FRACTURES

Dr Jack Marjot
Assembled from multiple sources in 2022-2023.
Major references: Dunn EM online manual, Therapeutic Guidelines, RCH Melbourne, ACI (NSW), LITFL,
UpToDate, OrthoBullets, Radiopedia, Pocus101, Radiology Masterclass
Standard disclaimer
Most of the original text/graphics are compiled from other resources; all credit to those
resources, I claim no ownership of that material
Please do not copy and re-distribute
Special mention to Dunn online manual - please consider subscribing if you are using these
notes
It was up to date to best of my knowledge in 2022-2023
I didn’t write it for public consumption so apologies if there are errors, typos, or any of the
mnemonics are rude
It’s a summary not a full curriculum
This is not a peer reviewed resource and is not for direct application into clinical practice,
including drug doses etc
Please use this 'Feedback' link to let me know if there are errors or updates, so I can
correct

Hand bones:

4+4
trapezium is under the thumb (articulating with the first metacarpal)
trapezoid is inside (surrounded by four other bones)

Foot bones:

Named fractures

Jeffersons # C1 (atlas) burst # from axial loading injury

Fracture of anterior + posterior arches

Hangman's # Bilateral # of C2 pars interarticularis

From hyperEXTENSION
C2 displaced anteriorly on C3

Clay-Shoveller's # C-spine spinous process #

From flexion
C7 > C6 > T1
D
rJ
ac
k
M

Chance # Thoracolumbar flexion-distraction injury

Complete # through all 3 columns
Seat-belt injury, often aw intestinal/mesenteric injury
ar
jo
t

Maisonoeuvre # Proximal fibula # + unstable ankle injury:

Proximal fibula # AND:
+ tear of the distal tibiofibular syndesmosis + interosseous
membrane
+ medial ankle injury (medial malleolus # / rupture of deltoid ligament)
Due to external rotation of foot

Segond # small avulsion fracture of the proximal lateral tibia

associated with severe internal disruption of the knee
Sports injury
Almost always a/w ligament damage - ACL+ medial meniscus + lateral
collateral

CF lateral tibial plateau #

ACL
Medial meniscus
Medial collateral

Pilon # Distal tibial # involving ankle articular surface (tibial plafond #)

Often comminuted & a/w other ankle #s
Axial loading injury (e.g. fall from height)

Dont confuse with Segond #

Associated #s (fall from height):
Calcaneus #
Pilon # dital tibia
Tibial plateau #
NOF #
Acetabular #
Lumbar spine #

Tillaux # Avulsion # of tibia by distal tibiofibular joint

Most common site of a Salter-Harris type III fracture

Toddler's # Undisplaced spiral fracture of the tibial shaft

Occurs in 1-3 year olds
Often not visible on XR in first week
Treat clinically and repeat Xrays in 7-14 days if initial XR normal
Treatment
-analgesia
-weight bear as tolerated
-backslab / walking boot if pain severe
-orthopaedic FU in 2 weeks
Bankhart lesion Avulsion of anterior glenoid labrum
From shoulder dislocation

Hill-Sachs lesion Compression fracture of the humeral head

(on the hill of the From shoulder dislocation
humeral head)

Night stick # Isolated mid-shaft ulna fracture

Usually undisplaced
Direct Injuries: defence from being hit with a nightstick
Mx: cast

Colles # Transverse fracture distal radius

4 cm proximal to the wrist
dorsal + radial angulation
dorsal displacement

Smiths # Distal radius fracture

(inverse Colles) Volar displacement & angulation
Usually extra-articular

Bartons # Distal radius #

Intra-articular
With dislocation of the RADIO-CARPAL joint in the direction of the fracture
fragment.
Either:
Dorsal lip of distal radius (Dorsal Barton's #)
Volar lip of distal radius (Volar Bartons' #) - commoner

Torus # Buckle injury of distal radius

Paediatrics
D

Chauffer / Radial styloid fracture (wrist)

rJ

Hutchinson #
ac
k
M

Dequervain’s common sheath containing

tenosynovitis Extensor pollicis brevis
Abductor pollicis longus
ar
jo
t

Bennett's # Fracture dislocation of base of thumb MC

+ Dislocation carpo-metacarpal joint of thumb
Needs ORIF

Rolando's # 3 part fracture at base of 1st metacarpal

Needs ORIF

Boxer's # # of 5th MC neck

Volar displacement of MC head

Rarely requires reduction

Do not attempt to reduce the fracture unless significant deformity
Angulation > 45°
Otherwise just buddy strap 4th + 5th, or ulnar gutter cast, then hand FU

Metacarpal Acceptable angulation

10% for 2nd MC
20% for 3rd and 4th MCs
30% for 5th MC.

Skiers thumb Hyper-abduction injury of the MCP joint

Ulnar collarteral ligament of 1st MCPJ ligament seperates from base of
proximal phalynx of thumb
May need surgical repair

Lovers triad Lover’s triad (jumping out of bedroom window)

calcaneal fractures
lumbar compression fractures
forearm fractures

Lisfranc # Tarsometatarsal fracture dislocation

Disruption to articulation medial cuneiform + base of 2nd MT
≥1mm gap between 1st and 2nd MT
Mechanism:
Direct – compressive force, crush injury
Indirect – axial load through a plantar-flexed ankle
 March # Stress # of second MT

Jones # Transverse # of base of 5th MT

Jones fracture needs to be NWB

This is in contrast to tuberosity avulsion # which can WB
So need to be careful when you interpret the XR

Holstein-Lewis A spiral fracture of the distal one-third of the humeral shaft

fracture Often radial nerve injury

Osgood- Traction apophysitis at tibial tuberosity

Schlatters

Perthe's Avascular necrosis of the femoral head

5-10yo boys
Reduced ROM and leg shortening
joint effusion: widening of the medial joint space
asymmetrical femoral epiphyseal size (smaller epiphysis on the affected
side)
increased density of the femoral head epiphysis
D

fragmentation of femoral head

Small, dense, fragmented epiphysis, in a bigger joint space
rJ
ac

SCFE >10yo, fat boys

A/w hypothyroidism
Distruption of line of Kline (should normally transect some of the epiphysis)
k
M
ar

Sever's disease Traction apophysitis of the calcaneus at site of insertion of Achille's tendon
jo
t

AVN bones Femoral head

Knee (distal femoral + proximal tibial)
Talus
Scaphoid

Dislocations

Knee Anterior (tibia forwards)

Complications: CLAP-FC
Common peroneal nerve
Ligaments
Amputation
Popliteal artery
Fractures
Compartment syndrome

Hip 90% Posterior

10% anterior

Avascular necrosis can develop within 6 hours stressing the need for prompt
identification and reduction
Hip Exam
Posterior Dislocation: flexed, adducted and internally rotated
Anterior Dislocation: mildly flexed, abducted and externally rotated
Special Considerations
Complete a full trauma survey given frequency of associated injuries
Most common associated injury = acetabular #
Complete a full neurovascular exam
Sciatic nerve injuries occur in up to 10% of cases.
Check dorsiflexion of the ankle and large toe

Posterior:

Flexed, ADducted, internally rotated

(Cf NOF# which is externally rotated)

Dashboard injury (axial loading of hip in flexion)

Complications of posterior hip dislocation:

Acetabular # (common)
Femoral head #
AVN femoral head
Sciatic nerve

Always do a post-reduction CT to check for associated # if traumatic dislocation of the

native joint

Anterior:
EXtended, ABducted, EXternally rotated

femoral artery / nerve damage

Reduction techniques
Captain Morgan
Place your bent knee just distal to the patient's knee
Lift up under their knee with one hand whilst pushing down on their lower leg with the
other hand, using your knee as a pivot.

Allis Maneuver
Hold leg below knee and flex to 90 degrees applying upwards traction in line with femur

Stimpson
Place the patient in a prone position with the legs over the side of the bed in 90 degrees
flexion. Place downward traction on the leg in line with the femur.

Shoulder Anterior dislocation mechanism due to:

anterior Force/blow to abducted and externally rotated +/- extended arm (ie. Blocking
dislocatio basketball shot)
n

Immobilisation
<30 - 3 week immobilisation
>30 years old, the rate of redislocation is lower and early mobilization (after one
week) is needed to limit joint stiffness
Once dislocated it looks like:
Arm is held in internally rotated and ABducted position
Prominent acromion
 Axillary view: Acromion points Anteriorly

Recurrence rate by age at first dislocation

-12 - 22 years - 66% - 2/3 recur if done before 20yo
-30 - 40 years - 24%
Kocher: traction, external rotation, adduction, internal rotation

Cunningham:
Position: shoulder adducted, humerus not flexed, elbow flexed. Tell patient “shoulders
back, chest out.”
Massage: deltoid + biceps at mid-humeral level
Rock: gently move humerus back + forward

Milch: traction, external rotation, abduction, to above head position

same as Kocher but abduct

Scapular rotation
Modified Stimpson with medial rotation of inferior scapula tip

FU:
Immobilize in sling for 3-4 weeks (older patients 1-2 weeks to avoid joint stiffening)
There is no evidence that any immobilisation reduces recurrence
may be better to immobilise in external rotation
Early mobilisation is probably better

Recurrance:
12 - 22 years - 66%
30 - 40 years - 25%
less likely in older patients
D

Note the is a stimpson technique for both shoulder and hip, both involve joint hanging
over edge of bed

Inferior Luxatio Erecta (Inferior Glenohumeral Joint Dislocation)

shoulder Humerus is trapped underneath the coracoid and glenoid
rJ

dislocatio Very commonly associated with neurovascular injury

n Shoulder held in a fixed, abducted position
Treatment is closed reduction and assessment of possible concomitant neurovascular
injury
High-energy injury - forced hyperabduction of the arm
Associated injury:
brachial plexus injury
axillary artery injury
rotator cuff tears
ac

greater tuberosity #
Reduction
traction-countertraction - similar technique as for anterior shoulder dislocations
OR 2-step: convert to anterior dislocation the reduce the anterior dislocation

Posterior Appearance:
shoulder Arm is fixed, internally rotated, and ADDucted
dislocatio (cf. anterior, that is internally rotated and abducted)
n
k
M
ar

Mechanism:
Electrocution
Seizure
FOOSH onto internally rotated + adducted arm

Clincial appearance:
prominent posterior shoulder
jo

prominent coracoid (as opposed to acromion in anterior dislocation)

cannot externally rotate shoulder
Depalma method
Traction, internal rotation, adduction
Then, maintaining traction and internal rotation, the medial aspect of the upper
arm is pushed laterally, disengaging the humeral head from the glenoid fossa.
t

Kocher: traction, external rotation, adduction

DePalma: traction, internal rotation, adduction
Anterior dis: ABducted + internally rotated
Posterior dis: ADducted + internally rotated

Elbow Elbow dislocation

90% of all elbow dislocations are posterolateral
Brachial artery injury occurs in 10% of elbow dislocations
Ulnar nerve is the most commonly injured nerve – 8-21% of patients

Brachial artery
Ulnar neve
Often a/w medical epicondyle # that can be stuck in joint space after reduction
Always do post reduction XR
Any concern for boney fragments - do CT/MRI

Ankle Normally posterior

Mechanism: force applied to plantarflexed foot (as with Lisfranc)
Often a/w lateral ankle stuff: lateral malleolus #, lateral talofibular ligament injury

Fracture grading

Pelvic # Young-Burgess Lateral compression (LC) - commonest, careful with binder

Classification A-P compression (APC) - open book, internal iliac artery injury
Vertical sheer (VS) - jumping from height, worst prognosis,
most vessel injury

APC all have some degree of symphysis disruption

If you see iliac crest # - think LC

Anteroposterior compression (APC)

Pubic diastasis
SIJ diastasis
APC I: stable
pubic diastasis <2.5 cm
APC II: rotationally unstable, vertically stable
pubic diastasis >2.5 cm
disruption and diastasis of the anterior part of the sacroiliac
joint, with intact posterior sacroiliac joint ligaments
APC III: equates to a complete hemipelvis separation; unstable
pubic diastasis >2.5 cm
disruption-diastasis of both anterior and posterior
sacroiliac joint ligaments with dislocation
Lateral compression (LC)
S+I pubic rami #
Sacral ala #
Iliac crest #
Most common type.
LC I: stable
LC II: rotationally unstable, vertically stable
LC III: unstable

Vertical shear (VS)

S+I pubic rami #
Sacral ala #
Vertical displacement of the hemipelvis

Most severe and unstable type with a high association of visceral

injuries.
VS looks a bit like LC but with the upwards displacement

Stable:

Unstable:

Pelvic # Tile classification Considers:

stability
force direction
pathoanatomy
Less useful than Y-B classification

Ankle # Potts classification Unimalleolar - one malleolus

Bimalleolar - both malleoli
Trimalleolar - both + posterior tibia
Ankle mortise Look at the mortise view of the ankle (not AP)

Mortise is not widened if:

Medial joint space < 4mm
If widening of the mortise (distruption of distal tibio-fibular
syndesmosis) look for proximal fibular injury to suggest
maisonnouvre

Ankle lateral Weber classification

malleolus
(distal
fibular) #

Weber A - boot, WBAT, 1 week #clinic

Weber B - short leg BS, NWB, d/w ortho
Weber C - short leg BS, NWB, d/w ortho
Medial malleolus (isolated) - short leg BS, NWB, 1 week #clinic
Bimalleolar / trimalleolar / #dislocation: reduce + short leg BS +
d/w ortho
Contact ortho for anything that is:
displaced
fibula + medial malleolus # (maisonnouvre)
fibula + suspected medial ligament injury (tenderness on
medial side)
widening of mortice
Only Weber A can WB
Everything else short leg BS + NWB

Ankle With any medial malleolus injury

medial/posteri image the whole fibula (look for Maisonnouvre)
or malleolus Any other injury (boney or ligamentious) is likely to be unstable
Posterior malleolus injury
As with medial malleolus, contact ortho unless truely isolated

Ligament G1-3
injury

Knee tibital Schatzker III is commonest - depression of the lateral tibial plateau
plateau # classification Lateral tibial plateau # is a/w injury to:
ACL
Medial collateral ligament
Assess for NV injury & compartment syndrome
Immobilisation of the knee
NWB
Ortho r/v in ED
Common peroneal nerve most often affected

Paeds tibial Tibial shaft # in all ages high risk for compartment syndrome
shaft #

Reduce a paediatric tibial # if...

Patella Mechanism: direct trauma or rapid contracture of the quadriceps
fracture with a flexed knee
Can lead to loss of the extensor mechanism.
Diagnosis can be made clinically with the inability to perform a
straight leg raise and confirmed with radiographs of the knee.
Treatment is either immobilization or surgical fixation depending on
fracture displacement and integrity of the extensor mechanism.
DDx: bipartate patella
Indications for ORIF:
Disruption of the extensor mechanism (cant SLR)
Articular incongruity with >2 mm of stepoff
>3 mm of separation between primary fracture fragments
Open fractures

Knee Flex knee to 30 degrees then apply varus/valgus stress

ligaments No laxity, just pain = sprain
<1cm laxity and firm end point = partial tear
>1cm and no firm end point = complete tear
Laxity in complete knee extension is worse (normally involves cruciates)

NOF# - Garden classification Intracapsular = more risk of complication (AVN)

INTRAcapsula
r Gardner I&II / young people / intertrochanteric
SCREW (internal fixation)

Gardner III/IV
HEMIARTHROPLASTY
(Consider TOTAL in young person)

NOF# - Evans classification Evans 1-5 SCREW

EXTRAcapsul Worsening comminution and trochanter involvement
ar
intertrochante
ric
D
rJ
ac
k

Intertrochanteric # is EXTRAcapsular

Occult NOF # Up to 30% of patients with occult NOF# have normal XR

MRI most sensitive
M

Femoral shaft Winquist and

# Hansen classification
ar

Paeds Relatively common

jo

femoral shaft fall is the most common cause < 10 years old
# motor vehicle accident is the most common cause > 10 years old
In young children, minimal trauma and twisting injuries during
ordinary play may cause fractures.
High index of suspicion of NAI < 1yo
Hemodynamic instability should raise suspecion for associated
t

injuries (in a child, isolated femoral # shouldnt lead to shock)

Epiphyseal # Salter-Harris The peak age for injury to the growth plate is in the pre- T1 + 2 - conservative (closed reduction if displaced)
classification adolescent growth spurt. 3+ needs ORIF
The Salter-Harris type II fracture is the most common type
(75%) BUT any displaced needs reduction
Distal radial physeal fractures are uncommon in children <5yo
T1 +2
The most common mechanism of injury is a FOOSH + Undisplaced: Below-elbow plaster backslab or removable
hyperextension splint for 4 weeks
Often a/w dorsal displacement of the distal fragment Displaced: Closed reduction and below-elbow plaster
Commonly there is an associated ulna fracture (greenstick, backslab for 4 weeks
physeal or styloid). Reduction is not advisable after ≥5 days of initial injury
Refer to orthopaedics if unable to perform closed reduction

T3+4+5
Refer to orthopaedics - usually requires open reduction and
internal fixation (ORIF)
Urgent referral to ortho
1. Fractures with associated neurovascular compromise
2. Open fractures
3. Salter-Harris types III / IV / V
4. Inability to achieve an acceptable reduction
5. An associated fracture in the same upper limb
Complications
Median nerve injury
SH1

Dear M|E you've broken your epiphysis

SH2

SH 2 - FOOSH + hyperextension, distal radius

SH 3 - distal tibia pulled off by fibula syndesmosis (Tillaux #)
SH 4 - lateral condyle distal humerus (not epicondyle)

SH3

SH4

Lateral condyle of the humerus - fracture through the CAPITELLUM

growth plate

Open # Gustilo-Anderson
classification

Periprosthetic A-B-C
#
Clavical # Neer classification usually occurs after a direct compressive force is applied to the Lateral 1/3:
(lateral 2/3) for the lateral 1/3 shoulder, i.e. after a fall or trauma
2, 4, 5 need operative management - which seems to be the
Class I: stable, conservative ones where the proximal clavicle is displaced upwards
lateral to coracoclavicular ligament ORIF if Neer 2,4,5:
non-displaced Unstable (determined by whether coracoclavicular
supporting ligaments intact ligaments [trapezoid and conoid] are intact)
Class II: unstable, needs ORIF Displaced >5mm
Middle 1/3 most
disruption of conoid and trapezoid ligaments Comminuted
common
upward displacement of proximal fragment Significant clavicular shortening
Class III: intra-articular (ACJ), conservative
intra-articular fracture Otherwise conservative management in broad arm sling
Class V: comminuted Need to also surgical fix a floating shoulder:

Clavicle # - Only 5% of clavicle fractures

medial May be missed on routine clavicle XRs
Consider CT angio if concerned for posterior displacement and
damage to mediastinal vessels

ACJ 1-6 ACJ space is abnormal if:

dislocation > 6 mm
or > 3 mm different between L & R
increased coraco-clavicular distance
normal: 10-13 mm
greater than 5 mm asymmetry (compared to the
contralateral side)
1-3 conservative
4-6 operative

Conservative:
Sling, rest, analgesia
Early shoulder range of motion
Aim for full functional motion by 6 weeks
Return to normal activity by 12 weeks

Clavicle # (distal 1/3) - Neer 1-5

ACJ dislocation - 1-6

Sternoclavicul Anterior: common, no intervention needed

ar joint
dislocation Posterior: high impact mechanism, CT with angiogram to assess for
mediastinal injury, reduction in OT

Posterior = risk of injury to:

trachea
oesophagus
great vessels
brachial plexus

Scapular # Scapula Fractures are uncommon

High energy trauma
90% have outstanding injuries
a/w pulmonary injury, head injury

Humeral neck Neer classification base on relationship of 4 segments Minimally displaced fractures:
(like lateral third greater tuberosity Sling immobilisation (usually broad arm)
clavicle #) lesser tuberosity Encourage early mobilisation
articular surface May need social admission
shaft Complex / displaced: surgical fixation vs arthroplasty

Complications Axillary nerve:

Axillary nerve injury Deltoid patch sensation
Axillary artery - check radial pulse Abduction of shoulder beyond the first 15d
Avascular necrosis of humeral head

Humeral shaft Most # managed conservatively if no NV compromise

U-slab
Need surgery if:
Cant get acceptable position on closed reduction
NV comprimise (not compulsory if radial nerve neuropraxia)
Open #
Also a # of forearm ('floating elbow')
Pathological #

Good Open #
indications NV comprimised
for surgical Cant achieve closed reduction
repair of # Floating joint

Elbow joints lines Anterior Humeral Line:

At least 1/3 of capitellum in front
(supracondylar #)

Radiocapitellar line:
Pass through centre of capitellum
(radial head dislocation)
D

Elbow Loss of equilateral triangle (present in normal + supracondylar) Always XR before reduction (look for joint space fragments)
dislocation
Traction/counter traction with some flexion
Push method:
Firm pressure is applied posteriorly to the olecranon to
bring it distally and anteriorly around the humeral trochlea
rJ

Check post-reduction XR for boney fragments in joint space

Then cast at 90 degrees flexion
ac
k

Look out for injury to BJ-CUM

Brachial artery
Ulnar nerve
Medial epicondyle #
Joint space fragments
M

Coronoid process #

Supracondyla Gartland # NO-AB-CD

r humeral # NOn-displaced
Angulated, Back cortex ok
Completely Displaced
ar

Type 1
1. URGENT orthopaedic review if vascular compromise
detected
2. no reduction needed
3. elbow in 90degrees flexion (not more)
4. above elbow backslab from wrist to shoulder with side
gutters
jo

Needs TRUE LATERAL XR to work out Gartland (look for figure of '8') 5. sling and elevate
6. consider admission for all fractures
Type 2/3
Closed vs Open reduction
Get ortho opinion before reducing in ED
i.e. get ortho involved early in all # and consider admission of all
t

Cold, pulseless hand - urgent reduction in OT (or ED if no other

option)
Warm pulseless hand - little more time to get to OT

Most likely to be damaged:

Brachial artery (15% of T3 #)
AION > radial > median > ulnar
A>R>M
Ulnar nerve injury unlikely in supracondylar #
But commonest injury in posterior elbow dislocation

Elbow Medial - often conservative Mx (a/w elbow dislocation)

epicondyles Lateral - normally surgical Mx (insertion of extensors)

Paeds medial 50% of medial epicondyle fractures are associated with an elbow <5mm displacement of med epicondyle
epicondyle # dislocation. Above-elbow back-slab
Elbow at 90 degrees
Following reduction of elbow dislocation, repeat XR always needed to
check medial epicondyle not stuck in joint space. Any displacement >5mm - d/w ortho

Medial epicondyle only appears at 5 yrs so cant be injured before then

Paeds medial To be distinguished from EPIcondyle #

condyle # Condyle # is intra-articular of elbow joint - needs ORIF
Much less common

Paeds lateral Lateral CONDYLE # Can be Salter-Harris 4 ("through") #

condyle # Intra-articular
Much more common than medial condyle #
15–20% of all elbow fractures in children (most common between 6 and
10 years)

Worry about medial EPIcondyle (esp in elbow dislocation)

But the LATERAL CONDyle is more likely to #

CRITOE Paediatric elbow

CRITOE
1,3,5,7,9,11

Medial epidcondyle doesn't appear until 5 years

After 5 years look for medial epicondyle injury with elbow
dislocation

Suspect avulsion of internal (medial) epicondyle if it is absent but the

trochela ossification is present

Pulled elbow Partial subluxation of the radial head, with the annular ligament Reduction:
slipping off the end of the radius Hyperpronation
Age 1-4yo OR
F>M `
Non-dominant hand
Marked resistance and pain on attempted supination of the forearm.

Pressure over radial head

Whilst supinating and flexing elbow

Examination:
not using the affected limb
elbow in extension and the forearm in pronation
distressed only on elbow movement
no swelling, deformity or bruising of the elbow or wrist
on palpation tenderness is usually absent
marked resistance and pain with supination of the forearm.
Diagnosis
Clinically established with a classic history and examination.
Plain radiographs are indicated when a differential diagnosis is suspected:
significant tenderness, swelling, bruising or deformity
reduction fails
Treatment
Perform a reduction manoeuvre
expect distress and pain
a click may be felt over the radial head
review after ten minutes
if reduction fails, consult with senior medical staff

Radial head # Mason criteria Commonest elbow # in adults Ortho r/v:

Intra-articular
A/w collateral ligament damage + other boney injury
Look for other injury further down the arm
XR may just show fats pads
Treatment may be nonoperative for non-displaced fractures
Operative management is indicated for displaced fractures /
mechanical block to motion / instability
Mason Type I – Nondisplaced fractures (displacement ≤2mm)
Mason Type II – Displaced fractures >2mm
Mason Type III – Comminuted fractures
Mason Type IV – Radial head fracture with associated elbow
dislocation. Conservatively Mx if:
< 1/3 of articular surface involved
< 3 mm of displacement
< 30 degrees angulation
This usually equated to Mason 1 - isolated minimally displaced
fracture with no mechanical block.

Shaft of All require urgent ortho r/v Needs long arm cast
radius / ulna (except isolated distal 1/3 ulnar / nightstick)
Look for associated #/dis of other bone
Fracture is at Monteggia # Monteggia fracture-dislocations can be easily missed on x-ray. For both Monteggia and Galeazzi, ALWAYS NEED REDUCTION
the thickest (Bado If an ulna fracture is present, always look for a radial head dislocation. Adults: ORIF
end of the classification) Bado classification Children: closed reduction
bone
Dislocation is MUR - Monteggia = For children, the reduction usually takes place in OT under GA
at same end Ulnar # (proximal Reduction is urgent
as # 3rd), radial
dislocation @ elbow Normal ED management is to splint the # without reduction and
talk to ortho
Urgent reduction but speak to ortho first - ? need to be done in
OT

MUR - Radial nerve affected - and its continuation - Posterior

Interosseous Nerve (PIN)

In a child the ulnar may have a greenstick # with plastic deformity, rather
than an obvious#

Galeazzi # GRU - Ulnar nerve effected As above

And PIN
GRU - Galeazzi =
Radial # (distal 3rd),
ulnar dislocation at
wrist (DRUJ)

Monteggia - MUR - radial nerve injury (PIN)

Galeazzi - GRU - ulnare nerrve injury (and PIN)

Monteggia = Radius dislocation = Radial nerve injury (PIN)

Galeazzi = Ulnar dislocation = Ulnar nerve injury

Colles # HIT11,22,11 = Height, Inclination, Tilt

Reduce and immobilise in a neutral wrist position (slight ulnar

deviation) with a short arm backslab

Attention to:
Median Nerve
Extensor Pollicis Longus
Ulnar styloid #

Buckle # Also known as a torus injury

(aka Torus #) distal radial metaphysis
result of compressive forces from an axial load on softer bones in
children
X-Ray changes may be subtle with mild cortical bulging on the AP
view and angulation on the lateral view
Simple dorsal buckle fractures must have ALL of the following features:
No cortical breach
No volar angulation
Less than 15 degrees dorsal angulation
Involves the distal third of the radius
No greenstick or complete fracture of the ulna (buckle of the ulna
is acceptable)
Management
Manage in a wrist splint worn day and night for 3 weeks with no
contact sports for a further 3 weeks after splint removal.
No specific follow up is needed.
If a wrist splint is unavailable, use a below elbow plaster back slab
instead.
Dont manage as buckle # if:
Buckle fracture with volar angulation (left)
Disruption of cortex of volar aspect of radius- arrow (right)
.... manage with backslab and # clinic FU

Scaphoid # Herbert classification 30% # not visible on XR

D

(Treat MRI
LUNATE # Most sensitive imaging in the first 24 hours.
similarly due Sens + spec nearly 100%
to risk of Bone scan @ 3 days
AVN) 100% sensitivity @ 72 hours.
rJ

But lower specificity

CT is 90% sensitive

Mx confirmed #:
Scaphoid cast for >6/52
Immobilise MCP joint of thumb
Orthopaedic review (immediate / 1 week depending on #
location)
ac

ORIF if any displacement

Ortho r/v in ED if:

Proximal #
Displaced
k

Triquetrum # Second most common carpal bone #

a/w perilunate dislocation (capitate off lunate)
M

a/w distal radius / ulnar #

FOOSH
Treatment is generally nonoperative but injuries associated with
wrist instability require surgical fixation.
Pooping duck sign:
ar
jo
t

Wrist XR Gilula's lines

SLuT CH

CSLR (central specimen lab reception)

Wrist ossification centres: CHild - Capitatate (1) --> Hamate (2) -->
onwards

Scapholunate Terry Thomas Sign - Scapho-Lunate widening:

dislocation Gap >3mm

Can get ischaemic necrosis of the lunate (Kienbock disease).

Arthroscopy if gold standard for Dx

Lunate Lunate off radius 'Lunate dislocation' = dislocation of the lunate from the radius Immediate closed reduction and splinting should take
dislocation 'Peri-lunate dislocation' = capitate from the lunate. place with early operative referral

Lunate dislocation:
Mechanism - FOOSH with forseful hyperextension of wrist
Usually a volar dislocation
XR:
AP: "piece-of-pie" sign
Lateral: "spilled tea cup" sign
Complications:
Median nerve injury
Ligaments (radiolunate, scapholunate)

Note the tea-cup really needs to be on its side

Best to look at the lateral and see what is in line with the radius:
If capitate in line: then lunate is dislocated (lunate)
If lunate in line, the capitate is dislocated (peri-lunate)

Peri-lunate Capitate off lunate Mechanism: fall onto a dorsiflexed wrist (as above)
dislocation Dislocation of the capitate relative to the lunate
Dorsal dislocation
Lunate stays in position on the radius
Around 60% of perilunate dislocations are associated with a
scaphoid fracture which is then termed a trans-scaphoid
perilunate dislocation.
Capitate fracture also common
A/w ligament injuries and # of carpal bones
Injuries of the The four stages of ligamentous injuries in the wrist are: Scapholunate dislocation - need ortho but not emergency
wrist carpus stage I: scapho-lunate widening (>3mm) - commonest wrist injury Lunate + Perilunate dislocation - need urgent ortho r/v
stage II: perilunate dislocation (emergency)
stage III: perilunate dislocation a/w dislocation/fracture triquetrum
stage IV: lunate dislocation.

Increasingly high energy FOOSH + hyperextension of wrist

MC # Contact ortho if: MC shaft #

Boxer's # Significant shortening Reduce (Jahss technique) then XR
Significant displacement Ortho involvement if concerning features
significant degree angulation (volar/dorsal) Splint for 3-4 weeks
Any malrotation Follow-up in # clinic with XR @ 1 week
Intra-articular involvement PT (hand therapy)
Open #
Boxers # (neck)
Acceptable angulation and shortening depends on the finger and location Avoid reduction unless significant angulation (>45 degrees)
of the facture (shaft vs neck) Hand clinic FU

For base/head MC #, contact ortho if:

>2mm articular surface displacement
Base # involves other carpal bones (common)

Boxers = MC neck # (usually 5th) with volar (palmar) angulation

Talus # Hawkins
classificiation
(Talus neck #)

Always needs CT (if confirmed on XR, or normal XR but high suspicion)

Talus is at risk of AVN
Needs urgent reduction in ED if significant displacement
Normally surgical Mx
Truly undisplaced fractures can be placed in a below-knee cast with ankle
at 90 degrees and seen in fracture clinic within a week. Must be full NWB.

Calcaneus Fall from height - look for bilateral

Needs specific XR views

Always needs CT (if confirmed on XR, or normal XR but high suspicion)

Most need ORIF

Flattening of Boehler's angle - abnormal <20

Flattening of calcaneus --> reduced Boehler's angle

Boehler's angle flattening

Acute tarsal tunnel syndrome may develop with compression of

the medial neurovascular bundle

Talus & Calcaneus #s need CT and ortho involvement ugently

Talus at high risk for AVN

Lisfranc Mechanism: Adequate analgesia

Direct impact to dorsum of foot (crush injury, MVA) High index of suspicion based on clinical presentation and
Axial force +/- twisting through a plantar-flexed foot mechanism.
Foot and ankle X-rays.
Tarsometatarsal fracture/dislocation CT if required.
Disruption to articulation intermediate cuneiform + base of 2nd MT Orthopaedic consult to decide whether it is an unstable
Note the Lisfranc ligament is between medial cuneiform + second MT injury requiring an ORIF or a stable injury.
base Unstable Injuries – immobilisation with a backslab + fixation
Dorsal midfoot pain, and pain on inv/evers of forefoot in OT
All need ortho r/v Stable injuries - Cam Boot for 6-10 weeks, weight bearing as
tolerated.

Careful for:
# of the 2nd metatarsal base
# of medial cuneiform
dorsalis pedis artery injury

Base of 5th
MT #
D

Tuberosity # -
walking boot, WB, non-urgent # clinic or GP follow-up
rJ

All other # -
short leg back-slab, NWB, # clinic in 1 week
ac

Fractures of the metaphyseal/diaphyseal junction more likely to

have problems with non-union (due to poor blood supply)
k

Other MT # First MT# is usually high energy Metatarsal shaft fractures with
> 4 mm displacement in the dorsal/plantar plane
Non-displaced fractures of the metatarsal shaft 2-4 usually require only a or > 10 degrees angulation in this plane
soft dressing followed by a firm, supportive shoe and progressive weight ...generally require reduction.
M

bearing.
(10 degrees angulation is same limit as for non-boxer MC #)

Paeds hip Red flags: WASP47

pain Weight bearing not possible
Awaking at night with pain
Systemic symptoms: fever / weight loss / sweats
ar

Petechiae
Age < 4 years
Durations > 7 days
jo
t

SCFE - disruption of line of Kline

Perthes XR:
joint effusion: widening of the medial joint space
Epiphysis on affected side is:
Smaller
Denser
Fragmented

Facial # McGrigor Campbell

lines on XR

Zygomatic Common
May cause masseter muscle entrapment

Tripod # face TRIPOD # Examination of tripod #:

Zygoma is separated at its 3 processes: Facial flattening and asymmetry
1. Maxillary bone + inferior orbital rim Infraorbital nerve anaesthesia / paraesthesia
2. Frontal bone Step deformity in infraorbital rim
3. Temporal bone Diplopia
Subcutaneous emphysema
Associated with # to: Mx:
Orbital floor Analgesia
Lateral wall of maxillary antrum IV Abx
Surgery (ORIF)

Orbital 'teardrop' sign - herniation of orbital contents into the maxillary antrum. Examination
blow-out # Should do CT diplopia present in 85%
limitation of upward gaze
due to inferior rectus entrapment and/or oedema
lowering of globe and enophthalmos
Eye damage: corneal abrasion, hyphema
subcutaneous emphysema
Mx:
Analgeisa
ABx (Augmentin DF)
Don't blow nose
Referal to MaxFax + opthalmology

Alveolar # Commonest fractures of the maxilla

(maxillary) Associated with avulsion of teeth
Facial # Le Fort

Le Fort 2 may be associated with infra-orbital nerve injury

Le Fort 3 involves the orbit and ocular assessment is needed

Le Fort 2+3 can cause:

CSF rhinorrhoea
Epistaxis
Haemorrhage control:
Reduction
Ballon tamponade
Packing
IR embolisation
Usually open # due to mucosal tears
ABx
Tetanus booster

Le Fort 3

NOE complex Naso-orbital-ethmoid #

# Causes avulsion of medial canthal ligament of eye
Causes a laterally displaced palpebral fissure (telecanthus)
ENopthalmus
>4cm intercanthal distance

Mandible # Examination:
facial or dental deformity
reduced jaw movement (trismus)
deviation of jaw on opening
malocclusion
mental nerve anaesthesia
Dental assessment

Always look for:

2 x fracture Management of mandible #
Fracture + TMJ dislocation Protect airway
Analgesia
BODY is commonest site of # (Dunn) ABx + tetanus (considered 'open fractures' as mucosa is
torn)
Surgical repair depending on site and displacement
preserve and replace teeth
most mandibular # need internal fixation

C-SPINE Atlanto-axial Power's Ratio Assess atlanto-axial subluxation by looking for:

Flexion subluxation Normal = 1 Power's ratio > 1
UNSTABLE / fatal > 1 indicates anterior subluxation Pre-dental space > 3mm
Predental space should be:
< 3 mm in adults
< 5 mm in adolescents and children

Paeds
lateral C-
spine XR

C spine soft
tissue
D

C1-3: 1/3 VB (7mm)

C4 down: 1 VB (21mm)
rJ

Picture shows retropharyngeal abscess

Flexion C2# - Dens

Ty1 - stable
Ty2/3 - UNSTABLE
ac
k
M
ar

Dens may be unfused in children < 12yo

Flexion Flexion teardrop Any level between C3 and C7 Extension teardrop - C2 - central cord syndrome
UNSTABLE + often HyperFLEXION + axial (e.g. diving) Flexion teardrop - C3-C7 - anterior cord syndrome
jo

neurology Highly unstable - ANTERIOR cord injury

VB (except for teardrop) displaces posteriorly into spinal canal FLEXION TEARDROP is the most unstable C spine #
t

Flexion C-spine bilateral Can be dislocation without #

facet joint Anterior displacement of VB > ½ width of the VB
dislocation 'Perched facets' keep the vertebrae dislocated
UNSTABLE

Flexion C-spine unilateral Anterior displacement of VB < ½ width of the VB

facet joint Bow-tie
dislocation
Stable

Flexion Spinous process # - Mechanism of repeated forceful flexion associated with shovelling.
clay-shoveller's
Stable

Flexion Anterior wedge # Wedge fractures are stable

Stable

Flexion Transverse process # Stable In transverse process # in T-L, look for associated injuries of:
kidney / ureteric injury
splenic / hepatic injury
pelvic injury

In neck consider vertebral artery injury if # through foramen

transversarium

Extension #posterior arch C1

UNSTABLE

Extension C2# - Hangman's High force hyperEXTENSION

UNSTABLE Bilateral fracture in the pars interarticularis of the axis (C2)
Anterior displacement of body and peg of C2 on C3

Extension C2# - extension Hyperextension may result in avulsion of the anterior corner of a vertebral Extension teardrop - C2 - central cord syndrome
teardrop body - usually C2 Flexion teardrop - C3-C7 - anterior cord syndrome
UNSTABLE + The anterior longitudinal ligament remains attached to the bone fragment Extension teardrop fractures are stable in flexion
central cord which is separated from the vertebral body. and unstable in extension
syndrome
 Teardrop fractures to the anterioinferior part of the cervical vertebra can
occur in flexion and extension and despite appearing small and
insignificant on plain radiography, is associated with significant and
complete disruption of the ligamentous structures at the level of the
injury. These fractures are unstable

Compression C1# - Jefferson A typical mechanism of injury is diving headfirst into shallow water.
UNSTABLE Compression # of C1 bony ring --> fracture of both anterior +
posterior arch --> lateral masses splitting and transverse ligament
tear
Radiographic features: displacement of the lateral masses of C1 beyond
margins of body of C2 (CT required)

Compression Burst # of VB Comminuted but ligaments intact Burst # = mechanically stable + A+P ligaments intact, BUT the
Stable but can Mechanically stable fragments can cause spinal injury
have cord injury Fracture fragments retropulsed and may still injure the cord
E.g. due to jumping from a height

Thoracic / High mechanism injury

lumbar # Vertebral fracture concomitant with dislocation of facet joints
dislocation High rate of spinal cord injury

Ucinate From lateral flexion injuries

process #

SCIWORA

SCIWORA is more common in children

Paediatric C SCIWORA is most frequently seen in younger children (especially under about 8 years of age), and in injuries of the cervical spine
spine C spine imaging in paediatric trauma:
Lateral
AP
Odontoid
The common findings that cause concern are:
pseudo-subluxation of C2 on C3 (seen in up to 25% of children),
exaggerated atlanto-dens distance (seen in 20% of children under 8 years of age)- < 5mm
radiolucent synchondrosis between the odontoid and C2 (seen in all children under 4 and in 50% of those under 10 years of age).
Other normal findings that can be misinterpreted include:
variable anterior soft tissue width altering with head-positioning and crying;
the anterior ring apophyses of the vertebral bodies;
the anterior wedging of the vertebral bodies (especially C3).
All of these normal findings can be mistaken for acute traumatic injuries in children following trauma.
Gap between C1-2 spinous process can be large
The other C spine spinous processes should have a small and consistent space
Children more than 8 years old have radiographic appearances similar to adults.

SWISCHUK lines:
Differentiate pseudosubluxation of C2/3 from pathology
D
rJ
ac

Pelvic
avulsion #
k
M
ar

Pubic rami # uncommon to have solitary ramus injury except in the elderly
jo

Minor pubic rami fractures

usually treated conservatively, especially in the frail
early mobilisation is encouraged
Displaced or bilateral pubic rami fractures
usually internally fixed
t

Landing on if landing on feet from a height

feet from Calcaneal fractures
height Pelvic fractures (VS on Young-Burgess classification)
Thoracolumbar fractures
Retroperitoneal injuries
Intracranial injuries if severe

Sacral # Dennis # zones

Zone-I #
commonest
lateral to the sacral foramina and are the most common fracture
pattern.
Neurological injury in 6%, usually L4 and L5 nerve roots.

Zone-II
second most common pattern.
Neuro injury in 28% of patients - L5, S1 or S2 nerve root.

Zone-III
Any # involving the spinal canal
Uncommon
Highest risk of neurological injury (57% of patients)
Bowel and bladder control or sexual function is often impaired

Lower back Recovery of symptoms in uncomplicated LBP

pain <6 weeks: 60–70%
<12 weeks: 80–90%
>12 weeks: the recovery will be unpredictable and slow.

Sciatica L4,5 + S1,2,3

Compartment Symptoms:
syndrome Pain out of proportion
Signs:
Tense compartment (woody hardness)
Pain with passive stretch
Paraesthesia
Paralysis late signs
Absent pulses
Commonest locations
Forearm (esp volar compartment)
Lower leg (esp anterior compartment)
Investigations
X-ray to exclude underlying fracture
Send bloods: FBC, LFTs, CK
Urine dipstick for myoglobinuria
Measure compartment pressure:
Methods:
Stryker device
Needle technique
Measurements:
>30 mmHg
delta value < 30
Delta value (or delta p) = Diastolic blood pressure – Intra-compartmental pressure
Management
Relieve/cut any constricting dressing or cast (if the causative factor)
If underlying fracture identified, reduce and splint/cast and reassess for CS
Elevate affected compartment to the level of the heart
IV access: fluids, analgesia, anti-emetics
Refer to the orthopaedic or plastic teams promptly

Dr Jack Marjot
Noticed a mistake? Know about a change in the evidence?
Contribute to keeping these notes updated by letting me know via this form: Feedback
Thanks for your contribution.
JM