- Section 7: The trauma oral
- 23. Trauma oral topics
401
23. Trauma oral topics 403
Abayomi Animashawun and
Paul A. Banaszkiewicz
SECTION 7
The trauma oral
403
23
The trauma oral where fewer slides are shown
but the questions are more detailed and a more
thorough answer is expected. Usually it con-
tains one or more of the dreaded “describe the
surgical approach you would use to fix this frac-
ture” type of question
3. The complex trauma oral
This is where complex trauma cases are shown
and the discussion centres on the management
of these difficult cases
4. The mixed trauma oral
A combination of the above three styles: some
straightforward questions, a couple of topics
probed in detail and a couple of difficult frac-
tures to discuss
A straw poll of candidates who recently sat the
examination would seem to suggest most of the
trauma orals were either style 1 or 4. Occasionally
a candidate encountered oral style 2 or 3 but these
were the exception. Essentially the style of trauma
oral one gets depends on who examines you.
The classic trauma oral
With oral style 1 a large part of the exam can consist
of straightforward bread and butter trauma cases
that you come across on a daily basis in the fracture
clinic. These should present no problem to the aver-
age candidate.
The oral usually consists of a series of fast-moving
radiographs and clinical pictures. In the 30 min it is
not uncommon to view upwards of over 15 slides.
Introduction
The original plan was to write a concise account of
orthopaedic trauma that would be all things to all
candidates about to sit the FRCS (Tr & Orth) exam.
The reality is that there are a lot of very good concise
orthopaedic trauma textbooks available (to read and
revise from). Therefore, what follows is an attempt to
present an overview of the trauma oral section to give
a candidate a flavour of what to expect. At the end of
the chapter we discuss possible trauma long cases.
Trauma long cases can be awkward as they usually
involve complex management issues often second-
ary to complications from initial trauma care.
Differing oral styles
Many candidates regard the trauma oral as the
easiest oral to pass. Perversely a fair number of
candidates have come out of it saying it was the
worst one of the lot. There seem to be broadly four
styles of trauma oral that you may encounter in the
examination:
1. The classic trauma oral
A series of fast-moving slides where you describe
the injury and your preferred method of man-
agement. There is barely enough time to catch
your breath before the next slide is shown. This
type of oral covers a lot of ground very quickly
but the discussion is fairly superficial. It can be
an enjoyable oral if you know your stuff well
2. The probing trauma oral
Trauma oral topics
Abayomi Animashawun and Paul A. Banaszkiewicz
Postgraduate Orthopaedics: The Candidate’s Guide to the FRCS (Tr & Orth) Examination, Ed. Paul A. Banaszkiewicz,
Deiary F. Kader, Nicola Maffulli. Published by Cambridge University Press. © Cambridge University Press 2009.
404 Section 7: The trauma oral
shown. The style 2 orals are more likely to catch out
the less prepared candidate. A candidate may only
have a superficial working knowledge of trauma and
be able to get through a rapid series of clinical slides
without this being exposed. When grilled in detail
about a trauma topic a lack of in-depth knowledge is
easily uncovered by an examiner.
The complex trauma oral
The style 3 oral scenario probably arises because an
examiner expects you to have a good working knowl-
edge of the management of most trauma conditions.
He or she therefore only shows you very difficult or
complex clinical cases for you to discuss. This is the
most difficult type of oral to deal with. Get the basics
out first before jumping in with an elaborate manage-
ment plan so at least you can score enough marks to
scrape through. This is the nightmare type of oral,
usually the last one of the day when everything seems
to be going reasonably well and the end of the exami-
nation is in sight. The candidate is expecting to breeze
through this final hurdle and then suddenly gets hit
with an impossible oral, gets mixed up, starts to waffle
and backtrack. Calm it down; get basic first principles
out and hope you have done enough to pass.
The mixed trauma oral
There is not particularly much to say about a style 4
oral. It is neither one thing nor the other. Probably
more difficult than style 1, it is probably easier to
pass than either style 2 or 3.
There are certain key topics that tend to be asked
in the trauma oral. Compartment syndrome is
probably the most important topic to learn. You are
almost certain to be asked about it and there are no
excuses for not knowing this subject inside out and
back to front. Ideally you should have gone through
a couple of dry runs with a colleague so that you do
not just answer the topic well, you go to town on it
and murder it.
Other reasonably common topics are some sort
of spinal fracture, a proximal humerus fracture or
shoulder dislocation (usually posterior, spot diagno-
sis), a foot fracture, distal radius fracture and either
In general you are shown a radiograph, occasion-
ally a clinical photograph or given a short history, etc.
Start off by describing the radiograph or clinical
photograph in general terms. If possible classify the
fracture (if appropriate). You are then most likely to
be asked about the management of the condition,
“what are you going to do next?”.
It is not unreasonable to mention searching for
other associated injuries (if the fracture is high
velocity) and to discuss your initial resuscitation
and management (of the injury). However, once you
have alerted the examiner to this line of approach in
the first couple of slides and set the tone, skip over
it; do not keep repeating the same story line as it will
slow you down, irritate examiners and not score you
any points.
“Assuming that all things being equal and there are no
other associated injuries or co-morbidity factors present
and the patient is adequately resuscitated then I would
manage this fracture with . . .”
You can either list various management options, dis-
cussing the pros and cons of each, or state your own
management preference first and why you have cho-
sen it over other possible methods of management.
When discussing management options the exam-
iner may prefer that you answer how “you yourself”
would manage the fracture rather than give the
options available.
Candidate: This fracture is suitable for either conservative
management initially in a long leg cast and then Sarmiento
brace or closed reamed intra-medullary nailing.
Examiner: I didn’t ask for the various treatment options I
asked, “How are YOU going to manage this fracture?”
In many cases there will be several ways to manage
a fracture and your own preferred method may be
different to that of the examiners. If you suggest a
particular management plan be able to defend your
point of view if challenged by the examiners (assum-
ing that it is a sensible option).
The probing trauma oral
Some examiners prefer to show fewer slides but expect
a more thorough and detailed discussion of each one
Chapter 23: Trauma oral topics 405
fractures of the glenoid fossa. Mayo classifica-
tion2 (1998) is a modification of Ideberg’s classifi-
cation. The Zdravkovic3 classification is based on
anatomy.
Zdravkovic–Damholt classification of scapula
fractures (1974)
Type I: scapular body fracture
Type II: coracoid or acromial fracture
Type III: scapular neck or glenoid fossa fracture
Clinical presentation
Pain – with active/passive shoulder motion or •
deep inspiration
Local tenderness•
Ecchymosis•
Local swelling•
Deformity – rare without associated clavicle frac-•
ture or ACJ separation
Imaging
Often an incidental finding on a trauma skeletal •
survey
AP/lateral scapular radiographs•
CT is useful for more complex fracture patterns, •
i.e. glenoid fossa
Management
It is important to recognize the high incidence of •
associated life- and limb-threatening injuries
Pulmonary injuries, including rib fractures, pul-•
monary contusions and haemo/pneumothorax
(30% of cases)
Significant closed head injury (33%)•
Ipsilateral clavicular fracture (25%)•
Brachial plexus and vascular injury•
2 Mayo KA, Benirschke SK, Mast JW (1998) Displaced fractures
of the glenoid fossa: results of open reduction and internal
fixation. Clin Orthop 347: 122–30.
3 Zdravkovic D, Damholt VV (1974) Comminuted and severely
displaced fractures of the scapula. Acta Orthop Scand 45: 60–5.
a pelvic or acetabular fracture. There are usually two
or three children’s fractures shown as well.
As trauma surgeons we see a huge number of dif-
ferent fractures in the fracture clinic. It is therefore
not uncommon to be shown two or three radio-
graphs of some minor or obscure fracture that you
will not have read about recently (mallet finger is
a classic example and also a common question in
the hands oral). With the experience gained from
a reasonably busy trauma job you should be able
to come up with some sort of half decent answer
that satisfies the examiners, who will then hope-
fully move on to another topic, with which you are
more familiar.
Scapula fractures
Scapula fractures account for fewer than 1% of all
fractures and 3%–5% of shoulder girdle injuries. The
mean patient age range is 35–45 years. RTAs account
for 70% of all scapula fractures (50% motor car, 20%
motor cycle). Major trauma is required to fracture the
scapula so other injuries and complications are com-
mon (50%–90% of cases). In the majority of situations,
closed management of these fractures is the norm.
Mechanism of injury
Indirect – caused by axial loading on an out-•
stretched arm
Direct – usually high-energy trauma including •
falls from a height and RTA
The most common fracture site is the scapular body
(35%) followed by scapular neck fractures (27%).
Spine, glenoid and acromion fractures have similar
occurrence rates.
Classification
Several classifications exist for scapula fractures.
Ideberg’s system1 (1984) classifies intra-articular
1 Ideberg I (1984) Fractures of the scapula involving the
glenoid fossa. In Bateman JE, Welsh RP (eds.) Surgery of the
Shoulder. Philadelphia: Decker, pp. 63–6.
406 Section 7: The trauma oral
direct trauma in up to 91%–94% of cases and indi-
rect trauma (fall on outstretched hand) in 6%–9% of
cases.
The primary classification system divides frac-
tures into medial third (5%), middle third (85%) and
lateral third (10%) (Allman).
Neer’s classification
Fractures of the lateral third are further divided
based on the integrity of the coracoclavicular liga-
ment (CCL) complex in relation to the injury:
Type I: Non-displaced
Type IIA: Fracture medial to conoid and trapezoid
ligaments
Type IIB: Fracture between conoid and trapezoid
ligaments
Type III: Fracture into the AC joint without CCL
injury
Type IV: Epiphyseal separation (children)
Type V: Three-part fracture, with intact ligaments
connected to middle fragment
Examination and investigation
Neuromuscular examination – exclude brachial •
plexus injury
Vascular injury – particularly the subclavian/axil-•
lary vessels
Pneumothorax (3%)•
Open injuries or compromise of the skin•
Medial third fractures are usually associated with •
high-energy trauma and multiple injuries
Imaging
AP radiographs•
45° cephalic/caudal views•
Weight-bearing views of both shoulders are used •
to demonstrate ligament integrity in distal third
fractures
CT scan demonstrates intra-articular extension in •
medial/lateral third fractures
Simple fractures of the scapular body, even with
significant displacement, may be managed by being
closed in a sling followed by assisted mobilization.
Displaced scapular neck fractures can result in a
high incidence of residual disability. Greater than
40° displacement in the coronal/transverse plane
or >1 cm medial displacement may require fixation.
Displaced fractures of the glenoid, especially those
associated with glenohumeral instability, need
ORIF to prevent secondary osteoarthritic changes
or shoulder instability. Malfunction of the rota-
tor cuff may occur with spine fractures, and weak-
ness on abduction and pain may follow. There is a
risk of non-union with fractures at the base of the
acromion with >5 mm displacement. The key factor
that influences management of the scapula fracture
is its effect on shoulder function including gleno-
humeral stability, rotator cuff function and gleno-
humeral movement. In recent years there has been
a trend towards more thorough evaluation of these
fractures as not all of them are benign, with a greater
role of surgery for these fractures than previously
was the case.
Surgical approach
Anterior deltopectoral approach for anterior glen-•
oid rim and coracoid fractures
Posterior (Judet) approach for posterior glenoid •
rim, neck and glenoid fossa fractures
Good/excellent results of surgical fixation as high •
as 79% have been reported in experienced hands
Examination corner
Radiograph of a glenoid fossa fracture
Classification system used
Indications for surgical fixation and surgical approach
Clavicle fractures
These account for 5% of all fractures and 35%–44%
of fractures around the shoulder girdle. Caused by
Chapter 23: Trauma oral topics 407
advantages over plate fixation including minimal
soft-tissue and periosteal stripping, better cos-
mesis (smaller skin incision) and ease of removal.
Ability to resist torsional forces is much less than
with a conventional plate. Examples include the
Rockwood clavicle pin, titanium elastic nail (TEN,
Synthes) and Herbert cannulated bone screw
External fixation is occasionally indicated in mul-•
tiply injured patients
Coracoclavicular screw fixation for distal third •
fractures with CCL disruption
Resection of distal clavicle – following degenera-•
tive change with type III distal third fractures
Arthroscopic fixation•
ORIF gives superior results in type II and type V •
fractures of the distal third as these have a higher
rate of non-union if managed conservatively
Complications
Non-union
More commonly seen in middle third fractures due
to their higher incidence, but lateral third fractures
are more prone to develop non-unions. Lower rates
following non-operative management (0.1%–4%)
but more favourable fracture types are more likely
to heal than those chosen for fixation. Predisposing
factors in middle third fractures include:
Severity of injury (high-velocity injuries)•
Primary operative management. Aggressive soft-•
tissue stripping, inability to reduce the fracture,
and inadequate internal fixation
Re-fracture•
Completely displaced fracture with shortening •
2 cm
Patient’s age•
Non-union rate is 30% for a non-operated type II
distal third fracture. The management of a symp-
tomatic non-union is open reduction, bone grafting
and fixation.
Malunion
A distinct clinical entity with characteristic clini-
cal and radiographic features. Defined as union of
the fracture in a shortened, angulated, or displaced
Management
Non-operative management
Broad arm sling or collar and cuff are the mainstay
of non-operative management. Mobilize when clin-
ical union occurs. Radiological union occurs after
clinical union. Distal third fractures, types I and III,
are usually managed conservatively.
Indications for operative management
Open fractures•
Fractures with neurovascular injury•
Compromised overlying skin•
Floating shoulder•
Type II distal third fractures because of the high •
rate of non-union
Polytrauma•
Symptomatic non-union or degenerate AC joint•
Greater than 1 cm of displacement or 2 cm of •
shortening
Contraindications for operative management
Active infection in• the operative area
Prior soft-tissue irradiation of the operative• area
Burns over the clavicular area•
Significant co-morbidity medical factors•
A• high risk of poor patient compliance, especially
due to drugs and/or alcohol
An elderly patient with a sedentary• lifestyle
Methods of fixation
Plate fixation (reconstruction plate, 3.5-mm •
dynamic compression plate (DCP), precontoured
clavicle locking plate, hook plate). Semitubular
plates should not be used. Reconstruction plates
more easily contoured but greater risk of non-
union
Intramedullary fixation but traditionally a high •
complication rate including infection, non-union
and implant migration. Newer designs and modi-
fications in the technique used for fixation have
recently led to renewed interest. Significant
408 Section 7: The trauma oral
• Useofaclavicularhookplate
• Rehabilitationafterhook plate xation. Specically the
examiners wanted to discuss the possibility of causing
rotator cuff damage with unrestricted range of shoulder
movement
• Need for plate removal (yes, as part of planned
treatment)
Acromioclavicular joint dislocation
Rockwood classification (1984)4
Type I: Sprain
Type II: Rupture of AC joint. Sprain of CCLs
Type III: Rupture of AC joint and CCLs with <100%
displacement
Type IV: Rupture of AC joint and CCLs with poste-
rior displacement (clavicle may be trapped in the
trapezius muscle). Best viewed from the side or
above
Type V: Rupture of AC joint and CCLs with >100%
displacement
Type VI: Rupture of AC joint and CCLs with inferior
displacement (clavicle may be trapped under the
conjoint tendon)
Or more simply the “Six S’s”
Type 1: Sprained
Type 2: Subluxed
Type 3: Superior dislocation
Type 4: Superior/posterior dislocation
Type 5: Severe superior dislocation
Type 6: Severe inferior dislocation
Types I–III account for 98% of these injuries.
Controversies of surgical versus non-surgical man-
agement surround type III fractures, which make up
40% of all ACJ injuries.
4 Rockwood CA Jr. (1984) Subluxations and dislocations
about the shoulder. Injuries to the acromioclavicular joint.
In: Rockwood CA Jr., Green DP (eds.) Fractures, edn. 2, vol. 1.
Philadelphia: JB Lippincott, pp. 860–910.
position with weakness, rapid fatigability, pain with
overhead activity, neurologic symptoms (numbness
and paresthesia of the hand and forearm with eleva-
tion of the limb), and shoulder asymmetry.
Neurovascular compromise
Acute compromise relates to fracture displacement
while chronic compromise relates to excessive cal-
lus formation or a mobile non-union. Typically, the
proximal part of the distal fragment in middle third
fractures is pulled inferiorly/posteriorly against the
neurovascular bundle.
Osteoarthritis
May follow SC joint and AC joint injury.
Floating shoulder
Double disruption of the superior shoulder complex
(scapula, clavicle and soft tissue). This results from
fracture of the clavicle and scapula and this com-
bination of injuries should be stabilized. The clav-
icle should be plated. If the scapula fracture (usually
of the glenoid neck) does not reduce spontaneously,
ORIF is indicated.
Examination corner
Trauma oral 1
Adult middle third clavicular fracture
• Non-unionrate
• IndicationsforORIF
• Complications of xation (non-union, delayed union,
infection, skin breakdown over the plate, new fracture
around the plate, etc.)
Trauma oral 2
Radiograph of a fractured lateral third
of clavicle
• Classication
• Management
Chapter 23: Trauma oral topics 409
major procedure with more risks involved than
are necessary such as musculocutaneous nerve
injury and loss of fixation
Coracoclavicular cerclage. A well-established •
technique, materials include tendons, wire loops
and synthetic ligament substitutes such as Dacron
or Mersilene tape
Clavicular hook plate. Needs removing after heal-•
ing of the soft tissues
Arthroscopic techniques. The CCL is dissected •
from the undersurface of the acromion and is
reinserted on the inferior clavicle by transosseous
suture fixation. Other techniques involve the use
of a semitendinosus allograft to reconstruct the
CCL. The accuracy of reduction of the joint is
more difficult to assess arthroscopically
Complications of conservative management
Cosmetic “bump” on the distal clavicle•
Painful ACJ with degenerative changes. If severe, •
it is managed with excision of the distal clavicle
and reconstruction of the CCL by using the cora-
coacromial ligament (Weaver–Dunn procedure)
Prognosis
Up to 100% good/excellent results with type I/II •
injuries
Patients with non-operative management of type •
III injuries may experience mild discomfort, but
no reduction of strength or endurance compared
to the non-injured side at 4 years
Return to work and rehabilitation are quicker with •
non-operative management for type I–III injuries
Examination corner
Trauma oral 1
Radiograph of a grade V ACJ dislocation
Examiner: This is a 23-year-old male who sustained the above
injury when playing football. It is a week later on and you see
him in your fracture clinic. How are you going to manage him?
Imaging
AP with 10°–15° cephalic tilt – outlines joint/loose •
bodies
Stress radiograph with 4-kg weight suspended •
from patient’s wrist – helps differentiate between
type II and III injuries
Management
Types I and II are managed non-operatively; types
IV–VI, with surgery. Controversy surrounds the type
III injury, as to whether to manage operatively or
non-operatively. There is possibly a case for surgery
in a heavy manual labourer or an athlete.
A wide variety of operative procedures have been
described but none has been shown to be clearly
superior to the others. Newer arthroscopic tech-
niques to manage ACJ injuries are evolving, they
cause less disruption to the soft tissue envelope but
there is a steep learning curve.
Non-operative management
Sling or brace for 6–8 weeks•
Loss of shoulder and elbow motion•
Soft-tissue calcification•
Interference with ADLs•
Late ACJ osteoarthritis•
Operative management
The use of K-wires to fix the ACJ is now contraindi-•
cated. It is dangerous as pin breakage and migration
can occur, it gives relatively poor fixation and a sec-
ond procedure for hardware removal is required
Steinman pin across the ACJ. Given the wider •
range of better implants now available, this is not
recommended
Coracoclavicular lag screw (Bosworth screw) with •
repair of CCL and plication of the torn deltoid and
trapezius. Gone out of favour as concerns with
loss of screw fixation or screw breakage, etc.
Dynamic muscle transfers. Transfer of the lateral •
half of the conjoined tendon to the distal clavicle
augmented by EndoButton fixation of the ACJ. A
410 Section 7: The trauma oral
backward and downward movement of the shoul-
der. A posterior dislocation is usually due to a blow
over the posterolateral aspect of the shoulder or less
commonly a direct blow over the clavicle. Diagnosis
is made from the site of pain, swelling and deform-
ity. Patients with hypermobility may exhibit volun-
tary joint subluxation. Anterior dislocation is more
common (20:1) and less dangerous because of the
mechanism of injury and potential complications
from management.
Imaging
Diagnosis can be difficult due to artefacts from •
neighbouring structures
The serendipity view is a 40° cephalic tilt. In •
anterior SCJ dislocations the clavicle is high
riding whilst in a posterior SCJ dislocation the
clavicle is below the interclavicle line. Details
of avulsion fractures and the relationship of the
clavicle to the mediastinal structures are difficult
to interpret
CT is the investigation of choice•
Vascular studies should be considered in a •
posterior dislocation where there has been a
significant risk of injury to the great vessels
(superior vena cava, subclavian vascular system,
laceration of the innominate vein and carotid
artery compression) or severe thoracic outlet
syndrome
MRI may be useful in assessing the extent of soft •
tissue injury
Associated injuries
Posterior dislocation may impinge on closely related
structures:
Great vessels, trachea (lacerations), oesopha-•
gus (rupture – pneumomediastinum), heart and
pleura (pneumothorax)
Venous congestion in the neck or ipsilateral arm, •
hoarseness, cough, dysphagia or a feeling of chok-
ing suggest superior mediastinal obstruction from
posterior dislocation, and are indications for
urgent reduction
Anterior dislocation is relatively benign.
Candidate: This is either a Rockwood grade III or V injury to the
AC joint. If this was a grade III injury I would manage the
patient conservatively with a sling but if it was a grade V
injury I would manage him surgically.
Examiner: How are you going to manage this gentleman “you
yourself”?
Candidate: There is a large coracoid–clavicular interval so I
would probably want to fix it.
Examiner: You would not really want to leave this injury alone
would you?! (A very slight alarm in examiners voice – candi-
date has got to pick these types of clue up.)
Candidate: I would fix it with a Bosworth screw.
Examiner: Do you leave the screw in or take it out?
Candidate: I would take it out.
Examiner: When?
Candidate: At 8 weeks.
The candidate made it hard work for themselves. The injury
was grade V, there was no real debate about this from the
radiograph and it needed operative fixation. The candi-
date was too cautious (or unsure) with their answer; they
should have been more definite and confident with their
reply. Nowadays a Bosworth screw is a much less popular
method used to fix these injuries and as such they would
not be my first choice to mention to the examiners.
Trauma oral 2
Grade III ACJ dislocation
• Management:acuteversuschronic
• Weaver–Dunn:“Howdoyoudoit?”
Trauma oral 3
Clinical photograph of a middle-aged man
with a slightly prominent lateral end of
clavicle. A grade II ACJ dislocation
• Describewhatyousee
• Whatisyourmanagement?
• Chronicsymptoms
• Weaver–Dunnprocedure
Sternoclavicular joint dislocation
Rare, typically follows RTAs and sporting injuries.
Anterior dislocation is usually caused by forced
Chapter 23: Trauma oral topics 411
with a flat anterior contour of the shoulder, a promi-
nent coracoid and difficulty abducting the arm. The
most striking feature is inability to externally rotate
the shoulder.
Inferior dislocation presents with fixed abduc-
tion as the humeral head is locked underneath the
glenoid.
Imaging
AP shoulder (the plate is parallel to the scapula)•
Lateral scapular view•
Axillary view – single most important film to assess •
the presence and direction of glenohumeral
dislocation
“Light bulb” sign on AP view is classic of a poster-•
ior dislocation
Management
Closed reduction of anterior dislocation
The principle is to apply • gentle traction with mus-
cle relaxation
Kocher’s method involves traction and abduc-•
tion, followed by adduction and internal rotation.
However, this has been linked with fractures of
the humeral neck and higher rates of recurrent
dislocation
The Hippocratic method is still recommended •
using traction with or without rotation
Counter traction is with the foot in the axilla or a •
sheet looped through the axilla
Closed reduction of posterior dislocation
Traction is along the adducted arm•
Avoid forceful external rotation due to the risk of •
fracture
Closed reduction of inferior dislocation
Traction alone is usually sufficient. Open reduc-•
tion may be necessary if the head buttonholes
through the capsule
Management of anterior dislocations
Closed reduction under GA with a sandbag between
the scapulae and shoulder abducted. Reduction is
often unstable even with a figure-of-eight sling. The
rate of recurrence following closed reduction var-
ies from 20% to 60%. If recurrence is symptomatic
stabilization with tendon grafting or resection of the
medial end of the clavicle can be undertaken.
Management of posterior dislocations
One must first assess for any airway and vascular
injuries. A closed reduction technique similar to
that used for anterior dislocation should be initially
attempted. A towel clip may be used to facilitate
reduction. Reduction is usually stable and postop-
eratively, a sling is worn for 3 months. Fixation with
K-wires, or similar devices, to stabilize the relocated
joint has been described but is not recommended.
There are concerns with the rotational and trans-
lational torques involved leading to breakage or
migration. There are reports of fatalities following
wire migration.
Shoulder joint dislocation
Thirty-eight percent of all traumatic dislocations
involve the glenohumeral joint. Ninety-eight per-
cent are anterior dislocations (usually subcoracoid).
Less commonly, the humeral head sits in a subgle-
noid, subclavicular or an intra-thoracic position fol-
lowing anterior dislocation. The remaining 2% are
posterior, with the exception of “luxatio erecta” and
superior dislocations. The soft tissues including the
rotator cuff, glenoid labrum and the glenohumeral
capsular ligaments provide most of the stability of
the shoulder.
Anterior dislocations occur when the shoulder
is abducted and externally rotated. The dislocated
arm is held in slight abduction and external rota-
tion. It is characterized by emptiness felt beneath
the acromion or squaring of the shoulder contour.
Fifty percent of posterior dislocations are missed
on first presentation. Suspect a posterior dislocation
412 Section 7: The trauma oral
Neurological injury
Incidence increases with age. Axillary, suprascapu-
lar and musculocutaneous nerves are the most
commonly injured. Nerve injury is rare with pos-
terior dislocation. Almost all luxatio erecta present
with neurological compromise, which resolves with
reduction.
Vascular injury
May occur at time of injury and manifest as vas-
cular occlusion or haemorrhage. The second and
third parts of the axillary artery are most commonly
involved. Arterial occlusion may occur in the pres-
ence of palpable distal pulses.
Indications for acute operative management
Associated vascular injury•
Open dislocation•
Failure of closed reduction (may be biceps ten-•
don/rotator cuff interposition)
Displaced greater tuberosity or glenoid fractures•
Significant impaction of humeral head•
Gross instability following posterior dislocation•
Examination corner
Trauma oral 1
Posterior shoulder dislocation and reversed Hill–Sachs
lesion
Trauma oral 2
Radiograph demonstrating inferior shoulder dislocation
(luxatio erecta). Discussion and management of the condi-
tion. Incidence of rotator cuff injuries
Trauma oral 3
Radiograph shown of a young male patient with a frac-
ture dislocation of the glenohumeral joint. You are called
Post-reduction care
Repeat radiographs to ensure adequate reduction.
Immobilize for 3–6 weeks following anterior dislo-
cation. Early mobilization is desirable in patients
over 40 years old to avoid stiffness. Physiotherapy
to strengthen the muscular stabilizers (rotator cuff
muscles) is necessary. Avoid positions that provoke
instability. Posterior dislocation is often unstable
post-reduction. A shoulder spica in neutral rotation
(handshake cast) is desirable.
Complications
Recurrent dislocation
Inversely related to age of first dislocation: 80%
of those under 20 years of age have a recurrence
within 2 years. The rate is 10%–15% over the age of
40 years. Recurrence is rare with a greater tuber-
osity fracture. A Bankart lesion is associated with
younger patients (stripping of labrum and cap-
sule from anterior glenoid). Older patients stretch
the capsule or avulse the greater tuberosity. Early
repair of Bankart lesion in the young reduces recur-
rence from 80% to 14%.
Rotator cuff tears
Common in older patients. Suspect with excessive
bruising and slow rehabilitation. Repair is usually
required.
Fractures
Intra-articular fractures of the head and extra-ar-
ticular fractures are associated with dislocation. A
Hill–Sachs lesion (impaction fracture of the poste-
rolateral head seen in anterior dislocation) is seen
in 35% of acute cases and 60% of chronic cases.
Reverse Hill–Sachs is seen in posterior disloca-
tions. Impaction exceeding 20% may need surgical
correction. Glenoid fractures may need fixation if
displaced or if associated with joint subluxation.
Fractures of the greater tuberosity usually reduce
after reduction. Persistent displacement of greater
than 1 cm (0.5 cm in the young) requires ORIF and
cuff repair.
Chapter 23: Trauma oral topics 413
The rotator cuff muscles (teres minor, suprasp-•
inatus and infraspinatus) insert into the greater
tuberosity and pull the fracture fragment
posterosuperiorly
Subscapularis inserts into the lesser tuberosity •
and pulls the fracture fragment anteromedially
Pectoralis major inserts distal to the surgical neck, •
pulling the shaft medially with a surgical neck
fracture
The humeral head lies under the acromial arch and
the aim is to maintain adequate space under the
arch to prevent impingement.
Neer’s classification
The classification system considers anatomy, bio-•
mechanical forces and displacement of fracture
fragments, relating these to diagnosis and man-
agement. Defines the fracture according to the
number of osseous segments (Codman’s parts)
that are displaced
Displacement is defined as separation >1 cm or •
45° angulation
A further category is the fracture associated with •
dislocation
Splitting or impaction of the articular surface, •
quantifying impaction according to the percent-
age of head involvement
Clinical examination
Neurovascular assessment is mandatory (neurolog-
ical deficits are reported in up to 36% and vascular
injury in 5% of patients).
Imaging
AP, scapular lateral and axillary views (latter to •
determine displacement of the lesser tuberosity
and humeral head injury)
CT and/or MRI may be helpful in evaluating the •
fracture pattern, amount of articular involvement,
the displacement of fracture fragments and soft-
tissue involvement especially if surgical interven-
tion is contemplated
down to casualty because the A/E doctor has failed to
reduce it.
• Your management
What structures may be preventing reduction?•
The possibility of an associated occult humeral neck •
fracture and management if present
Trauma oral 4
Male aged 40 years. Radiograph shown of traumatic anter-
ior shoulder dislocation
Management•
Splint for how long? Evidence?•
Failure to recover: possible causes – rotator cuff tear, •
subclinical brachial plexus injury
How would you investigate – ultra-sound scan or EMG •
(both!)
Proximal humeral fractures
Proximal humeral fractures account for 5% of
all fractures and 75% of all humeral fractures in
people >40 years. This fracture is associated with
severe osteoporosis in the elderly. There are 70%
as many proximal humeral fractures as there are
femoral neck fractures. These fractures should
be managed individually taking into account age,
bone stock, fracture configuration and patient
expectations.
Anatomy
The anatomical neck encircles the base of the
articular surface. The surgical neck is more distal
and closely related to the axillary nerve. The axil-
lary nerve runs through the quadrangular space.
The surgical neck is most frequently fractured. The
anterior circumflex humeral artery primarily sup-
plies the head although the posteromedial vessel
alone can sustain it.
Codman divided the proximal humerus into
four parts (head, greater/lesser tuberosity and the
shaft).
414 Section 7: The trauma oral
for elderly patients with osteopenic bones and for
any patient with poor bone quality
Neer introduced the shoulder hemiarthroplasty •
in the 1950s. Primary hemiarthroplasty ideally
provides a pain-free shoulder with active forward
flexion to 90° or more. The rotator cuff should
be re-attached and the natural humeral head
retrover sion of 35° maintained. Can be a chal-
lenging procedure with a number of technical
issues. Complications include dislocation, infec-
tion, residue pain, stiffness, tuberosity malunion
or non-union, nerve injury, loosening, hetero-
topic ossification and degenerative changes in the
glenoid
The results of early hemiarthroplasty are supe-•
rior to those of delayed primary arthroplasty, or
late arthroplasty to revise failed internal fixation
Fracture/dislocation
Fracture of the greater tuberosity associated with •
dislocation of the shoulder often reduces spon-
taneously after reduction of the shoulder. If the
fragment is still displaced, ORIF and cuff repair
are necessary. Care must be taken not to displace
the undisplaced fracture on manipulation. The
tuberosity fragment displaces proximally and
posteriorly to become incarcerated within the
subacromial space
Two- and three-part fracture dislocation may be •
treated with ORIF
Four-part fracture dislocations generally have •
a poor outcome due to AVN. They should be
managed with a hemiarthroplasty in an elderly
patient. In younger patients an attempt at fixation
is not an unreasonable option if there are large
fragments and good bone quality
Impaction or splitting of >45% of the articular sur-•
face is an indication for hemiarthroplasty
Complications
Neurological impairment• is seen in up to 36%
of patients. Most commonly injured is the
axillary nerve. Injuries to the suprascapular,
Management
Non-operative management
Suitable for up to 85% of cases that are impacted •
or non-displaced
High arm collar and cuff•
Pendular exercises at 7–14 days followed by more •
vigorous mobilization and physiotherapy
Operative management
The aim is to restore the anatomy and function of
the proximal humerus with an intact rotator cuff
function, which does not impinge. Avoid devascu-
larizing fracture fragments and leaving hardware
that interferes with shoulder movements.
ORIF of greater tuberosity fractures displaced by •
more than 10 mm (5 mm in the young patient).
Rationale is to avoid prominence in order to pre-
vent impingement. Usually associated rotator
cuff tear which needs to be carefully repaired to
relieve tension on the tuberosity repair
Surgical neck fractures can usually be managed •
non-operatively. Displaced fractures can be
managed with intramedullary nailing if the head
is intact
Three-part fractures have a better outcome if the •
bony anatomy is restored. Fixation with plates
and screws is associated with AVN rates of 30%.
Tension band wiring is also a popular method of
fixation but technically difficult
Four-part fractures have a poor result with non-•
operative management. The rate of AVN can
approach 80%–90%. Reconstruction may be
attempted with a fixed angle plate such as the
PHILOS plate in young fit patients with good
bone quality preferably by an experienced trauma
upper limb/shoulder surgeon. Technical details
include limited surgical exposure, careful soft-
tissue dissection, use of small cancellous screws,
and placement of the plate high on the head
without impingement. Good results have been
reported, therefore move towards ORIF as the ini-
tial management of four-part fractures, with pri-
mary prosthetic replacement hemiarthroplasty
Chapter 23: Trauma oral topics 415
Humeral shaft fractures
The humeral shaft extends from the upper border of
pectoralis major insertion proximally to the supra-
condylar ridge distally. The proximal shaft is circu-
lar in cross-section and the cortex thin. By midshaft
the cortex is very thick and the medullary cavity is
narrow. Distally, the shaft cross-section changes
to trapezoidal and there is a flat posterior surface
between the medial and lateral cortical ridges.
Humeral shaft fractures are not common (3%
of all fractures) and the majority are managed
conservatively.
The majority are caused by direct trauma, either
RTA or a fall. Rarer causes include gunshot or other
penetrating missiles, arm wrestling, javelin throw-
ing, using “bullworkers” and pathological fractures.
In high-energy mechanisms, soft-tissue disrup-
tion and extensive fracture comminution may be
seen. This renders closed management less predict-
able. A thorough examination is required for associ-
ated injuries including the cervical spine and air-
way to exclude instability or intubation difficulties.
Clinical examination
As many as 18% of humeral shaft fractures have an
associated radial nerve injury either a laceration or
entrapment at the fracture site, so look for wrist and
finger drop. The majority (90%) are neurapraxia and
recover in 3–4 months. Examination of the shoulder
and elbow is difficult in the presence of a shaft frac-
ture, but they should be gently palpated to detect
injury or stiffness as this may influence the decision
of whether to IM nail.
In proximal fractures the rotator cuff abducts
and internally rotates the proximal fragment, and
the distal fragment is pulled medially by pectoralis
major. Fractures that occur between the pectoralis
major insertion and the deltoid insertion display
adduction of the proximal fragment and lateral dis-
placement of the distal fragment. In fractures dis-
tal to the deltoid insertion, the proximal fragment
is abducted with proximal migration of the distal
fragment.
musculocutaneous and radial nerves have also
been reported
Axillary artery damage• occurs in up to 5% of
these injuries with 27% of these still having palpa-
ble distal pulses
AVN• is related to the severity of the injury and
occurs in 5%–15% of three-part fractures and
10%–34% of four-part fractures
Malunion• is not uncommon following proximal
humeral fractures. Conservative management of
surgical neck fractures often results in increased
anterior angulation. Failed ORIF is due to exces-
sive scar formation, muscle atrophy, tuberosity
displacement, malrotation of the head, varus/val-
gus deformity of the shaft
Shoulder stiffness• may be a result of poor rehabili-
tation, myositis ossificans, malunion and AVN.
Involvement of the soft tissues leads to adhesions
and scar formation of the capsule and ligaments
and rotator cuff atrophy
Examination corner
Trauma oral 1
Radiograph of a three-part fracture of the
proximal humerus
• Classication
• Managementoptions
• “Whatareyougoingtodo?”
• Currentliteratureandrecommendations
Trauma oral 2
Anteroposterior radiograph of a four-part
proximal humeral fracture
• Failedplatexationwithscrewcutoutandloosening
• Surgicalexposureused:deltoid-pectoralapproachtothe
shoulder
• Re-dosurgery.Revisiontoahemiarthroplastyisatech-
nically difficult procedure. Problems encountered at
surgery include soft-tissue contractures, scarring, mal-
union, etc.
416 Section 7: The trauma oral
management include non-compliance and poor
tolerance by elderly patients.
Indications for operative management
Surgery is the exception rather than the rule for
humeral shaft fractures. For routine fractures the
risks and problems of surgical intervention gener-
ally outweigh the benefits. Indications for surgical
fixation include:
Open fractures•
Pathological fractures•
Ipsilateral upper-limb fractures or dislocation •
(floating elbow)
Fractures associated with a radial nerve palsy •
AFTER a closed reduction
Bilateral humeral fractures•
Polytrauma/multiple injuries (lower extremity, •
pelvis)
Associated vascular injury•
Intra-articular extension•
Inability to maintain reduction (failure of conser-•
vative management)
Delayed/non-union•
Methods of internal fixation
Compression plate and screws• . Using either a
broad 4.5-mm plate or a 3.5-mm plate with a small
humerus. Use either an anterolateral approach,
extensile both proximally to the shoulder and dis-
tally to the elbow, or a posterior approach for distal
shaft fractures. The radial nerve must be identi-
fied. A low threshold for bone grafting is advised.
The complication rate averages 10%, including
non-union (2%), radial nerve palsy and sepsis.
Care with exposure and instrumentation is criti-
cal. Fixation may be difficult in osteoporotic bone
Antegrade locked intramedullary nails• . Insertion
may be antegrade, which is applicable to middle
and distal fractures. Advantages of intramedullary
nailing include limited surgical exposure with less
soft-tissue stripping, the ability to perform indirect
Imaging
Full-length AP and lateral radiographs, which must
include the shoulder and elbow joints.
Classification
The humerus is divided into thirds for descriptive
purposes. The fracture pattern is described accord-
ing to the configuration (transverse, spiral, oblique,
segmental, etc.). The Holstein–Lewis fracture is a
spiral fracture of the distal third of the humeral shaft
that may be associated with a radial nerve injury.
Management
Non-operative management
This is associated with good/excellent results in
95% of patients. Acceptable displacement includes
<3 cm of shortening, <20° of anteroposterior angu-
lation and <30° of varus-valgus angulation. The
reported mean time to clinical union is 8 weeks,
with 95% of fractures radiographically united by 12
weeks and 90% of patients having normal function
at 12 weeks.
Splinting may be by hanging cast. The length of
the collar and cuff controls varus/valgus alignment.
The position of the loop on the forearm controls
AP alignment. Avoid a heavy cast distracting the
fracture as this may lead to delayed or non-union,
particularly in transverse fractures. A U-slab may
be useful in the acute setting, but it is bulky and
predisposes to axillary irritation. The slab should
be applied beyond the fracture site to avoid the
fractures levering around the end of the cast. The
functional cast brace as described by Sarmiento
(pre-fabricated anterior and posterior shells secured
with Velcro strap) may be applied after 1–2 weeks
when the swelling has decreased. This may be pro-
gressively tightened as the swelling further dimin-
ishes. Early mobilization of the elbow and shoulder
is encouraged.
Attention to detail is required for conservative
management. Problems associated with brace
Chapter 23: Trauma oral topics 417
most common, and 90% resolve without treat-
ment. In cases of complete radial nerve dysfunc-
tion, EMG and nerve conduction studies should be
performed 6 weeks after injury. If motor function
is present (action potentials), continued observa-
tion is indicated. If studies show no evidence of
innervation (denervation fibrillation), exploration
of the nerve is usually indicated. Acute exploration
is indicated in open injuries (64% involve nerve
damage or nerve interposition). With post-manip-
ulation palsy, many surgeons would advise explo-
ration despite the fact that the majority will resolve
spontaneously.
Vascular injury
Extremely rare but may follow direct trauma or com-
partment syndrome, most commonly in the proxi-
mal and middle third fractures. Requires urgent
management with skeletal stabilization before arte-
rial repair. Fasciotomies may be required. Ischaemic
time should be kept below 6 hours. Note that dis-
tal pulses may be present in patients with brachial
artery injury due to the collateral blood flow. The
role of angiography is controversial as in many cases
the clinical picture is clear and the delay in surgery
needs to be justified.
Non-union
Defined as >4 months without healing. The inci-
dence is 2%–5%. It is most common in the proxi-
mal and distal thirds. Predisposing factors include
systemic factors (age, diabetes, nutritional status)
and local factors (transverse fracture, distraction,
soft-tissue interposition, segmental fractures, inad-
equate immobilization, poor fixation, high-energy
trauma). Management is operative with plate and
screw fixation with bone grafting at the fracture
site (union rate 89%–96%) or with a reamed, locked
intramedullary nail (union rate 87%). The complica-
tion rate with intramedullary nailing is lower (12%
versus 21%). Osteoporotic bone and pathological
fractures may be more amenable to intramedullary
nail fixation to reduce the dependence on screw
fixation.
reduction, rotational control of the fracture with
cross screws and added stability in osteoporotic
bone. Static locking (distal and proximal nail
locking) is generally recommended to enhance
both rotational and axial stability. Complications
associated with antegrade intramedullary nailing
include rotator cuff injury, shoulder pain, proxi-
mal prominence of the implant, non-union and
fractures near the tip of the nail
Retrograde intramedullary locking nails• . They
may result in decreased elbow extension, hetero-
topic ossification and distal implant migration.
There is also a theoretical risk of supracondylar
humeral fracture
A non-reamed, locked intramedullary nail• .
Reasonable option for a pathological fracture
to reduce operating time and avoid reaming the
medullary canal (increased bleeding, emboliza-
tion of marrow contents) in unfit patients. For
proximal and distal fractures, a plate may be
used with possible augmentation with methyl
methacrylate
External fixation• with a conventional or ring fixa-
tor is only rarely utilized. Most common indica-
tion has been for severe open fracture (type III
Gustilo open fracture). Pins must be inserted in
a controlled fashion with some authors recom-
mending an open technique under direct vision
to guard against neurovascular injury. A safe
portal for proximal pins is from lateral to medial.
Distal pins can be placed from posterior to anter-
ior. The radial nerve crosses the posterior aspect
of the midshaft and so placing pins just proxi-
mal to the olecranon fossa is safe. Anterior distal
pin placement is possible but requires an open
technique
Complications
Radial nerve injury
Such injury occurs in 2%–20% of cases and whilst
classically associated with the Holstein–Lewis
fracture it is more common following middle
third fractures. Neurapraxia or neurotemesis is
418 Section 7: The trauma oral
intercondylar, condylar (medial/lateral), epicondy-
lar and isolated fractures of the articular surface.
The principles of management are closed treatment
whenever possible and ORIF for displaced, unsta-
ble or intra-articular fractures. Early mobilization
should be encouraged to optimize outcome and
prevent elbow stiffness.
Supracondylar fractures
The most common pattern is displacement into
extension with the distal fragment posterior.
Classified by Gartland into:
Type I: undisplaced•
Type II: displaced with the posterior cortical hinge •
intact
Type III: completely displaced•
Undisplaced fractures are managed non-opera-
tively in a long arm cast, with early mobilization
after 3 weeks. Displaced fractures tend to be unsta-
ble and require MUA and percutaneous pinning or
open reduction and K-wire fixation. Cross K-wires
placed from the medial and lateral sides provide
the greatest stability and rotational control. The
risk of iatrogenic nerve injury is reduced by a small
skin incision medially and dissection down to bone.
With open reduction posterolateral displacement
is exposed through an anteromedial approach and
posteromedial displacement is exposed through an
anterolateral approach. Neurovascular injury must
be excluded. Displacement of a distal fragment into
flexion is rare (<4%) but more difficult to reduce.
Very swollen limbs and cases where the radial
pulse is compromised with flexion can be managed
with Dunlop traction until the swelling subsides,
followed by definitive plaster or K-wire fixation.
Transcondylar fractures
These are more distal to supracondylar fractures
and are less common injuries. They are managed
in the same manner as supracondylar fractures.
They are more unstable, especially in rotation, and
a lower threshold for fixation is necessary as there is
a greater potential for non-union.
Examination corner
Trauma oral 1
Management of radial nerve palsies
occurring at the time of closed humeral
shaft fractures
• Conservative initial management versus early surgi-
cal exploration. Advantages and disadvantages of each
approach
• Deniteindicationsforearlyexploration(openfractures,
post-manipulation palsy)
• Literatureonthesubject
• Roleofnerveconductionstudies
Trauma oral 2
AP radiograph of a displaced midshaft
humeral fracture in a 72-year-old female
• Discussionofthemeritsofconservativeversusoperative
management
• This led to a more formal review of the indications for
conservative and operative management. The examin-
ers were pushing me towards operative fixation, imply-
ing it would be an extremely difficult fracture to manage
conservatively
• Discussionoftheadvantagesanddisadvantagesofcom-
pression plating versus intramedullary nailing fixation
• Ratesofhealingforeachtechnique
• Anyrecentpublicationsonthesubject
• IwaspushedbytheexaminersforwhatIwoulddomyself;
they wanted me to say plate fixation because of the risks
of radial nerve injury from nailing with fracture location
Distal humeral fractures
Account for approximately 2% of all fractures and one-
third of fractures around the elbow. Occur in three
age groups: children, young adults usually following
high-energy injuries and in the elderly (in whom there
is typically an osteoporotic fracture pattern).
Distal humeral fractures may be intra or extra-
articular. Supracondylar fractures are extra- articular.
Intra-articular fractures include transcondylar,
Chapter 23: Trauma oral topics 419
Bryan and Morrey classification of capitellum
fractures
Type I: Complete fracture
Type II: Osteochondral (shear) fracture
Type III: Comminuted fracture
Non-displaced fractures may be managed with early
mobilization. Unstable or displaced fractures need
ORIF with a lag screw or a Herbert screw. Some
comminuted fractures with minimal subchondral
bone, or fractures in the elderly may not be amena-
ble to stable internal fixation and are best managed
by excising the fragment. Arthroscopic excision has
resulted in improved motion compared to open
excision.
Epicondylar fractures
May occur in younger adults and are usually man-
aged non-operatively. They must be distinguished
from delayed closure of the ossification centre. The
medial epicondyle is more commonly affected.
Persistent ulnar nerve symptoms require surgery, or
an unsightly lump necessitates late excision of the
bony fragment.
Management
Internal fixation of distal humeral fractures
Preoperative planning is essential as surgical recon-
struction of the fracture can be very challenging.
For complex fractures the posterior approach to
the elbow is preferred. This gives optimal access to
the distal humerus but requires an olecranon oste-
otomy. It is essential to identify and protect the
ulnar nerve. A bright coloured rubber sling is used
as a gentle retractor and protective marker. An ole-
cranon chevron osteotomy is performed through
a non-articular segment about 2 cm from the ole-
cranon tip. It is advisable to pre-drill the olecranon
fragment to enable TBW fixation with either a can-
cellous lag screw or K pins on closure. The tip of the
olecranon, carrying triceps, is then retracted proxi-
mally to expose the distal humerus. Full exposure of
the posterior aspect of the distal humerus by medial
Intercondylar fractures
There may be T- or Y-shaped fracture patterns,
passing between and separating the condyles.
Riseborough and Radin classification of
intercondylar T or Y fractures
Type I: Undisplaced fracture between the capitel-
lum and trochlea
Type II: Displaced, non-rotated fracture
Type III: Displaced, rotated fragments
Type IV: Severely comminuted with wide separa-
tion of the humeral condyles
Non-displaced fractures may be managed by
immobilization in a plaster cast. Displaced frac-
tures require ORIF through a posterior approach
with olecranon osteotomy or triceps turn down.
The principle is to reconstruct the two columns of
the distal humerus and fix them back to the humeral
shaft. Severely comminuted fractures may be man-
aged with early elbow replacement.
Isolated condylar fractures
Isolated condylar fractures follow the Milch
classification:
Type I: fractures pass through the capitellum or •
medial condyle, leaving the trochlear ridge intact
Type II: fractures pass close to the trochlear sul-•
cus, and include the trochlear ridge in the fracture
fragment
Type III: fractures are associated with disloca-•
tion of the elbow and collateral ligament rupture.
These fractures are usually childhood fractures.
Undisplaced fractures should be immobilized in
pronation for medial fractures and in supination for
lateral fractures. Displaced fractures need ORIF. A
single lag screw is often sufficient.
Capitellum fractures
These fractures are rare. They follow a fall on to the
outstretched hand. They often involve a shear frac-
ture of the capitellum rather than the trochlea.
420 Section 7: The trauma oral
Trauma oral 3
Paediatric Gartland III supracondylar
fracture of the humerus
• Everypossiblescenarioconcerningthevascularstatusof
this injury was covered including pulse, position fracture,
capillary refill, loss of pulse post fixation and if/when to
call the vascular surgeons
Trauma oral 4
Paediatric supracondylar fracture of the
humerus
• Nerveinjurypatterns
• MethodsofmanagementincludingK-wirexation(how
many, where and when to remove)
Examiner: Do you really need to open up a Gartland III supra-
condylar fracture? Can’t you use just reduce it and fix it with
K-wires?
Candidate: This question unnerved me and I stumbled a bit with
it. I replied that it was worth attempting to percutaneously
fix a Gartland III supracondylar fracture but that often closed
reduction would be unsuccessful.
Trauma oral 5
Clinical picture of a child with a severely
swollen, bruised, deformed elbow
• Diagnosis of supracondylar fracture with vascular
compromise
• Initialmanagementincludingthepossibilityofperform-
ing an angiogram and vascular reconstruction
• Possiblecomplications
Trauma oral 6
Supracondylar fracture in a young boy
approximately 8 years old
• Acutemanagement
• Chronic(late)complications
and lateral dissection is required. The distal intra-
articular fragments are first reconstructed and then
reattached to the humerus with a double-plate tech-
nique, without violating the articular surfaces or any
of the three fossae around the elbow. DCP, malleable
pelvic reconstruction plates or the newer low-profile
pre-contoured plates may be used in planes at 90° to
each other, one in the frontal plane and one in the
sagittal. Provisional K-wire fixation is often required.
A large defect of the articular surface should be filled
with an iliac crest bone graft. Complications of sur-
gery include neurovascular compromise, compart-
ment syndrome, infection, mal-union, non-union,
joint stiffness, heterotopic bone formation, myositis
ossificans and post-traumatic osteoarthritis.
Timing of surgery should be within 24–36 h or
after 7–10 days of the fracture, as the swelling begins
to subside. By 10 days the risk of myositis ossificans
greatly increases. With rigid fixation, mobilization
may commence when wound healing is satisfac-
tory. Good/excellent results are reported in 75% of
cases (stable elbow, minimal pain, flexion from 15°
to 130° and a return to pre-injury activity).
Examination corner
Trauma oral 1
• Radiographofadistalextra-articularhumeralfracture–
surgical approach for fixation and structures at risk
• This was followed by a radiograph of an intra-articular
distal humeral fracture – again what surgical approach
would you take for fixation and what structures are at
risk?
Trauma oral 2
• Radiograph of a comminuted intra-articular supra-
condylar humeral fracture in a 40-year-old male
• Management
• Articularreconstructionanddoubleplatingdiscussed
• Shown post-xation radiographs of such an ORIF and
asked to critique – articular step present
• IwasaskedaboutwhatsurgicalapproachIwoulduse
• TheexamineraskedmetodrawtheBaumann’sangle
Chapter 23: Trauma oral topics 421
the joint. Alternatively, axial loading of the slightly
flexed joint is thought to cause dislocation.
Classification
According to the direction of forearm
displacement:
Anterior•
Posterior (most common)•
Medial•
Lateral•
Divergent dislocation•
Ulnar or radial dislocation in isolation•
Divergent dislocation occurs when the radius and
ulna dissociate to either side of the humerus. This
may be anteroposterior with the radius anterior and
the ulna posterior, or mediolateral. Ulnar and radial
dislocation may also occur in isolation.
Clinical presentation
Presentation is usually acute. Delayed presentation
of more than 7 days is classed as a “neglected” case
and often needs open reduction. The equilateral tri-
angle formed by the olecranon, medial and lateral
epicondyles is disrupted, differentiating dislocation
from supracondylar fracture. Neurovascular sta-
tus must be thoroughly assessed and documented
at presentation. It must be repeated following
reduction.
Associated injuries
Vascular injury
The presence of distal pulses does not exclude vas-
cular injury. An arteriogram may be necessary fol-
lowing reduction.
Nerve damage
The median, ulnar, anterior interosseous and radial
nerves can all be injured. The ulnar nerve is most
commonly injured, followed by the median nerve.
The radial nerve is the least of all involved. An injury
• Supracondylar fracture presenting late at 1 day.
Discussion of the role of Dunlop traction
Trauma oral 7
Radiograph of a supracondylar fracture of
the humerus in a child
• Describe
• Doyouknowanyclassicationsforthisinjury?
• Whattypeisthis?
• Howwillyoumanagethisfracture?
• Detailed discussion about the management of various
types of supracondylar fractures
• Complicationsandmanagementofcomplications
Trauma oral 8
Radiograph of a Gartland type 3
supracondylar fracture of the humerus
Every possible scenario concerning management of this
injury was discussed including how to reduce the fracture
and vascular compromise:
Examiner:
• Would you wake your consultant in the middle of the
night?
• Here,this ismyarm;showmehowyoureduceasupra-
condylar fracture. How do you specifically correct the dis-
placement and rotational deformity of the fracture?
• Thereisvascularcompromise.Whatareyougoingtodo?
• Youcannotgetintotheatrebecausethegeneralsurgeons
are doing an emergency laparotomy. What are you going
to do?
• You x the fracture with K-wires. There is good capillary
refill of the fingertips but no radial pulse. What are you
going to do?
Elbow dislocation
Dislocation at the elbow is second only to dislo-
cation at the shoulder. A simple dislocation car-
ries a good prognosis. The mechanism of injury is
hyperextension of the arm causing the olecranon
to impinge on the olecranon fossa, levering it out of
422 Section 7: The trauma oral
Vascular injury requiring surgery•
Ligamentous repair (seldom improving the result)•
Irreducible neglected dislocation•
Management of persistent instability
Ligamentous repair (usually lateral)•
Hinged external fixator or brace•
Pass a Steinman pin across the joint (stiffness, •
heterotopic ossification and pin breakage may
follow)
Prognosis
Good in simple dislocation. Recovery takes 3–6
months. Many patients are left with 10°–15° fixed-
flexion contractures.
Complications include heterotopic ossification
and chronic instability.
Proximal radius and ulna fractures
Radial head fractures
Common injuries of the adult elbow.
Mason’s classification
Type I: Undisplaced fracture
Type II: Marginal with displacement >2 mm or 30°
articular surface
Type III: Comminuted
Type IV: Associated with elbow dislocation (added
by Johnston)
Clinical examination
Swelling secondary to haemarthrosis. This may be
aspirated and local anaesthetic infiltrated into the
joint for pain relief. Pronation/supination can then
be assessed.
Imaging
AP and lateral radiographs of the elbow. Note any
“fat pad” sign.
to the anterior interosseous nerve is difficult to
diagnose due to lack of sensory involvement. The
median and ulnar nerves can be trapped within
the joint during reduction and the development
of post-reduction palsy requires surgical explora-
tion. Pre-reduction palsy is traditionally managed
expectantly. After 3 months, if recovery has not
occurred spontaneously and EMG studies indicate
that the nerve is non-functioning, surgical explora-
tion is indicated.
Fracture dislocation
The incidence of associated fractures ranges from
16% to 62%, reflecting the unreliable detection
of osteochondral lesions. Fracture dislocation is
associated with a poorer outcome than dislocation
alone.
Medial condylar avulsion
Needs to be recognized and managed, as retained
fragments within the joint lead to articular surface
damage. ORIF or removal is needed.
Management
Non-operative management
Posterior dislocations can often be reduced closed
under sedation. Reduction may be by longitudi-
nal forearm traction with digital pressure over the
olecranon or extension of the elbow to “unlock” it
(predisposes to nerve entrapment). The elbow is
immobilized in 100° flexion in a plaster for 7–10
days before commencing mobilization. Forced
passive mobilization should be avoided. If a sig-
nificant fracture such as unfixed coronoid proc-
ess fracture is present, immobilization may be
increased to 3 weeks.
Indications for open surgery
Open dislocation•
Significant fracture requiring fixation•
Entrapped soft tissue blocking reduction•
Chapter 23: Trauma oral topics 423
Management
All type I and most type II fractures are amenable
to non-operative management. All type III and
some type II injuries are unstable. This is caused by
the disruption of the osseous integrity of the ulna-
humeral articulation and disruption of the anterior
capsule thereby rendering the MCL incompetent.
These unstable injuries require ORIF. If instabil-
ity persists, a collateral ligament repair should be
undertaken. A hinged external fixator may be used
for added stability.
Olecranon fractures
Olecranon fractures are classically caused by pull of
the triceps mechanism, or a direct blow following
a fall.
Colton’s classification
Type I: Fractures are undisplaced/stable
Type II: Fractures are displaced. A: avulsion, B:
oblique/transverse fracture, C: comminuted frac-
ture, D: fracture dislocation
Management
Undisplaced fractures are immobilized in a cast •
for 3 weeks followed by supervised mobilization
Displaced fractures may be managed with ORIF •
(tension band wire, plating). Occasionally for
unreconstructable fractures olecranon excision
with reattachment of the triceps mechanism to the
proximal ulna may be indicated, but this is usually
associated with a poor functional outcome
Examination corner
Trauma oral 1
Radiograph of a Mason’s type II radial head
fracture in an adult
• Classicationandmanagement
• Whentouseradialheadreplacements
Management
Type I injuries may be mobilized early. This
approach may be followed with type II injuries if
there is no mechanical block to pronation/supina-
tion. However, if a block exists, then ORIF should
be performed. This provides pain relief, increased
motion and grip strength. If reconstruction proves
impossible, excision of the radial head may be per-
formed. Where instability exists after radial head
excision, radial head replacement using a Silastic®
or metal head should be carried out.
ORIF is carried out, if possible, for type III injuries
but it is often not achievable and radial head exci-
sion is the only viable option. Consider radial head
replacement if there is valgus elbow instability or
longitudinal forearm instability.
If the fracture is associated with dislocation (type
IV), an attempt should be made to keep the radial
head to prevent recurrent dislocation and valgus
instability. If this proves impossible, then repair of
the collateral ligaments is necessary. This may be
augmented with a prosthetic radial head implant.
In certain situations a hinged external fixator may
be utilized to maintain mobility during recovery.
Coronoid process fractures
The coronoid process forms an anterior buttress to
the elbow. The anterior capsule and the medial col-
lateral ligament attach to the coronoid process and
the brachialis inserts just distal to it. Two to ten per-
cent of dislocations of the elbow are associated with
fractures of the coronoid. One-third of fractures are
secondary to elbow dislocation. Complications of
a large coronoid fragment that has not united may
include a mechanical block to motion and elbow
instability.
Regan and Morrey classification
Type I: Simple avulsion fracture of the tip of the
coronoid
Type II: Fracture involving half or less of the cor-
onoid process
Type III: Fracture involving more than half of the
coronoid process
424 Section 7: The trauma oral
associated injuries, bone quality and the patient’s
functional status and physical demands. The bowed
radius rotates around the ulna allowing pronation
and supination. The aim of treatment is to restore
bony anatomy and preserve this movement.
Clinical examination
Examination must include evaluation of the elbow
and wrist for tenderness. Also carry out a full neu-
rovascular assessment, including a check of radial
and ulnar pulses and an examination of median,
ulnar and radial nerves. Check for early signs of
compartment syndrome. Clinical signs include
deformity, abnormal limb movement, prominent
swelling, crepitus and severe pain.
Imaging
AP and true lateral radiographs of the forearm
including careful assessment of the elbow and wrist
to rule out associated joint instability, dislocation or
intra-articular fracture. The radial head should pass
through the capitellum in all planes in the normal
elbow.
Signs of DRUJ injury include fracture of the base
of the ulnar styloid, widening of the joint on AP
radiograph, dislocation of the ulna on a true lateral
projection and radial shortening of <5 mm. Assess
fracture location, displacement, angulation, con-
figuration, shortening and comminution.
Management
Non-displaced fractures are rare. Angulation of
<10° and translation of <50% is acceptable. Closed
reduction is difficult to achieve and maintain such
that ORIF is the preferred method of management
when both bones of the forearm have been frac-
tured in an adult.
Non-operative management consists of an above-
elbow cast that incorporates the hand to prevent
pronation-supination with weekly radiographs for
at least 4 weeks to monitor the fracture. Problems
associated with conservative management include
Trauma oral 2
Radiograph of radial head fracture fixed
with mini fragment screws and plate
• Critiquethexation
• ThisledintoadiscussionaboutEssex–Loprestiinjury
Trauma oral 3
Radiograph of a displaced comminuted
oblique fracture of the olecranon
Examiner: Describe your surgical management of this patient.
Candidate: I would use an interfragmentary screw and then a
contoured one-third tubular plate. The fracture is not amen-
able to management with a tension band wire as the com-
pression achieved is axial along the ulna and will displace an
oblique fracture.
Trauma oral 4
Radiograph of a displaced transverse
fracture of the olecranon
A very long drawn out discussion of the principles of ten-
sion band wiring for this particular fracture. Biomechanics
discussed in great detail. The candidate was invited to draw
out a diagram of the elbow TBW to help them explain the
biomechanical principles better. The examiner wasn’t
happy with the explanation and ended up drawing it out
themselves.
Candidate: The examiner seemed to want punchy catch phrases
which I wasn’t able to deliver quickly enough for him. We
therefore spent what seemed like forever labouring various
biomechanical points.
Examiner: The candidate didn’t come across as though they
knew what they were talking about particularly well and as a
result needed to be probed in greater detail than usual.
Fractures of the forearm
The most common mechanisms of injury are falls on
the outstretched hand or a direct blow. Management
of these injuries is dependent on the injury pattern,
Chapter 23: Trauma oral topics 425
the proximal third, the supinator is stripped off the
bone (to prevent damage to the posterior interos-
seous nerve). Distally flexor pollicis longus and pro-
nator quadratus are stripped off the radius at their
insertion.
Dorsal (Thompson) approach
The muscle and neurological interval is between the
extensor carpi radialis brevis (radial nerve) and the
extensor digitorum communis and extensor pollicis
longus (posterior interosseous nerve). This approach
allows the plate to be placed on the tension side of
the bone, but is more technically demanding due to
the risk posed to the posterior interosseous nerve.
Monteggia fracture
Middle to proximal ulna fracture with associated
radial head dislocation. Comprises 1%–2% of all
forearm fractures. Easily misdiagnosed because of
the focus on the obvious ulna fracture.
Bado’s classification
Based on the direction of radial head displacement:
Type I: Anterior (most common)
Type II: Posterior
Type III: Lateral
Type IV: Dislocation associated with both radius
and ulna fracture
A stable reduction of the radial head is commonly
achieved with ORIF of the ulna fracture. Open
reduction is needed if reduction is blocked by an
interposed capsule or annular ligament (10% of
cases). Repair of the annular ligament is contro-
versial. Some authors suggest repair is required for
greater early elbow stability whilst others suggest
that repair may contribute to scarring and loss of
elbow motion.
Nightstick fracture
This is an isolated ulna fracture and is usually the
result of a direct blow to the ulna. These fractures
loss of fracture alignment, decreased forearm
motion, delayed and non-union.
Surgical options include plates, intramedullary
nails or external fixation.
Methods of fixation
Plate fixation• (DCP, locking plates). The advan-
tages of plating include anatomical reduction,
rigid fixation and early movement. Disadvantages
include the extensive soft-tissue dissection that
is required for application, the risks of neuro-
vascular injury, infection and scarring. The use of
supplemental bone graft is controversial. A useful
guideline is to graft if cortical continuity is lost for
more than one-third of the circumference. Union
rates are >95% and good/excellent results are
achieved in >90% of patients
Unlocked intramedullary nailing• . This does not
provide rotational or longitudinal stability. It is
difficult to re-establish the radial bow and non-
union rates of 10%–20% have been reported.
However, flexible nailing in paediatric fractures
has proved very successful and is gaining increas-
ing popularity in the management of forearm
fractures in this age group
External fixation• is generally used for Gustilo
type IIIB and IIIC severe open injuries with signif-
icant soft-tissue loss that are not suitable for plat-
ing or intramedullary nails. Ten percent require
fixator adjustment and superficial infection is
common. Otherwise, ORIF may be used for most
other open injuries. Thorough debridement, irri-
gation and antibiotic prophylaxis are necessary.
External fixation provides temporary stabiliza-
tion of the fracture while permitting access to the
soft tissues but long-term unilateral fixation is
unable to maintain the radial bow or resist rota-
tional loads
Henry’s approach to the forearm
The muscle and neurological interval is between the
brachioradialis (radial nerve) and the pronator teres/
flexor carpi radialis (median nerve). In exposing
426 Section 7: The trauma oral
Non-union• – risk is increased by open fractures,
severe comminution, segmental fractures, seg-
mental bone loss and inadequate fixation. Treat
with autogenous bone grafting
Radial ulnar synostosis• – reported in 2% of fore-
arm fractures. Associated with:
High-energy complex fractures•
Fractures with concomitant head injury•
Open fractures•
Fracture of both bones at the same level•
Infection•
A single surgical approach•
Delay of surgery by >2 weeks•
Mal-reduction with loss of the radial bow or •
screw fixation that crosses the interosseous
membrane
Vince and Miller’s classification of synostosis
(1987)1
Type I: At the DRUJ. Responds poorly to resection
Type II: Middle two-thirds. Amenable to resection (rela-
tively low recurrence rate)
Type III: Proximal third. Intermediate prognosis
1 Vince KG, Miller JE (1987) Cross-union complicating
fracture of the forearm. Part I: Adults. J Bone Joint Surg Am
69(5): 640–53.
Resection of the synostosis is best performed
between 1 and 2 years post injury. Bony resection
after 2 years is less successful due to muscle atrophy
and interosseous membrane fibrosis.
Forearm metalwork removal
Late problems due to retained metalwork include •
symptomatic hardware, stress risers at the bone–
implant interface and cortical bone atrophy
Risks of metalwork removal include a re-fracture •
rate of 2.5%–20% and a neurological injury rate of
10%–20%
Risk of re-fracture is increased by early plate •
removal, delayed or non-union, inadequate fixa-
tion techniques and removal of a 4.5-mm plate
can be transverse with minimal displacement or
comminuted and displaced. Angulation of 10°
and translation of <50% may be accepted. ORIF is
required for displaced fractures >50%, short oblique
or comminuted fractures and for distal third ulna
fractures.
Galeazzi fracture
Isolated fracture of the distal or middle third of the
radius with DRUJ dislocation. Management is ORIF
of the radius with plates and screws and reduction
of the DRUJ. The injury is known as the “fracture of
necessity” because closed conservative manage-
ment is contraindicated. Careful assessment of the
DRUJ is essential as the functional deficit associ-
ated with a missed ligamentous injury to the DRUJ
can be severe. The DRUJ is often found to be stable
following ORIF of the radius and DRUJ reduction.
If reduction is unstable transarticular K-wire fixa-
tion is required for 4–6 weeks. In a small number of
cases, the dislocation is irreducible due to interpo-
sition of the ECU tendon. This necessitates open
reduction and pin fixation.
Early complications
Compartment syndrome• – seen with vascular
injury, high-energy injuries and crush injuries
Nerve injury• – rare. Posterior interosseous nerve
palsy is seen in 20% of Monteggia fractures. There
is usually a neurapraxia and most resolve within
3 months
Vascular injuries• – more prevalent with open
fractures, in particular high-energy or penetrating
injuries
Late complications
Stiffness• – depends on the severity of injury and
quality of reduction post ORIF
Failure of fixation• – caused by infection and poor
fixation
Infection• – rates are low. Treat with debridement.
Metalwork should be retained till loose
Chapter 23: Trauma oral topics 427
Radial length – 11 mm between a transverse line •
across the radial styloid and across the distal
ulna
Radial inclination – 22°•
Step in articular surface – >2 mm•
Management
Below-elbow POP cast with three-point fixation•
MUA and percutaneous K-wire fixation. Poor at •
maintaining length in the presence of bi-cortical
comminution or osteoporosis
External fixation. Used in more complex com-•
minuted fractures or open fractures of the distal
radius
ORIF with AO locking plate. Mandatory for most •
volar displaced fractures
Complications
Loss of reduction – re-manipulation is possible at •
up to 3 weeks
Neurological complication – occurs in 10%. •
Median nerve most common (carpal tunnel
syndrome)
Compartment syndrome – <1%•
Acute tendon injury – rare in closed reduction•
Late tendon rupture – 1% EPL classically following •
non-displaced or minimally displaced fractures
(rupture at level of Lister’s tubercle – a vascular
watershed)
Stiffness•
Reflex sympathetic syndrome – up to 25%•
Malunion – >2 mm residual displacement leads •
to symptomatic degeneration in 50% at 30 years.
Reduced to 5%–10% with anatomical reduction
Prognosis
Ninety percent of patients regain 90% of func-
tion by 1 year. Grip strength is usually reduced.
In extra-articular fractures, the main predictor of
a good result is restoration of normal radiocarpal
alignment.
There is concern regarding the long-term effects •
of retained plates on bone mineral density and
forearm grip strength
Removal of symptomatic metalwork is associated •
with worsening of symptoms in 9%
Bone density beneath a plate does not return to •
normal for a mean of 21 months
Distal radius fractures
Account for one-sixth of fractures. Young patients
present following high-energy trauma. Elderly
osteoporotic patients present following low-energy
falls onto outstretched hands.
Classification
Several classifications for distal radius fractures
exist such as Frykman,5 Melone (1984)6 and the AO
system.
Frykman classification
Type I: Extra-articular
Type III: Intra-articular involving the radiocarpal
joint
Type V: Intra-articular involving the radioulnar
joint
Type VII: Intra-articular involving both the radio-
carpal and radioulnar joints
(Even numbers denote an associated ulnar styloid
fracture)
Imaging
Volar tilt – 11°• seen in the lateral radiographic
view
5 Frykman G (1967) Fracture of the distal radius including
sequelae – shoulder-hand-finger syndrome, disturbance in
the distal radio-ulnar joint and impairment of nerve function.
A clinical and experimental study. Acta Orthop Scand Suppl
108:3+.
6 Melone CP Jr. (1984) Articular fractures of the distal radius.
Orthop Clin North Am 15: 217–236.
428 Section 7: The trauma oral
Pelvic ring fractures
Pelvic ring fractures follow high-energy trauma;
they are usually due to motor vehicle accidents and
are frequently seen in association with major skele-
tal, thoracic, abdominal and pelvic trauma. Stability
of the fracture depends on the integrity of the pel-
vic ring. Approximately 25% of fatal accidents have
associated pelvic fracture and the mortality rate fol-
lowing pelvic fractures is 10%–20%.
They may occur following a low-energy trauma
in elderly osteoporotic patients, usually an acci-
dental fall.
Anatomy
Pelvic ring – two innominate bones and the •
sacrum
Sacroiliac joint (SI joint) – stabilized by multiple •
ligaments
Posterior SI ligaments – strongest ligaments in the •
body
Also anterior SI ligaments, sacrotuberous, sacro-•
spinous, iliolumbar and lumbosacral ligaments,
which add stability to the pelvic ring
Pubic symphysis stabilizes the pelvic ring anteriorly•
Classification
Tile classification7
Combines mechanism of injury and stability and
aids in prognosis and treatment:
Type A: stable
Type B: rotationally unstable. Vertically stable
Type C: rotationally and vertically unstable
Young and Burgess classification8
Considers mechanism of injury and alerts the sur-
geon to potential resuscitation requirement and
associated injury patterns.
7 Tile M (1988) Pelvic ring fractures:should they be fixed? J
Bone Joint Surg Br 70(1):1–20.
8 Burgess AR, Eastridge BJ, Young JW (1990) Pelvic ring
disruptions: effective classification system and treatment
protocols. J Trauma 30(7): 848–56.
Examination corner
Trauma oral 1
Lateral radiograph of Colles’ fracture of the
distal radius in an 81-year-old female
• Patientwas previouslyselfcaring andthe fractureisin
her dominant hand. Dorsally angulated 30°.
• Discussionof management options,complications and
outcome
Trauma oral 2
Radiograph of an extra-articular, displaced
distal radius fracture in a 50-year-old
female with carpal tunnel syndrome
• Management
Hand oral 3
Complication of a Colles’ fracture
As soon as EPL rupture was mentioned there was a change
of emphasis in the oral questions as how to manage an EPL
rupture, which operative technique to use, principles of
tendon transfers, etc.
Hand oral 4
How will you manage this fracture?•
Principles of POP management (moulding, three-point •
fixation, etc.
When will you manipulate?•
Hand oral 5
Radiograph of a closed fracture of the
distal radius/ulna in a 12-year-old
boy with the inferior radio-ulnar joint
dislocated as well
Management•
Missed DRUJ dislocation (loss of supination).•
How to correct and when•
Chapter 23: Trauma oral topics 429
Nerve damage• . Sacral fractures through neural
foramina – lumbosacral plexus damage. Sciatic/
other nerve damage depending on injury
Imaging
AP pelvis•
Pelvic inlet/outlet views•
Judet views•
Obturator oblique – view of anterior column •
and posterior rim
Iliac oblique – view of posterior column and •
anterior rim
CT scans•
FAST scan to exclude intra-abdominal injury•
Management
Mechanism of injury determines energy and the prob-
ability of associated injuries. Emergency care includes
management of life-threatening injuries using ATLS
protocols. Only one surgeon assesses the stability of
the pelvis with bimanual compression/distraction at
initial assessment. Anti-shock garment may be useful
in the acute setting (risk of lower extremity compart-
ment syndrome). Where there is uncontrolled haem-
orrhage despite an external fixator, the patient may
need angiography and embolization. With an unsta-
ble pelvic injury, laparotomy presents great risk if an
external fixator has not been applied.
External fixator
Applied in the haemodynamically unstable patient
not responding to initial fluid resuscitation.
Inverted A-frame external fixator (may be suitable •
for definitive treatment – retained for 8–12 weeks)
Ganz pelvic C clamp (posterior closure of pelvis)•
Definitive surgical management
External fixator (open book – Tile type B1 – SI liga-•
ments are intact)
Internal fixation (dependent on the fracture •
configuration)
Stabilize the pubic symphysis with two plates •
through a Pfannenstiel incision
Antero-posterior compression
Following direct anterior or posterior trauma.
Divided into three subtypes: APC-I, APC-II and
APC-III. Patients with APC-I have minimally dis-
placed, usually vertical, pubic rami fractures or
mild pubic symphysis diastasis. In type APC-II
injuries the anterior sacroiliac, sacrospinous and
sacrotuberous ligaments are torn and the pelvis is
splayed open like a book. In type APC-III injuries
all the sacroiliac structures are disrupted including
the posterior ligaments and they have the high-
est incidence of life-threatening haemorrhage.
This is the most common severe injury seen in
pedestrians.
Lateral compression
Divided into three subtypes: LC-I, LC-II and LC-III,
differentiated by disruption of the posterior sacro-
iliac structures. In LC-III injuries, the pelvis opens
on the contralateral side as the deforming force is
transmitted through the pelvis, resulting in a wind-
swept pelvis.
Vertical shear
Usually occurs as a result of a fall from a height.
There is a fracture pattern through the pubic rami
and posterior pelvis with vertical displacement of
the hemipelvis.
Combined mechanism
Combination of LC and VS or LC and APC.
Associated injuries
Haemorrhage• – from the sacral venous plexus
and other great veins. Arterial bleeding, particu-
larly divisions of the internal iliac artery (superior
gluteal artery). Occasionally disruption of a major
vessel such as the common (or internal/external)
iliac artery and vein. Bleeding from exposed bone
surfaces
Urethral injury• – 10%. More common in males.
Bladder rupture in 5%. Check blood at the mea-
tus, penile bruising, a high riding prostate on per
rectum, and haematuria. Ureteric injury is rare
430 Section 7: The trauma oral
Trauma oral 4
AP radiograph of pelvic fracture
• Management including indications for surgery and
exposure
• Roleofexternalxators
Trauma oral 5
Clinical photograph of open supracondylar
femoral fracture with pelvic fracture
History given of a young female patient involved in a high
speed RTA with the above injuries and a pulseless leg.
Asked about management. ATLS, open fracture man-
agement, vascular injury, external fixation of the pelvis
and LISS plate for the femoral fracture. This then led on to
being asked about the principles of locking plates.
Trauma oral 6
Management of an open book pelvic fracture with life
threatening haemorrhage.
Acetabular fractures
Acetabular fractures often occur in the younger
population and are a significant skeletal injury.
Seventy-five percent follow RTAs. Fifty percent are
associated with another major fracture or injury.
Acetabular fractures may be associated with
hip dislocation or impaired sciatic nerve function.
Femoral head dislocations should be reduced as a
surgical emergency and maintained with traction
until definitive management is initiated.
Prognostic factors
Velocity of injury•
Stability of the femoral head•
Restoration of congruency of the weight-bearing •
surface of the acetabular dome
Displaced posterior injuries are fixed through a •
direct posterior approach (wound healing compli-
cations occur in 3%–25%) or an anterior (extended
ilioinguinal) approach to the SI joint
Reconstruction plates, iliosacral screws or inter-•
fragmentary lag screws (for crescent fractures if
the intact portion of the ilium is large and firmly
attached to the sacrum)
Iliac wing fractures are fixed with plates and •
screws or lag screws
Non-operative management includes protective •
weight bearing for stable injuries, skeletal traction
for vertically unstable fractures where surgery is
contraindicated or prolonged bed rest (this yields
poor results)
Examination corner
Trauma oral 1
• Classicationandmanagementofopenbookfractures,
haemodynamics, etc.
• External xator – whether to put on in Accident and
Emergency or in theatre. Discuss
Trauma oral 2
AP pelvic radiograph of a complex fracture
• ATLSprotocol
• Urologicalproblems
• Classication
• Surgicalmanagementoptions
Trauma oral 3
Radiograph of the pelvis with wide
diastasis of the pubic symphysis
• Youngfemalepatient,RTAnootherinjuries
• Discusstheassessmentandmanagementofthispatient
• Classicationofpelvicfractures
• Managementofpelvicfractureswithshock
• Discussionaboutexternalxation
Chapter 23: Trauma oral topics 431
CT
Spiral CT with three-dimensional reconstruction. •
Useful for head fractures and intra-articular loose
bodies. Improves understanding and surgical
reconstruction of acetabular fractures
Management
Indications for conservative management
Local/systemic infection•
Severe osteoporosis•
Non-displaced fracture (<2 mm of acetabular •
dome)
Low column, low transverse and low T-shaped •
acetabular fractures
Advanced age (considered with view to early total •
hip arthroplasty)
Associated medical conditions•
Associated soft-tissue and visceral injuries•
Conservative management
1. Non-displaced and minimally displaced
fractures
Less than 4 mm displacement of the acetabular •
dome
2. Fractures with significant displacement but in an
unimportant region of the joint
Low transverse fractures, low anterior column •
fractures
3. Secondary congruence in displaced fractures of
both columns
Often comminuted, two-column fracture frag-•
ments assume a position of articular second-
ary congruency around the femoral head, even
though the femoral head is displaced medially
and there may be gaps between the fracture
fragments
Manage with 8 weeks of traction and bed rest.
Indications for ORIF
4 mm articular step off•
Posterior wall fractures >40%•
Anatomy
The acetabulum is part of the innominate bone,
formed from the ilium, ischium and pubis. Letournel
described an inverted Y configuration with anterior
and posterior columns:
Anterior column – pelvic brim, anterior wall, •
superior pubic ramus and anterior border of iliac
wing
Posterior column – greater/lesser sciatic notch, •
posterior wall, ischial tuberosity and most of the
quadrilateral surface
Letournel and Judet classification of
acetabular fractures9
Simple fractures
Posterior wall•
Posterior column•
Anterior wall•
Anterior column•
Transverse•
Complex associated fractures (combination of
two simple fractures)
Associated posterior column and posterior wall•
Associated transverse and posterior wall•
T-shaped•
Associated anterior wall or column and posterior •
hemi-transverse
Both columns•
Imaging
Radiographs
AP pelvis, pelvis inlet and outlet views•
Judet views: obturator oblique and iliac oblique •
views
9 Judet R, Judet J, Letournel E (1964) Fractures of the
acetabulum:classification and surgical approaches for open
reduction. J Bone Joint Surg 46 A:1615–1647.
432 Section 7: The trauma oral
Heterotopic ossification. • Incidence varies from
5% to 15% of surgically treated patients, but
usually asymptomatic. Prophylaxis should be
given
AVN. • Reported rate of 10% after posterior
dislocation
Post-degenerative OA. • Where reduction is good
90% will have a favourable result; where reduc-
tion is poor 50%–70% will achieve a satisfactory
result
Chondrolysis• . Following acetabular trauma it
may occur with or without surgical intervention.
It is usually a manifestation of early osteoarthritis
without surgery. After ORIF, suspect infection or
the presence of metal in the joint. On occasion,
AVN of acetabular fragments causes early collapse
and chondrolysis may ensue
Complications of non-operative management
Severe osteoporosis•
Sepsis•
Systemic illness•
Age and functional demands•
Examination corner
Trauma oral 1
• Classicationofacetabularfractures
• Broadoutlineofmanagement
• Approaches to the acetabulum: indications, complica-
tions of surgery
• Radiographs shown with both columns xed and with
trochanteric osteotomies
Trauma oral 2
Acetabular fractures
• Classication
• Principlesofsurgicaltreatment
• Heterotopicossication
• Surgicalapproaches
Marginal impaction fractures•
Loss of acetabular congruity•
Intra-articular debris•
Irreducible fracture/dislocation•
Roof arc measurement <45° suggests significant •
involvement of weight-bearing dome and need
for ORIF
All acetabular fractures resulting in hip joint •
instability
Reconstruction
The aim of reconstruction is to achieve anatomical
reduction and fixation with a combination of screws
and contoured pelvic reconstructive plates. Surgical
approaches can be simple or extensile.
Anterior ilioinguinal approach
For anterior column fractures and possibly two-
column fractures. Gives access to the interior ileum,
anterior column and superior pubic ramus.
Extended Kocher–Langenbeck approach
This is indicated for a posterior injury and is the
workhorse of acetabular surgery. Gives access to
the posterior wall and posterior column below the
greater sciatic notch.
Ipsilateral femoral shaft and
acetabular fracture
Compression plate fixation or retrograde intramed-
ullary nailing is indicated. Keep the wound away
from the pelvis. Address acetabular fracture later
following necessary investigations.
Complications of surgery
Sciatic nerve injury. • Occurs in up to 10%–15% of
acetabular fractures
DVT/PE. • Occurs in one-third of patients (one-fifth
of those <40 years old, half of patients >40 years
old). PE occurs in 4%–7% of patients
Infection. • Reported to occur in 1%–5% of patients
and may destroy the hip joint
Chapter 23: Trauma oral topics 433
Thompson and Epstein classification for
posterior hip dislocation (1951)10
Type I: Pure dislocation with or without minor
fracture of the acetabulum
Type II: Dislocation with a large, single posterior
rim fracture
Type III: Dislocation with a comminuted posterior
wall fracture
Type IV: Dislocation with associated fracture of the
posterior acetabular wall and floor
Type V: Dislocation with associated fracture of the
femoral head (5%–10%)
Epstein classification for anterior dislocation11
Type I superior and type II inferior, with further
sub-divisions as follows:
A: No associated fracture
B: Associated femoral head fracture
C: Associated acetabular rim fracture
Pipkin classification12
Thompson and Epstein type V fractures (posterior
hip dislocation with associated fracture of the femo-
ral head) have been subdivided by Pipkin into four
types:
Type I: Caudal head fragment (below the fovea
centralis)
Type II: Cephalad fracture (below the fovea
centralis)
Type III: Type I or II injury with associated femoral
head and neck fracture
Type IV: Type I or II injury with associated acetabu-
lar rim fracture
10 Thompson VP, Epstein HC (1951) Traumatic dislocation
of the hip; a survey of two hundred and four cases covering
a period of twenty-one years. J Bone Joint Surg Am 33A(3):
746–78.
11 Epstein HC (1973) Traumatic dislocations of the hip. Clin
Orthop Relat Res 92: 116–42.
12 Pipkin G (1957) Treatment for grade IV fracture dislocation
of hip. J Bone Joint Surg 29: 1027–42.
Long case 1
Young man with AVN of his right hip and secondary
osteoarthritis several years following acetabular fixa-
tion. Now presents with a painful and stiff hip requiring
arthroplasty.
Discussion included:
Acute management of acetabular fractures•
Surgical approaches to the acetabulum•
Complications and results of acetabular fixation•
What to do now with the hip•
MOM hip resurfacing•
Management of an infected MOM hip resurfacing pre-•
senting at 1 year
Traumatic hip dislocation
Background
The vast majority (80%) of traumatic hip dislo-
cations are caused by RTAs, often secondary to
severe violent injury. The remainder include falls
from a height, industrial accidents and sports
injuries. Hip dislocations can be either anter-
ior, posterior or central. Dislocations with either
acetabular or femoral fractures are almost always
posterior (90%), whilst anterior dislocations often
have an associated femoral head fracture and/or
impaction injury. Reduction should be as a surgi-
cal emergency within 6 hours of injury to reduce
the risk of AVN developing. Prognosis is propor-
tional to the time interval between occurrence
and reduction. One-half of patients have other
fractures (patella, femoral or tibial condyles) and
30% have soft-tissue injury of the knee from hit-
ting the dashboard (PCL injury and posterolateral
rotational instability).
Classification
Classifications for hip dislocation include Epstein
for anterior dislocation, Thompson and Epstein for
posterior dislocation and central fracture disloca-
tions within the AO comprehensive classification of
fractures of the pelvis and acetabulum.
434 Section 7: The trauma oral
Femoral head fractures•
Most femoral head fractures are seen with a •
posterior dislocation since posterior disloca-
tions are more frequent (90%)
However, a higher percentage of anterior dislo-•
cations have an associated femoral head frac-
ture (68% compared to 7%)
Femoral neck fractures are uncommon with hip •
dislocation
Femoral shaft fractures are uncommon but make •
reduction difficult
Patella fractures and knee dislocations may lead •
to knee instability
Complications
AVN
The reported risk of AVN is between 2% and 17%
following posterior dislocation. The medial femo-
ral circumflex artery is the key vessel to the femoral
head at the superolateral articular margin. A poste-
rior dislocation puts this vessel at risk whereas an
anterior dislocation will relax the vessel. Difficult
problem to manage as these patients are usually
young and active. THA may not be an appropriate
option; consider trabecular metal AVN rod or vas-
cularized fibular grafting.
Sciatic nerve palsy
Occurs almost exclusively with posterior disloca-
tions, with a reported incidence of 10%–23%. At
least partial nerve recovery can be expected in
60%–70% of patients. Sciatic nerve may be damaged
by ischaemia secondary to sustained pressure from
the femoral head or large fragments of bone or lac-
erated or impaled by bone fragments.
Acetabular labral injuries
May be source of symptoms (persistent pain) even
after successful reduction. May cause intermittent
clicking or catching. Clinically diagnosis is made
with a positive impingement test. Hip arthroscopy
is sometimes required for management.
Imaging
Anteroposterior radiograph of the pelvis. A careful •
search should be made for associated fractures of
the acetabulum, femoral head and femoral shaft
Pelvic inlet/outlet views•
Obturator/iliac oblique (Judet) views. Not always •
easy to obtain because of pain issues but they
allow assessment of the anterior and posterior
walls and columns of the acetabulum
Repeat radiographs are obtained post reduction •
to determine adequacy of reduction, presence or
absence of fracture fragments trapped within the
joint and the presence of any associated fractures
of the acetabulum or femoral head and neck pos-
sibly initially missed
CT. Post reduction to assess congruity of the hip •
joint and to look for any free osteochondral frag-
ments within the joint. The incidence of instability
is high if the remaining posterior articular surface
is <34%. Hips with >55% of the remaining poster-
ior articular surface are stable
MRI. Useful if post reduction radiographs suggest •
incongruency, to exclude soft-tissue interposition
(labrum, muscle and capsule) in the articular
space.
Initial management
The injury follows major trauma so initial man-•
agement must follow ATLS protocol
Assessment and resuscitation of patient•
Neurological injuries must be assessed and docu-•
mented before and after hip reduction. Sciatic
nerve injuries occur in 10%–23% of posterior dis-
locations, the peroneal component more com-
monly involved and usually more severely affected
than the tibial component
Hip dislocation should be reduced as an emer-•
gency. Other fractures may be addressed later
Associated bony injuries
Acetabular fractures – usually posterior wall •
(dashboard injury) but any fracture pattern is
possible
Chapter 23: Trauma oral topics 435
is slowly flexed beyond 90°, internally rotated and
adducted. Reduction of the hip is not subtle and is
easily palpable.
Stimson technique
The patient is prone with the hip flexed 90° off the
edge of the table. Force is applied to the back of the
proximal calf. The reduction manoeuvres are the
same as for anterior dislocation.
Anterior dislocation
Anterior dislocations are harder to reduce than pos-
terior dislocations. Position of the leg is reversed.
With the leg in external rotation, abduction and
flexion, inline traction is applied.
Open reduction
Indications include hips that cannot be reduced
closed, hips with associated fractures that are unsta-
ble after closed reduction and hips that are not con-
gruent after closed reduction.
Significant rim fractures
Significant rim fractures usually require ORIF as
the hip is generally unstable following reduction.
Fragments are usually posterior and often commi-
nuted. They should be stabilized with interfragmen-
tary screws and a reconstruction plate.
Retained fragments
Retained fragments can be diagnosed on a post-
reduction CT and are removed by arthrotomy or
hip arthroscopy. There is a high risk of developing
post-traumatic osteoarthritis when patients with
intra-articular fragments are managed in traction.
Widening of the hip joint on plain radiographs is
not evident when fragments of 2 mm are present in
the hip joint.
Large head fragments
Large head fragments require ORIF or removal if
they are not involving the weight-bearing area.
Joint capsule injury
If the femoral head buttonholes through the capsule
it can block reduction.
Muscle injury
Short external rotators are frequently torn during
posterior dislocations.
Arterial injury
The femoral artery can be injured with anterior
dislocations.
Chondrolysis
It is postulated that either an intra-articular hae-
matoma results in enzymatic degradation of the
articular cartilage, similar to the process of joint
destruction seen in patients with hemophilia, or
that ischaemia occurs secondary to increased cap-
sular pressure.
Recurrent dislocation
May be associated with unrecognized or untreated
acetabular fracture or impaction fractures of the
femoral head. Very rare; most are posterior.
Post-traumatic osteoarthritis
Incidence varies from 11% to 16%. The incidence
increases with age and significant acetabular frac-
tures and is reduced with accurate ORIF.
Heterotopic bone formation
Incidence is approximately 2%. Increases with ORIF,
delayed surgery, and associated head injury.
Methods of closed reduction for posterior
dislocation
Allis and Bigelow technique
The patient is supine with counter traction applied
to the ipsilateral anterior superior iliac crest. The leg
436 Section 7: The trauma oral
Trauma oral 3
•Nopropused.Discussionoftheclinicalfeaturesofanter-
ior versus posterior dislocation
• Posterior hip dislocations typically lie with the hip in a
position of flexion, adduction and internal rotation.
With an anterior dislocation the hip is externally rotated.
Movement of the hip is painful and restricted. With ipsi-
lateral fractures of the femoral neck or shaft the leg may
assume a near-normal position and the dislocation may
be missed
• Associatedinjuries
• DiscussionofAVNofthehip
• ManagementofestablishedAVNofthehip.Whichtype
of hip replacement to use. Survival analysis tables
Extracapsular femoral neck fractures
Account for approximately 50% of all femoral neck
fractures. The proportion is growing due to an
increasingly elderly population and an increase
in the age-specific incidence. Usually the frac-
ture occurs in elderly osteoporotic patients. The
majority are women (80%) with a mean age of
presentation of 80 years, who often present follow-
ing minimal trauma. Blood supply to the femoral
head is preserved. Union rates are high (large sur-
face area of cancellous bone at the fracture site).
Fractures occur in young patients following high-
velocity trauma.
Classification
Extracapsular fractures may be subdivided into tro-
chanteric and subtrochanteric fractures. The term
intertrochanteric refers to a fracture running trans-
versely in between (but not through) the lesser and
greater trochanters. The term pertrochanteric refers
to a fracture running obliquely and through the
greater to lesser trochanter.
Subtrochanteric fractures occur within 2.5 cm of
the lesser trochanter and account for a minority of
proximal femoral fractures (bimodal distribution in
the young and those over 65 years old).
Fractures of the femoral head associated with a
posterior hip dislocation are usually managed with
an anterior approach to the hip joint. Fragments
are often cephalad and attached to the ligamentum
teres and cannot be adequately visualized using the
posterior approach. Fractures of the femoral head
associated with anterior hip dislocation usually
require a posterior approach to the hip joint.
The fragments are fixed using small fragment
screws or Herbert screws.
Hip movements should be started early. Toe-
touch weight bearing for 6 weeks is increased to full
weight bearing over the next 6 weeks.
Examination corner
Trauma oral 1
Pipkin type III posterior dislocation of the
hip with a fracture of the neck of femur in
a 53-year-old patient
• Managementofthispatient.LeastcommonPipkininjury.
Approach to use. Closed reduction contraindicated. The
femoral neck fracture must be stabilized before reduc-
tion of the hip dislocation
• Whatisthemanagementwhenthereisconcernregard-
ing the vascular supply to the femoral head?
• Discussionregardinghemiarthroplastyagainsttotalhip
arthroplasty and then unipolar hemiarthroplasty against
bipolar hemiarthroplasty
Trauma oral 2
AP radiograph of the pelvis of a 45-year-
old male driver in a car who has a front
head-on collision with another vehicle
Presents to casualty with a shortened and externally rotated
right leg and some paraesthesia in his right lower leg.
• Differential diagnosis, management of traumatic hip
dislocation
• Pipkinfemoralheadfractureclassicationsystem,femo-
ral neck fracture classification systems (Garden, Evans,
Pauwels)
Chapter 23: Trauma oral topics 437
Type V: Subtrochanteric intertrochanteric fracture.
This group includes any subtrochanteric fracture
with extension through the greater trochanter
Imaging
AP pelvis and lateral hip radiographs•
Only rarely is a CT or MRI scan required, if the •
diagnosis is disputed
If no obvious fracture exists and pain persists, •
repeat X-rays after 3–4 days to check for fracture
propagation
Management
Aim is for early mobilization of the patient. This
prevents prolonged bed rest and its associated com-
plications. Ideally, surgery should be within 24 h of
hospital admission. Non-operative management is
considered only in the very sick patient with a poor
prognosis or where there is a definite contraindica-
tion to surgery, or the patient is completely immo-
bile prior to surgery.
Non-operative treatment
Skilful neglect
Only appropriate for a patient who is completely
immobile prior to the fracture. Fracture deform-
ity with shortening and external rotation occurs.
Nursing care is difficult.
Active conservative management
Consists of applying skin or skeletal traction for 6–8
weeks. Regular radiographs are required to check
on fracture position. This is indicated if a patient
is unfit for surgery, refuses surgery, where there is
a lack of surgical implant, the absence of an experi-
enced surgeon and a lack of surgical facilities.
Operative management
Extramedullary fixation (sliding hip screw-plate
system)
Refers to applying a side plate to the proximal femur
attached to a lag screw, which is passed proximally
Evans’ classification (1949)13
Based on the direction of the fracture and division
of fractures into stable and unstable:
Type I: Undisplaced two-fragment fracture
Type II: Displaced two-fragment fracture
Type III: Three-fragment fracture without postero-
lateral support, owing to displacement of greater
trochanter fragment
Type IV: Three-fragment fracture without medial
support, owing to displaced lesser trochanter or
femoral arch fragment
Type V: Four-fragment fracture without posterola-
teral and medial support (combination of type III
and type IV)
R: Reversed obliquity fracture
Seinsheimer’s classification (subtrochanteric
fractures)14
This classification is based on fracture fragments
and the location and shape of the fracture lines:
Type I: Undisplaced fracture with less than 2 mm
displacement of fracture fragments
Type II: Two-part fracture
Type IIA: Two-part transverse femoral fracture
Type IIB: Two-part spiral fracture with lesser tro-
chanter attached to proximal fragment
Type IIC: Two-part spiral fracture with lesser tro-
chanter attached to distal fragment
Type III: Three-part fracture
Type IIIA: Three-part spiral fracture in which lesser
trochanter is part of third fragment, which has an
inferior spike of cortex of varying length
Type IIIB: Three-part spiral fracture of the proximal
third of the femur, with the third part being a but-
terfly fragment
Type IV: Comminuted fracture with four or more
fragments
13 Evans EM (1949) The treatment of trochanteric fractures of
the femur. J Bone Joint Surg Br 31B: 190–203.
14 Seinsheimer F (1978) Subtrochanteric fractures of the
femur. J Bone Joint Surg Am 60(3): 300–6.
438 Section 7: The trauma oral
a tendency for the head to rotate as the sliding hip
screw is inserted. An anti-rotation screw or supple-
mentary guidewire should be inserted superior to
the sliding screw guidewire before insertion of the
sliding screw.
Reverse oblique fractures
Reverse oblique fractures run in the inferolateral
to superomedial direction, creating a tendency for
the shaft to displace medially. The sliding axis of
the sliding hip screw is therefore parallel to the frac-
ture line as opposed to being perpendicular. The
benefits of the sliding hip screw are therefore lost,
leading to suboptimal fixation. This fracture pattern
is best managed with an intramedullary device or a
90° fixed-angle plate system.
Subtrochanteric fractures
Subtrochanteric fractures can be managed with a
sliding hip screw or a long intramedullary device.
Complications
A number of complications relating to the fracture
can occur after an extracapsular fracture:
Mortality: 33% at 6 months, 38% at 12 months (3% •
<60 years, 50% >90 years)
In-hospital mortality: 15%•
Wound infection: 2%–15%•
Limb shortening•
Rotational deformity•
Re-fracture•
Detachment of the implant from the femur•
Breakage or disassembly of the implant•
Screw cut-out rate•
AVN: <0.5%•
Examination corner
Trauma oral 1
Radiograph of the pelvis and both hips. One side of the
trochanteric fracture fixed with a dynamic hip screw, the
other side with a gamma nail.
Comment on the fixation methods used on both sides and
the pros and cons of each.
across the fracture site up the femoral neck. These
implants can be static or dynamic. Static implants
have no capacity for sliding and cannot allow for
any bone collapse that occurs around the fracture
site. Examples of static implants include Jewett and
McLaughlin nail plates. Dynamic implants do allow
sliding at the plate–screw junction and allow for
collapse at the fracture site. Examples include the
dynamic hip screw (sliding hip screw) and the Pugh
nail. Good anatomical reduction is required with
alignment of the medial calcar. This hip screw should
be in the centre of the head on both AP and lateral
views and within 10 mm of the articular surface (in
strong subchondral bone) to prevent cut out.
Cephalic-condylar intramedullary devices
This refers to an intramedullary implant that is
passed distally within the femur from an insertion
point in the greater trochanter. They are especially
useful where the lesser trochanter is fractured.
They provide better mechanical advantage as load
sharing is improved and the bending moment is
reduced. The hip screw position is the same as for
the sliding hip screw.
Until recently results of all randomized trials
found no major difference between intramedul-
lary and extramedullary fixation. Latest research15
with the newer intramedullary hip screw implants
suggests a lower incidence of complications in the
more difficult comminuted fractures (reverse frac-
ture lines, subtrochanteric fractures).
Arthroplasty
A small number of cases have been reported using
long-stem, cemented hemiarthroplasty for com-
minuted trochanteric fractures. This is probably a
role best reserved for revision surgery after failure
of internal fixation.
Basilar neck fractures
Basilar neck fractures are two-part fractures and are
managed with a sliding hip screw. However, there is
15 Parker MJ, Handoll HH (2005) Gamma and other
cephalocondylic intramedullary nails versus extramedullary
implants for extracapsular hip fractures. Cochrane Database
Syst Rev 2005(4): CD000093.
Chapter 23: Trauma oral topics 439
Pauwels’ classification17
Based on the angle formed by the fracture line and
the horizontal plane: the more vertical the fracture
line, the higher the shear forces across the fracture
and the poorer the prognosis:
Type I: Fracture line 30° from the horizontal•
Type II: Fracture line 50° from the horizontal•
Type III: Fracture line 70° from the horizontal•
Management
The pros and cons of ORIF versus hemiarthroplasty
in intracapsular fractured neck of femur are given in
Table 23.1, and the advantages and disadvantages
of using cement are given in Table 23.2. These are
favourite questions of examiners who, for an exit
orthopaedic exam, would expect a snappy answer
from a candidate
Impacted fractures
Early mobilization may be attempted if the head is
tilted into valgus and weight bearing is tolerated.
Stabilization with three parallel cannulated screws
is generally advised.
Undisplaced fractures
Osteosynthesis with three parallel cannulated
screws or a sliding hip screw with an additional anti-
rotational screw is advised. Recommended for a
patient with a physiological age of less than 75 years.
Arthroplasty is generally indicated for patients older
than 75 years. This usually equates with only one
surgical procedure with no healing complications
despite a higher complication rate.
Displaced fractures
There is a relatively low threshold for performing
hemiarthroplasty in displaced fractures as the femo-
ral head’s blood supply is likely to be compromised.
17 Pauwels F (1935) Der Schenkelhalsbruch – ein mechanisches
Problem: Grundlagen des Heilungsvorganges, Prognose und
Therapie. Stuttgart: Ferdinand Enke Verlag.
Intracapsular femoral neck fractures
They may be subcapital (junction of head and neck)
or transcervical (passing through the neck). They
account for just under half of all femoral neck frac-
tures. Incidence is increasing. Mean age of presenta-
tion is around 80 years and 80% occur in women such
that the fracture has been called widow’s disease. It
is uncommon in the presence of osteoarthritis.
Intracapsular fractures put the blood supply to
the femoral head at risk. This is especially so with
displaced fractures where there is a substantial risk
of AVN or non-union.
Non-union
Non-displaced and impacted <5%•
Displaced >20%–30%•
Patient’s age•
Poor fracture reduction•
Symptoms include progressive groin, thigh or but-
tock pain or a combination thereof.
AVN
Non-displaced or impacted <8%•
Displaced 10%–20%•
Classification
Garden classification (1961)16
Based on the degree of displacement of an intra-
capsular neck fracture on the AP radiograph of the
pelvis:
Type I: Incomplete or impacted into valgus.
Trabeculae are angulated
Type II: Complete fracture with minimal/no dis-
placement. Trabeculae are interrupted but not
broken
Type III: Displaced fracture with angulation of the
trabecular lines
Type IV: Grossly displaced with trabecular lines of
the head and acetabulum parallel
16 Garden R (1961) Low-angle fixation in fractures of the
femoral neck. J Bone Joint Surg Br 43:647–61.
440 Section 7: The trauma oral
particular prosthesis is associated with anterior
thigh pain due to the poor fit and “toggling” of the
prosthesis.
Young patients
This constitutes patients under the age of 60.
Preservation of the femoral head by reduction and
internal fixation within 6 h of injury is the accepted
management. The Leadbetter manoeuvre (traction
along the line of the femur with the hip and knee
flexed at 90°, followed by internal rotation and
abduction) is used to reduce the fracture before
internal fixation. A good result can be expected in
up to 84% of cases. Alternatively, primary THA may
be performed. Risks include a higher incidence of
dislocation, infection, HO and earlier failure com-
pared to elective THA.
There are no healing complications of the fracture
if the femoral head is replaced with a metal one.
However, management depends on a patient’s pre-
fracture level of mobility and associated medical
co-morbidity factors. Consider internal fixation in
younger patients with displaced intracapsular frac-
tures. If proceeding with arthroplasty a cemented
bipolar prosthesis is recommended in younger,
healthier patients. The theory is that the bipolar
mechanism will decrease wear at the acetabulum.
There are no reported benefits of bipolar prosthesis
in patients over the age of 80 years.
Alternatively, a cemented mono-block hemiar-
throplasty may be used in older patients. In very
frail patients when a quick procedure may be
required due to concurrent medical issues, then
a non-cemented prosthesis such as the Austin–
Moore hemiarthroplasty is used. However, this
Table 23.1 Pros and cons of ORIF versus hemiarthroplasty in intracapsular fractured necks of
femur
Internal fixation Arthroplasty
Non-union 20%–30% Avoided
AVN 10%–20% Avoided
Dislocation Avoided 5% hemi 10% total
Acetabular erosion Avoided 20% long-term survivors
Prosthetic loosening Avoided 10%
Sepsis around implant 2%–5% (mortality >50%)
Re-operation rate 1 year 18.6% (Parker et al.)14.8%
Re-fracture around implant Rare 2%–4%
1Parker MJ, Khan RJ, Crawford J, Pryor GA (2002) Hemiarthroplasty versus internal fixation for
displaced intracapsular hip fractures in the elderly. A randomised trial of 455 patients. J Bone
Joint Surg Br 84(8): 1150–5.
Table 23.2 Use of cement
Advantages of cement Disadvantages of cement
Less thigh pain More demanding operation
Reduced revision rate Revision more difficult
Increased mobility Increased mortality
More secure fixation Cement reaction
Chapter 23: Trauma oral topics 441
Distal femoral fractures
Background
Distal femoral fractures account for 4%–7% of all
femoral fractures and are difficult fractures to man-
age. Fifty per cent are extra-articular supracondy-
lar fractures. Fifty per cent have an intra-articular
extension. Twenty-five per cent of all fractures are
open. There is a bimodal age distribution: usu-
ally young males following high-energy trauma or
elderly osteoporotic females following minimal
trauma. Management may result in knee stiffness
due to damage and scarring of the extensor mech-
anism and/or intra-articular pathology (cartilage
contusion, osteochondral fractures and menis-
cal tears) and adhesions. Ligament injuries occur
in 20% of fractures (collateral/cruciate ligament
injuries).
Mechanism of injury
Several muscle groups insert or arise in the
supracondylar region and cause deformity after
fractures. The gastrocnemius rotates the distal
fragment posteriorly while the strong adductors
cause varus angulation. Intercondylar fractures
are splayed open by discordant muscle action. The
hamstrings muscles cause posterior fracture dis-
placement and angulation with associated med-
ial or lateral deformation. The quadriceps muscle
shortens the fracture.
Management
Non-operative management
Undisplaced or minimally displaced fractures can
be managed conservatively either with a long leg
cast or with skeletal traction. Maintaining accur-
ate reduction is difficult. The gastrocnemius mus-
cle attachment causes a hyperextension deformity
of the distal segment. Prolonged skeletal traction
is associated with knee stiffness and medical risks
of immobilization. Malunion and non-union are
common.
Examination corner
Trauma oral 1
Radiograph of a displaced intracapsular
fractured neck of femur
• Describe
• How will you manage this patient: details of history
and preoperative assessment
• Whatisthementaltestscore?
• Whatoperationwouldyouadviseandwhy?
Trauma oral 2
Radiograph of a displaced Garden type IV
intracapsular fractured neck of femur
• Femaleaged88years
• Classication
• Management
• Differencesbetweencemented,uncementedandbipolar
hemiarthroplasty of the hip
Trauma oral 3
Radiograph of a displaced fractured neck of
femur in a 70-year-old female
• Classication
• ManagementofGardengradeIVfractureandprognosis
Trauma oral 4
Radiographs of an undisplaced subcapital
fractured neck of femur in a female aged
60 years with Parkinson’s disease
• Describetheradiographs
• Howdoyoumanagethisfracture?
• Closedreductionandxation
• Aspiration of the joint to decrease the incidence of
AVN – when is this indicated, what evidence is there for
this procedure in the literature?
442 Section 7: The trauma oral
or buttress plates. The plate does not have to be
close to the bone and therefore it does not need to
be closely contoured to the periarticular surface as
with a standard buttress plate. These modifications
allow easier insertion and less damage to the bone
and its blood supply. Specially shaped unicortical
screws are used with the LISS plate.
Retrograde intramedullary nail
A retrograde intramedullary nail causes minimal
soft-tissue damage and is associated with low infec-
tion rates. In the elderly fixation can be tenuous and
a cast brace support is often necessary. Non-weight-
bearing or cast bracing is encouraged for 3 months
after the operation. However, due to the preserva-
tion of the soft tissue around the knee, early knee
movement is often regained.
External fixation
External fixation is indicated for severe or open inju-
ries. This may be with an anterior bridging fixator
(when stabilization is needed for soft tissue and vas-
cular reconstruction). A circular frame may be used
to supplement minimal open reduction and percu-
taneous screw or wire fixation. This allows for early
movement of the knee.
Complications
Early complications
Vascular compromise•
Infection•
Mal-reduction•
Fixation failure•
Late complications
Malunion (rotational, flexion/extension, varus/•
valgus alignment)
Non-union (especially fractures above a stiff •
knee)
Knee stiffness•
Joint destruction (if intramedullary nail left •
prominent)
Associated injuries
The associated injuries depend on the position of the
patient’s lower extremity at the time of the injury:
simultaneous injuries can result in hip dislocation,
femoral shaft fracture, tibial plateau fracture, tibial
shaft fractures (floating knee) and patella fractures
(10%). Popliteal vessel injury is rare.
Operative management
Several methods available, which are now
discussed.
Cancellous lag screw fixation
For unicondylar fractures. Most commonly used as
a supplement to other devices.
A 95° condylar blade plate
Technically demanding and requires precision
in placement. Requires extensive soft-tissue exp-
osure therefore compromising the blood supply to
the bone. There may also be stress shielding of the
bone.
Dynamic condylar screw (DCS)
The compression screw is cannulated to allow easy
application over a guidewire. Bone grafting is often
required. Requires an adequate distal fracture frag-
ment to allow insertion of the compression screw.
Condylar buttress plate
Weaker construct than either a condylar screw or a
blade plate. Errors in alignment, particularly valgus,
are common.
LISS plate fixation
LISS stands for less invasive stabilization system.
A LISS plate is similar to a buttress plate with several
modifications. The screw holes in a LISS plate are
round and threaded so that the screws are locked
onto the plate. This allows adequate stabilization
with only unicortical screws rather than the bicor-
tical fixation required with standard compression
Chapter 23: Trauma oral topics 443
Imaging
AP, mortise and lateral views•
CT scan demonstrates the fracture configuration •
and helps preoperative planning
Classification
Rüedi and Allgöwer (1979)18 is the most widely used
classification. It both helps planning and is of prog-
nostic value. Other classifications include Kellam
and Waddell (1979),19 Ovadia and Beals (1986)20 and
the AO/ASIF (1996).
Rüedi and Allgöwer classification
Type I: Undisplacement T shaped intra-articular
fracture of the distal tibia without comminution
Type II: Significant displacement of the intra-ar-
ticular components without comminution
Type III: Displaced intra-articular multifragmen-
tary fracture with impaction and comminution of
the articular surface
Low-energy fractures tend to be type I or II. High-
energy fractures are usually type III fractures.
Associated injuries
Skeletal• (calcaneum, long bone fractures, shear
fractures of the pelvis and axial spine fractures)
Soft tissues• . There may be significant soft-tissue
damage without an open fracture
Neurovascular injuries• . These must be excluded
Other injuries • secondary to high-energy injuries
(head, thorax, abdomen)
18 Rüedi TP, Allgöwer M (1979) The operative treatment of
intra-articular fractures of the lower end of the tibia. Clin
Orthop Relat Res 138: 105–10.
19 Kellam JF, Waddell JP (1979) Fractures of the distal tibial
metaphysis with intra-articular extension – the distal tibial
explosion fracture. J Trauma 19(8): 593–601.
20 Ovadia DN, Beals RK (1986) Fractures of the tibial plafond.
J Bone Joint Surg Am 68(4): 543–51.
Examination corner
Knee stiffness following supracondylar
fracture
Quite common as a potential trauma long case with other
associated injuries. The discussion of management options
can be difficult.
Results from injury to the quadriceps mechanism and/or
articular surface either during the initial trauma or during
surgery. The combination of muscle adhesions, arthrofi-
brosis and ligamentous contractures causes knee stiffness.
Iatrogenic causes such as protruding hardware and articu-
lar mal-reduction can also contribute.
Difficult problem to manage; MUA with or without
arthroscopic lysis of adhesions or quadricepsplasty are
possible options.
Tibial plafond fractures
Also known as tibial pilon fractures, tibial plafond
fractures account for fewer than 1% of all lower limb
fractures and 5%–7% of tibial fractures. The fracture
involves the weight-bearing articular surface of the
distal tibia, the diaphysis and the distal fibula (75%
of cases). Occasionally, there is diaphyseal exten-
sion into the tibial shaft.
Twenty percent of plafond fractures are associated
with an open injury. The wound is often anterome-
dial. Swelling and skin contusions may be severe at
an early stage, worsening with time.
Mechanism of injury
Rotational injuries cause low-energy fractures with
relatively little associated soft-tissue injury or com-
minution. Axial compression causes high-energy
fractures with extensive soft-tissue disruption and
“explosive” comminution of the plafond.
Axial loading with the ankle in plantar flexion •
(posterior articular comminution)
Axial loading with the ankle in dorsiflexion (anter-•
ior articular comminution)
Rotational (shear) forces (wide array of injury pat-•
terns are seen)
444 Section 7: The trauma oral
ORIF• with reconstruction of the fibular length
with a plate, reconstruction of the articular sur-
face with interfragmentary screws, cancellous
bone grafting and stabilization of the medial tibia
with a buttress plate (Rüedi and Allgöwer)
External fixation• with a unilateral external fixator
spanning the ankle to provide ligamentotaxis and
effect indirect reduction. The results are no better
than ORIF for type III injuries. A circular external
fixator such as the Ilizarov external fixator con-
sists of fine wires (1.8 mm) for interfragmentary
fixation. Ilizarov frames allow for early weight-
bearing and ankle joint movement
Combined fixation• with a fibular plate to restore
length and an external fixator placed medially,
crossing the ankle joint. They are combined with
minimal open reduction, bone grafting and inter-
fragmentary screw fixation. The results are similar
to ORIF in type II fractures. However, good results
are achieved in >70% for type III fractures
Early arthrodesis• is a reasonable option in the
severely comminuted fracture that is non-recon-
structable. It facilitates earlier rehabilitation
Complications
Early complications
Delayed wound healing or wound sloughing•
Infection of wound or pin tracks•
Osteomyelitis•
Neurovascular injury•
Loss of reduction•
Late complications
Mal/non-union•
Joint stiffness•
Ankle joint instability•
Post-traumatic arthritis (relates to cartilage •
damage at time of surgery despite optimal
management)
Late arthrodesis is 50% in some series for type III •
injuries
Amputation•
Management
Objectives of surgical management
Anatomical reduction of the articular surface•
Restoration of length•
Bone union•
Viable soft tissue, which is not infected•
Early movement and restoration of function•
Timing of surgery
Timing is critical in the management of high-energy
tibial plafond fractures. ORIF, if attempted early,
should be within 6–12 h post injury. After 12 h post
injury, profound swelling means there is a high risk of
complications. Temporary stabilization with external
fixation is preferable. Surgery should be delayed for
7–10 days while swelling resolves with elevation and
cryo-cooling. Several centres advocate a two-stage
procedure with high-energy injuries with exten-
sively compromised soft tissues. In the first stage,
primary reduction and internal fixation of the articu-
lar surface is performed using stab incisions, screws
and K-wires. Temporary external fixation is applied
across the ankle joint. After recovery of the soft tis-
sues, the second stage entails internal fixation with a
medial plate using a reduced invasive technique.
Surgical management
Type I fractures
Type I fractures are preferably managed non-op-
eratively with cast immobilization and 6 weeks of
non-weight-bearing, followed by a further 6 weeks of
graduated weight-bearing. Surgical stabilization will
allow earlier movement. Bourne et al.21 reported >80%
satisfactory results with type I and II fractures. Only
44% of type III fractures had a satisfactory result.
Type II and III fractures
Type II and III fractures are difficult to manage.
Several methods of management are available:
21 Bourne RB, Rorabeck CH, Macnab J (1983) Intra-articular
fractures of the distal tibia: the pilon fracture. Trauma 23(7):
591–16.
Chapter 23: Trauma oral topics 445
2. Spiral/oblique fibular fracture (posterior at the
proximal end to anterior distally) at the level of
the syndesmosis
3. Posterior malleolar fracture or rupture of the
posterior tibiofibular ligament
4. Medial ligament rupture of low medial malleolar
fracture
Pronation (eversion)/abduction injuries (PA)
1. Deltoid ligament rupture (rare) or horizontal
fracture of medial malleolus
2. Both the anterior and posterior tibiofibular liga-
ments rupture (syndesmosis rupture). In the case
of the posterior ligament, the tibial attachment
may be avulsed instead
3. Short transverse or oblique fibular fracture at the
level of the joint. Comminution may occur with
formation of a triangular fragment with its base
directed laterally. The fibular fragment is tilted
laterally
Pronation (eversion)/external rotation injuries
(PER)
1. Deltoid rupture or oblique fracture of medial
malleolus
2. Disruption of the anterior tibiofibular ligament
causing avulsion of the tibial attachment (Tillaux
fracture) or rupture
3. Spiral or oblique fibular fracture above the joint
(obliquity fibular fracture is in the opposite
direction found in supination-lateral rotation
injuries). If the fracture is in the proximal fibula,
this is a Maisonneuve fracture
4. Disruption of the posterior tibiofibular ligament
or avulsion of the bony attachment (posterior
malleolar fracture). If displacement of the talus
continues, the interosseous membrane tears
and gross diastasis occurs (Dupuytren’s fracture
dislocation)
Pronation-dorsiflexion (vertical compression
fracture – pilon type fracture)
The anterior part of the talus is forced between
the malleolus shearing off the medial malleolus.
Trauma oral 1
Radiograph of a severe open pilon fracture
ABC ATLS resuscitation in A&E: cut short by examiners, •
not wanted
General management principles of open fractures: again •
cut short, not what the examiners want to talk about
Classification•
Current thinking about management and recent •
literature
Candidate: Might have been better if I had cut to the chase and
just described the radiograph and then moved onto classifica-
tion rather trying the ABC ATLS waffle
Ankle fractures
High-energy injuries include RTAs, falls from height
and sports injuries. Low-energy injuries include
falls, twists and slips. Common in young sportsmen
and in late-middle-aged obese women.
Classification
Lauge-Hansen classification22
The first description refers to the position of the foot
at the time of injury (supinated or pronated). The sec-
ond refers to the direction in which the talus moves
within the ankle mortise (abduction, adduction or
external rotation). The injuries occur in a step-wise
fashion as the deforming force progresses.
Supination (inversion)/adduction injuries (SA)
1. Transverse distal fibula fracture or lateral liga-
ment rupture
2. Vertical medial malleolar fracture
Supination (inversion)/external rotation
injuries (SER)
1. Anterior talofibular ligament rupture ±avulsion
of the anterolateral tibia (Tillaux fracture)
22 Lauge-Hansen N (1949) Ligamentous ankle fractures;
diagnosis and treatment. Acta Chir Scand 97(6): 544–50.
446 Section 7: The trauma oral
Undisplaced fractures that are potentially unsta-•
ble may be managed with below-knee cast as
long as there is close radiographic monitoring for
at least 3 weeks. If this is not possible, then fixa-
tion gives a better outcome. Note that 5%–10%
of medial malleolar fractures go on to non-union
and therefore should be followed-up closely
Displaced bi- or tri-malleolar fractures may be •
managed non-operatively with reduction and
POP cast only when surgery is contraindicated,
i.e. poor skin, elderly, diabetics, alcoholics and
the immunocompromised. Redisplacement is
common when the swelling resolves
Operative management
Timing of surgery is essential to prevent soft-tissue
problems. Surgery should be undertaken within 24
h of injury or after 7–10 days to avoid excess swelling
of the tissues at the time of operation. It is essential
that the limb be elevated as soon as possible. Cryo-
cooling will help reduction of swelling.
Displaced isolated malleolar fractures should be •
reduced and fixed with plates and screws, tension
band wiring or screw fixation
Displaced bi- and tri-malleolar fractures are gen-•
erally unstable and require ORIF
Accurate reduction of the lateral malleolus is the •
key to restoration of joint congruity. This fracture
is addressed first. Oblique fractures are managed
with a lag screw and a one-third tubular neutral-
ization plate. A posterior anti-glide plate is recom-
mended in porotic bone. Transverse fractures are
stabilized with dynamic compression plates
Medial malleolar fractures are fixed with lag •
screws or tension banding
Posterior malleolar fractures need fixation only if •
25% of the articular surface is involved. This is
performed by lag screw fixation passed anteriorly
to pick up the posterior fragment
Stabilization of the syndesmosis is performed •
with one or two fully threaded 4.5-mm screw
passed across at least three cortices just above the
syndesmosis with the ankle in neutral (widest part
of the talus is engaged in the mortise). Patient to
Continued force fractures the anterior tibial margin
and lateral malleolus. Finally the inferior articular
surface of the tibia (pilon) fractures in an irregular
fashion with severe communition.
Weber classification
This is based on the level of the fibular fracture rela-
tive to the syndesmosis:
A: Below
B: At the level
C: Above (more proximal type C fractures are
unstable)
Imaging
AP, lateral and mortise (15° internal rotation) •
radiographs
CT scans for more complex patterns (pilon •
fractures)
Radiographic features to note
1. Medial and superior joint space. The joint space
should be 4 mm throughout or <1 mm difference.
Talar shift of 1 mm reduces the area of joint con-
tact by 40%
2. Talar tilt is the angle between the tibial articu-
lar surface and the superior talus on the mortise
view. This should be <5°
3. Talocrural angle is the angle between the tibial
articular surface and the malleoli. This should be
8°–15°
4. A greater than 2-mm step in the articular surface
5. Tibiofibular overlap should be >1 mm on all
views
Management
Conservative management
Undisplaced fractures, including lateral malleo-•
lus alone without talar shift, are managed with
below-knee cast for 6 weeks. Weight bearing may
be allowed after 2–4 weeks if radiographs demon-
strate no displacement
Chapter 23: Trauma oral topics 447
Trauma oral 2
Mechanism of ankle fractures
• Lauge-Hansenclassication
• FixationmethodsforWeberCfracture
Achilles tendon rupture
Classically occurs in middle-aged sedentary males
performing unaccustomed sporting activity such as
squash or tennis. The mean age of presentation is
35 years with 60% of ruptures occur during recrea-
tional sport.
Mechanism of injury
Sudden ankle dorsiflexion•
Excessive strain during the heel-off phase of gait•
Following direct trauma•
Diagnosis
Hear or feel a pop•
Immediate weakness of push-off followed by pain •
and swelling, with difficulty walking
Visible and palpable defect in the tendon•
Weakness of plantar flexion•
Inability to heel raise•
Simmond’s test is positive for Achilles tendon •
rupture – with the patient prone or kneeling on a
chair, squeezing the calf does not produce passive
plantar flexion
O’Brien’s needle test•
Where clinical findings are equivocal, the diagnosis
can be confirmed by ultrasound or MRI scans.
Pathological process
The pathological process leading to rupture is
poorly understood. A watershed area is present
3–6 cm above the calcaneal insertion. This is an
area of relatively poor blood supply aggravated by
decreased perfusion during stretching, contraction
be non-weight-bearing for 6–10 weeks. The screw
may be removed or left in situ after this time
Indication for fixation of Weber type C fractures
1. Associated medial ligament rupture (repair of lig-
ament alone is not adequate). Medial fractures, if
fixed, will prevent talar shift
2. Fractures 4.5 cm or more above the joint are likely
to have residual diastasis despite fibular fixation.
Those below 3 cm above the joint are generally
stable. Fractures occurring within 3 and 4.5 cm
may be assessed intra-operatively by hooking the
fibula and pulling. This will identify significant
dynamic diastasis
3. Proximal fibular fractures are rarely fixed.
However, a diastasis screw should be inserted
Complications
Early complications
Inadequate reduction•
Redisplacement (non-operative treatment)•
Delayed wound healing•
Wound infection•
Osteomyelitis•
Nerve injury (sural nerve)•
Late complications
Mal or non-union and diastasis•
Joint stiffness•
Ankle joint instability•
Post-traumatic arthritis (relates to cartilage •
damage at time of surgery despite optimal
management)
Examination corner
Trauma oral 1
Radiograph of a trimalleolar fracture ankle
• Assessmentandmanagement
448 Section 7: The trauma oral
Examination corner
Examiner: What are the advantages and disadvantages of con-
servative versus operative management for acute tendon
rupture?
Candidate:Non-operativemanagementisfavouredbyanum-
ber of surgeons to avoid the complications of surgery, which
are essentially wound healing problems. However, there may
be situations in which operative treatment may be the pre-
ferred option. These would include, etc.
Examiner: What do you do? How do YOU treat an acute Achilles
rupture tendon?
Candidate: I would sit down with the patient and explain the
pros and cons of surgery versus non-operative treatment and
let them decide. I would however be guided by age, level
of sporting activity and any co-existing medical condition in
recommending a choice.
Intramedullary fixation techniques
Implant design characteristics
Diameter• : stiffness is proportional to fourth
power of the radius
Length• : working length is the distance over which
the nail is unsupported by the bone. Bending stiff-
ness is inversely proportional to the square of the
working length. Torsional stiffness is inversely
proportional to the working length
Shape:• unreamed nails have relatively small
diameter, but are solid to give adequate stiffness.
Cannulated nails may be rigid or slotted
Cross-sectional characteristics:• most are cylin-
drical (therefore lighter). Some are cloverleaf
shaped in cross-section (increases stiffness)
Material:• infection may be higher with stainless
steel implants
Locking screws:• reduce the need for close contact
between the implant and the endosteal bone
Complications
Fat emboli:• excessive reaming is associated with
increased fat and platelet aggregates. Identify
patients at risk (polytrauma, ARDS, hypovolae-
mia). Unreamed nail can still cause fat emboli
Infection:• 1%–2% for closed fractures
and advancing age. In addition there are changes to
the cross-linking of collagen fibres and degenerative
changes with age.
Two theories
Chronic tendon degeneration•
Acute mechanical overload•
Both factors usually involved.
Management
Non-operative management
Basically avoids the risk of surgical complications•
Higher re-rupture rate approx 15% (4%–50%)•
Greater tendon elongation and weaker plantar •
flexion (20% versus 10% surgery)
Cast for 8/52 initially in equinus•
Conflicting reports of whether the cast should be •
below or above the knee and when weight bearing
is begun
Advantages of surgery
Re-rupture rate is lower at 2% (0%–7%)•
Rehabilitation is more rapid•
Earlier return to work•
Quicker return to sport•
Disadvantages of surgery
Overall complication rate approximately 10%•
Deep infection•
Superficial infection•
Fistula•
Skin necrosis•
Suture granuloma•
Damage to the sural nerve•
Surgical technique
Posteromedial incision•
Lateral incision: risk of injury to sural nerve•
Midline: prone to adhesions and subsequent irri-•
tation by footwear
Chapter 23: Trauma oral topics 449
The components and mechanics of external
fixators
Pins or wires for fixation to bone•
Frames (rods and/or rings) connect to the pins or •
wires
Bone–pin interface important to frame stability•
Bending rigidity of the pin is proportional to the •
fourth power of the radius
Diameter of pins is only limited by the size of the •
bone being fixed
Pins greater than one-third of the bone diameter •
risk fatigue fracture of the bone
Pins may be half pins (pass through one side of •
the limb only) or transfixion pins or wires (pass all
the way through the limb)
Most pins are stainless steel and have a threaded •
portion
Transfixion wires of 1.5–1.8 mm are unthreaded•
These may be tensioned to 90–120 kg to enable •
deforming forces to be resisted
Bone purchase is by tension and friction•
Some wires have enlargements (olives) at one end •
to prevent movement of bone during fixation, or
to allow a deforming force to be applied
Factors affecting stability and rigidity
Configuration of the frame•
Total number of Schanz screws used•
Degree of contact between bone ends•
Extent of the soft-tissue injury•
Degree to which the clamps are correctly tightened•
Quality of bone at Schanz screw interface•
Factors affecting construct stiffness
Clamp type•
Number and orientation of rods•
Clamp-to-bone distance•
Side bars/bone separation distance•
Type and number of pins and their orientation •
and size
Pin separation across fracture site. Site the outer •
(peripheral) Schanz pins as far away from the frac-
ture as possible. Inner (central) Schanz pins should
be placed as near to the fracture site as possible
Non- or delayed union:• non-union rates are
low (2%). Dynamization occasionally needed.
Bone grafting of large defects may be necessary.
Exchange nailing can be performed for patients
with delayed union or non-union
Malunion:• rare. This is best avoided by accurate
reduction at the time of surgery. Two percent of
femoral fractures will have >20° malunion
Neurovascular injury:• traction injuries. Caution
in humeral shaft fractures
Principles of external fixation
Advantages of external fixation
Rapid skeletal stabilization•
Versatile for different injuries and anatomy•
Adjustment of alignment and fixation during frac-•
ture healing (spatial frame, limb lengthening)
Indirect reduction by ligamentotaxis•
Allows good access to the wound•
Soft tissues not disturbed•
Easy to remove•
Technically easy to perform•
Indications for external fixation in trauma
Fractures associated with significant soft-tissue •
trauma (grade III open fractures, closed degloving
injuries)
Polytrauma•
Peri-articular and metaphyseal fractures•
Types of fixator
Simple fixators• . These may be uni- or multi- planar.
They may use clamps or pins. Pin types allow little
scope for adjustment once applied. Clamp type
fixators allow reduction after application
Ring fixators• . These comprise rings or half-rings
surrounding the limb with the use of pins and
wires for stabilization. They allow considerable
adjustment once applied. Examples are Ilizarov
and Taylor Spatial frames
Hybrid fixators• . These are a combination of sim-
ple and ring fixators
450 Section 7: The trauma oral
Crush injuries•
Burns•
Gunshot wounds•
Surgery•
Prolonged use of tourniquet or pneumatic anti-•
shock garment
Clinical features
The first sign is severe pain out of all character to
the original injury. The earliest and most reliable
feature is significant pain with passive stretching of
an involved muscle group. Paraesthesia is another
early sign (first web space of the foot for lower leg
compartment syndrome). Pallor, pulselessness and
paralysis are late features.
Compartment pressure monitoring is useful if the
patient is paralysed or intoxicated. Clinical suspi-
cion is enough to warrant surgical exploration with-
out the need for fancy monitoring.
The normal fascial compartment pressure is
around 0 mmHg. Pressures within 30 mmHg of the
diastolic blood pressure or an absolute value >40
mmHg require urgent surgical decompression by
fasciotomy. This should be done within 4 h of onset
of symptoms.
Lower leg
Compartment syndrome of the lower leg follows
closed or open fractures and intramedullary nail-
ing. The four compartments in the lower leg are the
anterior, lateral, posterior and deep posterior com-
partments. All four must be released. The anterior
compartment is most commonly involved.
An anterolateral incision, 15–20 cm long, is made
between the fibula and the tibial crest (anterior bor-
der tibia). This decompresses the anterior and lat-
eral compartments. Use a gloved finger to palpate
the intermuscular septum and beware of the super-
ficial peroneal nerve.
Make a posteromedial incision, 15–20 cm long
and 2 cm behind the posterior medial tibial mar-
gin (medial border tibia). Beware of the saphenous
nerve and vein. This decompresses the superficial
Place the connecting rods (stainless steel or car-•
bon fibre) as near to the skin as possible
Considerations for application
Avoid neurovascular structures•
Avoid muscle tethering and the use of relieving •
skin incisions to reduce the risk of necrosis and
infection
Half pins are generally safe in the subcutaneous •
border of the tibia and ulna or around the lateral
intermuscular septum of the humerus
In the proximal tibia, transverse wires are safe in •
the anterior arc of 220°
Avoid thermal injury at the pin–bone interface by •
cooled pre-drilling
A strict pin-care regimen is important to reduce •
infection frequency and severity. The patient can
be taught to self-care for their pin sites
Complications
Pin tract infection (50% – from minor infection to •
osteomyelitis)
Joint stiffness•
Non-union (5%–10% of all external fixations)•
Malunion (5%)•
Neurovascular damage•
Pin loosening•
Frame failure is rare•
Compartment syndrome
Definition
Compartment syndrome is caused by increases in
soft-tissue pressure within an enclosed fascial space
of an extremity leading to tissue ischaemia, severe
muscle necrosis and fibrosis, functional impair-
ment and nerve damage.
Aetiology
Fractures•
Soft tissue•
Chapter 23: Trauma oral topics 451
cause elevated compartment pressures. The
eschar should be released with a longitudinal inci-
sion. Full-thickness burns may be released in the
emergency room if urgent, as the skin is rendered
anaesthetic.
Fasciotomy wounds are inspected under GA at
48 h. At this stage part of the wound may be closed
but usually a split-skin graft is needed for coverage.
Delayed or untreated compartment
syndrome
Fibrosis of necrotic tissue leads to contracture and
ineffective muscle function. Contracture may be
mild (clawing of the toes), or florid (Volkmann’s
contracture). Tendon transfer may be indicated to
improve function.
Examination corner
Basic science oral 1
Cross-section of calf: identify nerves and muscles
Compartment syndrome: diagnosis and management
Trauma oral 1
Compartment syndrome
•Denition
•Causes
•Diagnosis
•Useofcompartmentpressuremeasurements
•Incisionsforlowerlegfasciotomies
Trauma oral 2
Compartment syndrome: everything possible was asked.
The examiner rolled up his trousers, waved his leg in my
face and said “show me on my own leg exactly where you
would perform your incisions”. Then he asked about the
superficial peroneal nerve and whether it travels posterior
to anteriorly in the leg or vice versa. This was a tough and
intimidating but fair grilling by the examiner.
and deep posterior compartments. Muscle viability
is determined by the 4Cs: colour, consistency, con-
tractibility and capacity to bleed.
Forearm (volar ulnar decompression)
Incision begins above the elbow laterally. A curved
incision is made across the flexor crease of the
elbow. The incision is completed distally, staying
on the ulnar side of the forearm and then into the
carpal tunnel.
The dorsal incision is made in the line of the lat-
eral epicondyle of the humerus and distal to the
radioulnar joint.
Hand
There are four dorsal interosseous compartments,
and three volar interosseous compartments: the
abductor pollicis compartment, and thenar and
hypothenar compartments.
Two dorsal longitudinal incisions over the sec-
ond and fourth metacarpals are made. Longitudinal
incisions parallel to the radial aspect of the first
metacarpal and ulnar aspect of the fifth metacarpal
are made.
Foot
There are five major compartments of the foot:
medial, lateral, central, interosseous and calca-
neal. Nine compartments in the foot have been
recorded using injection studies. All can be reached
through two dorsal incisions plus one medial inci-
sion. The dorsal incisions are placed over the sec-
ond and fourth metatarsals (these allow access to
all compartments). When no dorsal decompression
is required or trauma is limited to the hindfoot, a
plantar medial approach provides access to all
compartments.
Full-thickness burns
Full-thickness burns cause contraction of the
skin, which may be circumferential, and can
452 Section 7: The trauma oral
Biomechanics of implants in trauma
Bone screws
A screw is a mechanism that produces linear motion
as it is rotated. The main function of a screw is to fix
together two or more objects by compressing them
against each other.
The main components of a screw are the head,
shaft, thread and tip.
The head
Provides an attachment for the screwdriver •
(RECESS)
Provides a buttress to stop the whole screw sink-•
ing into the bone
The hexagonal head recess design most popular •
because:
It avoids slippage of the screwdriver•
It allows better directional control during screw •
insertion
The torque is spread between six points of •
contact
Screw shaft
Smooth link between the head and thread•
The run out is the transitional area between the •
shaft and thread. This is the area where screws
break
Screw thread
The standard orthopaedic screw has a single •
thread
Core/root diameter = the narrowest diameter•
Outer/thread diameter•
The larger the outer diameter the greater the •
resistance to screw pullout
Talar fracture
Talar fractures are uncommon but important due
to the complex bony anatomy, articulations and
vascularity. There are no muscle origins or inser-
tions. Over 60% of the talus is covered by articular
cartilage.
Talar neck fractures are classified by Hawkins23
with type 4 later added by Canale and Kelly24.
Examination corner
Hawkins type III fracture
Displaced fracture with dislocation of the body of the talus
from both the subtalar and ankle joints. No other injury in
the history.
Examiner:
• Describewhatyouseeontheradiograph
• ClassifytheriskofAVNineachoftheHawkinssubgroups
• Howwouldyoumanagethisfracture?Thisfracturerequires
urgent anatomical reduction and fixation. These fractures
are open in 25% of cases. Document the neurovascular sta-
tus of the foot
• Whatsurgicalapproachwillyouuse?
Candidate: Three surgical approaches are described: antero-
medial, anterolateral and posterolateral. A medial malleolar
osteotomy is sometimes used, which is said to preserve the
blood supply through the deltoid ligament.
Examiner: A medial malleolar osteotomy is a recognized
approach for a talar neck fracture. What is your postoperative
management? When would you allow weight bearing? What
is Hawkins sign?
Candidate: Hawkins sign is a radiographic appearance on AP
radiograph with the foot out of plaster. After 6–8 weeks’ dis-
use osteopenia is seen as subchondral atrophy in the dome
of the talus. This would not occur if there was no blood sup-
ply. Subchondral atrophy generally excludes the diagnosis of
avascular necrosis.
Examiner: If Hawkins sign is absent can you be sure there will
beAVN?
Candidate: AVN may not necessarily occur with an absent
Hawkins sign.
Examiner:IfyoususpectAVNwhatwillyoudo?
Candidate: I would mange expectantly with non-weight-bear-
ing but active ROM and wait for revascularization to occur,
which may take up to a year.
23 Hawkins LG (1970) Fractures of the neck of the talus. J Bone
Joint Surg Am 52(5): 991–1002.
24 Canale ST, Kelly FB Jr. (1978) Fractures of the neck of the
talus. Long-term evaluation of seventy-one cases. J Bone Joint
Surg Am 60(2): 143–56.
Chapter 23: Trauma oral topics 453
weakening its hold in bone provided it is carefully
inserted. If, however, the screw is inadvertently
angled it will cut a new path and destroy the thread
that has already been cut. Self-tapping screws
should therefore not be used as a lag screw.
Cancellous screws do not have flutes, but gain a
better hold when cancellous bone is not tapped.
Principle of the lag screw
This allows compression of two fracture fragments
as the screw thread engages only the furthest frag-
ment and slides through the proximal fragment.
“Lagging” may be achieved in two ways:
Use of a partially threaded screw•
“Lagging” the proximal fragment. By over-drill-•
ing the proximal fracture fragment to a diameter
slightly larger than the thread diameter, this cre-
ates a gliding hole. The distal fracture fragment
is drilled as normal to the core diameter and if
needed tapped to the thread diameter. The screw
thread only gains purchase in the distal fragment
so when the head comes into contact with the
proximal fragment it allows compression of the
two objects.
Instruments for inserting screw
Drill bits: Usually have two to three cutting edges.
Flutes allow bone cuttings (swarf) to escape. The
direction of drilling is important, as drilling in the
reverse direction means the drill bit will not clear
the swarf.
Taps: Correspond to the thread diameter, shape
and pitch of individual screws.
Depth gauge: Oblique holes may have two depth
readings depending on which side the measure-
ment is made. The longer measurement should
be used. A screw hole will only be used optimally
if completely filled with a screw.
Screw drivers: Ensure screwdrivers are not worn
and that they are fully seated in the screw head to
prevent stripping of the head. Stripping prevents
purchase of the screwdriver in the screw head
making screw removal difficult.
Screw pitch • is the distance between adjacent
threads
Cortical screws have a small pitch and cancel-•
lous screws a large pitch
Lead • is the linear distance through which a screw
advances with one turn
The smaller the lead the greater the mechanical •
advantage of the screw
Tensile strength
The resistance to breaking is proportional to •
the diameter of a screw (diameter of the core)
squared
Pull-out strength
This depends on the outside diameter of the •
threads and the area of thread in contact with the
bone. To increase the pull-out strength of a screw,
the outer diameter may be increased or the pitch
reduced. Over the first 6 weeks following inser-
tion, the pull-out strength increases to 150% of
that at insertion
Shear strength
Shear strength of a screw is proportional to the •
cube root of its diameter
Self-tapping versus non-self-tapping screws
A tap is designed in such a way that it is not only
much sharper than the thread of the screw, but it
also has a more efficient mechanism for clearing
bone debris that therefore does not accumulate and
clog its threads.
A non-self-tapping screw is generally superior
at holding bone, except in extremely thin cortical
bone, cancellous bone, and in flat bones such as
those of the face, the skull, and the pelvis, where
self-tapping screws have been shown to have better
holding power.
Experimental evidence has shown that a self-tap-
ping screw can be removed and reinserted without
454 Section 7: The trauma oral
Use of eccentric hole in a dynamic compression •
plate (DCP). There is the potential of 1.8 mm of
glide when two holes are compressed. This pro-
duces 600 N of compression
An external tensioning device•
Pre-bending the plate by 1–2 mm•
Plating the tension side of the bone•
Bridge plate.• In a multifragmentary fracture, the
plate bridges fracture fragments
Buttress. • Usually periarticular, used to buttress
up articular surfaces
Tension band. • Bones are not always loaded evenly
along all axes. If the fracture is fixed on the side
tending to open (tension side) then the tension
forces on one side are converted to compression
forces on the opposite cortex
Types of plate
One-third tubular plates•
DCP•
Low-contact dynamic compression plates •
(LCDCP)
Less invasive stabilization system (LISS) plates•
Locking compression plates (LCP)•
Methods to avoid fracture following plate
removal
Complications following removal of metalwork vary
from 3% to >40%. The main problems include re-
fracture and neurovascular damage. The removal
of forearm plates is most frequently associated with
problems. Causes of re-fracture are now discussed:
Removed screws cause a stress riser in the bone. •
If the size of the screw is 20%–30% the diameter of
the bone, the risk rises exponentially. Thus 3.5-mm
screws are recommended for the forearm
Demineralization of bone under a plate as a result •
of stress shielding or bone necrosis caused by the
plate occluding periosteal blood supply
Re-fracture may occur through an unhealed frac-•
ture site if the plate is removed prematurely
Plates should be retained for at least 18–21 months •
to allow bone density to return to its pre-fracture
level before removal of plates. This allows time for
blood supply to be re-established. Fracture rates
Examination corner
Basic science oral 1
• Variousscrewshandedtocandidatetodescribe
Basic science oral 2
• HandedasmallfragmentAOcorticalscrewtodescribe
• Askedtodrawoutthelagprinciple
• Askedaboutvariousdrillandtapsizes
Basic science oral 3
• Givena pileofvariousscrews(AOtypescrews, awood
screw) and asked to talk about them
• Discussthesize,pitch,type(cortical/cancellous,partial/
fully threaded), core diameter, and the need to tap or not
Basic science oral 4
• Handedvarioustypesofscrews
• Askedtodescribethem
• Whatdoyouthinktheyareusedfor?
• Followed on by discussion of the biomechanics of
implants
Trauma oral
• Screwdesign,etc.
• Basicallydiscussedandpointedoutthevariousfeatures
of a screw
Plates
Plate strength is defined by the formula BH3 (B is
width, H is height or thickness). Increasing the plate
height increases plate rigidity to the power of three.
Plate failure occurs as a result of metal fatigue. A gap
between the bone ends following fracture fixation
increases the risk of plate failure.
Functions of a plate include:
Neutralization• . To protect a lag screw from tor-
sional, shear and bending forces
Compression• , achieved by:
A lag screw through the plate•
Chapter 23: Trauma oral topics 455
Torsional stiffness is inversely proportional to •
working length
Bending stiffness is inversely proportional to the •
square of working length
Therefore, for a long working length the nail bone
composite is less able to resist bending and tor-
sional forces. The working length can vary 1–2 mm
with transverse fractures at the isthmus to the dis-
tance between proximal and distal locking screws in
very comminuted fractures.
Area moment of inertia
This is the resistance of a structure to bending dur-
ing static loading. If an area is considered to be
made up of infinitesimal sections, the moment of
inertia measures the average of the square of the
perpendicular distance that each of the infinitesi-
mal sections is from the axis of bending.
Polar moment of inertia
This is the resistance of a structure to torsion or
twisting. The polar moment of inertia measures the
average of the square of the perpendicular distance
of each infinitesimal section of material from the
axis of torsion.
Torsional rigidity
Torsional rigidity is a measure of the resistance of a
material of a particular size and shape to torsional
forces.
Proportional to 1/length – doubling the length •
decreases rigidity by a factor of 2
Proportional to the fourth power of the radius • –
doubling the radius increases rigidity by a factor
of 16
The • rigidity or stiffness of a cylindrical structure
in bending and torsion is proportional to the
fourth power of the radius (r4; bending) (Young’s
E measure of stiffness)
The • strength in bending is proportional to the
third power of the radius (r3; breaking)
The relationship between stiffness and strength
is not a simple one. Both factors are related to the
drop with later plate removal. The forearm should
be protected for 6 weeks following removal of a
plate
Fracture with initial comminution•
Plating with 4.5-mm DCP•
Examination corner
Trauma oral 1
Plates: types of plate, uses, differences, strength, effect of
making holes in the bone, stress risers, oval versus square
hole, principle of tension band wiring.
Basic science oral 1
• Whatisbiologicalplating?
• Causesofplatefailureinafracture
• Whathappensifyouleavescrewholesemptyinaplate?
• Isthereadifferenceiftheemptyholesarelyingagainst
the bone or lying against the fracture?
Basic science oral 2
LCDCP
• Materialusedandprinciplesoftheplate
Trauma oral 2
Radiograph of patella fracture
• Questionsontheprinciplesoftensionbandwiring
Biomechanics of intramedullary nails
A nail functions as a form of internal splint, which
stabilizes long bone fractures with minimal damage
to the surrounding soft tissues.
Working length
This is the length of a nail between the most distal
point of fixation in the proximal fragment and the
most proximal point of fixation in the distal frag-
ment. More simply put, it is the unsupported por-
tion of nail between the bone fragments.
456 Section 7: The trauma oral
Discussion
Current management of an infected femoral intramedul-•
lary nail at 2 weeks post surgery
General discussion about osteomyelitis•
Cierny classification of osteomyelitis including condition •
of the host, functional impairment caused by the disease,
site of involvement and extent of bony necrosis
Draw different types of traction•
Principles of how traction works•
Management for the hip and knee•
Investigation of osteomyelitis•
Trauma long case 2
The patient was male, about 28 years old. He had sustained
a compound fracture of the right distal femur and a closed
comminuted fracture of his right tibia 18 months previously.
These fractures had been treated with an Ilizarov frame
fixation.
His main problems now were a leg length discrepancy of
4 cm in the right leg and a stiff but relatively painless right
knee.
Difficult historian, not sure why he was in hospital and
what else was going to be done with his leg.
Examination included:
Gait•
Leg length measurements•
Assessment of rotation•
Examination of the knee including collateral and ACL •
ligaments
Trauma long case 3
History
Mr Brown is a 48-year-old married farmer with two chil-
dren. He sustained a severe Lisfranc injury to his right foot
3 years ago, which was not anatomically reduced at the
time of his injury. He now presents with a history, over
several months, of progressively worsening pain and stiff-
ness in this right foot. He has difficulty with shoe wear, par-
ticularly wearing his wellington boots. He is taking regular
analgesia, up to eight paracetamol a day and ibuprofen
400 mg three times a day.
His sleep is disturbed most nights•
He has an unremarkable past medical history•
He has had no other operations•
diameter of the nail. As nails get a bit stronger they
get considerably stiffer. Very stiff nails may damage
bone if there is any discrepancy between the shape
of the nail and that of the bone.
Nail diameter is the principle factor that alters
bending stiffness. The cross-sectional shape also
affects bending and torsional stiffness. A slot is the
principle factor that alters torsional stiffness. A slot
has little effect on nail bending stiffness but a non-
slotted nail is 40× more stiff in torsion. A slot reduces
torsional stiffness by 98%.
Examination corner
Trauma oral 1
Biomechanics of intramedullary nails
• Areamomentandpolarmoment
• Workinglengthofanail
• Effectofreamingontheworkinglength
Trauma oral 2
Radiograph of a patella fracture
Questions on the principles of tension band wiring
Examination corner
Trauma long case 1
Mr Jones is a 59-year-old retired joiner, married with 3
children.
The presenting complaint was of a left femoral mal-un-
ion with an external rotational deformity and shortening
secondary to RTA and fracture 30 years previously.
The femur was treated with intramedullary nailing at
the time, which became infected. There was subsequent
removal of the nail and traction for 6 months.
Multiple sinuses. Recurrent osteomyelitis and abscesses.
Current problem now is of a degenerate arthritic knee
with FFD 40°, hip and thigh pain.
Examination of the left knee included:
Demonstration of FFD knee•
Lachman’s test•
Varus/valgus instability•
Chapter 23: Trauma oral topics 457
• On examination; describe scars, frame, sinus
LLD: blocks, Galeazzi, test, tape measure, role of CT•
Discussion: management of the initial fracture; is it safe •
to nail a 3b tibial fracture and in the middle of the night?
Exchange nailing for infected tibial non-union versus •
circular frame
What to do now•
Miscellaneous trauma oral questions
It is impossible to cover every possible trauma oral
topic that could be asked in the FRCS Orth exam
in detail. Below however are some less well known
questions that candidates may be asked.
It is easy for these trauma questions to be read
very superficially and then the whole process can
become a pointless exercise consisting of a very
long list of possible trauma topics that the examin-
ers could ask. Imagine yourself in the trauma oral
having to talk around each topic for 2–3 minutes.
For example with the T12/L1 fracture subluxation
a candidate will almost certainly be shown a radio-
graph demonstrating the condition. They would
need to describe the radiographic abnormalities
present. This will be a severe injury with disrup-
tion of all three columns of the spine with a high
incidence of associated neurological deficits. The
majority will probably require surgery.
ATLS, assessment for associated injuries, mecha-•
nisms of injury, imaging
Denis three column concept•
What are the indications for surgery?•
Do the indications for surgery differ if there is a •
complete neurological deficit?
What type of surgery is required?•
What approach is to be used for the procedure? •
(You should be able to describe the anterior, pos-
terior or thoracoabdominal approach to the lum-
bar spine fully to the examiners if asked)
Advantages and disadvantages to each approach
The point being it is very easy to superficially glance
over these questions without thinking about how it
will run in the examination. Make sure you actively
think through the following questions with due care
and preparation rather than a passive read through
of the list.
• He denies any history of asthma, tuberculosis, angina,
hypertension, myocardial infarction and epilepsy
He is otherwise fit and healthy•
Examination
On examination he looks well for his age•
He is a tall, well-built individual•
There is a plantar deformity of the first ray and degenera-•
tion of the tarsometatarsal joints
Discussion
Discussion concentrated on the classification of Lisfranc •
injuries and the associated patterns of injury
Early management•
Early and late complications•
Trauma long case 4
A 43-year-old lady previously fit and healthy, who had an
RTA 6 months previously.
She sustained a posterior dislocation of the hip and exten-
sive lacerations of the ipsilateral knee with an ACL rupture.
Examination of the knee included :
Demonstration of an effusion•
Lachman and Pivot shift•
Apley’s grinding test•
Explain the pathophysiology of the Pivot shift•
Discussion included:
Classification of hip dislocations•
Management of an acute hip dislocation•
Identification and classification of Pipkin’s fracture/•
dislocation
Complications of hip dislocation and their incidence•
Investigation and management of AVN•
Description of the surgical approach and fixation of an •
acetabular wall fracture
Management of the ACL-deficient knee: the role of phys-•
iotherapy and bracing
Trauma long case 5
Middle-aged man. Infected tibial non-union with leg still in
external fixator. Open comminuted tibial fracture managed
initially with IM nailing and then severe infection occurred
leading to nail removal and external fixator
History: RTA, initial management •
458 Section 7: The trauma oral
Trauma oral 4
Bone screws: describe them, what do you think they are •
for? The biomechanics of implants
Radiograph of a fixed-angle trefoil device for intertro-•
chanteric fracture fixation put in badly, why did this fail
and what would you do about it?
Radiograph of the elbow of a radial head fixed with •
mini fragment screws and a plate. Discussion of Essex–
Lopresti injury
Radiograph of paediatric hip fracture: classification, •
management, AVN
Fracture subluxation of knee: classification, manage-•
ment of knee dislocation, arteriography, ligament
reconstruction
Trans-scaphoid perilunate dislocation•
Trauma oral 5
Infected femoral nail•
Segmental femoral fracture including co-existing femo-•
ral neck fracture
Calcaneal fracture: types, classification, surgical •
approaches, complications
Removal of forearm plate: risks, literature, the Henry •
approach
Humeral atrophic non-union with K nail protruding into •
cuff muscles of the shoulder: management
Tibial hypertrophic non-union: management•
Displaced patellar fracture: principles of tension band •
wiring including drawing out a diagram to explain
Trauma oral 6
Monteggia fracture•
Periprosthetic supracondylar fracture of the femur: pros •
and cons of conservative versus surgical management
Hamilton Russell traction. “• Draw me Hamilton Russell
traction for a femoral fracture”
Principles of cast bracing•
Crush injury of the foot•
Lisfranc fracture/dislocation: management and types, •
importance of the second metatarsal bone, assessment
of reduction, prognosis
Foot compartments and releases for compartment •
syndrome
Examination corner
Trauma oral 1
T12/L1 fracture subluxation•
Comminuted closed intercondylar fracture of the distal •
femur
Os calcis fracture•
Fractured tibia: management options•
Fracture dislocation of the elbow•
Mid shaft clavicle fracture in a young adult >2 cm over-•
lap. How do you manage it? Why do we operate on these
fractures? Complications of surgery. What type of plate
to use. Approach and surgical dissection. If it goes onto a
non-union after surgery how do you manage it?
Trauma oral 2
High-energy open fractured distal femur in a young •
female with vascular compromise: management
Compartment syndrome: basic science and theory•
Severely comminuted, closed, distal radius fracture in •
the dominant hand of a young patient
Management of a closed intercondylar fracture of the •
distal femur
Haemarthrosis: radiographic findings in dislocation of •
the elbow
Osteochondral fragment in a child’s knee: management •
and surgical approach
Monteggia fracture: Bado classification and management•
Stress fracture of the metatarsal•
Trauma oral 3
Clinical photograph of soft-tissue/degloving injury of the •
lower leg: management
Compartment syndrome of the lower leg: everything, •
including incisions for fasciotomy
Soft-tissue coverage – flaps, grafts, etc.•
Compound tibial fractures•
Gustillo classification of open fractures•
Distal radial fractures•
RSD•
DHS: modes of failure•
Four-part unstable intertrochanteric fracture of the •
femur. What are the management options for fixation
and biomechanics of the fixation devices?
