for patients and family in adaptation to changed physical status; education of patients and relatives in all aspects of long-term care.

Physiotherapy

This involves care of both the chest and paralysed limbs initially. Later care involves help with strengthening non-paralysed muscles, adaptation to a wheelchair, relearning ability to balance, transfer from wheelchair to bed, toilet, etc. and bracing and gait training.

Occupational therapy

This helps adjustment to a lifetime of disability. Help is given to reach the highest levels of physical and psychological independence at home and at work. Help is provided with the activities of daily living, home alterations, recreation and work.

Social services

This provides help with finance, adaptation of home and employment.

Others

Long-term help with bladder problems, chronic pain, and sexual problems will be required.

Prognosis

It is important to indicate the probable degree of recovery at an early stage to both patients and relatives. Recovery after a complete cord lesion is unlikely. It is, however, difficult to forecast the degree of recovery in an incomplete lesion as improvement may occur after resolution of oedema and contusion. The most encouraging signs are those of incompleteness of paralysis or early return of cord function. Patients with early recovery usually achieve the most recovery. In incomplete lesions improvement may continue for several years. Death in the first days after injury is likely to be due to respiratory failure with high tetraplegia.

The level of cervical transection is crucial to long-term prognosis. Above C4 the patient usually dies of respiratory failure. At C4, patients are able to use their mouth to control a wheelchair. At C5 with special aids they can feed, wash and move their chair. However, they cannot transfer in and out of the chair or dress themselves. At C6 they can drive a special car and dress the upper body but they are unable to transfer themselves from a chair. At C7 their ability is intermediate between that of C6 and C8, the latter being the ability to lead an independent wheelchair life. The other causes of morbidity and mortality include PE, pressure sores and CRF (late).

Pelvic fractures

The pelvis is a ring of bone and ligaments, which includes the innominate bone, sacrum, sacroiliac joints, and the pubic symphysis. When fractures occur, the ring tends to break in two places. If only one fracture is visible on radiograph the possibility of sacroiliac joint disruption should be considered. Pelvic fractures occur in the younger patient in RTAs. Elderly patients may sustain isolated pubic ramus fractures, which respond to analgesics and mobilization. Mortality for closed pelvic fractures varies between 5% and 15% with a mortality of 50% for open fractures. The pelvis is very vascular and injuries are associated with considerable blood loss. Pelvic visceral and urethral damage may occur.

Symptoms and signs

Fall in the elderly. RTA in young patients (beware of associated injuries). Pelvic pain. Abrasions. Bruising. Shock. Inability to pass urine. Bleeding per urethram. Bleeding PR. Bleeding PV. Perineal bruising. High ‘floating’ prostate on examination PR.

Investigations

• Pelvic radiograph (anteroposterior and inlet and outlet views)

• Urethrogram.

Treatment

Shock

Intensive resuscitation as bleeding may be dramatic (3–4 L). For ‘open book’ types of fracture, emergency stabilization with an external fixator reduces bleeding. For other fractures, radiological intra-arterial embolization is the best option to slow bleeding.

The fracture itself

Acetabular fractures require accurate reduction and fixation. A CT scan is required to assess for loose bodies and articular congruity. A tertiary referral service should be involved to assess the patient and provide definitive care. A variety of internal fixation methods is available followed by ipsilateral non-weight-bearing for 3 months.

Urethral trauma

Avoid catheterization. If the patient can pass urine and it is clear, all is well. Otherwise, consider suprapubic catheterization or cystotomy. Retrograde urethrogram and IVU may be required.

Complications

Haemorrhage and shock, urethral or bladder injury, rectal injury, paralytic ileus, DVT, damage to hip joint. Late post-traumatic OA may occur in acetabular injuries. Vaginal injury, sciatic nerve injury, mal-union may lead to obstetric difficulties. Sexual dysfunction.

Injuries to the lower limb

Hip and thigh

Traumatic dislocation of the hip

The majority are posterior and follow impact directed along the femoral shaft when the hip is flexed and adducted, e.g. RTA when the knee strikes the dashboard. Anterior, inferior and central dislocations are rare, the latter being caused by the head of the femur being driven into the acetabulum.

Fractures of the proximal femur

The blood supply to the head of the femur comes from three sources:

• Retinacular vessels in the capsule

• Medullary vessels in the femoral neck

• Via the ligamentum teres.

The main source is via the retinacular vessels and these may be damaged in fractures of the femoral neck. Fractures may be classified as intracapsular (subcapital, transcervical), or extracapsular (basal, intertrochanteric → Fig. 17.4). Extracapsular fractures do not damage the blood supply to the femoral head and therefore there are no risks of avascular necrosis of the femoral head and non-union. They are most common in the elderly, especially females with osteoporotic bones when the traumatic cause is relatively trivial, e.g. a fall in the house. In the young patient they result from major trauma.

Figure 17.4 Fractures of the femoral neck. The arrowed line separates intracapsular (to the left) and extracapsular (to the right) fracture sites. Intracapsular fractures are associated with avascular necrosis of the femoral head.

Symptoms and signs

Elderly female. Minor trauma. Tripped over carpet. Tripped over pavement. Pain in the hip. Adduction of limb. Shortening and external rotation only if the fracture is displaced. Movements painful. Weight-bearing usually impossible. Beware hypothermia.

Complications

These are of the elderly undergoing surgery, e.g. pneumonia, MI, CVA, DVT and PE; 30% of elderly patients are dead within 6 months of the injury. Avascular necrosis of the femoral head. Non-union. Mal-union with varus angulation and shortening.

Treatment

General

Pain relief. Bed rest. DVT prophylaxis. Further investigation if pathological fracture suspected (CA, CXR, bone scan, long films to include joints above and below, myeloma screen).

Fracture

Surgery to allow nursing, mobilization, and rehabilitation:

• Intracapsular: undisplaced (fixed with screws); displaced – femoral head replacement, i.e. hemiarthroplasty, e.g. Exeter trauma stem or primary total hip replacement

• Extracapsular: cantilever device, e.g. dynamic hip screw; load sharing device, e.g. cephalomedullary nail, e.g. gamma nail.

Fractures of the femoral shaft

Common in younger people and usually result from severe trauma in RTAs. They may occur at any site and be of variable pattern. Treatment is either conservative (traction – rarely used) or more often operative (internal fixation or external fixator device). There are frequently associated injuries, especially ipsilateral femoral neck fractures.

Symptoms and signs

Severe pain in thigh. Deformity. Shock. Associated injuries. Check head, chest, abdomen, spine. Vascular injury to femoral vessels. Injury to sciatic nerve.

Investigations

• Radiographs in two planes

• Femoral angiography may be required if vascular injury is suspected.

Treatment

Splint leg. Transport to hospital. Pain relief. i.v. fluids. FBC, U&Es. Cross-match (blood loss can be 2–4 units). Check if fracture is open. Give tetanus prophylaxis and antibiotics if open fracture.

Conservative

Skin traction and temporary stabilization in Thomas’ splint. Conservative definitive treatment – pre-toddler (<3 years) – gallows traction followed by hip spica. Toddler to adult – balanced traction until moves comfortably on bed then hip spica. In adults, skeletal traction with a Steinmann pin and balanced traction applied through the skeletal pin with the knee flexed on a special knee flexion attachment. Fractures heal quickly in children. In adults cast bracing may be used after 6–8 weeks.

Surgical

• Internal fixation: Open physes – elastic stable intramedullary nails (ESIN-Nancy nails) aged 5–13. Closed physes – achieved by a locked intramedullary nail. This allows accurate reduction and compression and ensures early mobilization of the patient. There is a risk of infection and osteomyelitis. This form of treatment is useful for multiple fractures, pathological fractures and when there is associated vascular injury.

• External fixation: used especially for open fractures where there is soft tissue damage. Pins are inserted above and below the fracture site and reduction and alignment maintained by an external fixator device.

Complications

DVT. PE. Fat embolism. Infection. Shortening. Angulation. Non-union.

Fractures and dislocations around the knee

Fractures are usually intra-articular causing haemarthrosis, which should be aspirated to decrease pain. They can be caused by a direct blow (car bumper, car dashboard), vertical compression (fall from a height) or excessive strain (forced abduction at the knee). Associated ligamentous and neurovascular injuries are common. Conservative treatment for these injuries involves a long leg cylinder plaster then a hinged cast brace. This type of treatment is also used after open reduction/internal fixation. The knee joint needs accurate repair of the articular surfaces to reduce the risk of post-traumatic OA.

Supracondylar fractures (→ Fig. 17.6)

These are intra-articular or extra-articular. The distal fragment is pulled backwards by the gastrocnemius. The popliteal artery may be damaged by the distal fragment. Conservative treatment is by skeletal traction via the proximal tibia with the knee in about 30° of flexion. Internal fixation is required for all displaced intra-articular fractures (polyaxial/fixed angle locking plates, retrograde intramedullary nails).

Figure 17.6 A supracondylar fracture of the femur. In the lateral view, the distal fragment is tilted backwards and may damage the popliteal artery.

Isolated femoral condylar fractures

These are usually displaced so internal fixation is advised with lag screw or headless compression screw.

Tibial plateau fractures

In these fractures, vertical compression forces or strains drive the femoral condyle through the tibial plateau. Fragments of tibial plateau/condyle may be cleaved off, depressed, or both. Both condyles may be damaged. Displaced or depressed fragments should be reduced and internally fixed, often with support from a bone graft and a buttress plate.

Dislocation of the knee

This is an uncommon injury. It is usually associated with damage to the popliteal artery or local nerves. After reduction under anaesthesia any ruptured ligaments should be repaired. Immobilization in plaster then cast brace is required for several months.

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