• the axial skeleton, consisting of the skull, vertebral column, ribs and sternum – supports and protects vital organs

• the appendicular skeleton, consisting of the shoulder girdle, pelvic girdle and limbs – provides shape and facilitates movement.

• organic matrix of collagen – creates tensile strength

• mineral matrix of calcium and phosphate – creates rigidity and strength

• bone cells, including osteoblasts, osteoclasts, osteocytes and fibroblasts.

Bone cells

Osteoblasts are present on all bone surfaces and form a uniform layer. Their purpose is the synthesis and secretion of collagen and protein, and they promote calcification during rapid phases of this process, e.g., fracture repair. Osteoblasts create the trabeculae of cancellous bone.

Osteocytes form from osteoblasts trapped in matrix. The exact function of these cells is not known, but they appear to act as a pump, controlling calcium release in response to hormones.

Osteoclasts are found near the bone surface. They destroy dead bone and are responsible for reabsorption of bone. They are very mobile and are found in great numbers where bone is undergoing erosion. Their activity is controlled by a number of hormones including parathyroid and thyroxin.

Joints

Joints are the area of contact between bone and bone, or bone and cartilage. They are classified by the type of movement they permit.

Fibrous joints permit no movement at all, e.g., skull joints. Fibrous connective tissue merges into the periosteum of each bone.

Cartilaginous joints permit limited movement because of flexible cartilage between bones. The symphyses have cartilage pads, or discs, between bones, e.g., symphysis pubis or intervertebral joints. Complex ligament arrangements stabilize these cartilage pads to limit movement and facilitate recoil. Synchondroses are cartilage joints that ossify into bone in adulthood preventing movement, e.g., epiphysis of long bone.

Synovial joints form most of the body’s joints. They are further classified by the type and range of movement they allow (see Table 6.1). All synovial joints have a number of similar structured features. They are enclosed in a capsule that is lined with a synovial membrane, which secretes synovial fluid. Bone ends are not in direct contact and are covered by hyaline cartilage. The fibrous capsule is held in place by a number of ligaments.

Muscular system

Muscle tissue is formed to convert chemical energy into mechanical contraction, creating movement. Movements are generated both at joints and in soft tissue. Muscles also assist in maintaining body posture and muscular activity is associated with maintaining body heat.

Muscles are made up of bundles of fibres (fasciculi). The length of these fibres relates to the range of movement the muscle performs; that is, the longer the fibre, the greater is the range of movement. The number of fibres relates to the strength of the muscle. Muscles are attached to the periosteum by tendons. There are two points of attachment, the origin of which remains fixed during contraction while the insertion moves. Skeletal muscles have a rich blood supply which increases dramatically during exercise.

Tendons

Tendons are made up of fibrous connective tissue carrying parallel bundles of collagen fibres. This gives greater flexibility but prevents stretching when under pressure, such as in muscle contraction. They act like a spring, allowing the transition of movement from muscle to bone. Tendons have a sparse blood supply that inhibits healing if damaged.

Ligaments

Ligaments are made up of bundles of collagen that are not designed to stretch. They are attached to bone and are responsible for maintaining joint stability. Undue force may tear some fibres, resulting in them being painful, swollen and in severe cases can result in unstable joints.

Anatomy and physiology

The pelvis is designed to provide structure, strength for weight-bearing and protection of internal organs. It houses the rectum, bladder and, in women, the reproductive organs. The pelvis forms a ring, comprising the sacrum and two innominate bones, each made up of an ilium, pubic bone and ischium (Fig. 6.3).

These bones are supported by strong ligaments at the sacroiliac joint and a cartilaginous joint at the symphysis pubis. In children the innominate bones are supported by cartilage until they fuse around 16–18 years of age. The pelvis has a rich blood supply from the internal and external iliac arteries. The stability of the pelvic ring is dependent on the strong posterior sacroiliac, sacrotuberous and sacrospinous ligaments. Disruption of the pelvic ring can result in significant trauma to the neurovascular and soft tissue structures it protects.

Mechanism of injury

Major trauma to the pelvic girdle is relatively uncommon and accounts for approximately 3–6 % of all skeletal injuries and 20 % of polytrauma cases (Smith 2005); however, the mortality associated with major pelvic fractures may reach 57 % where shock is present on the patient’s arrival (Starr et al. 2002). Most pelvic fractures are caused by motorcycle accidents, accidents involving pedestrians, direct crush injuries, or falls from a height (American College of Surgeons 2008). Falls are also the second highest cause of unintentional death after motor vehicles (Middleton 2011).

Fracture patterns

In adults, isolated pelvic fractures rarely occur. This is because of the strength and ligamentous stretch of the pelvic ring. If significant force is applied, two or more breaks in the pelvic ring are likely to occur. The pelvis has predictable areas of strength and weakness, and therefore, in adults, potential patterns of fractures are easy to predict. In children, the increased elasticity of the pelvis prior to fusion of the innominate bones makes isolated fractures far more likely.

Lateral compression (LC) fractures (graded I, II, III) are caused by a side impact, usually to motorcyclists or pedestrians in collision with vehicles. A compression fracture of the pubic bone or rami is combined with compression fracture on the side of impact (Fig. 6.4A). With greater force of impact, the iliac wing on the side of the impact will also break; this is a grade II injury (Fig. 6.4B). A grade III injury involves an additional fracture on the opposite side to the impact (Fig. 6.4C).

Anteroposterior compression (APC) fractures (graded I, II, III) are caused by direct pressure or crushing and result in the pelvis opening outwards from wings rather like a book. The result is the fracturing of the pubis or rami together with sacroiliac distribution. In grade I injuries, the symphysis is separated by less than 2 cm (Fig. 6.5A); in grade II injuries the sacrospinous and sacrotuberous ligaments rupture (Fig. 6.5B); and in grade III injuries the iliolumbar ligament can rupture (Fig. 6.5C). This type of pelvic fracture has double the mortality rate of the lateral compression injuries.

Vertical shearing force fractures result from falls or from knees hitting a car dashboard with great speed. The pattern of injury is similar to anteroposterior compression, but with vertical displacement (Fig. 6.6). With combined mechanical forces, such as being run over by a motor vehicle, a combination of the above fracture patterns may occur simultaneously.

Patterns of single fracture injury to the pelvis include:

Assessment of pelvic ring injury

Fractures involving the pelvic ring carry potentially life-threatening complications if not rapidly identified and treated. Because of the force exerted to cause such fractures, attendant injury to underlying organs and haemorrhage is common and associated with high morbidity and mortality rates. Injuries can include among others: neurological, 26 %; rectal/gastrointestinal tract, 7 %; renal, 7 %; and bladder, 10 % (Scalea & Burgess 2004); urethral, up to 24 % (Ingram et al. 2008); ureteral, 7 % (penetrating trauma) to 18 % (blunt trauma) (Lynch et al. 2005) as well as genitalia; haematuria and haemodynamic instability due to hypovolaemic shock (Routt et al. 2002).

Mechanisms of injury should give some clues as to a potential pelvic fracture. The assessing nurse should carry out a primary assessment following the ABCDE approach laid out in Advanced Trauma Life Support (ATLS) guidelines (American College of Surgeons 2008). A patient with a pelvic ring fracture will have severe pelvic pain and progressive flank, perianal or scrotal swelling and bruising. Disruption of the pelvic ring can also be identified by differences in leg length and external rotation of a leg without an associated limb fracture.

Mechanical instability of the pelvis can be tested by manual manipulation or compression of the pelvis. This should be carried out only once by an experienced clinician and only when X-rays have excluded unstable pelvic fractures. It is a very painful procedure for the patient and undue force carries the risk of exacerbating haemorrhage. When the clinician manipulates the pelvis, pressure should be applied gently to the iliac crest. If the pelvis has rotated, the clinician will be able to close the ring by gently pushing the iliac crests together. Most patients with a pelvic ring fracture will have moderate to severe hypotension.

Assessment should also include examination of the groin, perineal area and genitalia. Femoral pulses should be checked on both sides. Absent pulses are indicative of damage to the external iliac artery and emergency surgery is required to preserve the limb of the affected side. Decreased pulse pressure should be closely monitored, as it may be indicative of a worsening systemic condition or damage to the iliac artery. The perineum should be inspected for laceration and bleeding. Prophylactic antibiotics should be prescribed for wounds because of the high infection risk from faecal flora (Ruiz 1995).

In men, the testicles should be examined as a swollen testicle is indicative of testicular rupture requiring surgical decompression. The penis should be examined for blood at the meatus, suggestive of urethral damage. In women, the vulva should be examined and the vagina and urethral meatus inspected for blood. In male and female patients where there is no evidence of urethral injury, a urinary catheter should be inserted. If urethral injury is likely then suprapubic catheterization should be considered for bladder decompression. A rectal examination should be performed to test sphincter tone; a reduction in tone is suggestive of a sacral fracture. Frank blood is usually indicative of a rectal tear and surgical intervention is necessary. In men, the position of the prostate should be established as a high, boggy prostate indicates a urethral transection.

Management of pelvic ring fractures

Pelvic fracture can be a life-threatening injury often accompanied by significant haemorrhage and injury to the genitourinary system (Hauschild et al. 2008). Arterial injuries occur in 20 % of patients and posterior fractures are more likely than anterior fractures to cause bleeding. Initial management focuses on volume replacement, stabilization of fractures and, therefore, the rate of haemorrhage and pain control. Fluid replacement should follow ATLS guidelines with a rapid infusion of warmed crystalloid fluid, ideally Ringer’s lactate or Hartmann’s solution (American College of Surgeons 2008). Ringer’s solution closely resembles the electrolyte content of plasma and therefore provides transient intravascular expansion followed by interstitial and intracellular replacement. Normal saline can be used, but large amounts are not recommended because it can induce hypercholaemic acidosis. After an initial 2 L, or 20 mL/kg in children, blood or colloid solutions should be commenced. The patient’s haemodynamic condition should be continuously monitored during this period.

Haemorrhage control relies on fracture stabilization. Early external fixation provides definitive haemorrhage control. As an interim measure, longitudinal skin traction can be used (American College of Surgeons 2008). The use of a pneumatic anti-shock garment (PASG) also known as military anti-shock trousers (MAST) serves a dual purpose of haemorrhage and pain control. It provides mechanical stabilization of the fractures and external counter-pressure. When used, circulation to extremities should be regularly checked as compartment syndrome is a known risk. Decompression should take place in a controlled environment, at a pace that does not exacerbate haemodynamic instability, generally in the operating theatre. The use of PASG in no longer emphasized in ATLS as Dickinson & Roberts (2004) found that there was no benefit from their use, while Mattox et al. (1989) demonstrated PASG increased morbidity and mortality. Pain control is initiated by fracture immobilization with intravenous opiates; inhaled analgesia, such as entonox in the conscious patient may be used where not contraindicated by other potential injuries.

Uncomplicated, isolated pelvic fractures not involving the pelvic ring should be assessed in a similar manner. The management of these injuries is usually conservative. Patients usually require hospital admission for initial bed rest, pain control and rehabilitation support. Most of these fracture injuries have an uncomplicated recovery pattern. Acetabular fractures, however, have a high morbidity rate. They are caused by extreme force, commonly road traffic accidents (RTAs), where the knees hit the dashboard at speed. Long-term prognosis is improved by surgical intervention (Snyder 2002).

Anatomy and physiology

The femoral head and neck lie within the joint capsule of the hip joint. The head of the femur moves within the acetabulum. This is supported by three ligaments: iliofemoral, ischiofemoral and pubofemoral. Blood supply to the head of the femur is largely from the profunda femoris artery, which has circumflex branches around the neck of femur, off which smaller branches supply the head. This pattern of blood supply is particularly vulnerable to disruption from impacted fractures, hence the high risk of vascular necrosis with neck of femur fractures. The periosteum is very thin or non-existent around the neck of femur, therefore making it very susceptible to fractures. This susceptibility increases with age, particularly for women where osteoporosis has further weakened bone strength.

Classification of fractures

Assessment of patients with hip injury

These patients are usually elderly, predominantly women, and commonly attend the ED following a fall. The average age of a person with a hip fracture is 84 years for men and 83 years for women; 76 % of fractures occur in women. Mortality is high; about 10 % of people with a hip fracture die within one month of injury and one-third within 12 months (National Clinical Guideline Centre 2011).

The patient usually complains of groin pain and pain through the thigh to the knee. Pain is worsened by any movement and the majority of patients will have been unable to weight-bear since injury. In most NOF and intertrochanteric fractures, the injured limb will be externally rotated and is shortened if displacement exists at the fracture site. Neurovascular integrity should be checked distally to the fracture, although damage of this type is extremely uncommon. The patient’s haemodynamic status should be regularly observed, particularly with intertrochanteric fractures where blood loss from surrounding tissues is higher than NOF fractures. The patient’s general health should be discussed and pre-existing medical conditions and medication established. It is also necessary to establish the cause of the fall to rule out medical reasons. The patient’s hydration and nutritional status should be assessed, as should skin integrity and risk level for pressure sores (Lisk et al. 2011).

Initial management

In most instances, these fractures can be broadly diagnosed clinically. X-rays provide supplementary information necessary for ongoing management. As a result, patients with clinically diagnosed fractures should receive appropriate analgesia, such as morphine sulphate, prior to X-ray. Hydration at an early stage reduces mortality, and therefore intravenous fluids should be commenced, particularly for patients with intertrochanteric fractures where blood loss is greater. Regular observations should be undertaken to ensure haemodynamic stability is maintained, and to ensure the patient is neither dehydrated nor becomes overloaded by fluid replacements. Early oxygen therapy has been demonstrated to be beneficial as hypoxaemia is evident in elderly patients with a fractured NOF. Most hospitals now have fast-track policies to get patients into a ward bed and off hard emergency trolleys (Audit Commission 2000). If tissue viability is to be maintained, this together with regular pressure area care is vital (Wickham 1997). If the patient’s general condition prohibits internal repair of the fracture, skin traction is advised at the earliest opportunity.

Hip dislocation

The majority of hip dislocations occur in people with total hip replacements or femoral head replacements. Hip dislocations in patients who have not had previous hip surgery are uncommon and demand a great deal of force. Posterior dislocation is commonly caused by high-impact RTAs where the patient’s knee hits the dashboard and account for about 90 % of non-prosthetic dislocations. The patient will present in severe pain, with an internally rotated, flexed leg. Neurological examination is important, particularly in those with marked internal rotation, as the dislocation may compress the sciatic nerve and its branches, resulting in deficits especially in the perineal nerve region. Anterior dislocation is much less frequent and results from a fall from a height where the patient lands on an extended leg. This type of injury can be confused with a fractured NOF in elderly patients, and therefore careful history-taking and limb assessment are vital.

In both anterior and posterior dislocations, early limb relocation is essential. Closed reduction should be performed, provided associated fractures of the femoral head have been excluded. Management priorities in ED involve pain relief, X-ray and relocation of the hip joint under sedation. Once the hip is relocated, the patient should be admitted for traction. If relocation attempts are unsuccessful with conscious sedation in the ED, then urgent transfer to theatre for closed or open reduction under general anaesthetic is appropriate.

Anatomy and physiology

Limbs form part of the appendicular skeleton and are vital for movement. Both arms and legs comprise long bones, with complex joints and bone systems in the hands and feet. Limb injuries treated in the ED fall into two categories: fractures and soft tissue injury.

Classification of fractures

A break or fracture of the bone occurs when it is no longer able to absorb the mechanical energy placed on it. This usually results from trauma (Bickley & Szilagyi 2008). Fractures are classified into the following groups (Fig. 6.9):

Fracture healing follows a specific pattern. It has three main phases: inflammatory, reparative and remodelling.

The inflammatory phase lasts approximately 72 hours. Initially a homeostatic response to the physiological damage to bone, tissue and blood vessels occurs. A clot is formed in which the fibrin networks collect debris, blood and marrow cells. Capillary network increases over 24 hours and neutrophils invade the area. In the following 48 hours, phagocytosis takes place. In the reparative stage chondroblasts and osteoblasts proliferate. The chondroblasts unite fracture ends in a fibrous tissue called callus which begins to calcify after 14 days. During this phase osteoblasts create the trabeculae of cancellous bone while osteoclasts destroy dead bone. Remodelling takes several months: osteoblasts and osteoclasts restore bone shape, replacing cancellous with compact bone (Fig. 6.10).

Assessment of limb injury

Following ATLS principles, assessment of extremity injury should take place after only the primary survey is completed and more serious injuries are dealt with. The assessment has three stages:

Assessment should follow a set pattern regardless of how severe or trivial an injury may appear. The assessing nurse should establish the history, perform an examination and, if appropriate, refer the patient for X-ray. When assessing the history, the nurse should establish a number of factors (Box 6.1). Mechanism of injury should include what happened, the direction and magnitude of force, and how long the patient was exposed to the force. When determining symptoms, the nurse should establish pain, loss of function and perceived swelling. The nurse should also enquire about the duration of symptoms and whether they are worsening or improving. Past history should include pre-existing injuries to that limb, medical conditions that affect the musculoskeletal system or bone density, and factors which would influence recovery.

Examination

Examination should follow a specific pattern, starting from the joint above, moving through the site of the injury, and finally checking neurovascular function distal to the injury. Principles of examination are shown in Box 6.2. Examination starts from the joint above the injury site to assess both function and limits of injury and to gain the patient’s cooperation and confidence. It should be systematic and considering of both the bony and soft tissue structures involved. The examination should also include assessment of pain, and factors influencing it, such as movement, pressure and guarding (Bickley & Szilagyi 2009).

If a patient presents with a mechanism of injury or the clinical examination is suggestive of a fracture then X-ray should be requested. X-rays should not, however, be performed for purely medico-legal reasons (Ward 1999).

Assessment

Fractures of the femur fall into three anatomical categories: proximal, mid-shaft and distal. Examination findings are shown in Box 6.3. The patient should be carefully assessed for signs of hypovolaemic shock as blood loss from a closed shaft of femur fracture averages 1200 mL (Cadogan 2004). Although isolated femoral fractures rarely cause significant shock, fractures occurring with other traumatic injury do contribute to significant hypovolaemia. Observation should therefore be vigilant and X-ray will confirm diagnosis. Severe muscle spasms cause significant pain following femoral fracture and also cause the limb to shorten. Crepitus occurs over the fracture site as bone pieces move (O’Steen 2003).

Management priorities

Management priorities in the ED are twofold: preventing secondary damage and pain control. Preventing secondary damage includes managing blood loss by initiating intravenous fluid replacement. Reduction in blood loss and significant pain reduction can be achieved by correct application of an appropriate traction splint, such as a pneumatic Donway traction splint or a traditional Thomas half-ring splint or its modified version Hare traction splint may be used. These stabilize the fracture until definitive repair can take place. In doing this, the extent of the trauma to surrounding soft tissue is minimized. Pain is reduced because bone ends are immobilized. Distal and proximal pulses, capillary refill and sensation should be rechecked after splint application. If the fracture is open, broad-spectrum antibiotics should be given and the patient’s tetanus status checked. The wound should be covered with a damp dressing; care should be taken to avoid wound maceration if a delay to surgery is possible. Povidone-iodine soaks are commonly used because of the devastating effects of infection (see also Chapter 24). Intravenous analgesia should also be given. Fractured femurs take about 8–16 weeks to heal in an adult and 6–12 weeks in a child. Definitive treatment is usually internal fixation for an adult, which means they can usually be walking within two weeks post-surgery. Surgery is not recommended for children because of growth and speed of repair; therefore traction is recommended for older children, and plastering with hip spica for toddlers and small children.

Supracondylar fractures of the femur are assessed in the same way as shaft fractures. The mechanisms of injury are similar, with pain usually localized to the knee. Fractures involving the femoral condyles usually involve the knee joint and there may be associated knee joint injuries, particularly osteochondral fractures of the patella (Rowley & Dent 1997). These fractures do not cause the same extent of blood loss as shaft fractures and are repaired by either long leg casting or surgery.

Patellar fractures and dislocations

Patellar fractures occur following a direct blow or fall onto the knee. Indirect twisting injury can also result in a fracture as the patella is ripped apart by the quadriceps muscles. The patient presents with pain, swelling and a knee effusion. As a result, range of movement is restricted, particularly full extension. Usually, patellar fractures can be repaired by long leg cylindrical casting for 4–6 weeks. Surgical intervention is necessary for open fractures, those fractures where fragmentation of the patella leaves gaps greater than 4 mm and longitudinal fractures.

Patellar dislocation results from a direct blow to the medial aspect of the knee, common in football or similar contact sports. The knee locks and remains in a flexed position. On examination, obvious lateral deformity is present with medial tenderness and pain on attempted movement. Acute swelling between 2 and 12 hours of injury is likely to indicate haemarthrosis (Rourke 2003, Adams 2004). Treatment seeks to relocate the patella. This is usually straightforward and achieved by extension of the knee. It is painful because of muscle spasm and therefore analgesia and muscle relaxants should be used. A supportive long leg bandage should then be applied, or a long leg cast.

Tibial plateau fractures

Tibial plateau injury commonly occurs from pedestrian/car accidents, usually at lower speeds where the car bumper hits the standing pedestrian. Fractures also occur as a result of a fall from a height, causing compression of the plateau, or they may occur in elderly patients with osteoporotic bones. Patients usually present with pain and swelling over the fracture site and inability to weight-bear. Swelling varies considerably, with haemarthrosis sometimes present. Diagnosis of tibial plateau fractures is usually by X-ray and is classified using the Schatzker classification system (Schatzker et al. 1979) which records six levels of injury:

Choice of treatment is dictated by the classification of the injury, displacement of fragments, and the condition of skin, tissue and muscles. Conservative treatment includes long leg plaster casting, traction and functional cast bracing and is reserved for classes I–IV where surgery is not otherwise indicated. Internal fixation is more common because of the morbidity risk of prolonged immobilization, particularly in older patients (Harris & Haller 1995).

Tibial shaft fractures

Mechanisms of injury are varied. The tibia has little muscular protection, so fractures from direct blows are the commonest long bone fracture. They are also the most common open fracture. As the tibia is vulnerable to torsional injuries, for example in sporting injuries, and force transmitted through the feet is high, the incidence of injury is high (Smith 2005), particularly in children. Similar mechanisms cause tibial and fibular fracture, although much more force is needed to break both bones. Direct trauma tends to cause transverse or comminuted fractures, and indirect trauma causes oblique and spiral fractures. The patient presents with localized pain and is usually unable to weight-bear. Surrounding soft tissue damage varies from a haematoma, causing swelling, to an open wound caused by fracture ends. Treatment for tibial fractures varies: children with greenstick fractures need casting for 6 weeks; in adults, displaced fractures may need internal fixation. ED documentation of the neurovascular status is vital as the risk of compartment syndrome is high. Therefore admission for 24 hours, observation and limb elevation should be considered in very swollen proximal tibial fractures. Pain is managed with intravenous opiates and the lower leg should be plastered as soon as possible. Circumferential casts must never be applied in the acute phase because of the inherent risk of compartment syndrome.

Fibular fractures

Isolated fibular fractures are not common and usually occur in conjunction with tibial fractures. Isolated fibular fractures usually occur as a result of direct trauma to the lateral aspect of the calf. Distal fibular/malleolar fractures occur with excessive rotational forces. They are discussed in more detail under ankle injury below. The patient will complain of pain over the fracture site, with radiation along the length of the fibula on palpation. Because the fibula is not a weight-bearing bone, the patient may be walking with discomfort. Swelling is usually minimal. Depending on the degree of pain, isolated fractures are treated by either plaster cast or compression bandage.

Tibial and fibular fractures

Combined tibial and fibular fractures are fairly common in contact sports, such as football. In injuries where indirect force causes the fracture, the tibia and fibula may be fractured in different places. Commonly, the tibial shaft fractures at the distal third, and because of a twisting mechanism the fibula fractures at the proximal end. This reinforces the need to assess from the joint above to the joint below the injury. If injury is caused by direct force and both bones are fractured at the same level, the leg will appear unstable and flexible at the fracture site. It is important that temporary immobilization occurs as soon as possible, both to reduce pain and to prevent further soft tissue damage. These fractures will need surgical fixation (Gordon et al. 2012).

Ankle fractures

Most ankle injuries seen in the ED are soft-tissue injuries (Eisenhart et al. 2003). Patients with fractures risk significant morbidity if these are not identified and treated early. The ankle is a complex hinge joint made up of three bones: the tibia, fibula and talus, and three collateral ligaments: the lateral, medial and interosseous. These ligaments stabilize the ankle joint; the lateral ligament allows for some inversion of the joint, whereas the medial and interosseous have less stretch (Fig. 6.11). Injury patterns can be classified by the mechanism of injury (Box 6.4 and Fig. 6.12).

Isolated lateral malleolar fractures can occur following inversion injury. Patients present with pain, swelling, ecchymosis and bony tenderness on the lateral aspect of the ankle and are usually unable to weight-bear (Hopkins 2010). Most isolated fractures are either a chip or avulsion fracture with ligament injury. These can be treated by a below-knee weight-bearing cast. Some fractures above the joint line or comminuted fractures may warrant surgical intervention. Isolated medial malleolar fractures are less common and usually result from a direct blow or eversion and, occasionally, inversion injury. The patient presents with pain over the medial aspect, swelling and limited range of movement. Usually, the patient will be non-weight-bearing (Wyatt et al. 1999). Simple avulsion fractures can be managed by below-knee casting. Fractures into the joint space should be referred for specialist opinion as internal fixation may be necessary.

Bi-malleolar fractures involve two of the lateral, medial and posterior malleoli, usually the lateral and medial. The patient presents with a history of inversion or eversion injury and will have bilateral bony tenderness and swelling, with or without deformity, and will be non-weight-bearing. These are unstable fractures with a significant risk of ankle dislocation. The ankle should be temporarily immobilized, adequate pain relief should be given and hospital admission facilitated. Restoration of function requires accurate medial malleolus reduction and joint space alignment (Mayeda 2009). Good outcomes are also dependent on skilled plastering and surveillance for weeks. Increasingly surgeons prefer to avoid these uncertainties by routine accurate internal fixation (McRae 2006). Lateral malleolar reduction is desirable but less crucial. This is usually achieved by open reduction and fixation in theatre, but can be achieved by closed methods if surgery is contraindicated.

Tri-malleolar fractures involve the posterior malleolus as well and are usually combined with ankle dislocation. They are caused by falls or, most commonly, tripping, e.g., off a kerb. Management priorities are limb realignment (see discussion of dislocations below) and subsequent internal fixation, using the same principles as for bi-malleolar fractures.

The standard X-ray evaluation for the acutely injured ankle includes lateral, anteroposterior and mortice views. The requirement for X-ray of the adult ankle or foot may be determined using the Ottawa Ankle Rules (Stiell et al. 1992). These have shown that X-rays are only required for the ankle if there is any pain in the malleolar region and:

Foot X-ray is required if there is pain in the midfoot region and:

The Ottawa ankle rules (Fig. 6.13) apply to adults (>18 years) and have a >98 % sensitivity for detecting clinically significant malleolar ankle injuries. They also reduce the number of ankle X-rays by up to 40 % (Bachmann et al. 2003).

Ankle dislocation

Ankle dislocation occurs when significant force applied to the joint results in loss of opposition of the articular surfaces.

Dislocation occurs in one of four directions: anterior, lateral, superior and posterior. Posterior is the most common (Fig. 6.14). Stability of the ankle is normally maintained by tight articulation of the talus with the tibia and fibula. Isolated ankle dislocation is extremely rare (Georgilas & Mouzopoulos 2008) and may well be due to the amount of force required. It is usually associated with malleolar fractures and ligament rupture. Common causes of dislocation are sports injuries, direct force or RTAs (Harris 1995). Complicated dislocations associated with multiple ankle fractures are most common in osteoporotic women.

On examination the ankle will be oedematous, the joint locked, with the distal tibia prominent under stretched skin. Management priorities in the ED are to preserve neurovascular integrity. Early reduction is crucial, since delay may increase risk of neurovascular compromise or damage to articular cartilage. If there appears to be neurovascular compromise, the ankle dislocation should be reduced urgently, without waiting for X-rays. If neurovascular integrity appears intact, X-rays can be obtained, but the foot should remain supported to prevent further injury. Reduction should be carried out swiftly after X-ray. Nitrous oxide is a useful initial pain relief, for its therapeutic effects of analgesia, increasing oxygen intake and for its distraction potential, i.e., by getting the patient to concentrate on breathing (Bowie 2011). While the dislocation is being reduced, the patient should have adequate intravenous analgesia and muscle relaxant. The patient’s cardiac and respiratory function should be monitored during this procedure.

Ankle reduction is at least a two-person job. It is achieved by flexing the patient’s knee to reduce tension on the Achilles tendon. One carer supports the lower leg while the other applies downward traction to the foot and force is applied in the opposite direction to that of the original injury. An additional clinician should be present whenever intravenous analgesia and muscle relaxant are given to monitor and protect the patient’s cardiorespiratory state. When reduction is completed, neurovascular integrity should be rechecked, by checking for pedal pulse, capillary refill and sensation. The ankle should then be immobilized in an above-knee plaster that is either bivalved or guttered, because of the degree of swelling associated with fracture manipulation. Most patients need internal fixation of associated fractures.

The hindfoot

The talus supports the body weight and forces above by allowing movement at the ankle joint and between the calcaneus and midfoot. It is well secured by ligaments surrounding the ankle joint and therefore fracture is uncommon (Harris 1995). In the event of injury to the talus, the risk of complication is high because 60 % of the surface is covered by articular cartilage and vascular supply is low, creating a significant threat of avascular necrosis. It is usually injured as a result of falls, landing on the heel or forefoot, causing fractures through the body or neck of the talus. Fractures to the neck of the talus also result from head-on RTAs, where the driver’s foot is pressed against compressed floors or pedals, causing extreme dorsiflexion.

The patient will present with ankle pain, there may be visible disruption to normal ankle anatomy and swelling is common. Fractures to the talar neck are usually treated by below-knee casting, but if any displacement cannot be reduced, open reduction is necessary. Fractures to the talar body frequently require internal fixation. Fractures of the talar head are extremely uncommon and management varies with the extent of the injury and associated injuries. Specialist orthopaedic advice should be sought for specific management.

The calcaneus

This is the largest bone of the foot and it absorbs the body’s weight when standing or moving. The calcaneus is a relatively hollow bone consisting of an outer thin cortical shell filled with cancellous bone. As a result, it fractures when subjected to vertical forces such as falling from a height. There is an associated crush fracture of the lumbar spine in about 10 % of cases resulting from a fall. The Achilles tendon attaches to the tuberosity and can cause an avulsion fracture when damaged. Fractures resulting from a fall are most common in men between 30 and 50 years old, whereas avulsion fractures are more common in women showing signs of osteoporosis.

The patient presents with pain over the rear of the foot and both sides of the heel. Swelling is usually present and patients are usually unable to weight-bear on their heel. If the presentation to ED is a few hours post-injury, a horseshoe-shaped bruise may be present. Calcaneal fractures are categorized into two groups: those involving the subtalar joint and those which do not, i.e., extra-articular fractures. The outcome for patients with extra-articular fractures is considerably better than those involving the subtalar joint. Extra-articular fractures are managed conservatively with compression and elevation in the first instance. After swelling has subsided, the injury is immobilized in a cast. The majority of fractures will involve the subtalar joint and the prognosis for these patients is poor. About 50 % have some long-term problems from the injury (Mayeda 2009), including restricted movement, pain and subtalar arthritis. Most are treated with internal fixation. Fractures to other bones of the foot are not uncommon, and patients with suspected calcaneum fractures, or those who have fallen over six feet, must have a full examination of the spine and lower leg (Larsen 2002).

The midfoot

This region includes the navicular, cuboid, cuneiform and metatarsal bones. The midfoot provides foot flexibility. Fractures to this area are uncommon and result from direct force, such as crush injuries. Transverse dislocation of the forefoot results from direct force. Patients present with localized tenderness and swelling. These injuries heal well and can usually be treated with below-knee non-weight-bearing casts. There are two exceptions to this: the first relates to avulsion fractures of the navicular, which occur as a result of eversion injury. If 20 % or more of the articular surface is avulsed, the fracture should be internally fixed, if less than 20 % is avulsed, a below-knee cast should be adequate. The second exception is the Lisfranc dislocation, which occurs when the forefoot is dislocated across the metatarsal joints. This is an extremely rare condition, occurring in one in 55 000 cases (Mayeda 2009). Neurovascular compromise is common, partly because the force necessary to cause dislocation also causes extensive soft tissue damage, resulting in oedema and vascular compromise. The patient presents with moderate to severe midfoot pain and large amounts of swelling which can hinder diagnosis. There is usually a shortening of the foot length, compared with the uninjured foot, and the injured foot will have transverse broadening.

Patients with Lisfranc dislocation will not be able to stand on their toes. Treatment of this injury revolves around rapid reduction of the dislocation and cast immobilization, because the risk of circulation compromise and subsequent necrosis is so high. If a base of second metatarsal fracture coexists, an accurate reduction may not be possible, or will prove unstable. In such cases, internal fixation should be considered. Hospital admission is usually necessary during the initial days post-injury, whatever the method of reduction.

The forefoot

The forefoot consists of the five metatarsal bones and the phalanges.

Scapular fractures

The scapula is situated above and lateral to the posterior thorax. It is well protected from injury by thick muscle and extreme force is necessary to fracture it. Injuries commonly result from high-speed road traffic accidents, crushing or falls. Occasionally, a scapular fracture occurs as a result of electric shock, when one or both scapulae are fractured (Rana & Banerjee 2006). Fractured scapulae most frequently occur in young men (O’Steen 2003) because of the force needed to cause fractures and associated injuries such as pneumothorax, chest wall injury or related shoulder girdle injuries.

Anatomically, scapular fractures fall into three categories (Fig. 6.17):

Clavicular fractures

The clavicle provides anterior support for the shoulder. It is a slightly S-shaped bone that articulates laterally with the acromion process and medially with the sternum. The clavicle gives definition to body shape as well as providing protection for the subclavian neurovascular bundle. Clavicle fractures make up 5 % of all fractures, so are not uncommon and in children and adolescents it is a particularly common fracture (O’Steen 2003). Fracture of the clavicle is most commonly due to a violent upwards and backwards force such as a fall on the outstretched hand. Less commonly, the clavicle may be fractured by blows or falls on the point of the shoulder.

Clavicular fractures are divided into three groups: proximal third fracture, mid-clavicular fracture and distal fractures (Table 6.2).

Common presenting symptoms include pain over the fracture site, crepitus and sometimes a palpable deformity. The patient is usually supporting the arm of the injured side. In mid-clavicular fractures, deformity is common. The patient presents with a downward shoulder stump, sometimes rotated inward and forward. This is due to gravitational forces and contraction of the pectoralis major. The proximal fragment is displaced upward. Because of the location of the neurovascular bundles and the great blood vessels, a careful assessment of neurovascular function of the arm on the injured side must be carried out. Management of clavicular fracture is usually conservative. Immobilization with a simple sling is as effective as other less comfortable methods and is therefore the treatment of choice. Displaced fractures of the distal third often require surgical repair because of the risk of non-union. Complications frequently include malunion, regardless of the support mechanism used. While malunion is of little functional or cosmetic consequence, a persistent sharp clavicular spike may cause discomfort against clothes and require excision (Kelly 2004). Patients should be advised that a residual palpable or visible deformity may be present after healing has occurred (Smith 2005).

Shoulder dislocation

The glenohumeral joint of the shoulder girdle is a shallow synovial ball and socket joint that comprises five joints and three bones. The wide range of movement carried out at the shoulder, and its lack of bony stability, predisposes the joint to dislocation. Two main patient groups can be identified: men between the ages of 20 and 30 years (Zacchilli & Owens 2010), and women over 60 years, and approximately 55–60 % of shoulder dislocations are recurrent (Proehl 2009). Glenohumeral joint dislocation can be categorized into four groups: anterior (>90 % of dislocations), posterior (<5 %), inferior (<1 %) and superior (<1 %).

• women aged between 56 and 65 years, usually with osteoporosis – fractures occur as a result of a fall and occasionally direct force; injury is usually to the proximal humerus, neck or shaft

• young men aged between 16 and 24 years – mechanisms of injury include RTAs (transverse humeral fractures), falls from a significant height (oblique or spiral fractures) and stress fractures from throwing actions.

• traction to restore length and align fragment

• any angulation should be reduced

• initial immobilization for pain control and healing

• encourage mobilization of shoulder and elbow to prevent loss of function.

Supracondylar fractures

These are distal humerus fractures, proximal to the epicondyles. They are the most common fracture in children and adolescents, accounting for 50–70 % of elbow fractures (El-Adl et al. 2008) and 30 % of all limb fractures in under-7-year-olds (Babal et al. 2010). Supracondylar fractures are categorized into two groups depending on the mechanism of injury: extension and flexion fractures.

Elbow dislocation

Although elbow dislocation is not uncommon in adults, considerable force is needed to cause dislocation. As a result, a 1 in 3 likelihood of an associated fracture exists. The most common type of dislocation is posterior, where the coronoid process slips back and lies in the olecranon fossa, or impacts into the distal humerus. The joint capsule is damaged and collateral ligaments are torn.

The patient will have pain, the arm will be supported in mid-flexion and the limb will appear shortened. The olecranon is prominent. Careful neurovascular examination is essential, especially of the nerve and brachial artery. The median nerve may be assessed by feeling the muscle while the patient attempts to resist the thumb being pressed from a vertical position against the plane of the hand (Smith 2005). The brachial artery can be assessed by checking the radial pulse.

Management involves urgent relocation for both pain control and neurovascular integrity. This is achieved with muscle relaxants and adequate analgesia followed by a traction/counter-traction approach where one carer applies sustained traction distally from the wrist followed by flexion with posterior pressure. When the reduction is completed, range of movement should be checked to rule out a mechanical blockage, neurovascular integrity should be rechecked, and then the arm should be immobilized in at least 90 % flexion. Medial, lateral and anterior dislocations can also occur, but these are less common and should be managed by the orthopaedic team.

Radial head fractures

In this type of fracture the radial head becomes compressed upwards against the capitellum following a fall onto an outstretched hand. It is an important feature in elbow flexion/extension and forearm rotation. The patient will present with localized pain, which is worse with passive rotation of the forearm and an inability to fully extend the forearm. The presence of a fat pad elevation on X-ray is recognized as associated with an underlying radial head fracture in recent trauma (O’Dwyer et al. 2004). For management purposes, fractures are classified into three types (Table 6.4).

Fracture of both radius and ulna

This occurs following a direct blow, fall or road traffic accident involving significant force or longitudinal compression. These fractures are commonly open and nearly always displaced because of the force needed to break both bones. Injury commonly occurs where the mid- and distal thirds merge because there is less muscle protection. These fractures are easy to diagnose as the patient presents with severe pain and marked deformity, sometimes with abnormal movement of the forearm, which mainly depends on the degree of deformity. If there is no angulation or displacement, a long arm plaster of Paris (POP) slab with 90° flexion of the elbow is applied. Usually open reduction with internal fixation is required because displacement is common. If good reduction is not achieved and maintained, non-union of the bones or union with loss of function will occur.

Ulnar fractures

Ulnar shaft fractures sometimes known as nightstick fractures are caused by direct force to the arm, commonly when it is raised to protect the face from injury. The patient presents with pain over the area, and swelling and deformity if the fracture is displaced. Management depends on the degree of displacement. Fractures with more than 50 % displacement or 10 % of angulation should be internally fixed as they carry a significant risk of non-union. Fractures with less displacement/angulation can be treated in a long arm POP cast with the elbow in 90° flexion and the forearm in a neutral position. Non-displaced fractures initially treated by immobilization respond well to early remobilization at about ten days post-injury.

Proximal ulnar fractures rarely occur independently and are associated with radial head dislocation. This is called a Monteggia fracture and four major classifications of these exist (Wilkins 2002), these are defined by the position of the radial head. Monteggia fractures have a better outcome in children compared with adults (Wilkins 2002). In adults, these fractures are associated with increased morbidity including the complications of reduced function, non-union, infection and the need for revisionary surgery (Fayaz & Jupiter 2010). Radial nerve paralysis can also occur as a result of compression from the displaced radial head. This causes weak wrist and hand extensors. It has been argued that the implications of distal ulnar fractures are often insufficiently appreciated and may result in ineffective treatment, especially compared to distal radius fractures (Logan & Lindau 2008). Greenstick fractures of the ulna are often difficult to detect, which in part accounts for the reason that Monteggia fractures are frequently overlooked in children.

The patient presents with localized pain and, depending on the position of the radial head, it may be palpable, and shortening of the forearm may also be noted. The patient will resist any movement of the elbow. Management involves open reduction and internal fixation in adults, as non-union and persistent dislocation of the radial head is common. A closed reduction under general anaesthetic can usually be achieved in children, as slight radial angulation of the ulna will not restrict movement.

Fractures of the radius

Proximal third fractures are rare because of the muscular support attached to the forearm. When they do occur, these fractures are usually caused by direct force to the forearm. The patient usually has pain around the fracture site and pain on longitudinal compression of the radius. Deformity is not as easy to detect as in other forearm fractures because of the amount of soft tissue surrounding the proximal radius. Associated ulnar injury is common because of the force needed to fracture the radius at this level.

The shape of the radius must be maintained to restore function. In proximal third fractures this is complicated by the force exerted by the supinator and biceps brachii muscles, creating supination and displacement of the proximal fragment. The pronator teres muscle causes pronation of the distal fragment which compounds deformity. This deforming process can occur within a POP cast, and therefore if fractures occur proximal to the point of pronator teres insertion in the mid-third of the radius, internal fixation of the fracture is recommended. Fractures in the proximal fifth of the radius are unsuitable for internal fixation because orthopaedic metalwork/hardware cannot be accommodated. These fractures should be treated in a long arm cast with 90° elbow flexion and forearm supination to minimize muscle forces and maintain reduction. The outcome of closed reduction is better in children than in adults.

Distal third shaft fractures also occur because of direct force, but are more common because of the lack of soft tissue protection. Isolated fractures are less common than more complicated injury (Goldberg et al. 1992). Dislocation of the radio-ulnar joint is usually concomitant with fractures around the mid-shaft and distal shaft junction. This is called a Galeazzi fracture. These fractures have a high incidence of long-term functional disability and chronic pain when untreated (Perron et al. 2001). Pain is the primary diagnostic feature. Tissue swelling may obscure deformity, but shortening is sometimes apparent. The deforming forces, shown in Table 6.5, make closed reduction less successful than open reduction with internal fixation.

Colles’ fracture

The most common of these fractures is the Colles’ fracture (Fig. 6.24). This describes a distal radius fracture with dorsal displacement of the distal fragment. This causes a loss of the usual volar tilt and pronation of the distal fragment over the proximal fragment. An associated ulnar styloid fracture is present in 60 % of cases (Cooney et al. 1991). The injury is most prevalent in women over 50 years, particularly those with signs of osteoporosis. Colles’ fractures are easy to identify at initial assessment as the patient presents with classic dinner-fork deformity of the wrist because of dorsal displacement and loss of volar angulation (Harness et al. 2004).

The patient usually has significant swelling around the fracture site and localized pain. Nerve involvement is not uncommon and paraesthesia may be present in areas served by the median or ulnar nerve. Severe swelling can cause vascular compromise and compartment syndrome. Neurovascular function should therefore be carefully checked on assessment. All the digits should be touched to ensure there is feeling and therefore neurological deficit is present, and capillary refill should also be checked. Patients need adequate analgesia and a full explanation of what is going to happen before any examination of the wrist is undertaken (Summers 2005). Management priorities involve restoration of anatomical alignment, in particular the degree of volar tilt, and the exact restoration of a neutral radio-ulnar joint if good function of the wrist is to be restored. Fractures with minimal displacement with no shortening and maintenance of volar tilt are managed in a forearm POP back-slab or split cast with the hand pronated and ulnar deviation, and flexion at the wrist (Brown 1996).

Most displaced fractures can be managed by closed reduction in the ED. To facilitate this, adequate analgesia is required. Debate persists as to which method of anaesthesia is most appropriate, and various methods are discussed in Chapter 26. Bier’s block is often favoured by orthopaedic staff, but demands skilled operators. Haematoma block requires less skill but carries the risk of subsequent tissue toxicity from the lidocaine used, and has been criticized for providing inadequate anaesthesia to complete the reduction (Cooney et al. 1991). Despite this, haematoma block is commonly used and is successful in the treatment of elderly women. As a general rule, haematoma block is not suitable for Colles’ fracture reduction in younger patients, particularly men with greater muscle spasm creating resistance to reduction. An accurate reduction is vital for restoration of full function in younger patients, and therefore multiple attempts at manipulation are sometimes needed. This is more easily facilitated under Bier’s block.

The reduction involves a traction/counter-traction approach, with the first person applying longitudinal traction through the hand to lengthen the radius, while the second applies counter-traction through the forearm until disimpaction of the distal fragment can be felt. Then the first person applies pressure to the top of the distal fragment to reduce it. Again, volar movement will be felt and visible deformity should be resolved. The wrist should be immediately immobilized in a POP slab with ulnar deviation and wrist flexion. Post-reduction X-rays should be obtained to establish the degree of volar tilt, length and neutral radio-ulnar joint position (Greaves & Jones 2002). If this cannot be achieved by closed manipulation, open reduction and internal fixation should be considered. In complicated or severely comminuted injuries, open reduction and internal fixation should be considered and closed manipulation not attempted in ED.

Compartment syndrome, which is the compression of nerves and blood vessels in an enclosed space, can lead to permanent damage of these structures. Summers (2005) recommends the following symptoms of compartment syndrome – the ‘five Ps’ – should be discussed with patients, stressing that, if any of these symptoms manifest themselves, patients should contact their ED for advice.

The five Ps are:

As patients with Colles’ type fracture are often older, their social circumstances should be established before discharge to make sure they can cope at home.

Smith’s fractures

In both anatomical presentation and mechanism of injury, a Smith’s fracture represents the opposite of a Colles’ fracture. The distal radius is displaced proximally and the distal fragment is volar to the radial shaft. There are three classifications depending on the direction of the fracture (Fig. 6.25).

The mechanism of injury is an impact on the distal aspect of the hand. Because significant force is needed to cause this fracture, the cause is usually an RTA or cyclist going over the handlebars. Smith’s fractures are most common in young men. The patient presents with severe pain, obvious volar deformity of the wrist, making the hand appear anteriorly displaced, and often swelling to the dorsal aspect of the wrist. Neurological compromise to median and ulnar nerves is possible with significant deformity, as is vascular compromise. Careful triage will highlight these complications.

Type I fractures can usually be treated in the ED. Closed manipulation involves restoring length and dorsal alignment of the radius. This can be achieved using Bier’s block anaesthesia and manual traction. Once deformity is corrected, the arm should be immobilized in an above-arm split POP cast with the forearm in a supinated position.

Type II and type III fractures are unstable injuries and, to ensure maximum functional recovery, orthopaedic advice should also be sought. Open reduction with internal fixation is usually required.

Barton’s fractures

These are distal radius fractures with volar or dorsal dislocation of radiocarpal joint. Volar fractures are more common than dorsal (Harness et al. 2004). It differs from Colles’ or Smith’s fracture in that there is always intra-articular dislocation present. Barton’s fractures are often associated with high-velocity trauma (Aggarwal & Nagi 2004) although they can result from a fall upon an outstretched, pronated arm.

Treatment is usually by surgery as conservative care has an elevated risk of complications, including ‘early osteoarthrosis, deformity, subluxation, and instability’ (Aggarwal & Nagi 2004).

Carpal fractures

The carpal bones form two rows (see Fig. 6.23). The proximal row consists of the scaphoid, lunate, triquetrum and pisiform bones. The scaphoid has a bridging position with the distal row which consists of the trapezium, capitate and hamate bones. These bones are supported by three strands of ligaments stemming from the radial styloid. The radial and ulnar arteries provide vascular supply, and the radial, ulnar and median nerves provide neurological function.

Fractures of the carpal bones are less common than other wrist injuries averaging at 8 % compared to phalanges (59 %) and metacarpals (33 %) (Van Onselen et al. 2003, Dennis et al. 2011). These fractures are often associated with ligament injury, creating an unstable wrist joint. Long-term disability is not uncommon in missed fractures. Assessment of wrist injury should focus on the mechanism of injury, force involved, and exact site of impact as well as the age of the patient, wrist anatomy and relative strengths change with age.

Scaphoid fracture

Because of its unique position in relation to the radius and both rows of carpal bones, the scaphoid is the most commonly fractured carpal bone and accounts for between 2 and 7 % of all orthopaedic fractures (McNally & Gillespie 2004). It occurs in both adults and children, most often between early teens and mid-life. The oblong-shaped scaphoid bone derives its name from the Greek word ‘skaphos’ meaning ‘boat’ and is divided into four anatomical areas (Fig. 6.26).

The scaphoid has a good vascular supply to the middle and distal areas, but the proximal pole has no dedicated blood supply. This results in a high incidence of vascular necrosis if fracture union is not rapidly achieved. Scaphoid fractures are usually classified as stable or unstable and time taken to union differs with the fracture location (Box 6.6). Stable fractures that are incomplete or completely undisplaced, heal rapidly and are treated with immobilization. An unstable fracture has been defined as displacement of the fracture by 1 mm or more on X-ray.

The most common mechanism of injury is a fall onto an outstretched hand. Externally, there is little visible evidence of a fracture, although swelling can sometimes be present. The patient will have generalized pain, which is worse on wrist movement, particularly gripping actions. On examination, patients will have specific tenderness in the anatomical snuffbox. The anatomical snuffbox is on the radial aspect of the dorsum of the wrist. They may also have pain when longitudinal pressure is applied to the thumb and index finger, and pain on dorsiflexion of the wrist. To assess the snuffbox, ask the patient to hyperextend the thumb with the wrist slightly deviated in the radial aspect. In this position the snuffbox becomes visible. The scaphoid can be palpated proximally in the floor of the snuffbox. The trapezium can be palpated distally. This test is sensitive but not specific (Phillips et al. 2004). Tenderness of the scaphoid tubercle is also a sensitive test but is more specific. To examine this with one hand extend the patient’s wrist while applying pressure on the scaphoid tuberosity at the proximal wrist crease with the other. If there is no tenderness with these two tests, a scaphoid fracture is unlikely.

Because of the location of pain and lack of external signs, patients often delay attending the ED as they do not automatically relate symptoms with a broken bone.

X-ray findings can be misleading as up to 20 % of patients with scaphoid fracture have normal initial X-rays (McNally & Gillespie 2004). Fractures not initially visible on X-ray will be apparent between 10–14 days post-injury (Hunter 2005). For this reason diagnosis should be based on clinical findings, specifically, mechanism of injury and localized tenderness in the anatomical snuffbox. Management of scaphoid fractures can be controversial (Hunter 2005). At present most non-complex fractures are treated conservatively with an excellent healing rate, however where the facilities and skill exist surgical treatment is increasing in popularity with a 100 % union rate and reduced immobilization time required (Vinnars et al. 2008). A general consensus exists that all fractures, whether clinical or radiological, should be immobilized as failure to do this can result in delayed or non-union healing or avascular necrosis. A POP cast or splint that incorporates the forearm and thumb, with the wrist in slight volar flexion, should be used. Complicated fractures should be referred to the orthopaedic team because of the risk of avascular necrosis. Some fractures are internally fixed at an early stage to prevent non-union and to ensure good functional recovery (Chin et al. 2009).

Lunate fracture

The lunate is in the middle of the proximal carpal row and rests in the lunate fossa of the radius. Injury of the lunate bone is relatively uncommon because it is protected by the lunate fossa. When fracture does occur it is usually due to a fall onto an outstretched hand, where force is taken through the heel of the hand. The patient presents with mid-dorsal pain and wrist weakness; however, swelling is uncommon. As a result, attendance in the ED is sometimes days or weeks after the initial injury.

Radiological evidence of fracture is not always obvious, therefore clinical diagnosis is necessary based on location of pain and mechanism of injury. Non-displaced fractures should be treated in a forearm POP cast, with orthopaedic follow-up. Displaced fractures are prone to avascular necrosis and non-union, with a potential for secondary osteoarthritis. For this reason, patients should be referred to the orthopaedic team for possible internal fixation.

Triquetrum fractures

The triquetrum is the second most commonly fractured carpal bone. Such fractures often occur with other carpal fractures or perilunate dislocation. Isolated injury is less common and usually minor. Triquetrum fractures are usually caused by hyperextension injury of significant force. The patient usually complains of pain over the dorso-ulnar area of the wrist. Management involves a short arm POP cast or splint for 3–6 weeks in the case of isolated injury or referral to the orthopaedic team where the fracture is associated with other wrist injuries. Other carpal fractures generally occur as part of a more complicated hand or wrist injury, and demand specialist orthopaedic input after initial diagnosis in the ED.

Perilunate and lunate dislocation

These dislocations occur as a result of disruption to the lesser arc of ligaments. They can be graded into four groups depending on the degree of disruption (Box 6.7). They are caused by extreme hyperextension, which might occur due to a motorcycle accident or fall from a height. Because of the force needed to cause perilunate and/or lunate dislocation, concurrent injury is common. The patient presents with extreme pain and a fork-type deformity, and is usually unable to hold the fingers in a flexed position. Nerve disruption is not uncommon, so paraesthesia may also be present. Fractures and severe ligament disruption are usual with these injuries, which should always be managed by the orthopaedic team and often require open reduction when associated with fractures.

Thumb injury

The flexor surface of the thumb is perpendicular to that of the fingers and has a saddle joint which allows 45° of rotation. The range of thumb movements includes flexion/extension, adduction/abduction and opposition. It provides both strength and grip. Thumb fractures are treated differently from other metacarpal fractures because of the degree of functional restoration needed.

First metacarpal shaft fractures

These usually occur in the proximal half of the bone and are often associated with adduction of the distal segment. Management usually involves longitudinal traction and POP cast incorporating the thumb. Early orthopaedic follow-up is advisable.

Base of first metacarpal fractures

These are usually more complicated and result from flexion injuries, commonly from clenched fists. They can be classified as intra-articular fractures, such as Bennett’s fractures, or extra-articular transverse or oblique fractures.

Extra-articular fractures occur within the joint capsule, but do not involve the articular surface of the joint (Fig. 6.28) and are the most common fracture type. These injuries are usually managed by closed reduction and POP cast incorporating the thumb. In order to retain good function, it is important not to hyperextend the thumb at the metacarpophalangeal joint. Some oblique fractures may remain unstable with closed reduction and plaster immobilization alone, and therefore orthopaedic referral for percutaneous pinning is necessary.

Intra-articular fractures can be divided into two groups: the more common Bennett’s fracture and Rolando’s fracture. The Bennett’s fracture is categorized by the displacement of the metacarpal shaft while the palmar articular fragment retains its correct anatomical location as shown in Fig. 6.29. The mechanism of injury is similar to that of an extra-articular fracture, with interpersonal fracas being a common cause of injury. The patient has limited movement of the base of the thumb with pain and swelling around the area. Effective emergency management is essential to prevent degenerative post-traumatic arthritis and to restore adequate range of movement. This injury is considered unstable because of the adductor pollicis longus tendon, which is attached to the base of the first metacarpal. Its tensile strength prevents union of fracture without the aid of percutaneous pins or orthopaedic reduction and internal fixation.

Rolando’s fracture is similar to a Bennett’s fracture, but in addition to the palmar articular fragment remaining in place, the dorsal fragment displaces from the base, creating a Y-shaped or more severely comminuted base of metacarpal fracture. Mechanism of injury and patient presentation are similar to those of a Bennett’s fracture, but the prognosis is poor as functional integrity is difficult to restore with orthopaedic reduction and internal fixation or closed reduction and immobilization. Persistent pain and degenerative arthritis are common.

Phalangeal fractures of the thumb are generally managed in the same manner as fingers.

Second to fifth metacarpal fractures

The metacarpals are anatomically sectioned into base, shaft, neck and head. Unlike other long bones, the base is at the proximal point and the head at the distal end.

Base of metacarpal fractures (II–IV)

The patient presents with a history of a fall onto an outstretched hand or punch injury. The fractures are often associated with carpal fractures and second and third metacarpal base fractures often have intra-articular involvement, but this causes little or no disability because of the relative immobility of the second and third carpo-metacarpal (CMC) joint. As a result, treatment focuses on maintaining patient comfort. A removable splint is the treatment of choice. Fractures of the fourth and fifth metacarpal bases are usually associated with CMC dislocation. Fourth metacarpal base fractures can usually be managed in the ED with closed reduction and splinting followed up by the orthopaedic team. Fifth metacarpal base fractures will usually require pinning because of displacement.

Good fracture alignment is necessary to retain normal mobility of the CMC joint. When splinting hand injuries, it is vital that metacarpo-phalangeal joints are immobilized in at least 70° of flexion to prevent shortening of the collateral ligaments. If these ligaments contract during immobilization, the patient is left with considerable disability because of joint stiffness.

Shaft of metacarpal fracture

These are caused by a number of mechanisms of injury (Table 6.6). Principles of management revolve around correction of any rotation, angulation and shortening of the finger to ensure functional recovery. Even a small degree of rotation can cause problems with flexion of the metacarpo-phalangeal joint. Effective closed reduction and immobilization are usually achievable in ED unless severe swelling or open fractures exist. If rotation cannot be corrected with manipulation, the patient should be referred for percutaneous pinning or orthopaedic reduction and internal fixation.

Metacarpal neck fractures

Second and third metacarpal neck fractures often need wiring to correct angulation in order to restore functional mobility, and therefore orthopaedic opinion should be sought. The fourth metacarpal is more mobile and neck fractures will heal without functional deficit even if volar angulation at the metacarpal neck exists. However, any rotation in these fractures must be corrected to prevent functional deficit.

Fifth metacarpal neck fracture, known as Boxer’s fracture, is one of the most common hand injuries treated in the ED and usually results from a punch injury. Management of these fractures is controversial (Winter et al. 2007), but there is a consensus that any rotational injury needs manipulation and either splinting or wiring. Volar angulation can, however, be treated in a number of ways, ranging from orthopaedic reduction and internal fixation to no treatment and early mobilization (Winter et al. 2007).

Clinical trials (Rusnak 1995) have found that no treatment at all or supportive splinting which facilitates mobilization has quicker functional repair, with minimal cosmetic deformity in the majority of cases. Where closed reduction is carried out, maintaining that reduction is difficult without causing further damage to the function of the hand. This is because 70° of flexion at the metacarpo-phalangeal joint is necessary to prevent contractures, but this position will not provide the three-point fixation needed to stabilize the metacarpal neck.

If the patient is exceptionally concerned about the cosmetic result and the possible loss of knuckle definition, then surgical fixation should be considered; however, recovery is significantly slower with this method. Whatever method is used, the patient should have adequate follow-up from a hand surgeon to ensure the fullest functional potential is achieved. Metacarpal head fractures should be managed conservatively unless they are displaced or comminuted, when an orthopaedic opinion should be sought.

Fracture of phalanges

As with other hand fractures, the key management priority is to maintain good function by correcting rotation. Neighbour-strapping is usually the treatment of choice for uncomplicated fractures.

Sprains

These are injuries to the fibres of ligaments supporting a joint. This results from abnormal movement of the joint causing stretching and tearing of the ligament. The degree of this varies from partial tearing to total disruption of the ligament complex supporting a joint (Table 6.7).

The patient will present with mechanisms of injury and symptoms similar to those with fractures. The joint has often been subjected to forces in opposite or abnormal directions, creating joint stress. The patient will usually describe a sudden onset of acute pain, and often describe hearing a ‘snap’ at the time of injury. Many patients are convinced this means they have broken their limb and the nurse must therefore be careful to assess the injury thoroughly and provide the appropriate reassurance (Loveridge 2002, Smith 2003) without offending by implying the injury should not be seen in ED. Although specific injury management can vary, common RICE principles of sprain management apply:

Strains

These are injuries to muscles and tendons. They occur after forced stretching or sudden violent contraction. As with sprains, the severity of strain injury is classified by the extent of damage (Table 6.8).

Treatment of strains is similar to that of sprains. Management of first-degree strains involves rest, ice, compression and elevation as described under ‘sprains’ above. Second-degree injuries may require immobilization, depending on the site affected, and usually take longer to heal. Third-degree injuries should be immobilized and the patient referred for early orthopaedic consultation at the fracture/STI clinic. Some injuries benefit from surgical repair, but many require simple immobilization. Many factors influence this decision: the site of injury, as well as the age, activity level and occupation of the patient (Loveridge 2002).

Tendinitis

This is an inflammatory condition usually caused by overuse. Less commonly it is caused by direct trauma. The patient complains of pain at the point where the tendon attaches to bone. Pain is worse on movement and function is sometimes restricted. Occasionally, palpable crepitus exists. Common sites include the rotator cuff of the shoulder (supraspinatus tendonitis), the insertion of hand extensors to the humeral lateral epicondyle (tennis elbow), the medial epicondyle (golfer’s elbow), the radial aspect of the wrist (De Quervain’s tenosynovitis) and the Achilles tendon. Management principally involves rest. NSAIDs are often used but their efficacy is currently debated particularly where overuse and degeneration are present (Khan et al. 2000).

Bursitis

This is inflammation of the bursa. The bursa is a sac of synovial fluid situated between muscle, tendon and bony prominences to facilitate movement. Bursitis can result from friction between the bursa and musculoskeletal tissue, direct trauma or infection. It results in inflammation and oedema, which causes sac engorgement, and the area becomes painful.

This condition is most common in middle age (Genge Jagmin 1995). The patient usually presents to the ED with a swelling at 2–3 days post-injury or strain. Pain can increase gradually over this time or may be of sudden onset. It is usually worse on movement and radiates distally from the site of bursitis. The area will appear classically inflamed with erythema and swelling and will be hot to the touch. Areas commonly affected include the knee (Adams 2004), elbow and big toe (gout bursitis).

If infection is suspected, e.g., following a puncture wound, or if the patient has pyrexia, the bursa should be aspirated and the aspirate sent to the laboratory for culture. Otherwise, the injured area should be managed conservatively with rest and analgesia with or without NSAIDs.

Haematoma

This is a collection of blood resulting from vascular injury within the soft tissues, bone or muscle. It is a result of direct or blunt trauma. Large haematomas not only threaten homeostasis, due to loss of circulatory volume, but are also a potential host for infection. As a result, surgical drainage and antibiotic therapy may be necessary. Smaller haematomas can be treated with compression bandages, ice as described above, and elevation.

Contusions

These usually result from direct trauma, which results in localized pain, swelling and bruising. Most are self-limiting and symptoms are relieved by ice treatment, analgesia and early mobilization.

Specific soft tissue injuries

There are a number of soft tissue injuries that are so commonly treated in EDs that they warrant individual discussion within this chapter.

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