Introduction

Musculoskeletal injuries comprise over one third of all trauma. That is why orthopaedic injuries occupy a sizeable part
of this text.
Fractures are described according to (Fig. 13.1):

• which bone

• which part of that bone (proximal, middle, distal)

• fracture pattern/direction (oblique/spiral, transverse (pathological), segmental or comminuted).

• then displacement/alignment of the position of distal fragment as tilt (angulation), shift (% end-to-end
contact) and twist (rotation - maybe hard to assess but often important).

• whether nearby joint involved

• associated factors (dislocation, open fractures etc.)

The mechanism of injury is useful to know to assess the "personality" of the fracture and so treatment (e.g.
compression forces result in angulated or T-type fractures; rotational forces in spiral fractures; traction injuries in
avulsion fractures).

Essential orthopaedic references include:

• WorldSurg, www.worldsurg.com

• Wheeless' Textbook of Orthopaedics, www.medmedia.com

• Manual of Internal Fixation

• Principles of Fractures and their Treatment

Open fractures
These fractures communicate with the skin and should be handled with extreme care as contamination and soft
tissue disruption may result in disaster. Formal, thorough debridement with irrigation (normal saline), preferably
pulsed should be performed within eight hours of injury. Otherwise serious infection may result.
The basic steps to the management of open fractures are:
1. Debride the soft tissues and debride the bone.
2. Stabilize the soft tissues and stabilize the bone;
3. Reconstruct the soft tissues and reconstruct the bone.

First or second generation cephalosporin and an aminoglycoside should be given for 48 hours. Use of penicillin
should be considered for barnyard or clostridial infections. Also appropriate immobilization and fixation is required.
See Chapter 00.

Gunshot wounds are open fractures (see Chapter 00 and appendix 00). The resultant soft tissue disturbance and
bone destruction is usually based on the velocity of the bullet. For instance the relative low velocity of handguns
causes the least soft tissue destruction. Treatment usually consists of entry and exit wound debridement. The high
velocity of military rifles causes massive soft tissue destruction, which requires stage II debridement of the entire
missile track. Intra-articular bullets should be removed as these may cause lead intoxication. Beware of arterial injury.
Signs include diminished pulses and haematoma. An arteriogram should be sought.

Life threatening conditions

A.T.L.S. guidelines should be followed. If these guidelines are applied preventable death has decreased markedly -
from 14% to 3%. See Chapter 00

Concept of the golden hour

The causes of adult trauma include gunshot wounds, road traffic accidents, stabbings, industrial accidents, sport,
recreational and domestic accidents. First stabilize - ‘life before limb’.

Do not delay surgery but make sure everything is ready and optimal (metabolic and cardiopulmonary status, the team
is available, equipment and your plan). Then - assess the associated bone trauma once the patient is stabilized.

Orthopaedic procedures
X-rays are important to assess bony and soft tissue trauma. Obtain standard AP and lateral x-rays with joints above
and below the fracture. Appendix 00 shows the full list of x-ray views. For peri-articular fractures, oblique views are
useful. Tomograms (a cross section ‘slice’) are helpful. MRI provides excellent three dimensional images but is
expensive and is best reserved for spinal work. CAT scans are useful for most injuries except spinal, pelvic and
calcaneus. Bone scans will 'find" injuries including stress fractures and are also useful in child abuse screening

Reduce the fracture

The inexperienced often agonize over which fractures to reduce, how to reduce them, in what position to hold them
and how to hold them. In principle a displaced fractured often needs to be reduced . The best position is the original
anatomic position (if possible). And the best way to hold the reduction is the simplest method (usually plaster of Paris,
POP).

Having said that there are a lot of difficult fractures (multiple, pathological, open, comminuted, into joint and involving
growth plates), under difficult circumstances (war or simply no proper equipment, hospital, staff), with difficult patients
(obese, unwell, unreliable, drug addicts).

Technique of closed reduction for e.g. Colles fracture (Fig 13.2):

Functional bracing
An excellent way of treating selected fractures of the tibia, humerus, ulna developed by Sarmiento (1999), which
allows nearby joints to move. Indications in foot note .
Relative contraindications (1) selected diaphyseal tibial fracture with an intact fibula; fractures in poly-trauma who
cannot use an aid to walk; (2) axially unstable fractures with initial shortening >12mm where length has been restored
by traction unless patients are kept from weight bearing for a period of time to allow stability to develop.

Humeral shaft fracture

For: closed diaphyseal fractures without marked distraction between fragments; closed fracture associated with radial
nerve palsy similar to above; open fractures without significant soft-tissue injury.

Relative contraindications: bilateral humeral fractures; polytrauma where not able to ambulate with support.

Isolated ulnar fracture

For: isolated shaft fracture without displacement; type 1 &11 open fracture as above; no dislocation of proximal
radius; bilateral closed ulnar fracture without polytrauma.

Relative contraindications: open fractures with a lot soft tissue injury; where dislocation of radial head

Sarmiento 1999 Functional Fracture Bracing J. AAOS 7 p66-75

Technique to apply traction

See appendix 00.

Reduction maybe closed (manipulate/apply traction or open usually with internal fixation i.e. ORIF). Hold either
externally with POP, functional brace, splint , external fixateur or internally with plates, screws, nails. Joint surface
involvement demands near-an-atomic reduction [< 2mm]. Consider age and state of the wound and pre-injury
function.

Immobilization
Immobilization decreases movement at the fracture, prevents displacement and relieves pain. Achieved by traction,
internal and or external fixation, splinting, functional bracing, casting, orthotics.

Preserve function
Ultimate goal is rehabilitation. See Chapter 00.

Orthopaedic complications
May result from the injury or other organ systems. Include bone healing problems usually due to limited healing
potential from limited or disturbed blood supply. Caused by infection or inadequate fixation, inadequate blood supply,
excessive space between fracture fragments, too much or too little motion at the fracture site, soft tissue interposition,
delayed union (where free movement of bone ends >4 months after injury/beginning of treatment), nonunion (free
movement >6 months).
Classified as hypervascular (hypertrophic) or avascular (atrophic) based on their biologic reaction. Treatment includes
injection of bone marrow or other osteo-stimulating materials, more secure internal fixation, excise gap tissue, apply
compression across gap, bone graft, electrical stimulation, and prosthetic replacement.

Malunion (heal in a 'crooked' position)

May result from management problem or unavoidable. Causes shortening where overlap. Treatment means
correction-ostetomy .NB shortening can also result from bone loss or growth plate injuries.

Avascular necrosis (AVN)

Bone death. Seen in intra-articular fractures especially of the femoral head/neck/ femoral condyles/ proximal
scaphoid/ talar neck and proximal humerus. From disruption of the blood supply. AVN causes nonunion, may lead to
OA and collapse

Infection
Possible complication of open fractures (immediate and adequate debridement of all open fractures is essential - both
initially, and again if infection becomes apparent). Watch for ‘fight bites’ and the bites of cats or dogs. Symptoms are
persistent pain, stiffness and progressive, concentric joint space narrowing. May result in severe pain, systemic
disturbance or become life threatening.

Beware of tetanus caused by clostridium tetani which flourishes in dead tissue (an exotoxin which passes to the
CNS). Avoided by early toxoid boosters and extreme care. Signs and symptoms are contractions (jaw asphyxia).
Treatment includes→and facial muscles then diaphragm, intercostals IV antitoxin /heavy sedation with a muscle
relaxant/ tracheal intubation, if necessary.

Gas gangrene
Due to clostridium species or, in rare cases, a G. streptococcal infection. Severe symptoms within 24 hours include a
foul smelling, serosanguinous brown discharge, oedema, progressive pain, ultimate toxaemia and coma. A life
threatening condition.
Treatment includes penicillin G, 20 million units per day in adults, and clindamycin, hyperbaric oxygen, and
amputation if advanced.

Toxic shock syndrome

Caused by gram-positive bacteria superinfection results from toxaemia not septicemia. Symptoms (severe) are fever,
hypotension, an erythematous macular rash, systemic disturbance and serious exudate (Gram +ve cocci). Treatment
requires I & D ASAP plus IV antibiotics/+IV fluid.

Necrotizing fasciitis
An aggressive, life threatening fascial infection usually with an underlying vascular disease (e.g. diabetes). Often
associated with streptococcal gangrene and polymicrobial with both aerobes and anaerobes). Treatment is: wide
surgical I &D/IV antibiotics
Acute osteomyelitis
May develop into chronic osteomyelitis. Occurs in metaphyses or epiphyses of long bones. Staph. aureus is the most
common organism. Symptoms include pain/loss of function, +/- soft tissue abscess with soft tissue swelling,
demineralization, +/- sequestra/in the latter stages- involucrum. Treatment is to identify organism, select and give
appropriate antibiotics, halt tissue destruction.

Soft tissue (direct/indirect injuries to nerves/ vessels/soft tissue)

Key points

• Determines final function.

Injuries are:

• arterial: rare but devastating. Seen with shoulder dislocations, knee dislocations, and supracondylar elbow
fractures. Repair, if necessary, within 6 hours. Fasciotomy may be required. See Chapter 00.

• Nerve injuries, uncommon, most injuries are neuropraxias from stretch (>70% heal within 6 weeks). See
pages 00

• Compartment syndrome: pressure can lead to serious sequelae. Further risk with use of antishock
garments.

Key points

• Compartment syndrome is most common following serious injury to the forearm and/or leg.

Symptoms include pain ( with active and passive movement of muscle involved), paraesthesia, and much later (too
late)-pallor, paralysis, pulselessness

See Chapter 00.

Treatment includes fasciotomy within 48 hours (to avoid muscle necrosis) and judicious muscle debridement for any
ischaemic muscle lacking the capacity to bleed or contract.

Pulmonary complications

• Pulmonary embolism; the most common pulmonary complication. Requires: intermittent pneumatic
compression, low-molecular-weight heparin and warfarin.

• Adult Respiratory Distress Syndrome (A.R.D.S.): from aspiration/inhalation or from shock/sepsis. Hallmark is

pulmonary oedema/ pulmonary function, made worse by prolonged hypovolaemia and left ventricular
function. A.B.G is useful. Treatment is with ventilation with P.E.E.P.
 • Fat embolism: a a form of A.R.D.S. which usually follows cases of multiple fractures, mostly the long bones.
Results in changes in chylomicron stability and conversion to free fatty acids in the lung tissue. Symptoms,
within 72 hours, are:tachycardia, hyperthermia, tachypnoea, hypoxea and change in mental state
(confusion). Treatment includes: stabilization of the bony injury (the earlier the better, especially for pelvic
fractures) and pulmonary support (steroids may help).

Bleeding disorders
Excessive bleeding can cause hypovolemic shock and disseminated intravascular coagulation (shock= the

manifestation of tissue perfusion). It causes: pale & cool extremities/oliguria/tachycardia

Diagnoses of D.I.C. is made by noting antithrombin III, fibrinogen and values of PT/PTT and fibrin split
products.
Treatment includes: immediate whole blood, I.V. fluids, dextran solutions, treat underlying cause, cautious use of
heparin, platelets and DDAVP as excessive anticoagulation can lead to bleeding into the soft tissues. Avoid albumin.
Incresed swea

G.I. complications (either the result of trauma or a complication).

Include stress ulcers, cast syndrome(from compression of the 2nd part of the duodenum by the superior mesenteric
artery, with small bowel obstruction and projectile vomiting; seen with spine fractures in POP).

Treatment: remove cast and place nasogastric tube.

Reflex sympathetic dystrophy (also known as complex regional pain syndrome type 1) .

This is a neurological disorder after trauma, surgery or immobilization. There is intense pain, a vasomotor
disturbance, increased sweating, slow recovery, dryness, swelling, osteopaenia, and skin changes. Said to be caused
by a sustained efferent sympathetic activity locked into a reflex loop. Used to be called causalgia. Lankford and
Evans have described 3 stages:

• Acute. Onset within 3 months, there is pain, swelling, redness, ROM, and sweating. X-ray is normal.
Three-phase bone scan is positive.

• Subacute. Onset 3 to 12 months. pain, blueness, dryness, stiffness, skin atrophy, osteopaenia

• Chronic. > 12 months. pain, fibrosis, dry and cool skin, stiff joints, extreme osteopaenia.

Diagnosis is made on 4 main signs (large amount of pain, swelling, stiffness, discolouration). Use thermography,
xrays, and bone scan.
Treatment. Make early diagnosis. Use Physeiotherapy (ROM, fluidrotherapy and TENS). Sympathetic nerve blocks-
chemical (four of the stellate ganglion) or if unsuccessful then surgical (after > 6 months). Also add- N.S.A.I.Ds and
psychological help.

Late complications

• Myosotis ossificans. Occurs where large haematomas, as late as 6months post injury.

• Post traumatic OA

• Commonly follows intra-articular fractures (if not anatomically reduced). Treatment is adult reconstruction.

• Immobilization hypercalcemia. Rare. Seen after children and in Paget’s disease. Symptoms are nausea,
vomiting, severe abdominal pain and acute personality changes

• Heterotopic ossification. Seen after acetabular fracture surgery and in head injuries. Treatment is with
indomethacin and irradiation

Key points

The essential long-term goal of all orthopaedic trauma care is to avoid/minimize the development of secondary OA.

Soft tissue trauma

Important. May be severe or life threatening. Occurs with initial bone trauma then subsequently care.

• Thermal burns: freezing injuries, burns, electrical shocks, burns, chemical burns, chemotherapeutic
extravasation. See also chapter 00. Treatment is symptomatic, avoid infection, and sometimes amputation
(with electrical injury).

• High pressure injection injuries. From accidental injections (paint or grease guns) with resultant tissue
necrosis or fibrosis. Treatment is IV antibiotics, I&D plus steroids.

• Snake bites

May produce extensive soft tissue destruction often leading to compartment syndrome.
See chapter 00.

Principles of ORIF (Open Reduction and Internal Fixation)

Not all surgical details included here; only for common operations and as needed for inexperienced
clinicians/surgeon; some cases e.g. anterior acetabular fractures should probably only be done by an experienced
pelvic surgeon who would not need this book.

The AO school has worked out the principles of ORIF. "The Manual of Internal Fixation" is essential reading .

Key points
 • Fractures which are almost always treated by ORIF: pathological (especially tumours); femoral in adults and
femoral neck in children; polytrauma and where nursing diffculties (elderly and multiple injuries).

• Fractures almost never treated ORIF: most children's fractures; tibial shaft non-displaced; those of the
unreliable and the disturbed (interpret as you will).

The following fixation devices are commonly used. Pre-operative planning is essential as well as a thorough
knowledge of the local anatomy, mechanical demands and injury characteristics. See Appendix 00 for surgical
approaches, p. 00

Fixation devices (Fig 13.3)

• plates/screws: Lag screws are often used with compression plates (basis for AO technique). Compression of
the fracture is achieved by overdrilling the proximal cortex.

• compression plate(DCP):used on the tension side of transverse or short oblique fractures. They provide
stability and act as "a load sharing device" .

• reconstructive plates: useful for pelvic and distal humerus fractures. They are pliable and allow positioning
for use as a neutralization plate.

• intramedullary fixation (IM nails);old technique but still commonly used and successful method of fixation for
lower limb diaphyseal fractures .Allow early WB/place with a closed technique/allow good axial alignment
but canal diameter can limit size of nail used/disrupts endosteal blood supply/may cause embolism/may
need to lock to achieve rotational control/remove after 12 months.

• IM pins: reaming not required; may also be used in children (e.g. Nancy Nail from Landos).

• external fixation: useful for Grade 111 open tibial fractures. Where risk of infection for ORIF/allows
access to wound. Also for ant disruption pelivis/distal radial fractures.

• special devices: many, most useful are dynamic hip screws, a load sharing device allowing screw insertion
at various angles, most useful for femoral neck fractures; cannulated screws, very useful, for a variety of
fractures, especially femoral neck fractures, use guide wires; DC screw sideplates, useful for unstable
subtrochanteric fractures and distal femur fractures; tension band wiring, allows fixation on the tension side
and so relies on motion to promote union on the compression side, parallel K-wires placed close to the outer
cortex with cerclage wire under these before being tightened to apply compression, use for patella and
olecranon fractures.