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1

A 68 year old man presents to the plastics team with severe burns to his hands. He is not distressed by the burns. He has bilateral charcot joints. On examination; there is loss of pain and temperature sensation of the upper limbs.

A. Osteomyelitis
B. Potts disease of the spine
C. Scheuermanns disease
D. Transverse myelitis
E. Tabes dorsalis
F. Subacute degeneration of the cord
G. Brown-Sequard syndrome
H. Syringomyelia
I. Epidural haematoma

Syringomyelia

This patient has syringomyelia which selectively affects the spinotholamic tracts. Syringomyelia is a disorder in which a cystic cavity forms within the spinal cord. The commonest variant is the Arnold- Chiari malformation in which the cavity connects with a congenital malformation affecting the cerebellum. Acquired forms of the condition may occur as a result of previous meningitis, surgery or tumours. Many neurological manifestations have been reported, although the classical variety spares the dorsal columns and medial lemniscus and affecting only the spinothalamic tract with loss of pain and temperature sensation. The bilateral distribution of this patients symptoms would therefore favor syringomyelia over SCID or Brown Sequard syndrome. Osteomyelitis would tend to present with back pain and fever in addition to any neurological signs. Epidural haematoma large enough to produce neurological impairment will usually have motor symptoms in addition to any selective sensory loss, and the history is usually shorter.

Spinal disorders

Dorsal column lesion : Loss vibration and proprioception, Tabes dorsalis, SACD

Spinothalamic tract lesion
Loss of pain, sensation and temperature

Central cord lesion
Flaccid paralysis of the upper limbs

Osteomyelitis
Normally progressive
Staph aureus in IVDU, normally cervical region affected
Fungal infections in immunocompromised
Thoracic region affected in TB

Infarction spinal cord
Dorsal column signs (loss of proprioception and fine discrimination)

Cord compression
UMN signs
Malignancy
Haematoma
Fracture

Brown-sequard syndrome
Hemisection of the spinal cord
Ipsilateral paralysis
Ipsilateral loss of proprioception and fine discrimination
Contralateral loss of pain and temperature

Dermatomes
C2 to C4 The C2 dermatome covers the occiput and the top part of the neck. C3 covers the lower part of the neck to the clavicle. C4 covers the area just below the clavicle.
C5 to T1 Situated in the arms. C5 covers the lateral arm at and above the elbow. C6 covers the forearm and the radial (thumb) side of the hand. C7 is the middle finger, C8 is the medial aspect of the hand, and T1 covers the medial side of the forearm.
T2 to T12 The thoracic covers the axillary and chest region. T3 to T12 covers the chest and back to the hip girdle. The nipples are situated in the middle of T4. T10 is situated at the umbilicus. T12 ends just above the hip girdle.
L1 to L5 The cutaneous dermatome representing the hip girdle and groin area is innervated by L1 spinal cord. L2 and 3 cover the front part of the thighs. L4 and L5 cover medial and lateral aspects of the lower leg.
S1 to S5 S1 covers the heel and the middle back of the leg. S2 covers the back of the thighs. S3 cover the medial side of the buttocks and S4-5 covers the perineal region. S5 is of course the lowest dermatome and represents the skin immediately at and adjacent to the anus.

Myotomes

Upper limb
Elbow flexors/Biceps C5
Wrist extensors C6
Elbow extensors/Triceps C7
Long finger flexors C8
Small finger abductors T1

Lower limb
Hip flexors (psoas) L1 and L2
Knee extensors (quadriceps) L3
Ankle dorsiflexors (tibialis anterior) L4 and L5
Toe extensors (hallucis longus) L 5
Ankle plantar flexors (gastrocnemius) S1

The anal sphincter is innervated by S2,3,4

2

A 24 year old man presents with localised spinal pain over 2 months which is worsened on movement. He is known to be an IVDU. He has no history suggestive of tuberculosis. The pain is now excruciating at rest and not improving with analgesia. He has a temperature of 39 oC.

A. Osteomyelitis
B. Potts disease of the spine
C. Scheuermanns disease
D. Transverse myelitis
E. Tabes dorsalis
F. Subacute degeneration of the cord
G. Brown-Sequard syndrome
H. Syringomyelia
I. Epidural haematoma

Osteomyelitis

In an IVDU with back pain and pyrexia have a high suspicion for osteomylelitis. The most likely organism is staph aureus and the cervical spine is the most common region affected. TB tends to affect the thoracic spine and in other causes of osteomyelitis the lumbar spine is affected.

Spinal disorders

Dorsal column lesion : Loss vibration and proprioception, Tabes dorsalis, SACD

Spinothalamic tract lesion
Loss of pain, sensation and temperature

Central cord lesion
Flaccid paralysis of the upper limbs

Osteomyelitis
Normally progressive
Staph aureus in IVDU, normally cervical region affected
Fungal infections in immunocompromised
Thoracic region affected in TB

Infarction spinal cord
Dorsal column signs (loss of proprioception and fine discrimination)

Cord compression
UMN signs
Malignancy
Haematoma
Fracture

Brown-sequard syndrome
Hemisection of the spinal cord
Ipsilateral paralysis
Ipsilateral loss of proprioception and fine discrimination
Contralateral loss of pain and temperature

Dermatomes
C2 to C4 The C2 dermatome covers the occiput and the top part of the neck. C3 covers the lower part of the neck to the clavicle. C4 covers the area just below the clavicle.
C5 to T1 Situated in the arms. C5 covers the lateral arm at and above the elbow. C6 covers the forearm and the radial (thumb) side of the hand. C7 is the middle finger, C8 is the medial aspect of the hand, and T1 covers the medial side of the forearm.
T2 to T12 The thoracic covers the axillary and chest region. T3 to T12 covers the chest and back to the hip girdle. The nipples are situated in the middle of T4. T10 is situated at the umbilicus. T12 ends just above the hip girdle.
L1 to L5 The cutaneous dermatome representing the hip girdle and groin area is innervated by L1 spinal cord. L2 and 3 cover the front part of the thighs. L4 and L5 cover medial and lateral aspects of the lower leg.
S1 to S5 S1 covers the heel and the middle back of the leg. S2 covers the back of the thighs. S3 cover the medial side of the buttocks and S4-5 covers the perineal region. S5 is of course the lowest dermatome and represents the skin immediately at and adjacent to the anus.

Myotomes

Upper limb
Elbow flexors/Biceps C5
Wrist extensors C6
Elbow extensors/Triceps C7
Long finger flexors C8
Small finger abductors T1

Lower limb
Hip flexors (psoas) L1 and L2
Knee extensors (quadriceps) L3
Ankle dorsiflexors (tibialis anterior) L4 and L5
Toe extensors (hallucis longus) L 5
Ankle plantar flexors (gastrocnemius) S1

The anal sphincter is innervated by S2,3,4

3

A 22 year man is shot in the back, in the lumbar region. He has increased tone and hyper-reflexia of his right leg. He cannot feel his left leg.

A. Osteomyelitis
B. Potts disease of the spine
C. Scheuermanns disease
D. Transverse myelitis
E. Tabes dorsalis
F. Subacute degeneration of the cord
G. Brown-Sequard syndrome
H. Syringomyelia
I. Epidural haematoma

Brown-Sequard syndrome

Brown -Sequard syndrome is caused by hemisection of the spinal cord. It may result from stab injuries or lateral vertebral fractures. It results in ipsilateral paralysis (pyramidal tract) , and also loss of proprioception and fine discrimination (dorsal columns). Pain and temperature sensation are lost on the contra-lateral side. This is because the fibres of the spinothalamic tract have decussated below the level of the cord transection.

Spinal disorders

Dorsal column lesion : Loss vibration and proprioception, Tabes dorsalis, SACD

Spinothalamic tract lesion
Loss of pain, sensation and temperature

Central cord lesion
Flaccid paralysis of the upper limbs

Osteomyelitis
Normally progressive
Staph aureus in IVDU, normally cervical region affected
Fungal infections in immunocompromised
Thoracic region affected in TB

Infarction spinal cord
Dorsal column signs (loss of proprioception and fine discrimination)

Cord compression
UMN signs
Malignancy
Haematoma
Fracture

Brown-sequard syndrome
Hemisection of the spinal cord
Ipsilateral paralysis
Ipsilateral loss of proprioception and fine discrimination
Contralateral loss of pain and temperature

Dermatomes
C2 to C4 The C2 dermatome covers the occiput and the top part of the neck. C3 covers the lower part of the neck to the clavicle. C4 covers the area just below the clavicle.
C5 to T1 Situated in the arms. C5 covers the lateral arm at and above the elbow. C6 covers the forearm and the radial (thumb) side of the hand. C7 is the middle finger, C8 is the medial aspect of the hand, and T1 covers the medial side of the forearm.
T2 to T12 The thoracic covers the axillary and chest region. T3 to T12 covers the chest and back to the hip girdle. The nipples are situated in the middle of T4. T10 is situated at the umbilicus. T12 ends just above the hip girdle.
L1 to L5 The cutaneous dermatome representing the hip girdle and groin area is innervated by L1 spinal cord. L2 and 3 cover the front part of the thighs. L4 and L5 cover medial and lateral aspects of the lower leg.
S1 to S5 S1 covers the heel and the middle back of the leg. S2 covers the back of the thighs. S3 cover the medial side of the buttocks and S4-5 covers the perineal region. S5 is of course the lowest dermatome and represents the skin immediately at and adjacent to the anus.

Myotomes

Upper limb
Elbow flexors/Biceps C5
Wrist extensors C6
Elbow extensors/Triceps C7
Long finger flexors C8
Small finger abductors T1

Lower limb
Hip flexors (psoas) L1 and L2
Knee extensors (quadriceps) L3
Ankle dorsiflexors (tibialis anterior) L4 and L5
Toe extensors (hallucis longus) L 5
Ankle plantar flexors (gastrocnemius) S1

The anal sphincter is innervated by S2,3,4

4

A 24 year old man is brought to the emergency department have suffered a crush injury to his forearm. Assessment demonstrates that the arm is tender, red and swollen. There is clinical evidence of an ulnar fracture and the patient cannot move their fingers. Which is the most appropriate course of action?

Application of an external fixation device
Closed reduction
Debridement
Discharge and review in fracture clinic
Fasciotomy

Fasciotomy

The combination of a crush injury, limb swelling and inability to move digits should raise suspicion of a compartment syndrome that will require a fasciotomy. Paralysis is a very late sign.

Compartment syndrome

This is a particular complication that may occur following fractures (or following ischaemia re-perfusion injury in vascular patients). It is characterised by raised pressure within a closed anatomical space.
The raised pressure within the compartment will eventually compromise tissue perfusion resulting in necrosis. The two main fractures carrying this complication include supracondylar fractures and tibial shaft injuries.

Symptoms and signs
Pain, especially on movement (even passive)
Parasthesiae
Pallor may be present
Arterial pulsation may still be felt as the necrosis occurs as a result of microvascular compromise
Paralysis of the muscle group may occur

Diagnosis
Is made by measurement of intracompartmental pressure measurements. Pressures in excess of 20mmHg are abnormal and >40mmHg is diagnostic.

Treatment
This is essentially prompt and extensive fasciotomies
In the lower limb the deep muscles may be inadequately decompressed by the inexperienced operator when smaller incisions are performed
Myoglobinuria may occur following fasciotomy and result in renal failure and for this reason these patients require aggressive IV fluids
Where muscle groups are frankly necrotic at fasciotomy they should be debrided and amputation may have to be considered
Death of muscle groups may occur within 4-6 hours

5

A 19 year old sportswoman presents with knee pain which is worse on walking down the stairs and when sitting still. On examination there is wasting of the quadriceps and pseudolocking of the knee.

A. Chondromalacia patellae
B. Dislocated patella
C. Undisplaced fracture patella
D. Displaced patella fracture
E. Avulsion fracture of the tibial tubercle
F. Quadriceps tendon rupture
G. Osgood Schlatters disease

Chondromalacia patellae

A teenage girl with knee pain on walking down the stairs is characteristic for chondromalacia patellae (anterior knee pain). Most cases are managed with physiotherapy.

Ruptured anterior cruciate ligament
Sport injury
Mechanism: high twisting force applied to a bent knee
Typically presents with: loud crack, pain and RAPID joint swelling (haemoarthrosis)
Poor healing
Management: intense physiotherapy or surgery

Ruptured posterior cruciate ligament
Mechanism: hyperextension injuries
Tibia lies back on the femur
Paradoxical anterior draw test

Rupture of medial collateral ligament
Mechanism: leg forced into valgus via force outside the leg
Knee unstable when put into valgus position

Menisceal tear
Rotational sporting injuries
Delayed knee swelling
Joint locking (Patient may develop skills to "unlock" the knee
Recurrent episodes of pain and effusions are common, often following minor trauma

Chondromalacia patellae
Teenage girls, following an injury to knee e.g. Dislocation patella
Typical history of pain on going downstairs or at rest
Tenderness, quadriceps wasting

Dislocation of the patella
Most commonly occurs as a traumatic primary event, either through direct trauma or through severe contraction of quadriceps with knee stretched in valgus and external rotation
Genu valgum, tibial torsion and high riding patella are risk factors
Skyline x-ray views of patella are required, although displaced patella may be clinically obvious
An osteochondral fracture is present in 5%
The condition has a 20% recurrence rate

Fractured patella
2 types:
i. Direct blow to patella causing undisplaced fragments
ii. Avulsion fracture

Tibial plateau fracture
Occur in the elderly (or following significant trauma in young)
Mechanism: knee forced into valgus or varus, but the knee fractures before the ligaments rupture
Varus injury affects medial plateau and if valgus injury, lateral plateau depressed fracture occurs


Schatzker Classification system for tibial plateau fractures
Type Anatomical description Features
1 Vertical split of lateral condyle Fracture through dense bone, usually in the young. It may be virtually undisplaced, or the condylar fragment may be pushed inferiorly and tilted
2 Vertical split of the lateral condyle combined with an adjacent load bearing part of the condyle The wedge fragment (which may be of variable size), is displaced laterally; the joint is widened. Untreated, a valgus deformity may develop
3 Depression of the articular surface with intact condylar rim The split does not extend to the edge of the plateau. Depressed fragments may be firmly embedded in subchondral bone, the joint is stable
4 Fragment of the medial tibial condyle Two injuries are seen in this category; (1) a depressed fracture of osteoporotic bone in the elderly. (2) a high energy fracture resulting in a condylar split that runs from the intercondylar eminence to the medial cortex. Associated ligamentous injury may be severe
5 Fracture of both condyles Both condyles fractured but the column of the metaphysis remains in continuity with the tibial shaft
6 Combined condylar and subcondylar fractures High energy fracture with marked comminution

6

A tall 18 year old male athlete is admitted to the emergency room after being hit in the knee by a hockey stick. On examination his knee is tense and swollen. X-ray shows no fractures.

A. Chondromalacia patellae
B. Dislocated patella
C. Undisplaced fracture patella
D. Displaced patella fracture
E. Avulsion fracture of the tibial tubercle
F. Quadriceps tendon rupture
G. Osgood Schlatters disease

Dislocated patella

A patella dislocation is a common cause of haemarthrosis and many will spontaneously reduce when the leg is straightened. In the chronic setting physiotherapy is used to strengthen the quadriceps muscles.

Ruptured anterior cruciate ligament
Sport injury
Mechanism: high twisting force applied to a bent knee
Typically presents with: loud crack, pain and RAPID joint swelling (haemoarthrosis)
Poor healing
Management: intense physiotherapy or surgery

Ruptured posterior cruciate ligament
Mechanism: hyperextension injuries
Tibia lies back on the femur
Paradoxical anterior draw test

Rupture of medial collateral ligament
Mechanism: leg forced into valgus via force outside the leg
Knee unstable when put into valgus position

Menisceal tear
Rotational sporting injuries
Delayed knee swelling
Joint locking (Patient may develop skills to "unlock" the knee
Recurrent episodes of pain and effusions are common, often following minor trauma

Chondromalacia patellae
Teenage girls, following an injury to knee e.g. Dislocation patella
Typical history of pain on going downstairs or at rest
Tenderness, quadriceps wasting

Dislocation of the patella
Most commonly occurs as a traumatic primary event, either through direct trauma or through severe contraction of quadriceps with knee stretched in valgus and external rotation
Genu valgum, tibial torsion and high riding patella are risk factors
Skyline x-ray views of patella are required, although displaced patella may be clinically obvious
An osteochondral fracture is present in 5%
The condition has a 20% recurrence rate

Fractured patella
2 types:
i. Direct blow to patella causing undisplaced fragments
ii. Avulsion fracture

Tibial plateau fracture
Occur in the elderly (or following significant trauma in young)
Mechanism: knee forced into valgus or varus, but the knee fractures before the ligaments rupture
Varus injury affects medial plateau and if valgus injury, lateral plateau depressed fracture occurs


Schatzker Classification system for tibial plateau fractures
Type Anatomical description Features
1 Vertical split of lateral condyle Fracture through dense bone, usually in the young. It may be virtually undisplaced, or the condylar fragment may be pushed inferiorly and tilted
2 Vertical split of the lateral condyle combined with an adjacent load bearing part of the condyle The wedge fragment (which may be of variable size), is displaced laterally; the joint is widened. Untreated, a valgus deformity may develop
3 Depression of the articular surface with intact condylar rim The split does not extend to the edge of the plateau. Depressed fragments may be firmly embedded in subchondral bone, the joint is stable
4 Fragment of the medial tibial condyle Two injuries are seen in this category; (1) a depressed fracture of osteoporotic bone in the elderly. (2) a high energy fracture resulting in a condylar split that runs from the intercondylar eminence to the medial cortex. Associated ligamentous injury may be severe
5 Fracture of both condyles Both condyles fractured but the column of the metaphysis remains in continuity with the tibial shaft
6 Combined condylar and subcondylar fractures High energy fracture with marked comminution

7

An athletic 15 year old boy presents with knee pain of 3 weeks duration. It is worst during activity and settles with rest. On examination there is tenderness overlying the tibial tuberosity and an associated swelling at this site.

A. Chondromalacia patellae
B. Dislocated patella
C. Undisplaced fracture patella
D. Displaced patella fracture
E. Avulsion fracture of the tibial tubercle
F. Quadriceps tendon rupture
G. Osgood Schlatters disease

Osgood Schlatters disease

Athletic boys and girls may develop this condition in their teenage years. It is caused by multiple micro fractures at the point of insertion of the tendon into the tibial tuberosity. Most cases settle with physiotherapy and rest.

Ruptured anterior cruciate ligament
Sport injury
Mechanism: high twisting force applied to a bent knee
Typically presents with: loud crack, pain and RAPID joint swelling (haemoarthrosis)
Poor healing
Management: intense physiotherapy or surgery

Ruptured posterior cruciate ligament
Mechanism: hyperextension injuries
Tibia lies back on the femur
Paradoxical anterior draw test

Rupture of medial collateral ligament
Mechanism: leg forced into valgus via force outside the leg
Knee unstable when put into valgus position

Menisceal tear
Rotational sporting injuries
Delayed knee swelling
Joint locking (Patient may develop skills to "unlock" the knee
Recurrent episodes of pain and effusions are common, often following minor trauma

Chondromalacia patellae
Teenage girls, following an injury to knee e.g. Dislocation patella
Typical history of pain on going downstairs or at rest
Tenderness, quadriceps wasting

Dislocation of the patella
Most commonly occurs as a traumatic primary event, either through direct trauma or through severe contraction of quadriceps with knee stretched in valgus and external rotation
Genu valgum, tibial torsion and high riding patella are risk factors
Skyline x-ray views of patella are required, although displaced patella may be clinically obvious
An osteochondral fracture is present in 5%
The condition has a 20% recurrence rate

Fractured patella
2 types:
i. Direct blow to patella causing undisplaced fragments
ii. Avulsion fracture

Tibial plateau fracture
Occur in the elderly (or following significant trauma in young)
Mechanism: knee forced into valgus or varus, but the knee fractures before the ligaments rupture
Varus injury affects medial plateau and if valgus injury, lateral plateau depressed fracture occurs


Schatzker Classification system for tibial plateau fractures
Type Anatomical description Features
1 Vertical split of lateral condyle Fracture through dense bone, usually in the young. It may be virtually undisplaced, or the condylar fragment may be pushed inferiorly and tilted
2 Vertical split of the lateral condyle combined with an adjacent load bearing part of the condyle The wedge fragment (which may be of variable size), is displaced laterally; the joint is widened. Untreated, a valgus deformity may develop
3 Depression of the articular surface with intact condylar rim The split does not extend to the edge of the plateau. Depressed fragments may be firmly embedded in subchondral bone, the joint is stable
4 Fragment of the medial tibial condyle Two injuries are seen in this category; (1) a depressed fracture of osteoporotic bone in the elderly. (2) a high energy fracture resulting in a condylar split that runs from the intercondylar eminence to the medial cortex. Associated ligamentous injury may be severe
5 Fracture of both condyles Both condyles fractured but the column of the metaphysis remains in continuity with the tibial shaft
6 Combined condylar and subcondylar fractures High energy fracture with marked comminution

8

An 8 year old boy presents with symptoms of right knee pain. The pain has been present on most occasions for the past three months and the pain typically lasts for several hours at a time. On examination; he walks with an antalgic gait and has apparent right leg shortening. What is the most likely diagnosis?

Perthes Disease
Osteosarcoma of the femur
Osteoarthritis of the hip
Transient synovitis of the hip
Torn medial meniscus

Perches Disease

There are many causes of the irritable hip in the 10-14 year age group. Many of these may cause both hip pain or knee pain. Transient synovitis of the hip the commonest disorder but does not typically last for 3 months. An osteosarcoma would not usually present with apparent limb shortening unless pathological fracture had occurred. A slipped upper femoral epiphysis can cause a similar presentation although it typically presents later and with different patient characteristics.

Perthes disease
Idiopathic avascular necrosis of the femoral epiphysis of the femoral head
Impaired blood supply to femoral head, causing bone infarction. New vessels develop and ossification occurs. The bone either heals or a subchondral fracture occurs.

Clinical features
Males 4x's greater than females
Age between 2-12 years (the younger the age of onset, the better the prognosis)
Limp
Hip pain
Bilateral in 20%

Diagnosis
Plain x-ray, Technetium bone scan or magnetic resonance imaging if normal x-ray and symptoms persist.

Catterall staging
Stage Features
Stage 1 Clinical and histological features only
Stage 2 Sclerosis with or without cystic changes and preservation of the articular surface
Stage 3 Loss of structural integrity of the femoral head
Stage 4 Loss of acetabular integrity

Management
To keep the femoral head within the acetabulum: cast, braces
If less than 6 years: observation
Older: surgical management with moderate results
Operate on severe deformities

Prognosis
Most cases will resolve with conservative management. Early diagnosis improves outcomes.

9

Which of the following types of growth plate fractures may have similar radiological appearances?

Salter Harris types 1 and 5
Salter Harris types 4 and 5
Salter Harris types 3 and 5
Salter Harris types 1 and 2
Salter Harris types 1 and 3

Salter Harris types 1 and 5

Mnemonic: SALTER

S (Type 1): Straight through the growth plate
A (Type 2): Above - through growth plate and Above involving the metaphysis
L (Type 3): Lower -through growth plate and beLow involving the epiphysis
T (Type 4):Through - Through both metaphysis, epiphysis and growth plate
E (Type 5): Everything - Crush / compression injury
R (Type 5): Ruined
As recommended by one of our users

Salter Harris injury types 1 and 5 (transverse fracture through growth plate Vs. Compression fracture) may mimic each other radiologically. Type 5 injuries have the worst outcomes. Radiological signs of type 5 injuries are subtle and may include narrowing of the growth plate.

Epiphyseal fractures

Fractures involving the growth plate in children are classified using the Salter - Harris system.
There are 5 main types.

Salter Harris Classification
Type Description
Type 1 Transverse fracture through the growth plate
Type 2 Fracture through the growth plate to the metaphysis (commonest type)
Type 3 Fracture through the growth plate and the epiphysis with metaphysis spared
Type 4 Fracture involving the growth plate, metaphysis and epiphysis
Type 5 Compression fracture of the growth plate (worst outcome)

Management
Non displaced type 1 injuries can generally be managed conservatively. Unstable or more extensive injuries will usually require surgical reduction and/ or fixation, as proper alignment is crucial.

10

A 20 year old woman trips over a step, injuring her ankle. Examination reveals tenderness over the lateral malleolus and an x-ray demonstrates an undisplaced fracture distal to the syndesmosis.

A. Surgical fixation
B. Below knee amputation
C. Application of below knee plaster
D. Application of ankle boot
E. Application of external fixation device
F. Application of compression dressing and physiotherapy
G. Immediate reduction and application of backslab

Application of ankle boot

This is a Weber A fracture. It is a stable ankle injury and can therefore be managed conservatively. Whilst this patient could also be treated in a below knee plaster, most clinicians would nowadays treat this injury in an ankle boot. Patients should be advised to mobilise in the ankle boot, as pain allows, and can wean themselves out of the boot as the symptoms improve.

An ankle fracture relates to a fracture around the tibio-talar joint. It generally refers to a fracture involving the lateral, and/or medial and/or posterior malleolus. Pilon and Tillaux fractures are also considered to be ankle fractures, but are not covered here.
Ankle fractures are common. They effect men and women in equal numbers, but men have a higher rate as young adults (sports and contact injuries), and women a higher rate post-menopausal (fragility type fracture).

Osseous anatomy
The ankle (or mortise) joint consists of the distal tibia (tibial plafond and posterior malleolus), the distal fibula (lateral malleolus), and the talus. The main movement at the ankle joint is plantar and dorsiflexion.

Ligamentous anatomy
Medial side: Deltoid ligament. This is divided into superficial and deep portions. It is the primary restraint to valgus tilting of the talus.

Lateral side: Lateral ligament complex consisting from anterior to posterior of the anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL), and the posterior talofibular ligament (PTFL). Together they resist valgus stress to the ankle, and are a restraint to anterior translation of the talus within the mortise joint.

Syndesmosis: The syndesmosis is a ligament complex between the distal tibia and fibula, holding the two bones together. It is fundamental to the integrity of the ankle joint, and its disruption leads to instability. It consists of (from anterior to posterior) the anterior-inferior tibiofibular ligament (AITFL), the transverse tibiofibular ligament (TTFL), the interosseous membrane, and the posterior-inferior tibiofibular ligament (PITFL).

Presentation and initial management
Patients will present following a traumatic event with a painful, swollen ankle, and reluctance/inability to weight bear. The Ottawa rules can be applied to differentiate between an ankle fracture and sprain, but can be unreliable.
In high energy injuries, management should follow ATLS principles to identify more significant injuries first. Neurovascular status of the foot should be documented, and open injuries should be excluded. If an open injury is identified, it should be managed in line with BOAST 4 principles1. If an obvious deformity exists, it should be reduced as soon as possible with appropriate analgesia or conscious sedation. Radiographs of clearly deformed or dislocated joints are not necessary, and removing the pressure on the surrounding soft tissues from the underlying bony deformity is the priority. If the fracture pattern is not clinically obvious then plain radiographs are appropriate and will guide the subsequent manipulation during plaster-of-paris below knee backslab application.

Imaging
AP, lateral and mortise views (20o internal rotation) are essential to evaluate fracture displacement and syndesmotic injury. Decreased tibiofibular overlap, medial joint clear space and lateral talar shift all indicate a syndesmotic injury. (In subtle cases of shift, imaging the uninjured ankle can be helpful as a proportion of the population have little or no tibiotalar overlap 2.)

Where there is suspicion of syndesmosis involvement in the absence of radiographic evidence, stress radiographs can be diagnostic.
Complex fracture patterns (and increasingly posterior malleolar fractures) are best defined using CT.



Classification
The most commonly used classifications are Lauge-Hansen and Danis-Weber.

Lauge-Hansen
Comprises two parts: first part is the foot position, and the second part is the force applied. Useful for understanding the forces involved and therefore predict the ligamentous or bony injury. Results in four injury patterns:
Supination - Adduction (SA) - 10-20%
Supination - External rotation (SER) - 40-75%
Pronation - Abduction (PA) - 5-20%
Pronation - External rotation (PER) - 5-20%

Not often used in clinical practice but good for understanding the principles of ankle fracture.

Danis-Weber
Commonly used. Based on the level of the fibula fracture in relation to the syndesmosis. The more proximal, the greater the risk of syndesmotic injury and therefore fracture instability.
A - fracture below the level of the syndesmosis
B - fracture at the level of the syndesmosis / level of the tibial plafond
C - fracture above the level of the syndesmosis. This includes Maisonneuve fractures (proximal fibula fracture), which can be associated with ankle instability. Beware the high fibula fracture - it may be an ankle fracture!

The Weber classification is based purely on the the lateral side. All injuries can include a medial or posterior bony or ligamentous injury which also dictates fracture stability (bimalleolar and trimalleolar fractures are more unstable).

Treatment
When deciding upon treatment for an ankle fracture, one must consider both the fracture and the patient. Diabetic patients and smokers are at greater risk of post-operative complication, especially wound problems and infection. Likewise, the long term outcome of post-traumatic arthritis from a malunited ankle fracture is extremely important for a young patient, but not as relevant in the elderly. Therefore, normal surgical decision processes apply as with all fractures.

Defining stability of an ankle fracture underpins the treatment decision.
Weber A - Unimalleolar Weber A Weber fractures by definition are stable and therefore can be mobilised fully weight bearing in an ankle boot.

Weber C - Fractures tend to include syndesmotic disruption and are usually bimalleolar (either bony or ligamentous). They are therefore unstable and usually require operative fixation. In addition to the fracture fixation, the syndesmosis usually requires reconstruction/augmentation with screws to restore the joint integrity and function.

Weber B - B fractures vary greatly. They can be part of a trimalleolar injury and therefore extremely unstable, requiring fixation. Alternatively, a uni-malleolar Weber B fracture can be a stable injury, and therefore mobilised immediately in an ankle boot. Defining the stability can be challenging, and often involves stress radiographs, or a trial of mobilisation and repeat radiographs. Defining stability is the subject of much ongoing research. However, treating undisplaced ankle fractures in a below knee plaster, non-weight bearing for six weeks is still widely practised, and a safe approach.

When operative fixation is appropriate, it is usually via open reduction and internal fixation using plates and screws. It must be carried out when soft tissue swelling has settled in order to minimise the risk of wound problems. This can often take a week to settle.

The use of fibula nails is expanding, but is not yet mainstream. Ankle fractures can also be treated with external fixation, or with a hind foot nail in patients who need fixation but where soft tissue or bone quality is poor.


Post operative management
Ankle fractures generally take 6 weeks to unite enough to prevent secondary displacement. This is therefore an appropriate time period to keep a cast on in a conservatively managed patient. Weight bearing post-operatively depends on the quality of the fixation and bone quality, and preference varies between surgeons, ranging from aggressive early mobilisation to a period of non-weight bearing. Return to activities takes approximately three months, and often requires assistance of a physiotherapist to improve range-of-movement and muscle strengthening.

11

A 30 year old man injures his ankle playing football. On examination he has tenderness over both medial and lateral malleoli. X-ray demonstrates a bimalleolar fracture with a displaced distal fibula fracture, at the level of the syndesmosis and fracture of the medial malleolus with talar shift. The ankle has been provisionally reduced and splinted in the emergency department.

A. Surgical fixation
B. Below knee amputation
C. Application of below knee plaster
D. Application of ankle boot
E. Application of external fixation device
F. Application of compression dressing and physiotherapy
G. Immediate reduction and application of backslab

Surgical fixation

This is an unstable fracture pattern with a Weber B fracture of the distal fibula and a fracture of the medial malleolus. Talar shift indicates loss of ankle mortice congruity. This injury should therefore be treated with surgical fixation.

An ankle fracture relates to a fracture around the tibio-talar joint. It generally refers to a fracture involving the lateral, and/or medial and/or posterior malleolus. Pilon and Tillaux fractures are also considered to be ankle fractures, but are not covered here.
Ankle fractures are common. They effect men and women in equal numbers, but men have a higher rate as young adults (sports and contact injuries), and women a higher rate post-menopausal (fragility type fracture).

Osseous anatomy
The ankle (or mortise) joint consists of the distal tibia (tibial plafond and posterior malleolus), the distal fibula (lateral malleolus), and the talus. The main movement at the ankle joint is plantar and dorsiflexion.

Ligamentous anatomy
Medial side: Deltoid ligament. This is divided into superficial and deep portions. It is the primary restraint to valgus tilting of the talus.

Lateral side: Lateral ligament complex consisting from anterior to posterior of the anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL), and the posterior talofibular ligament (PTFL). Together they resist valgus stress to the ankle, and are a restraint to anterior translation of the talus within the mortise joint.

Syndesmosis: The syndesmosis is a ligament complex between the distal tibia and fibula, holding the two bones together. It is fundamental to the integrity of the ankle joint, and its disruption leads to instability. It consists of (from anterior to posterior) the anterior-inferior tibiofibular ligament (AITFL), the transverse tibiofibular ligament (TTFL), the interosseous membrane, and the posterior-inferior tibiofibular ligament (PITFL).

Presentation and initial management
Patients will present following a traumatic event with a painful, swollen ankle, and reluctance/inability to weight bear. The Ottawa rules can be applied to differentiate between an ankle fracture and sprain, but can be unreliable.
In high energy injuries, management should follow ATLS principles to identify more significant injuries first. Neurovascular status of the foot should be documented, and open injuries should be excluded. If an open injury is identified, it should be managed in line with BOAST 4 principles1. If an obvious deformity exists, it should be reduced as soon as possible with appropriate analgesia or conscious sedation. Radiographs of clearly deformed or dislocated joints are not necessary, and removing the pressure on the surrounding soft tissues from the underlying bony deformity is the priority. If the fracture pattern is not clinically obvious then plain radiographs are appropriate and will guide the subsequent manipulation during plaster-of-paris below knee backslab application.

Imaging
AP, lateral and mortise views (20o internal rotation) are essential to evaluate fracture displacement and syndesmotic injury. Decreased tibiofibular overlap, medial joint clear space and lateral talar shift all indicate a syndesmotic injury. (In subtle cases of shift, imaging the uninjured ankle can be helpful as a proportion of the population have little or no tibiotalar overlap 2.)

Where there is suspicion of syndesmosis involvement in the absence of radiographic evidence, stress radiographs can be diagnostic.
Complex fracture patterns (and increasingly posterior malleolar fractures) are best defined using CT.



Classification
The most commonly used classifications are Lauge-Hansen and Danis-Weber.

Lauge-Hansen
Comprises two parts: first part is the foot position, and the second part is the force applied. Useful for understanding the forces involved and therefore predict the ligamentous or bony injury. Results in four injury patterns:
Supination - Adduction (SA) - 10-20%
Supination - External rotation (SER) - 40-75%
Pronation - Abduction (PA) - 5-20%
Pronation - External rotation (PER) - 5-20%

Not often used in clinical practice but good for understanding the principles of ankle fracture.

Danis-Weber
Commonly used. Based on the level of the fibula fracture in relation to the syndesmosis. The more proximal, the greater the risk of syndesmotic injury and therefore fracture instability.
A - fracture below the level of the syndesmosis
B - fracture at the level of the syndesmosis / level of the tibial plafond
C - fracture above the level of the syndesmosis. This includes Maisonneuve fractures (proximal fibula fracture), which can be associated with ankle instability. Beware the high fibula fracture - it may be an ankle fracture!

The Weber classification is based purely on the the lateral side. All injuries can include a medial or posterior bony or ligamentous injury which also dictates fracture stability (bimalleolar and trimalleolar fractures are more unstable).

Treatment
When deciding upon treatment for an ankle fracture, one must consider both the fracture and the patient. Diabetic patients and smokers are at greater risk of post-operative complication, especially wound problems and infection. Likewise, the long term outcome of post-traumatic arthritis from a malunited ankle fracture is extremely important for a young patient, but not as relevant in the elderly. Therefore, normal surgical decision processes apply as with all fractures.

Defining stability of an ankle fracture underpins the treatment decision.
Weber A - Unimalleolar Weber A Weber fractures by definition are stable and therefore can be mobilised fully weight bearing in an ankle boot.

Weber C - Fractures tend to include syndesmotic disruption and are usually bimalleolar (either bony or ligamentous). They are therefore unstable and usually require operative fixation. In addition to the fracture fixation, the syndesmosis usually requires reconstruction/augmentation with screws to restore the joint integrity and function.

Weber B - B fractures vary greatly. They can be part of a trimalleolar injury and therefore extremely unstable, requiring fixation. Alternatively, a uni-malleolar Weber B fracture can be a stable injury, and therefore mobilised immediately in an ankle boot. Defining the stability can be challenging, and often involves stress radiographs, or a trial of mobilisation and repeat radiographs. Defining stability is the subject of much ongoing research. However, treating undisplaced ankle fractures in a below knee plaster, non-weight bearing for six weeks is still widely practised, and a safe approach.

When operative fixation is appropriate, it is usually via open reduction and internal fixation using plates and screws. It must be carried out when soft tissue swelling has settled in order to minimise the risk of wound problems. This can often take a week to settle.

The use of fibula nails is expanding, but is not yet mainstream. Ankle fractures can also be treated with external fixation, or with a hind foot nail in patients who need fixation but where soft tissue or bone quality is poor.


Post operative management
Ankle fractures generally take 6 weeks to unite enough to prevent secondary displacement. This is therefore an appropriate time period to keep a cast on in a conservatively managed patient. Weight bearing post-operatively depends on the quality of the fixation and bone quality, and preference varies between surgeons, ranging from aggressive early mobilisation to a period of non-weight bearing. Return to activities takes approximately three months, and often requires assistance of a physiotherapist to improve range-of-movement and muscle strengthening.

12

A 50 year old female slips on wet floor injuring her ankle. On examination, she has tenderness over the lateral and medial malleolus. X-rays demonstrate an undisplaced fracture of the distal fiibula at the level of the syndesmosis and a congruent ankle mortice.

A. Surgical fixation
B. Below knee amputation
C. Application of below knee plaster
D. Application of ankle boot
E. Application of external fixation device
F. Application of compression dressing and physiotherapy
G. Immediate reduction and application of backslab

Application of below knee plaster

This is a Weber B fracture and therefore potentially unstable. Medial malleolar tenderness indicates deltoid ligament injury. As the fracture is currently undisplaced and the ankle mortice is congruent, the injury can be initially managed conservatively in a below knee plaster but the patient should be monitored in the outpatient clinic for fracture displacement in the first few weeks.

An ankle fracture relates to a fracture around the tibio-talar joint. It generally refers to a fracture involving the lateral, and/or medial and/or posterior malleolus. Pilon and Tillaux fractures are also considered to be ankle fractures, but are not covered here.
Ankle fractures are common. They effect men and women in equal numbers, but men have a higher rate as young adults (sports and contact injuries), and women a higher rate post-menopausal (fragility type fracture).

Osseous anatomy
The ankle (or mortise) joint consists of the distal tibia (tibial plafond and posterior malleolus), the distal fibula (lateral malleolus), and the talus. The main movement at the ankle joint is plantar and dorsiflexion.

Ligamentous anatomy
Medial side: Deltoid ligament. This is divided into superficial and deep portions. It is the primary restraint to valgus tilting of the talus.

Lateral side: Lateral ligament complex consisting from anterior to posterior of the anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL), and the posterior talofibular ligament (PTFL). Together they resist valgus stress to the ankle, and are a restraint to anterior translation of the talus within the mortise joint.

Syndesmosis: The syndesmosis is a ligament complex between the distal tibia and fibula, holding the two bones together. It is fundamental to the integrity of the ankle joint, and its disruption leads to instability. It consists of (from anterior to posterior) the anterior-inferior tibiofibular ligament (AITFL), the transverse tibiofibular ligament (TTFL), the interosseous membrane, and the posterior-inferior tibiofibular ligament (PITFL).

Presentation and initial management
Patients will present following a traumatic event with a painful, swollen ankle, and reluctance/inability to weight bear. The Ottawa rules can be applied to differentiate between an ankle fracture and sprain, but can be unreliable.
In high energy injuries, management should follow ATLS principles to identify more significant injuries first. Neurovascular status of the foot should be documented, and open injuries should be excluded. If an open injury is identified, it should be managed in line with BOAST 4 principles1. If an obvious deformity exists, it should be reduced as soon as possible with appropriate analgesia or conscious sedation. Radiographs of clearly deformed or dislocated joints are not necessary, and removing the pressure on the surrounding soft tissues from the underlying bony deformity is the priority. If the fracture pattern is not clinically obvious then plain radiographs are appropriate and will guide the subsequent manipulation during plaster-of-paris below knee backslab application.

Imaging
AP, lateral and mortise views (20o internal rotation) are essential to evaluate fracture displacement and syndesmotic injury. Decreased tibiofibular overlap, medial joint clear space and lateral talar shift all indicate a syndesmotic injury. (In subtle cases of shift, imaging the uninjured ankle can be helpful as a proportion of the population have little or no tibiotalar overlap 2.)

Where there is suspicion of syndesmosis involvement in the absence of radiographic evidence, stress radiographs can be diagnostic.
Complex fracture patterns (and increasingly posterior malleolar fractures) are best defined using CT.



Classification
The most commonly used classifications are Lauge-Hansen and Danis-Weber.

Lauge-Hansen
Comprises two parts: first part is the foot position, and the second part is the force applied. Useful for understanding the forces involved and therefore predict the ligamentous or bony injury. Results in four injury patterns:
Supination - Adduction (SA) - 10-20%
Supination - External rotation (SER) - 40-75%
Pronation - Abduction (PA) - 5-20%
Pronation - External rotation (PER) - 5-20%

Not often used in clinical practice but good for understanding the principles of ankle fracture.

Danis-Weber
Commonly used. Based on the level of the fibula fracture in relation to the syndesmosis. The more proximal, the greater the risk of syndesmotic injury and therefore fracture instability.
A - fracture below the level of the syndesmosis
B - fracture at the level of the syndesmosis / level of the tibial plafond
C - fracture above the level of the syndesmosis. This includes Maisonneuve fractures (proximal fibula fracture), which can be associated with ankle instability. Beware the high fibula fracture - it may be an ankle fracture!

The Weber classification is based purely on the the lateral side. All injuries can include a medial or posterior bony or ligamentous injury which also dictates fracture stability (bimalleolar and trimalleolar fractures are more unstable).

Treatment
When deciding upon treatment for an ankle fracture, one must consider both the fracture and the patient. Diabetic patients and smokers are at greater risk of post-operative complication, especially wound problems and infection. Likewise, the long term outcome of post-traumatic arthritis from a malunited ankle fracture is extremely important for a young patient, but not as relevant in the elderly. Therefore, normal surgical decision processes apply as with all fractures.

Defining stability of an ankle fracture underpins the treatment decision.
Weber A - Unimalleolar Weber A Weber fractures by definition are stable and therefore can be mobilised fully weight bearing in an ankle boot.

Weber C - Fractures tend to include syndesmotic disruption and are usually bimalleolar (either bony or ligamentous). They are therefore unstable and usually require operative fixation. In addition to the fracture fixation, the syndesmosis usually requires reconstruction/augmentation with screws to restore the joint integrity and function.

Weber B - B fractures vary greatly. They can be part of a trimalleolar injury and therefore extremely unstable, requiring fixation. Alternatively, a uni-malleolar Weber B fracture can be a stable injury, and therefore mobilised immediately in an ankle boot. Defining the stability can be challenging, and often involves stress radiographs, or a trial of mobilisation and repeat radiographs. Defining stability is the subject of much ongoing research. However, treating undisplaced ankle fractures in a below knee plaster, non-weight bearing for six weeks is still widely practised, and a safe approach.

When operative fixation is appropriate, it is usually via open reduction and internal fixation using plates and screws. It must be carried out when soft tissue swelling has settled in order to minimise the risk of wound problems. This can often take a week to settle.

The use of fibula nails is expanding, but is not yet mainstream. Ankle fractures can also be treated with external fixation, or with a hind foot nail in patients who need fixation but where soft tissue or bone quality is poor.


Post operative management
Ankle fractures generally take 6 weeks to unite enough to prevent secondary displacement. This is therefore an appropriate time period to keep a cast on in a conservatively managed patient. Weight bearing post-operatively depends on the quality of the fixation and bone quality, and preference varies between surgeons, ranging from aggressive early mobilisation to a period of non-weight bearing. Return to activities takes approximately three months, and often requires assistance of a physiotherapist to improve range-of-movement and muscle strengthening.

13

A 30 year old woman presents with pain and swelling of the left shoulder. There is a large radiolucent lesion in the head of the humerus extending to the subchondral plate.

A. Osteosarcoma
B. Osteomalacia
C. Osteoporosis
D. Metastatic carcinoma
E. Osteoblastoma
F. Giant cell tumour
G. Ewing's sarcoma

Giant cell tumour

Giant cell tumours on x-ray have a 'soap bubble' appearance. They present as pain or pathological fractures. They commonly metastasize to the lungs.

A pathological fracture occurs in abnormal bone due to insignificant injury
Causes
Metastatic tumours
Breast
Lung
Thyroid
Renal
Prostate
Bone disease
Osteogenesis imperfecta
Osteoporosis
Metabolic bone disease
Paget's disease
Local benign conditions
Chronic osteomyelitis
Solitary bone cyst
Primary malignant tumours
Chondrosarcoma
Osteosarcoma
Ewing's tumour

14

A 72 year old woman has a lumbar vertebral crush fracture. She has hypocalcaemia and a low urinary calcium.

A. Osteosarcoma
B. Osteomalacia
C. Osteoporosis
D. Metastatic carcinoma
E. Osteoblastoma
F. Giant cell tumour
G. Ewing's sarcoma

Osteomalacia

Hypocalcemia and low urinary calcium are biochemical features of osteomalacia. Unfortunately surgeons do need to look at some blood results!

A pathological fracture occurs in abnormal bone due to insignificant injury
Causes
Metastatic tumours
Breast
Lung
Thyroid
Renal
Prostate
Bone disease
Osteogenesis imperfecta
Osteoporosis
Metabolic bone disease
Paget's disease
Local benign conditions
Chronic osteomyelitis
Solitary bone cyst
Primary malignant tumours
Chondrosarcoma
Osteosarcoma
Ewing's tumour

15

A 16 year old boy presents with severe groin pain after kicking a football. Imaging confirms a pelvic fracture. A previous pelvic x-ray performed 2 weeks ago shows a lytic lesion with 'onion type' periosteal reaction.

A. Osteosarcoma
B. Osteomalacia
C. Osteoporosis
D. Metastatic carcinoma
E. Osteoblastoma
F. Giant cell tumour
G. Ewing's sarcoma

Ewing's sarcoma

A Ewings sarcoma is most common in males between 10-20 years. It can occur in girls. A lytic lesion with a lamellated or onion type periosteal reaction is a classical finding on x-rays. Most patients present with metastatic disease with a 5 year prognosis between 5-10%.

A pathological fracture occurs in abnormal bone due to insignificant injury
Causes
Metastatic tumours
Breast
Lung
Thyroid
Renal
Prostate
Bone disease
Osteogenesis imperfecta
Osteoporosis
Metabolic bone disease
Paget's disease
Local benign conditions
Chronic osteomyelitis
Solitary bone cyst
Primary malignant tumours
Chondrosarcoma
Osteosarcoma
Ewing's tumour

16

An 8 year old boy falls onto an outstretched hand and is brought to the emergency department. He is examined by a doctor and a bony injury is cleared clinically. He re-presents a week later with pain in his hand. What is the most likely underlying injury?

Fracture of the distal radius
Fracture of the scaphoid
Dislocation of the lunate
Rupture of flexor pollicis longus tendon
Bennett's fracture

Scaphoid fractures in children are rare, will usually involve the distal pole and are easily missed. The initial clinical examination (and sometimes x-rays) may be normal and repeated clinical examination and imaging is advised for this reason. Whilst the other injuries may be sustained from a fall onto an outstretched hand they are less likely to be overlooked on clinical examination. In the case of a Bennetts fracture, the injury mechanism is less compatible with this type of injury.

Scaphoid fractures

Scaphoid fractures are the commonest carpal fractures.
Surface of scaphoid is covered by articular cartilage with small area available for blood vessels (fracture risks blood supply)
Forms floor of anatomical snuffbox
Risk of fracture associated with fall onto outstretched hand (tubercle, waist, or proximal third)
Ulnar deviation AP needed for visualization of scaphoid
Immobilization of scaphoid fractures difficult

Management
Non-displaced fractures - Casts or splints
- Percutaneous scaphoid fixation
Displaced fracture Surgical fixation, usually with a screw


Complications
Non union of scaphoid
Avascular necrosis of the scaphoid
Scapholunate disruption and wrist collapse
Degenerative changes of the adjacent joint

17

A 23 year old rugby player falls directly onto his shoulder. There is pain and swelling of the shoulder joint. The clavicle is prominent and there appears to be a step deformity.


A. Glenohumeral dislocation
B. Acromioclavicular dislocation
C. Sternoclavicular dislocation
D. Biceps tendon tear
E. Supraspinatus tear
F. Fracture of the surgical neck of the humerus
G. Infra spinatus tear

Acromioclavicular dislocation

Acromioclavicular joint (ACJ) dislocation normally occurs secondary to direct injury to the superior aspect of the acromion. Loss of shoulder contour and prominent clavicle are key features. Note; rotator cuff tears rarely occur in the second decade.

Shoulder fractures and dislocations
Fractures
Proximal humerus
Background
Third most common fragility fracture in the elderly.
Results from low energy fall in predominantly elderly females, or from high energy trauma in young males.
Can be associated with nerve injury (commonly axillary), and fracture-dislocation of the humeral head. Detailed neurological assessment is essential for all upper limb injuries.

Anatomy
Osteology
Consists of articular head, greater tuberosity, lesser tuberosity, metaphysis and diaphysis. Between the articular head and the tuberosities is the anatomical neck (previous physis). Between the tuberosities and the metaphysis is the surgical neck.
The supraspinatus, infraspinatus and teres minor muscles attach to the greater tuberosity. The subscapularis muscle attaches to the lesser tuberosity.

Vascular Supply
Humeral head is supplied by the anterior and posterior humeral circumflex arteries. Anatomical neck fractures are at greatest risk of osteonecrosis.

Imaging
Imaging aims to both delineate the fracture pattern, and confirm/exlude the presence of an associated dislocation.
Radiographs - True anteroposterior (AP), axillary lateral and/or scapula Y view.
CT - indicated to better define intra-articular involvement and to aid pre-operative planning. MRI is not useful for fracture imaging.

Classification
Description of the fracture is often more useful than classification. Particular attention should be paid to humeral alignment, fracture displacement, and greater tuberosity position (rotator cuff will pull the GT supero-posterioly, which can cause impingement problems with malunion).
- Neer Classification: Most commonly used. Describes fracture as 2,3,or 4 part depending upon the number main fragments. Also comments on the degree of displacement. Fragments:
-greater tuberosity
-lesser tuberosity
- articular surface
- shaft
Displacement: >1cm or angulation >45 degrees.

Treatment
The vast majority of proximal humeral fractures are minimally displaced, and therefore can be managed conservatively. This involves immobilisation in a polysling, and progressive mobilisation. Pendular exercise can commence at 14 days, and active abduction from 4-6 weeks.

Irreducible fracture dislocation is an indication for operative management. Other indications include large displacement, younger patient, head splitting (intra-articular fractures). However, the recent PROFHER trial (1) has suggested no benefit to operative intervention on patient outcome (it must be applied cautiously as majority of patients were elderly with extraarticular fractures). Options available for surgical management include:

ORIF Most commonly used. Plate and screw fixation. Can reconstruct complex fractures.
Intramedullary nail Suitable for extra-articular configuration, predominantly surgical neck +/- GT fractures.

Hemiarthroplasty Used for un-reconstructable fractures in the older patient who has good glenoid quality.
Total shoulder arthroplasty Unconstructable fractures where high functioning shoulder is required (hemiarthroplasty will cause glenoid erosion)
Reverse shoulder arthroplasty Total shoulder arthroplasty that provides better functional outcome than conventional total shoulder replacement.



Scapula
Background
Uncommon fractures usually associated with high energy trauma. Most commonly involve scapula body or spine (50%), glenoid fossa and glenoid neck. Important to exclude associated life threatening injury.

Imaging
Plain radiographs should include true anteroposterior (AP), axillary lateral and/or scapula Y view. CT scanning is useful for defining intra-articular involvement, displacement and for three dimensional reconstruction.

Classification
Based on the location of the fracture (coracoid, acromion, glenoid neck, glenoid fossa, scapula body). Beware of ipsilateral glenoid neck and clavicle fracture -floating shoulder - where limb is effectively dissociated from axial skeleton.

Treatment
The vast majority of scapula fractures are amenable to conservative management, consisting of sling immobilisation for two weeks followed by early rehabilitation. Floating shoulder will usually require fixation, and consideration of surgery should also be given to intra-articular and displaced/angulated glenoid fractures.

Dislocations

Types
Dislocations around the shoulder joint include glenohumeral dislocation, acromioclavicular joint disruption and sternoclavicular dislocation. Only glenohumeral dislocation will be covered here.

Glenohumeral dislocation
Diagnosis, classification and management are covered here.

Background
Shoulder dislocation is commonly seen in A&E. It has a high recurrence rate that is as high as 80% in teenagers. Initial management requires emergent reduction to prevent lasting chondral damage.

Early assessment and management
Usually a traumatic cause (multi-directional instability in frequent dislocations requires discussion with orthopaedics and is not covered here). Careful history, examination and documentation of neurovascular status of the limb, in particular the axillary nerve (regimental badge sensation). This should be re-assessed post manipulation. Early radiographs to confirm direction of dislocation.

Initial management consists of emergent closed reduction under under entanox and analgesia, but often requires conscious sedation. Arm should then be immobilised in a polysling, and XR to confirm relocation.

Imaging - True anteroposterior (AP), axillary lateral and/or scapula Y view. Reduced humeral head should lie between acromion and coracoid on lateral/scapula view.

Types
Direction Features Cause Examination Reduction techniques
Anterior Most Common >90% Usually traumatic - anterior force on arm when shoulder is abducted, eternally rotated Loss of shoulder contour - sulcus sign. Humeral head can be felt anteriorly.
Hippocratic.
Milch.
Stimson.

Kocher not advised due to complication of fracture
Posterior 50% missed in A&E 50% traumatic, but classically post seizure or electrocution Shoulder locked in internal rotation. XR may show lightbulb appearance. Gentle lateral traction to adducted arm.
Inferior Rare Associated with pectorals and rotator cuff tears, and glenoid fracture As for primary injury Management of primary injury

Superior Rare Associated with acrominon/clavicle fracture As for primary injury Management of primary injury



Associated injuries
Bankart lesion - avulsion of the anterior glenoid labrum with an anterior shoulder dislocation (reverse Bankart if poster labrum in posterior dislocation).
Hill Sachs defect - chondral impaction on posteriosuperior humeral head from contact with gleonoid rim. Can be large enough to lock shoulder, requiring open reduction. (Reverse Hill Sachs in posterior dislocation).
Rotator cuff tear - increases with age.
Greater or lesser tuberosity fracture - increases with age.
Humeral neck fracture - shoulder fracture dislocation. More common in high energy trauma and elderly. Should be discussed with orthopaedics prior to any attempted reduction.

Rotator Cuff Disease

Rotator cuff disease is a spectrum of conditions that ranges from subacromial impingement to rotator cuff tears and eventually to rotator cuff arthropathy (arthritis).

Anatomy
The rotator cuff is a group of four muscles that are important in shoulder movements, and maintenance of glenohumeral stability.
Muscle Scapular attachment Humeral attachment Action Innervation
Supraspinatus Supraspinatus fossa Superior facet of greater tuberosity Initiation of abduction of humerus Suprascapular nerve
Infraspinatus Infraspinatus fossa Posterior facet of greater tuberosity External rotation of humerus Suprascapular nerve
Teres Minor Lateral border Inferior facet of greater tuberosity External rotation of humerus Axillary Nerve
Subscapularis Subscapular fossa Lesser tuberosity Internal rotation of humerus Upper and lower subscapular nerve

The inferior rotator cuff muscles (infraspinatus, teres minor, and subscapularis) balance the superior pull of the deltoid. Injury/tear results in upward migration of the humeral head on the glenoid (can be seen on AP radiograph).
Likewise, the anterior muscles (subscapularis) are balanced with the posterior muscles (infraspinatus, teres minor).

Subacromial Impingement

The most common cause of shoulder pain, which results from impingement of the superior cuff on the undersurface of the acromion, and an inflammatory bursitis.
Associated with certain types of acromial morphology (Bigliani classification).
Presents as insidious pain which is exacerbated by overhead activities.

Rotator Cuff Tear

Often presents as an acute event on the background of chronic subacromial impingement in the older patient, but can present as an avulsion injury in younger patients.
Majority of tears are to the superior cuff (supraspinatus, infraspinatus, teres minor), though a tear to subscapularis is associated with subcoracoid impingement.
Tears present as pain and weakness when using the muscles in question.

Rotator Cuff Arthropathy

Defined as shoulder arthritis in the setting of rotator cuff dysfunction. Results from superior migration due to the loss of rotator cuff function and integrity. Unopposed deltoid pulls the humeral head superiorly.
Associated with massive chronic cuff tears.

Imaging

Plain radiographs
AP of the shoulder may show superior migration of the humerus with a cuff tear, and features of arthritis with arthropathy. Other causes of pain may also be identified (e.g. calcific tendonitis/fracture)
Outlet view is useful for defining the acromial morphology

USS
Allows dynamic imaging of the cuff, and is inexpensive. However, it is very user dependent.

MRI
Best imaging modality for cuff pathology.
Also allows imaging of the rest of the shoulder. When intra-articular pathology is suspected, can be combined with an arthrogram for improved sensitivity and specificity.

Treatment

Subacromial impingement
Physiotherapy, oral anti-inflammatory medication
Subacromial steroid injection can settle inflammation
Arthroscopic subacromial decompression by shaving away the undersurface of the acromion, more space is created for the rotator cuff. Cuff integrity is assessed also at time of surgery, and can be repaired if necessary.

Rotator cuff tear
When considering repair of a cuff tear, the age and activity of the patient, the nature of the tear (degenerative vs. acute traumatic), and the size and retraction of the tear should be considered when making a surgical plan.
Mild tears or tears in the elderly can be managed conservatively, as outlined above.
Moderate tears can be repaired arthroscopically. Massive or retracted tears will often require an open repair (occasionally with a tendon transfer). Subacromial decompression is performed at the same time to reduce impingement, symptoms and recurrence.

Calcific tendonitis
Calcific tendonitis involves calcific deposits within tendons anywhere in the body, but most commonly in the rotator cuff (specifically the supraspinatus tendon). When present in the shoulder, it is associated with subacromial impingement and pain.

Pathology
More common in women aged 30-60 years.
Association with diabetes and hypothyroidism

There are three stages of calcification
Formative phase characterized by calcific deposits
Resting phase deposit is stable, but presents with impingement problems
Resorptive phase phagocytic resorption. Most painful stage.

Presentation
Similar in presentation to subacromial impingement, with pain especially with over head activities. Atraumatic in nature.

Imaging
Plain radiographs show calcification of the rotator cuff, usually within 1.5cm of its insertion on the humerus. Supraspinatus outlet views can show level of impingment. Further imaging is rarely needed.

Treatment
Non-operative NSAIDS, steroid injection (controversial, but practiced) and physiotherapy. Approximately 75% will resolve by 6 months with conservative management.
Ultrasound guided or surgical needle barbotage can break down deposits and resolve symptoms. Occasionally surgical excision is required.

Adhesive capsulitis (Frozen Shoulder)
Pain and loss of movement of shoulder joint, which involves fibroplastic proliferation of capsular tissue, causing soft tissue scarring and contracture. Patients present with a painful and decreased arc of motion.
Associated with prolonged immobilization, previous surgery, thyroid disorders (AI) and diabetes
Classically three stages which can take up to two years to resolve:
Stage one the freezing and painful stage
Stage two the frozen and stiff stage
Stage three the thawing stage, where shoulder movement slowly improves

Imaging
Plain radiographs to exclude other causes of a painful shoulder
MRI arthrogram may show capsular contracture, and again may be used to exclude cuff pathology. However, often not performed as diagnosis is largely clinical.

Treatment
Non-operative NSAIDS, steroid injection and physiotherapy. Patience is required as condition can take up to 2 years to improve.
Operative MUA or arthroscopic adhesiolysis (release of adhesions) can expedite recovery, followed by intensive physiotherapy.

Glenohumeral Arthritis
Background
May be osteoarthritis (primary or secondary to cuff tear or trauma), rheumatoid arthritis, or as part of a spondyloarthropathy. Majority of those with RA will develop symptoms.
More common in the elderly
Presents like any other arthritis - pain at night and with movement

Imaging
AP and axillary radiographs will show features of arthritis.
CT/MRI is often useful to classify the shape of the glenoid and extent of bone loss when considering arthroplasty. MRI also essential to asses integrity of rotator cuff if considering shoulder replacement.

Treatment
Like all orthopaedics, start with simple measures:
NSAIDS, management of RA, physiotherapy, steroid injection.
Hemiarthroplasty can sometimes be considered if glenoid is in excellent condition or if patient has large comorbidity.
Arthroscopic debridement is useful if patient has isolated ACJ arthritis, but is rarely used for glenohumeral arthritis.
Total shoulder replacement is shown to produce superior outcome when compared to hemiarthroplasty in terms of pain relief, function and implant survival.
Total shoulder replacement can be anatomical (ball on humerus, with cup on glenoid), or reverse geometry (ball on glenoid, with cup on humerus). Anatomical TSR requires an in tact rotator cuff, so often reverse is preferable when the cuff if questionable in integrity.

18

A 22 year old man falls over and presents to casualty. A shoulder x-ray is performed, the radiologist comments that a Hill-Sachs lesion is present.


A. Glenohumeral dislocation
B. Acromioclavicular dislocation
C. Sternoclavicular dislocation
D. Biceps tendon tear
E. Supraspinatus tear
F. Fracture of the surgical neck of the humerus
G. Infra spinatus tear

Glenohumeral dislocation

A Hill-Sachs lesion occurs when the cartilage surface of the humerus is in contact with the rim of the glenoid. About 50% of anterior glenohumeral dislocations are associated with this lesion.

Shoulder fractures and dislocations
Fractures
Proximal humerus
Background
Third most common fragility fracture in the elderly.
Results from low energy fall in predominantly elderly females, or from high energy trauma in young males.
Can be associated with nerve injury (commonly axillary), and fracture-dislocation of the humeral head. Detailed neurological assessment is essential for all upper limb injuries.

Anatomy
Osteology
Consists of articular head, greater tuberosity, lesser tuberosity, metaphysis and diaphysis. Between the articular head and the tuberosities is the anatomical neck (previous physis). Between the tuberosities and the metaphysis is the surgical neck.
The supraspinatus, infraspinatus and teres minor muscles attach to the greater tuberosity. The subscapularis muscle attaches to the lesser tuberosity.

Vascular Supply
Humeral head is supplied by the anterior and posterior humeral circumflex arteries. Anatomical neck fractures are at greatest risk of osteonecrosis.

Imaging
Imaging aims to both delineate the fracture pattern, and confirm/exlude the presence of an associated dislocation.
Radiographs - True anteroposterior (AP), axillary lateral and/or scapula Y view.
CT - indicated to better define intra-articular involvement and to aid pre-operative planning. MRI is not useful for fracture imaging.

Classification
Description of the fracture is often more useful than classification. Particular attention should be paid to humeral alignment, fracture displacement, and greater tuberosity position (rotator cuff will pull the GT supero-posterioly, which can cause impingement problems with malunion).
- Neer Classification: Most commonly used. Describes fracture as 2,3,or 4 part depending upon the number main fragments. Also comments on the degree of displacement. Fragments:
-greater tuberosity
-lesser tuberosity
- articular surface
- shaft
Displacement: >1cm or angulation >45 degrees.

Treatment
The vast majority of proximal humeral fractures are minimally displaced, and therefore can be managed conservatively. This involves immobilisation in a polysling, and progressive mobilisation. Pendular exercise can commence at 14 days, and active abduction from 4-6 weeks.

Irreducible fracture dislocation is an indication for operative management. Other indications include large displacement, younger patient, head splitting (intra-articular fractures). However, the recent PROFHER trial (1) has suggested no benefit to operative intervention on patient outcome (it must be applied cautiously as majority of patients were elderly with extraarticular fractures). Options available for surgical management include:

ORIF Most commonly used. Plate and screw fixation. Can reconstruct complex fractures.
Intramedullary nail Suitable for extra-articular configuration, predominantly surgical neck +/- GT fractures.

Hemiarthroplasty Used for un-reconstructable fractures in the older patient who has good glenoid quality.
Total shoulder arthroplasty Unconstructable fractures where high functioning shoulder is required (hemiarthroplasty will cause glenoid erosion)
Reverse shoulder arthroplasty Total shoulder arthroplasty that provides better functional outcome than conventional total shoulder replacement.



Scapula
Background
Uncommon fractures usually associated with high energy trauma. Most commonly involve scapula body or spine (50%), glenoid fossa and glenoid neck. Important to exclude associated life threatening injury.

Imaging
Plain radiographs should include true anteroposterior (AP), axillary lateral and/or scapula Y view. CT scanning is useful for defining intra-articular involvement, displacement and for three dimensional reconstruction.

Classification
Based on the location of the fracture (coracoid, acromion, glenoid neck, glenoid fossa, scapula body). Beware of ipsilateral glenoid neck and clavicle fracture -floating shoulder - where limb is effectively dissociated from axial skeleton.

Treatment
The vast majority of scapula fractures are amenable to conservative management, consisting of sling immobilisation for two weeks followed by early rehabilitation. Floating shoulder will usually require fixation, and consideration of surgery should also be given to intra-articular and displaced/angulated glenoid fractures.

Dislocations

Types
Dislocations around the shoulder joint include glenohumeral dislocation, acromioclavicular joint disruption and sternoclavicular dislocation. Only glenohumeral dislocation will be covered here.

Glenohumeral dislocation
Diagnosis, classification and management are covered here.

Background
Shoulder dislocation is commonly seen in A&E. It has a high recurrence rate that is as high as 80% in teenagers. Initial management requires emergent reduction to prevent lasting chondral damage.

Early assessment and management
Usually a traumatic cause (multi-directional instability in frequent dislocations requires discussion with orthopaedics and is not covered here). Careful history, examination and documentation of neurovascular status of the limb, in particular the axillary nerve (regimental badge sensation). This should be re-assessed post manipulation. Early radiographs to confirm direction of dislocation.

Initial management consists of emergent closed reduction under under entanox and analgesia, but often requires conscious sedation. Arm should then be immobilised in a polysling, and XR to confirm relocation.

Imaging - True anteroposterior (AP), axillary lateral and/or scapula Y view. Reduced humeral head should lie between acromion and coracoid on lateral/scapula view.

Types
Direction Features Cause Examination Reduction techniques
Anterior Most Common >90% Usually traumatic - anterior force on arm when shoulder is abducted, eternally rotated Loss of shoulder contour - sulcus sign. Humeral head can be felt anteriorly.
Hippocratic.
Milch.
Stimson.

Kocher not advised due to complication of fracture
Posterior 50% missed in A&E 50% traumatic, but classically post seizure or electrocution Shoulder locked in internal rotation. XR may show lightbulb appearance. Gentle lateral traction to adducted arm.
Inferior Rare Associated with pectorals and rotator cuff tears, and glenoid fracture As for primary injury Management of primary injury

Superior Rare Associated with acrominon/clavicle fracture As for primary injury Management of primary injury



Associated injuries
Bankart lesion - avulsion of the anterior glenoid labrum with an anterior shoulder dislocation (reverse Bankart if poster labrum in posterior dislocation).
Hill Sachs defect - chondral impaction on posteriosuperior humeral head from contact with gleonoid rim. Can be large enough to lock shoulder, requiring open reduction. (Reverse Hill Sachs in posterior dislocation).
Rotator cuff tear - increases with age.
Greater or lesser tuberosity fracture - increases with age.
Humeral neck fracture - shoulder fracture dislocation. More common in high energy trauma and elderly. Should be discussed with orthopaedics prior to any attempted reduction.

Rotator Cuff Disease

Rotator cuff disease is a spectrum of conditions that ranges from subacromial impingement to rotator cuff tears and eventually to rotator cuff arthropathy (arthritis).

Anatomy
The rotator cuff is a group of four muscles that are important in shoulder movements, and maintenance of glenohumeral stability.
Muscle Scapular attachment Humeral attachment Action Innervation
Supraspinatus Supraspinatus fossa Superior facet of greater tuberosity Initiation of abduction of humerus Suprascapular nerve
Infraspinatus Infraspinatus fossa Posterior facet of greater tuberosity External rotation of humerus Suprascapular nerve
Teres Minor Lateral border Inferior facet of greater tuberosity External rotation of humerus Axillary Nerve
Subscapularis Subscapular fossa Lesser tuberosity Internal rotation of humerus Upper and lower subscapular nerve

The inferior rotator cuff muscles (infraspinatus, teres minor, and subscapularis) balance the superior pull of the deltoid. Injury/tear results in upward migration of the humeral head on the glenoid (can be seen on AP radiograph).
Likewise, the anterior muscles (subscapularis) are balanced with the posterior muscles (infraspinatus, teres minor).

Subacromial Impingement

The most common cause of shoulder pain, which results from impingement of the superior cuff on the undersurface of the acromion, and an inflammatory bursitis.
Associated with certain types of acromial morphology (Bigliani classification).
Presents as insidious pain which is exacerbated by overhead activities.

Rotator Cuff Tear

Often presents as an acute event on the background of chronic subacromial impingement in the older patient, but can present as an avulsion injury in younger patients.
Majority of tears are to the superior cuff (supraspinatus, infraspinatus, teres minor), though a tear to subscapularis is associated with subcoracoid impingement.
Tears present as pain and weakness when using the muscles in question.

Rotator Cuff Arthropathy

Defined as shoulder arthritis in the setting of rotator cuff dysfunction. Results from superior migration due to the loss of rotator cuff function and integrity. Unopposed deltoid pulls the humeral head superiorly.
Associated with massive chronic cuff tears.

Imaging

Plain radiographs
AP of the shoulder may show superior migration of the humerus with a cuff tear, and features of arthritis with arthropathy. Other causes of pain may also be identified (e.g. calcific tendonitis/fracture)
Outlet view is useful for defining the acromial morphology

USS
Allows dynamic imaging of the cuff, and is inexpensive. However, it is very user dependent.

MRI
Best imaging modality for cuff pathology.
Also allows imaging of the rest of the shoulder. When intra-articular pathology is suspected, can be combined with an arthrogram for improved sensitivity and specificity.

Treatment

Subacromial impingement
Physiotherapy, oral anti-inflammatory medication
Subacromial steroid injection can settle inflammation
Arthroscopic subacromial decompression by shaving away the undersurface of the acromion, more space is created for the rotator cuff. Cuff integrity is assessed also at time of surgery, and can be repaired if necessary.

Rotator cuff tear
When considering repair of a cuff tear, the age and activity of the patient, the nature of the tear (degenerative vs. acute traumatic), and the size and retraction of the tear should be considered when making a surgical plan.
Mild tears or tears in the elderly can be managed conservatively, as outlined above.
Moderate tears can be repaired arthroscopically. Massive or retracted tears will often require an open repair (occasionally with a tendon transfer). Subacromial decompression is performed at the same time to reduce impingement, symptoms and recurrence.

Calcific tendonitis
Calcific tendonitis involves calcific deposits within tendons anywhere in the body, but most commonly in the rotator cuff (specifically the supraspinatus tendon). When present in the shoulder, it is associated with subacromial impingement and pain.

Pathology
More common in women aged 30-60 years.
Association with diabetes and hypothyroidism

There are three stages of calcification
Formative phase characterized by calcific deposits
Resting phase deposit is stable, but presents with impingement problems
Resorptive phase phagocytic resorption. Most painful stage.

Presentation
Similar in presentation to subacromial impingement, with pain especially with over head activities. Atraumatic in nature.

Imaging
Plain radiographs show calcification of the rotator cuff, usually within 1.5cm of its insertion on the humerus. Supraspinatus outlet views can show level of impingment. Further imaging is rarely needed.

Treatment
Non-operative NSAIDS, steroid injection (controversial, but practiced) and physiotherapy. Approximately 75% will resolve by 6 months with conservative management.
Ultrasound guided or surgical needle barbotage can break down deposits and resolve symptoms. Occasionally surgical excision is required.

Adhesive capsulitis (Frozen Shoulder)
Pain and loss of movement of shoulder joint, which involves fibroplastic proliferation of capsular tissue, causing soft tissue scarring and contracture. Patients present with a painful and decreased arc of motion.
Associated with prolonged immobilization, previous surgery, thyroid disorders (AI) and diabetes
Classically three stages which can take up to two years to resolve:
Stage one the freezing and painful stage
Stage two the frozen and stiff stage
Stage three the thawing stage, where shoulder movement slowly improves

Imaging
Plain radiographs to exclude other causes of a painful shoulder
MRI arthrogram may show capsular contracture, and again may be used to exclude cuff pathology. However, often not performed as diagnosis is largely clinical.

Treatment
Non-operative NSAIDS, steroid injection and physiotherapy. Patience is required as condition can take up to 2 years to improve.
Operative MUA or arthroscopic adhesiolysis (release of adhesions) can expedite recovery, followed by intensive physiotherapy.

Glenohumeral Arthritis
Background
May be osteoarthritis (primary or secondary to cuff tear or trauma), rheumatoid arthritis, or as part of a spondyloarthropathy. Majority of those with RA will develop symptoms.
More common in the elderly
Presents like any other arthritis - pain at night and with movement

Imaging
AP and axillary radiographs will show features of arthritis.
CT/MRI is often useful to classify the shape of the glenoid and extent of bone loss when considering arthroplasty. MRI also essential to asses integrity of rotator cuff if considering shoulder replacement.

Treatment
Like all orthopaedics, start with simple measures:
NSAIDS, management of RA, physiotherapy, steroid injection.
Hemiarthroplasty can sometimes be considered if glenoid is in excellent condition or if patient has large comorbidity.
Arthroscopic debridement is useful if patient has isolated ACJ arthritis, but is rarely used for glenohumeral arthritis.
Total shoulder replacement is shown to produce superior outcome when compared to hemiarthroplasty in terms of pain relief, function and implant survival.
Total shoulder replacement can be anatomical (ball on humerus, with cup on glenoid), or reverse geometry (ball on glenoid, with cup on humerus). Anatomical TSR requires an in tact rotator cuff, so often reverse is preferable when the cuff if questionable in integrity.

19

An 82 year old female presents to A&E after tripping on a step. She complains of shoulder pain. On examination there is pain to 90o on abduction.


A. Glenohumeral dislocation
B. Acromioclavicular dislocation
C. Sternoclavicular dislocation
D. Biceps tendon tear
E. Supraspinatus tear
F. Fracture of the surgical neck of the humerus
G. Infra spinatus tear

Supraspinatus tear

A supraspinatus tear is the most common of rotator cuff tears. It occurs as a result of degeneration and is rare in younger adults.

Shoulder fractures and dislocations
Fractures
Proximal humerus
Background
Third most common fragility fracture in the elderly.
Results from low energy fall in predominantly elderly females, or from high energy trauma in young males.
Can be associated with nerve injury (commonly axillary), and fracture-dislocation of the humeral head. Detailed neurological assessment is essential for all upper limb injuries.

Anatomy
Osteology
Consists of articular head, greater tuberosity, lesser tuberosity, metaphysis and diaphysis. Between the articular head and the tuberosities is the anatomical neck (previous physis). Between the tuberosities and the metaphysis is the surgical neck.
The supraspinatus, infraspinatus and teres minor muscles attach to the greater tuberosity. The subscapularis muscle attaches to the lesser tuberosity.

Vascular Supply
Humeral head is supplied by the anterior and posterior humeral circumflex arteries. Anatomical neck fractures are at greatest risk of osteonecrosis.

Imaging
Imaging aims to both delineate the fracture pattern, and confirm/exlude the presence of an associated dislocation.
Radiographs - True anteroposterior (AP), axillary lateral and/or scapula Y view.
CT - indicated to better define intra-articular involvement and to aid pre-operative planning. MRI is not useful for fracture imaging.

Classification
Description of the fracture is often more useful than classification. Particular attention should be paid to humeral alignment, fracture displacement, and greater tuberosity position (rotator cuff will pull the GT supero-posterioly, which can cause impingement problems with malunion).
- Neer Classification: Most commonly used. Describes fracture as 2,3,or 4 part depending upon the number main fragments. Also comments on the degree of displacement. Fragments:
-greater tuberosity
-lesser tuberosity
- articular surface
- shaft
Displacement: >1cm or angulation >45 degrees.

Treatment
The vast majority of proximal humeral fractures are minimally displaced, and therefore can be managed conservatively. This involves immobilisation in a polysling, and progressive mobilisation. Pendular exercise can commence at 14 days, and active abduction from 4-6 weeks.

Irreducible fracture dislocation is an indication for operative management. Other indications include large displacement, younger patient, head splitting (intra-articular fractures). However, the recent PROFHER trial (1) has suggested no benefit to operative intervention on patient outcome (it must be applied cautiously as majority of patients were elderly with extraarticular fractures). Options available for surgical management include:

ORIF Most commonly used. Plate and screw fixation. Can reconstruct complex fractures.
Intramedullary nail Suitable for extra-articular configuration, predominantly surgical neck +/- GT fractures.

Hemiarthroplasty Used for un-reconstructable fractures in the older patient who has good glenoid quality.
Total shoulder arthroplasty Unconstructable fractures where high functioning shoulder is required (hemiarthroplasty will cause glenoid erosion)
Reverse shoulder arthroplasty Total shoulder arthroplasty that provides better functional outcome than conventional total shoulder replacement.



Scapula
Background
Uncommon fractures usually associated with high energy trauma. Most commonly involve scapula body or spine (50%), glenoid fossa and glenoid neck. Important to exclude associated life threatening injury.

Imaging
Plain radiographs should include true anteroposterior (AP), axillary lateral and/or scapula Y view. CT scanning is useful for defining intra-articular involvement, displacement and for three dimensional reconstruction.

Classification
Based on the location of the fracture (coracoid, acromion, glenoid neck, glenoid fossa, scapula body). Beware of ipsilateral glenoid neck and clavicle fracture -floating shoulder - where limb is effectively dissociated from axial skeleton.

Treatment
The vast majority of scapula fractures are amenable to conservative management, consisting of sling immobilisation for two weeks followed by early rehabilitation. Floating shoulder will usually require fixation, and consideration of surgery should also be given to intra-articular and displaced/angulated glenoid fractures.

Dislocations

Types
Dislocations around the shoulder joint include glenohumeral dislocation, acromioclavicular joint disruption and sternoclavicular dislocation. Only glenohumeral dislocation will be covered here.

Glenohumeral dislocation
Diagnosis, classification and management are covered here.

Background
Shoulder dislocation is commonly seen in A&E. It has a high recurrence rate that is as high as 80% in teenagers. Initial management requires emergent reduction to prevent lasting chondral damage.

Early assessment and management
Usually a traumatic cause (multi-directional instability in frequent dislocations requires discussion with orthopaedics and is not covered here). Careful history, examination and documentation of neurovascular status of the limb, in particular the axillary nerve (regimental badge sensation). This should be re-assessed post manipulation. Early radiographs to confirm direction of dislocation.

Initial management consists of emergent closed reduction under under entanox and analgesia, but often requires conscious sedation. Arm should then be immobilised in a polysling, and XR to confirm relocation.

Imaging - True anteroposterior (AP), axillary lateral and/or scapula Y view. Reduced humeral head should lie between acromion and coracoid on lateral/scapula view.

Types
Direction Features Cause Examination Reduction techniques
Anterior Most Common >90% Usually traumatic - anterior force on arm when shoulder is abducted, eternally rotated Loss of shoulder contour - sulcus sign. Humeral head can be felt anteriorly.
Hippocratic.
Milch.
Stimson.

Kocher not advised due to complication of fracture
Posterior 50% missed in A&E 50% traumatic, but classically post seizure or electrocution Shoulder locked in internal rotation. XR may show lightbulb appearance. Gentle lateral traction to adducted arm.
Inferior Rare Associated with pectorals and rotator cuff tears, and glenoid fracture As for primary injury Management of primary injury

Superior Rare Associated with acrominon/clavicle fracture As for primary injury Management of primary injury



Associated injuries
Bankart lesion - avulsion of the anterior glenoid labrum with an anterior shoulder dislocation (reverse Bankart if poster labrum in posterior dislocation).
Hill Sachs defect - chondral impaction on posteriosuperior humeral head from contact with gleonoid rim. Can be large enough to lock shoulder, requiring open reduction. (Reverse Hill Sachs in posterior dislocation).
Rotator cuff tear - increases with age.
Greater or lesser tuberosity fracture - increases with age.
Humeral neck fracture - shoulder fracture dislocation. More common in high energy trauma and elderly. Should be discussed with orthopaedics prior to any attempted reduction.

Rotator Cuff Disease

Rotator cuff disease is a spectrum of conditions that ranges from subacromial impingement to rotator cuff tears and eventually to rotator cuff arthropathy (arthritis).

Anatomy
The rotator cuff is a group of four muscles that are important in shoulder movements, and maintenance of glenohumeral stability.
Muscle Scapular attachment Humeral attachment Action Innervation
Supraspinatus Supraspinatus fossa Superior facet of greater tuberosity Initiation of abduction of humerus Suprascapular nerve
Infraspinatus Infraspinatus fossa Posterior facet of greater tuberosity External rotation of humerus Suprascapular nerve
Teres Minor Lateral border Inferior facet of greater tuberosity External rotation of humerus Axillary Nerve
Subscapularis Subscapular fossa Lesser tuberosity Internal rotation of humerus Upper and lower subscapular nerve

The inferior rotator cuff muscles (infraspinatus, teres minor, and subscapularis) balance the superior pull of the deltoid. Injury/tear results in upward migration of the humeral head on the glenoid (can be seen on AP radiograph).
Likewise, the anterior muscles (subscapularis) are balanced with the posterior muscles (infraspinatus, teres minor).

Subacromial Impingement

The most common cause of shoulder pain, which results from impingement of the superior cuff on the undersurface of the acromion, and an inflammatory bursitis.
Associated with certain types of acromial morphology (Bigliani classification).
Presents as insidious pain which is exacerbated by overhead activities.

Rotator Cuff Tear

Often presents as an acute event on the background of chronic subacromial impingement in the older patient, but can present as an avulsion injury in younger patients.
Majority of tears are to the superior cuff (supraspinatus, infraspinatus, teres minor), though a tear to subscapularis is associated with subcoracoid impingement.
Tears present as pain and weakness when using the muscles in question.

Rotator Cuff Arthropathy

Defined as shoulder arthritis in the setting of rotator cuff dysfunction. Results from superior migration due to the loss of rotator cuff function and integrity. Unopposed deltoid pulls the humeral head superiorly.
Associated with massive chronic cuff tears.

Imaging

Plain radiographs
AP of the shoulder may show superior migration of the humerus with a cuff tear, and features of arthritis with arthropathy. Other causes of pain may also be identified (e.g. calcific tendonitis/fracture)
Outlet view is useful for defining the acromial morphology

USS
Allows dynamic imaging of the cuff, and is inexpensive. However, it is very user dependent.

MRI
Best imaging modality for cuff pathology.
Also allows imaging of the rest of the shoulder. When intra-articular pathology is suspected, can be combined with an arthrogram for improved sensitivity and specificity.

Treatment

Subacromial impingement
Physiotherapy, oral anti-inflammatory medication
Subacromial steroid injection can settle inflammation
Arthroscopic subacromial decompression by shaving away the undersurface of the acromion, more space is created for the rotator cuff. Cuff integrity is assessed also at time of surgery, and can be repaired if necessary.

Rotator cuff tear
When considering repair of a cuff tear, the age and activity of the patient, the nature of the tear (degenerative vs. acute traumatic), and the size and retraction of the tear should be considered when making a surgical plan.
Mild tears or tears in the elderly can be managed conservatively, as outlined above.
Moderate tears can be repaired arthroscopically. Massive or retracted tears will often require an open repair (occasionally with a tendon transfer). Subacromial decompression is performed at the same time to reduce impingement, symptoms and recurrence.

Calcific tendonitis
Calcific tendonitis involves calcific deposits within tendons anywhere in the body, but most commonly in the rotator cuff (specifically the supraspinatus tendon). When present in the shoulder, it is associated with subacromial impingement and pain.

Pathology
More common in women aged 30-60 years.
Association with diabetes and hypothyroidism

There are three stages of calcification
Formative phase characterized by calcific deposits
Resting phase deposit is stable, but presents with impingement problems
Resorptive phase phagocytic resorption. Most painful stage.

Presentation
Similar in presentation to subacromial impingement, with pain especially with over head activities. Atraumatic in nature.

Imaging
Plain radiographs show calcification of the rotator cuff, usually within 1.5cm of its insertion on the humerus. Supraspinatus outlet views can show level of impingment. Further imaging is rarely needed.

Treatment
Non-operative NSAIDS, steroid injection (controversial, but practiced) and physiotherapy. Approximately 75% will resolve by 6 months with conservative management.
Ultrasound guided or surgical needle barbotage can break down deposits and resolve symptoms. Occasionally surgical excision is required.

Adhesive capsulitis (Frozen Shoulder)
Pain and loss of movement of shoulder joint, which involves fibroplastic proliferation of capsular tissue, causing soft tissue scarring and contracture. Patients present with a painful and decreased arc of motion.
Associated with prolonged immobilization, previous surgery, thyroid disorders (AI) and diabetes
Classically three stages which can take up to two years to resolve:
Stage one the freezing and painful stage
Stage two the frozen and stiff stage
Stage three the thawing stage, where shoulder movement slowly improves

Imaging
Plain radiographs to exclude other causes of a painful shoulder
MRI arthrogram may show capsular contracture, and again may be used to exclude cuff pathology. However, often not performed as diagnosis is largely clinical.

Treatment
Non-operative NSAIDS, steroid injection and physiotherapy. Patience is required as condition can take up to 2 years to improve.
Operative MUA or arthroscopic adhesiolysis (release of adhesions) can expedite recovery, followed by intensive physiotherapy.

Glenohumeral Arthritis
Background
May be osteoarthritis (primary or secondary to cuff tear or trauma), rheumatoid arthritis, or as part of a spondyloarthropathy. Majority of those with RA will develop symptoms.
More common in the elderly
Presents like any other arthritis - pain at night and with movement

Imaging
AP and axillary radiographs will show features of arthritis.
CT/MRI is often useful to classify the shape of the glenoid and extent of bone loss when considering arthroplasty. MRI also essential to asses integrity of rotator cuff if considering shoulder replacement.

Treatment
Like all orthopaedics, start with simple measures:
NSAIDS, management of RA, physiotherapy, steroid injection.
Hemiarthroplasty can sometimes be considered if glenoid is in excellent condition or if patient has large comorbidity.
Arthroscopic debridement is useful if patient has isolated ACJ arthritis, but is rarely used for glenohumeral arthritis.
Total shoulder replacement is shown to produce superior outcome when compared to hemiarthroplasty in terms of pain relief, function and implant survival.
Total shoulder replacement can be anatomical (ball on humerus, with cup on glenoid), or reverse geometry (ball on glenoid, with cup on humerus). Anatomical TSR requires an in tact rotator cuff, so often reverse is preferable when the cuff if questionable in integrity.

20

Which of the following statements relating to menisceal tears is false?

The medial meniscus is most often affected
True locking of the knee joint may occur
Most established tears will heal with conservative management
In the chronic setting there is typically little to find on examination if the knee is not locked
An arthroscopic approach may be used to treat most lesions

Most established tears will heal with conservative management - FALSE

Menisci have no nerve or blood supply and thus heal poorly. Established tears with associated symptoms are best managed by arthroscopic menisectomy.

Ruptured anterior cruciate ligament
Sport injury
Mechanism: high twisting force applied to a bent knee
Typically presents with: loud crack, pain and RAPID joint swelling (haemoarthrosis)
Poor healing
Management: intense physiotherapy or surgery
Ruptured posterior cruciate ligament
Mechanism: hyperextension injuries
Tibia lies back on the femur
Paradoxical anterior draw test
Rupture of medial collateral ligament
Mechanism: leg forced into valgus via force outside the leg
Knee unstable when put into valgus position
Menisceal tear
Rotational sporting injuries
Delayed knee swelling
Joint locking (Patient may develop skills to "unlock" the knee
Recurrent episodes of pain and effusions are common, often following minor trauma
Chondromalacia patellae
Teenage girls, following an injury to knee e.g. Dislocation patella
Typical history of pain on going downstairs or at rest
Tenderness, quadriceps wasting
Dislocation of the patella
Most commonly occurs as a traumatic primary event, either through direct trauma or through severe contraction of quadriceps with knee stretched in valgus and external rotation
Genu valgum, tibial torsion and high riding patella are risk factors
Skyline x-ray views of patella are required, although displaced patella may be clinically obvious
An osteochondral fracture is present in 5%
The condition has a 20% recurrence rate
Fractured patella
2 types:
i. Direct blow to patella causing undisplaced fragments
ii. Avulsion fracture
Tibial plateau fracture
Occur in the elderly (or following significant trauma in young)
Mechanism: knee forced into valgus or varus, but the knee fractures before the ligaments rupture
Varus injury affects medial plateau and if valgus injury, lateral plateau depressed fracture occurs
Classified using the Schatzker system (see below)

Schatzker Classification system for tibial plateau fractures
Type Anatomical description Features
1 Vertical split of lateral condyle Fracture through dense bone, usually in the young. It may be virtually undisplaced, or the condylar fragment may be pushed inferiorly and tilted
2 Vertical split of the lateral condyle combined with an adjacent load bearing part of the condyle The wedge fragment (which may be of variable size), is displaced laterally; the joint is widened. Untreated, a valgus deformity may develop
3 Depression of the articular surface with intact condylar rim The split does not extend to the edge of the plateau. Depressed fragments may be firmly embedded in subchondral bone, the joint is stable
4 Fragment of the medial tibial condyle Two injuries are seen in this category; (1) a depressed fracture of osteoporotic bone in the elderly. (2) a high energy fracture resulting in a condylar split that runs from the intercondylar eminence to the medial cortex. Associated ligamentous injury may be severe
5 Fracture of both condyles Both condyles fractured but the column of the metaphysis remains in continuity with the tibial shaft
6 Combined condylar and subcondylar fractures High energy fracture with marked comminution

21

A 15 year-old boy presents to the out-patient clinic with tiredness, recurrent throat and chest infections, and gradual loss of vision. Multiple x-rays show brittle bones with no differentiation between the cortex and the medulla.


A. Rickets
B. Craniocleidodysostosis
C. Achondroplasia
D. Scurvy
E. Pagets disease
F. Multiple myeloma
G. Osteogenesis imperfecta
H. Osteomalacia
I. Osteopetrosis
J. None of the above


Osteopetrosis

Osteopetrosis is an autosomal recessive condition. It is commonest in young adults. They may present with symptoms of anaemia or thrombocytopaenia due to decreased marrow space. Radiology reveals a lack of differentiation between the cortex and the medulla described as marble bone. These bones are very dense and brittle.

Paediatric fracture types
Type Injury pattern
Complete fracture Both sides of cortex are breached
Toddlers fracture Oblique tibial fracture in infants
Plastic deformity Stress on bone resulting in deformity without cortical disruption
Greenstick fracture Unilateral cortical breach only
Buckle fracture Incomplete cortical disruption resulting in periosteal haematoma only

Growth plate fractures
In paediatric practice fractures may also involve the growth plate and these injuries are classified according to the Salter- Harris system (given below):

Type Injury pattern
I Fracture through the physis only (x-ray often normal)
II Fracture through the physis and metaphysis
III Fracture through the physis and epiphyisis to include the joint
IV Fracture involving the physis, metaphysis and epiphysis
V Crush injury involving the physis (x-ray may resemble type I, and appear normal)

As a general rule it is safer to assume that growth plate tenderness is indicative of an underlying fracture even if the x-ray appears normal. Injuries of Types III, IV and V will usually require surgery. Type V injuries are often associated with disruption to growth.

Non accidental injury
Delayed presentation
Delay in attaining milestones
Lack of concordance between proposed and actual mechanism of injury
Multiple injuries
Injuries at sites not commonly exposed to trauma
Children on the at risk register

Pathological fractures
Genetic conditions, such as osteogenesis imperfecta, may cause pathological fractures.

Osteogenesis imperfecta
Defective osteoid formation due to congenital inability to produce adequate intercellular substances like osteoid, collagen and dentine.
Failure of maturation of collagen in all the connective tissues.
Radiology may show translucent bones, multiple fractures, particularly of the long bones, wormian bones (irregular patches of ossification) and a trefoil pelvis.

Subtypes
Type I The collagen is normal quality but insufficient quantity.
Type II- Poor collagen quantity and quality.
Type III- Collagen poorly formed. Normal quantity.
Type IV- Sufficient collagen quantity but poor quality.

Osteopetrosis
Bones become harder and more dense.
Autosomal recessive condition.
It is commonest in young adults.
Radiology reveals a lack of differentiation between the cortex and the medulla described as marble bone.

22

A 12 year-old boy who is small for his age presents to the clinic with poor muscular development and hyper-mobile fingers. His x-rays show multiple fractures of the long bones and irregular patches of ossification.


A. Rickets
B. Craniocleidodysostosis
C. Achondroplasia
D. Scurvy
E. Pagets disease
F. Multiple myeloma
G. Osteogenesis imperfecta
H. Osteomalacia
I. Osteopetrosis
J. None of the above

Osteogenesis imperfecta

Osteogenesis imperfecta is caused by defective osteoid formation due to congenital inability to produce adequate intercellular substances like osteoid, collagen and dentine. There is a failure of maturation of collagen in all the connective tissues.Radiology may show translucent bones, multiple fractures, particularly of the long bones, wormian bones (irregular patches of ossification) and a trefoil pelvis.

Paediatric fracture types
Type Injury pattern
Complete fracture Both sides of cortex are breached
Toddlers fracture Oblique tibial fracture in infants
Plastic deformity Stress on bone resulting in deformity without cortical disruption
Greenstick fracture Unilateral cortical breach only
Buckle fracture Incomplete cortical disruption resulting in periosteal haematoma only

Growth plate fractures
In paediatric practice fractures may also involve the growth plate and these injuries are classified according to the Salter- Harris system (given below):

Type Injury pattern
I Fracture through the physis only (x-ray often normal)
II Fracture through the physis and metaphysis
III Fracture through the physis and epiphyisis to include the joint
IV Fracture involving the physis, metaphysis and epiphysis
V Crush injury involving the physis (x-ray may resemble type I, and appear normal)

As a general rule it is safer to assume that growth plate tenderness is indicative of an underlying fracture even if the x-ray appears normal. Injuries of Types III, IV and V will usually require surgery. Type V injuries are often associated with disruption to growth.

Non accidental injury
Delayed presentation
Delay in attaining milestones
Lack of concordance between proposed and actual mechanism of injury
Multiple injuries
Injuries at sites not commonly exposed to trauma
Children on the at risk register

Pathological fractures
Genetic conditions, such as osteogenesis imperfecta, may cause pathological fractures.

Osteogenesis imperfecta
Defective osteoid formation due to congenital inability to produce adequate intercellular substances like osteoid, collagen and dentine.
Failure of maturation of collagen in all the connective tissues.
Radiology may show translucent bones, multiple fractures, particularly of the long bones, wormian bones (irregular patches of ossification) and a trefoil pelvis.

Subtypes
Type I The collagen is normal quality but insufficient quantity.
Type II- Poor collagen quantity and quality.
Type III- Collagen poorly formed. Normal quantity.
Type IV- Sufficient collagen quantity but poor quality.

Osteopetrosis
Bones become harder and more dense.
Autosomal recessive condition.
It is commonest in young adults.
Radiology reveals a lack of differentiation between the cortex and the medulla described as marble bone.

23

A 1 year-old is brought to the Emergency Department with a history of failure to thrive. On examination, the child is small for age and has a large head. X-ray shows a cupped appearance of the epiphysis of the wrist.


A. Rickets
B. Craniocleidodysostosis
C. Achondroplasia
D. Scurvy
E. Pagets disease
F. Multiple myeloma
G. Osteogenesis imperfecta
H. Osteomalacia
I. Osteopetrosis
J. None of the above

Rickets

Rickets is the childhood form of osteomalacia. It is due to the failure of the osteoid to ossify due to vitamin D deficiency. Symptoms start about the age of one. The child is small for age and there is a history of failure to thrive. Bony deformities include bowing of the femur and tibia, a large head, deformity of the chest wall with thickening of the costochondral junction (rickettary rosary), and a transverse sulcus in the chest caused by the pull of the diaphragm (Harrison's sulcus). X- Rays show widening and cupping of the epiphysis of the long bones, most readily apparent in the wrist.

Paediatric fracture types
Type Injury pattern
Complete fracture Both sides of cortex are breached
Toddlers fracture Oblique tibial fracture in infants
Plastic deformity Stress on bone resulting in deformity without cortical disruption
Greenstick fracture Unilateral cortical breach only
Buckle fracture Incomplete cortical disruption resulting in periosteal haematoma only

Growth plate fractures
In paediatric practice fractures may also involve the growth plate and these injuries are classified according to the Salter- Harris system (given below):

Type Injury pattern
I Fracture through the physis only (x-ray often normal)
II Fracture through the physis and metaphysis
III Fracture through the physis and epiphyisis to include the joint
IV Fracture involving the physis, metaphysis and epiphysis
V Crush injury involving the physis (x-ray may resemble type I, and appear normal)

As a general rule it is safer to assume that growth plate tenderness is indicative of an underlying fracture even if the x-ray appears normal. Injuries of Types III, IV and V will usually require surgery. Type V injuries are often associated with disruption to growth.

Non accidental injury
Delayed presentation
Delay in attaining milestones
Lack of concordance between proposed and actual mechanism of injury
Multiple injuries
Injuries at sites not commonly exposed to trauma
Children on the at risk register

Pathological fractures
Genetic conditions, such as osteogenesis imperfecta, may cause pathological fractures.

Osteogenesis imperfecta
Defective osteoid formation due to congenital inability to produce adequate intercellular substances like osteoid, collagen and dentine.
Failure of maturation of collagen in all the connective tissues.
Radiology may show translucent bones, multiple fractures, particularly of the long bones, wormian bones (irregular patches of ossification) and a trefoil pelvis.

Subtypes
Type I The collagen is normal quality but insufficient quantity.
Type II- Poor collagen quantity and quality.
Type III- Collagen poorly formed. Normal quantity.
Type IV- Sufficient collagen quantity but poor quality.

Osteopetrosis
Bones become harder and more dense.
Autosomal recessive condition.
It is commonest in young adults.
Radiology reveals a lack of differentiation between the cortex and the medulla described as marble bone.

24

A 60 year old male is admitted to A&E with a fall. He lives with his wife and still works as a restaurant manager. He has a past history of benign prostatic hypertrophy and is currently taking tamsulosin. He is otherwise fit and healthy. On examination there is right hip tenderness on movement in all directions. A hip x-ray confirms an intertrochanteric fracture.

A. Conservative management
B. Percutaneous pinning
C. Fracture reduction and internal fixation
D. Hemiarthroplasty
E. Total hip replacement
F. Dynamic hip screw
G. Intramedullary femoral nail

Dynamic hip screw

The blood supply to the femoral head may be intact and the fracture should heal with compression type devices such as gamma nails or dynamic hip screws. The latter device being the most commonly performed therapeutic intervention.

Neck of femur (NOF) fracture is a common orthopaedic presentation, with over 65000 fractures in the UK per year. Like many orthopaedic injuries, there is a bimodal age distribution. It is imperative to distinguish between the high energy injury in a young patient, and the low energy osteoporotic fracture in the elderly, as their management aims are very different:

Young patient - Usually high energy trauma (e.g road traffic accident, horse riding) and needs treating in accordance with Advanced Trauma Life Support (ATLS) principles. Will often have associated injuries. Aim is to retain the patients own anatomy, and optimise their function.

Elderly patient - Predominantly female, fall from standing height (fragility fracture). Often patients have multiple comorbidities that will ultimately dictate their prognosis. Aim of orthopaedic treatment is to immediately regain patient mobility so that morbidity (infection, thromboembolic events, pressure sores etc) and mortality associated with prolonged bed rest is avoided. Left untreated, a neck of femur fracture can be considered a terminal event. Historically, mortality associated with elderly hip fracture is 10% at one month, and 30% at one year. However, this has been improved in the UK with the introduction of multidisciplinary, orthogeriatric lead care and the National Hip Fracture Database and Best Practice Tariff.

Pertinent anatomy
Osteology - normal neck-shaft angle is 130 +/- 7 degrees, and 10 +/- 7 degrees of neck anteversion.
Vascular supply - The predominant blood supply to the femoral head and neck is from the medial and lateral femoral circumflex arteries (branches of profunda femoris). These anastomose and pierce the joint capsule at the base of the neck, mainly posteriorly. There is a small vascular contribution from the artery of the ligament teres. Understanding the blood supply is fundamental to the decision making process in treating NOF fractures.

Presentation and initial management
Typically, patients present with pain in the hip/groin, a shortened, abducted, externally rotated leg (due to the unopposed pull of the muscles that act across the hip joint) and the inability to straight-leg-raise. With undisplaced fractures, signs are more subtle.
High energy injuries should be treated in line with ATLS principles. All patients should be fluid resuscitated, have adequate pain relief (often with a fascio-iliiaca nerve block), and be optimised for surgery. In addition, elderly patients should be assessed by an orthogeriatrician.

Imaging
Anteroposterior and cross-table lateral plain radiographs are sufficient to diagnose the majority of NOF fractures. If the fracture extends below the level of the lesser trochanter, or there is any possibility of pathological fracture, full length femur views are essential to plan surgery.

Where there is a high index of suspicion of fracture, but plain radiographs are inconclusive, gold standard investigation is MRI. However, if unavailable within 24 hours, or if the patient will not tolerate MRI, CT is appropriate. The majority of fractures can be seen with modern CT techniques, and so this is becoming first line in many hospitals.

Classification
There has been a move away from named classification systems towards descriptive classification systems.
Two main types of NOF exist: Intra-capsular, and extra-capsular. Extra-capsular fractures are further divided into pertrochanteric or subtrochanteric (within 5cm distal to the lesser trochanter). All fractures are then described as undisplaced, minimally displaced, or displaced.
Femoral neck and head blood supply disruption is common with intracapsular NOF fractures, and rare with extracapsular fractures. This fundamental principle underpins the practise of arthroplasty for intracapsular fractures, and fixation for extracapsular fractures.

If you wish to use a named classification system, the most commonly used are below:
Elderly intracapsular - Garden Classification
Young intrasapsular - Pauvels Classification
Intertrochanteric - Evans
Subtrochanteric - Russell Taylor

Treatment
In general, NOF fractures are treated operatively except if the patient is deemed unlikely to survive an anaesthetic. Best Practice Tarif (BPT) dictates that surgery should happen within 36 hours, as delay of greater than 48 hours is associated with increased morbidity and mortality.

* The priority with the young patient is to retain the femoral head if possible, even with a displaced intracapsular fracture. The risk of avascular necrosis and non-union (and therefore revision surgery) associated with internal fixation needs weighing up against the sequelae of total hip replacement in the young (wear, dislocation, revision). Discussion is necessary with the patient, on a case by case basis.

** Undisplaced fractures in the elderly can be treated with internal fixation, often with cannulated screws. This is appropriate for valgus impacted subcapital fractures which are inherently stable, to prevent secondary displacement. This does still carry the risk of AVN or non-union, and therefore a future revision. For this reason, many surgeons advocate arthroplasty as a single surgery.

*** NICE guidance - patients who fulfil these criteria should be offered total hip replacement which conveys better function and prosthetic survivorship, compared with hemiarthroplasty, but at an increased risk of dislocation.

* Intertrochanteric fractures vary greatly in their stability. If the trochanter (and therefore lateral wall), and medial calcar is in tact, then the fracture configuration bears stability. This can be treated with a DHS, as collapse of the fracture is predictable. Where either or both structures are involved in the fracture, stability becomes compromised and many surgeons will favour using an intramedullary device. This is an ongoing debate, and difficult to test in an exam setting.

Post operative management
Patients should be mobilised fully weight bearing where possible. Care is multidisciplinary in its delivery. Elderly patients should have orthogeriatrician assessment of comorbidity, and bone health with secondary prevention measures if appropriate. There should be early involvement of physiotherapy and occupational therapy services.

25

An 86 year old retired pharmacist is admitted to A&E following a fall. She complains of right hip pain. She is known to have hypertension and is currently on bendrofluazide. She lives alone and mobilises with a Zimmer frame. Her right leg is shortened and externally rotated. A hip x-ray confirms a displaced intracapsular fracture.


A. Conservative management
B. Percutaneous pinning
C. Fracture reduction and internal fixation
D. Hemiarthroplasty
E. Total hip replacement
F. Dynamic hip screw
G. Intramedullary femoral nail

Hemiarthroplasty

Hemiarthroplasty is offered to older, less mobile individuals compared to fracture reduction and fixation in younger patients.

Neck of femur (NOF) fracture is a common orthopaedic presentation, with over 65000 fractures in the UK per year. Like many orthopaedic injuries, there is a bimodal age distribution. It is imperative to distinguish between the high energy injury in a young patient, and the low energy osteoporotic fracture in the elderly, as their management aims are very different:

Young patient - Usually high energy trauma (e.g road traffic accident, horse riding) and needs treating in accordance with Advanced Trauma Life Support (ATLS) principles. Will often have associated injuries. Aim is to retain the patients own anatomy, and optimise their function.

Elderly patient - Predominantly female, fall from standing height (fragility fracture). Often patients have multiple comorbidities that will ultimately dictate their prognosis. Aim of orthopaedic treatment is to immediately regain patient mobility so that morbidity (infection, thromboembolic events, pressure sores etc) and mortality associated with prolonged bed rest is avoided. Left untreated, a neck of femur fracture can be considered a terminal event. Historically, mortality associated with elderly hip fracture is 10% at one month, and 30% at one year. However, this has been improved in the UK with the introduction of multidisciplinary, orthogeriatric lead care and the National Hip Fracture Database and Best Practice Tariff.

Pertinent anatomy
Osteology - normal neck-shaft angle is 130 +/- 7 degrees, and 10 +/- 7 degrees of neck anteversion.
Vascular supply - The predominant blood supply to the femoral head and neck is from the medial and lateral femoral circumflex arteries (branches of profunda femoris). These anastomose and pierce the joint capsule at the base of the neck, mainly posteriorly. There is a small vascular contribution from the artery of the ligament teres. Understanding the blood supply is fundamental to the decision making process in treating NOF fractures.

Presentation and initial management
Typically, patients present with pain in the hip/groin, a shortened, abducted, externally rotated leg (due to the unopposed pull of the muscles that act across the hip joint) and the inability to straight-leg-raise. With undisplaced fractures, signs are more subtle.
High energy injuries should be treated in line with ATLS principles. All patients should be fluid resuscitated, have adequate pain relief (often with a fascio-iliiaca nerve block), and be optimised for surgery. In addition, elderly patients should be assessed by an orthogeriatrician.

Imaging
Anteroposterior and cross-table lateral plain radiographs are sufficient to diagnose the majority of NOF fractures. If the fracture extends below the level of the lesser trochanter, or there is any possibility of pathological fracture, full length femur views are essential to plan surgery.

Where there is a high index of suspicion of fracture, but plain radiographs are inconclusive, gold standard investigation is MRI. However, if unavailable within 24 hours, or if the patient will not tolerate MRI, CT is appropriate. The majority of fractures can be seen with modern CT techniques, and so this is becoming first line in many hospitals.

Classification
There has been a move away from named classification systems towards descriptive classification systems.
Two main types of NOF exist: Intra-capsular, and extra-capsular. Extra-capsular fractures are further divided into pertrochanteric or subtrochanteric (within 5cm distal to the lesser trochanter). All fractures are then described as undisplaced, minimally displaced, or displaced.
Femoral neck and head blood supply disruption is common with intracapsular NOF fractures, and rare with extracapsular fractures. This fundamental principle underpins the practise of arthroplasty for intracapsular fractures, and fixation for extracapsular fractures.

If you wish to use a named classification system, the most commonly used are below:
Elderly intracapsular - Garden Classification
Young intrasapsular - Pauvels Classification
Intertrochanteric - Evans
Subtrochanteric - Russell Taylor

Treatment
In general, NOF fractures are treated operatively except if the patient is deemed unlikely to survive an anaesthetic. Best Practice Tarif (BPT) dictates that surgery should happen within 36 hours, as delay of greater than 48 hours is associated with increased morbidity and mortality.

* The priority with the young patient is to retain the femoral head if possible, even with a displaced intracapsular fracture. The risk of avascular necrosis and non-union (and therefore revision surgery) associated with internal fixation needs weighing up against the sequelae of total hip replacement in the young (wear, dislocation, revision). Discussion is necessary with the patient, on a case by case basis.

** Undisplaced fractures in the elderly can be treated with internal fixation, often with cannulated screws. This is appropriate for valgus impacted subcapital fractures which are inherently stable, to prevent secondary displacement. This does still carry the risk of AVN or non-union, and therefore a future revision. For this reason, many surgeons advocate arthroplasty as a single surgery.

*** NICE guidance - patients who fulfil these criteria should be offered total hip replacement which conveys better function and prosthetic survivorship, compared with hemiarthroplasty, but at an increased risk of dislocation.

* Intertrochanteric fractures vary greatly in their stability. If the trochanter (and therefore lateral wall), and medial calcar is in tact, then the fracture configuration bears stability. This can be treated with a DHS, as collapse of the fracture is predictable. Where either or both structures are involved in the fracture, stability becomes compromised and many surgeons will favour using an intramedullary device. This is an ongoing debate, and difficult to test in an exam setting.

Post operative management
Patients should be mobilised fully weight bearing where possible. Care is multidisciplinary in its delivery. Elderly patients should have orthogeriatrician assessment of comorbidity, and bone health with secondary prevention measures if appropriate. There should be early involvement of physiotherapy and occupational therapy services.

26

A 74 year old male is admitted to A&E with a fall. He is known to have rheumatoid arthritis and is on methotrexate and paracetamol. He lives alone in a bungalow and enjoys playing golf. He is independent with his ADLs. He complains of left groin pain, therefore has a hip x-ray which confirms a displaced intracapsular fracture.

A. Conservative management
B. Percutaneous pinning
C. Fracture reduction and internal fixation
D. Hemiarthroplasty
E. Total hip replacement
F. Dynamic hip screw
G. Intramedullary femoral nail

Total hip replacement

This patient has pre-existing joint disease, good level of activity and a relatively high life expectancy, therefore THR is preferable to hemiarthroplasty.

Neck of femur (NOF) fracture is a common orthopaedic presentation, with over 65000 fractures in the UK per year. Like many orthopaedic injuries, there is a bimodal age distribution. It is imperative to distinguish between the high energy injury in a young patient, and the low energy osteoporotic fracture in the elderly, as their management aims are very different:

Young patient - Usually high energy trauma (e.g road traffic accident, horse riding) and needs treating in accordance with Advanced Trauma Life Support (ATLS) principles. Will often have associated injuries. Aim is to retain the patients own anatomy, and optimise their function.

Elderly patient - Predominantly female, fall from standing height (fragility fracture). Often patients have multiple comorbidities that will ultimately dictate their prognosis. Aim of orthopaedic treatment is to immediately regain patient mobility so that morbidity (infection, thromboembolic events, pressure sores etc) and mortality associated with prolonged bed rest is avoided. Left untreated, a neck of femur fracture can be considered a terminal event. Historically, mortality associated with elderly hip fracture is 10% at one month, and 30% at one year. However, this has been improved in the UK with the introduction of multidisciplinary, orthogeriatric lead care and the National Hip Fracture Database and Best Practice Tariff.

Pertinent anatomy
Osteology - normal neck-shaft angle is 130 +/- 7 degrees, and 10 +/- 7 degrees of neck anteversion.
Vascular supply - The predominant blood supply to the femoral head and neck is from the medial and lateral femoral circumflex arteries (branches of profunda femoris). These anastomose and pierce the joint capsule at the base of the neck, mainly posteriorly. There is a small vascular contribution from the artery of the ligament teres. Understanding the blood supply is fundamental to the decision making process in treating NOF fractures.

Presentation and initial management
Typically, patients present with pain in the hip/groin, a shortened, abducted, externally rotated leg (due to the unopposed pull of the muscles that act across the hip joint) and the inability to straight-leg-raise. With undisplaced fractures, signs are more subtle.
High energy injuries should be treated in line with ATLS principles. All patients should be fluid resuscitated, have adequate pain relief (often with a fascio-iliiaca nerve block), and be optimised for surgery. In addition, elderly patients should be assessed by an orthogeriatrician.

Imaging
Anteroposterior and cross-table lateral plain radiographs are sufficient to diagnose the majority of NOF fractures. If the fracture extends below the level of the lesser trochanter, or there is any possibility of pathological fracture, full length femur views are essential to plan surgery.

Where there is a high index of suspicion of fracture, but plain radiographs are inconclusive, gold standard investigation is MRI. However, if unavailable within 24 hours, or if the patient will not tolerate MRI, CT is appropriate. The majority of fractures can be seen with modern CT techniques, and so this is becoming first line in many hospitals.

Classification
There has been a move away from named classification systems towards descriptive classification systems.
Two main types of NOF exist: Intra-capsular, and extra-capsular. Extra-capsular fractures are further divided into pertrochanteric or subtrochanteric (within 5cm distal to the lesser trochanter). All fractures are then described as undisplaced, minimally displaced, or displaced.
Femoral neck and head blood supply disruption is common with intracapsular NOF fractures, and rare with extracapsular fractures. This fundamental principle underpins the practise of arthroplasty for intracapsular fractures, and fixation for extracapsular fractures.

If you wish to use a named classification system, the most commonly used are below:
Elderly intracapsular - Garden Classification
Young intrasapsular - Pauvels Classification
Intertrochanteric - Evans
Subtrochanteric - Russell Taylor

Treatment
In general, NOF fractures are treated operatively except if the patient is deemed unlikely to survive an anaesthetic. Best Practice Tarif (BPT) dictates that surgery should happen within 36 hours, as delay of greater than 48 hours is associated with increased morbidity and mortality.

* The priority with the young patient is to retain the femoral head if possible, even with a displaced intracapsular fracture. The risk of avascular necrosis and non-union (and therefore revision surgery) associated with internal fixation needs weighing up against the sequelae of total hip replacement in the young (wear, dislocation, revision). Discussion is necessary with the patient, on a case by case basis.

** Undisplaced fractures in the elderly can be treated with internal fixation, often with cannulated screws. This is appropriate for valgus impacted subcapital fractures which are inherently stable, to prevent secondary displacement. This does still carry the risk of AVN or non-union, and therefore a future revision. For this reason, many surgeons advocate arthroplasty as a single surgery.

*** NICE guidance - patients who fulfil these criteria should be offered total hip replacement which conveys better function and prosthetic survivorship, compared with hemiarthroplasty, but at an increased risk of dislocation.

* Intertrochanteric fractures vary greatly in their stability. If the trochanter (and therefore lateral wall), and medial calcar is in tact, then the fracture configuration bears stability. This can be treated with a DHS, as collapse of the fracture is predictable. Where either or both structures are involved in the fracture, stability becomes compromised and many surgeons will favour using an intramedullary device. This is an ongoing debate, and difficult to test in an exam setting.

Post operative management
Patients should be mobilised fully weight bearing where possible. Care is multidisciplinary in its delivery. Elderly patients should have orthogeriatrician assessment of comorbidity, and bone health with secondary prevention measures if appropriate. There should be early involvement of physiotherapy and occupational therapy services.

27

Of the list below, which is not a cause of avascular necrosis?

Steroids
Sickle cell disease
Radiotherapy
Myeloma
Caisson disease

Myeloma
Steroid containing therapy for myeloma may induce avascular necrosis, however the disease itself does not cause it. Caisson disease as may occur in deep sea divers is a recognised cause.

Avascular necrosis
Cellular death of bone components due to interruption of the blood supply, causing bone destruction
Main joints affected are hip, scaphoid, lunate and the talus.
It is not the same as non union. The fracture has usually united.
Radiological evidence is slow to appear.
Vascular ingrowth into the affected bone may occur. However, many joints will develop secondary osteoarthritis.

Causes
P ancreatitis
L upus
A lcohol
S teroids
T rauma
I diopathic, infection
C aisson disease, collagen vascular disease
R adiation, rheumatoid arthritis
A myloid
G aucher disease
S ickle cell disease

Presentation
Usually pain. Often despite apparent fracture union.

Investigation
MRI scanning will show changes earlier than plain films.

Treatment
In fractures at high risk sites anticipation is key. Early prompt and accurate reduction is essential.

Non weight bearing may help to facilitate vascular regeneration.

Joint replacement may be necessary, or even the preferred option (e.g. Hip in the elderly).

28

Which of the following is the first radiological change likely to be apparent in a plain radiograph of a 12 year old presenting with suspected Perthes disease

Multiple bone cysts
Sclerosis of the femoral head
Loss of bone density
Joint space narrowing
Collapse of the femoral head

Sclerosis of the femoral head
In Catterall stage I disease there may be no radiological abnormality at all. In Stage II disease there may be sclerosis of the femoral head.

Indication for treatment (aide memoire):Half a dozen, half a head
Those aged greater than 6 years with >50% involvement of the femoral head should almost always be treated.

Perthes disease
Idiopathic avascular necrosis of the femoral epiphysis of the femoral head
Impaired blood supply to femoral head, causing bone infarction. New vessels develop and ossification occurs. The bone either heals or a subchondral fracture occurs.

Clinical features
Males 4x's greater than females
Age between 2-12 years (the younger the age of onset, the better the prognosis)
Limp
Hip pain
Bilateral in 20%

Diagnosis
Plain x-ray, Technetium bone scan or magnetic resonance imaging if normal x-ray and symptoms persist.

Catterall staging
Stage Features
Stage 1 Clinical and histological features only
Stage 2 Sclerosis with or without cystic changes and preservation of the articular surface
Stage 3 Loss of structural integrity of the femoral head
Stage 4 Loss of acetabular integrity

Management
To keep the femoral head within the acetabulum: cast, braces
If less than 6 years: observation
Older: surgical management with moderate results
Operate on severe deformities

Prognosis
Most cases will resolve with conservative management. Early diagnosis improves outcomes.

29

A footballer is injured in a match and is being assessed in the outpatient department. On examination he has a positive valgus stress test and minimal joint effusion. What is the most likely underlying injury?

Injury to the lateral collateral ligament
Injury to the medial collateral ligament
Injury to the anterior cruciate ligament
Injury to the posterior cruciate ligament
Injury to the patellar tendon

Injury to the medial collateral ligament

A knee injury in the footballer with a positive valgus stress test is usually associated with MCL injury.

Knee collateral ligament

Anatomy
The tibial collateral ligament is a broad, flat band. Its upper end has an extensive attachment to the medial epicondyle of the femur with some fibres projecting onto the adductor magnus tendon. The ligament passes downwards and forwards to the medial side of the tibia. The deepest fibres are fused with the medial meniscus.
The fibular collateral ligament is round and cord like and stands clear of the thin, lateral part of the fibrous capsule. It is enclosed within the fascia lata. It passes from the lateral epicondyle of the femur to the head of the fibula in front of its highest point and splits the tendon of biceps femoris. On the lateral side of the joint the fibres are short and weak and bridge the interval between the femoral and tibial condyles. The popliteus tendon intervenes between the lateral meniscus and the capsule.
The tibial and fibular collateral ligaments prevent disruption of the joint at the sides. They are most tightly stretched in extension, and then their direction- the fibular ligament downwards and backwards, the tibial downwards and forwards- prevents rotation of the tibia laterally or the femur medially. Rotation may be demonstrated in the flexed knee.

Injury
The collateral ligaments are commonly injured, the medial is most often affected. It requires a significant force such as sporting tackle or motor vehicle to strike the side of the leg. Associated injuries to both the tibial plateau or menisci are not uncommon.

Grading and treatment
Grade of injury Features Treatment
1 Minor tearing of ligament fibres
Negative instability tests Conservative (analgesia and physiotherapy)
2 Ligament laxity (seen with knee in 30o flexion)
Knee stable when joint extended Usually splinting or casting for 4-6 weeks
3 Ligament completely torn
Joint instability Surgical ligament reconstruction

30

A 30 year old man is admitted overnight, following a road traffic accident. He has an open tibial fracture with a 20 cm wound and extensive periosteal stripping. He is neurovascularly intact and IV antibiotics and wound dressing have been administered in the emergency department.


A. Immediate skeletal stabilisation and application of negative pressure dressing
B. Combined skeletal and soft tissue reconstruction on a scheduled operating list
C. Thorough wound debridement in the emergency department
D. Immediate vascuIar shunting, followed by temporary skeletal stabilisation and vascular reconstruction
E. Intravenous antibiotics, photography and application of saline soaked gauze with impermeable dressing
F. Application of external fixator and conversion to internal fixation after two weeks
G. Fasciotomy with four compartment decompression
H. Skeletal fixation followed by vascular reconstruction

Combined skeletal and soft tissue reconstruction on a scheduled operating list

This patient has a Gustillo-Anderson Grade 3B open fracture. He will require definitive skeletal and soft tissue reconstruction, which should be performed on a combined ortho-plastic scheduled operating list, as per the BOA/BAPRAS guidelines. The surgery does not have to be performed out of scheduled hours unless there is marine/ sewage contamination, vascular compromise or it is a polytrauma.
Whilst it is reasonable to apply an external fixator prior to definitive skeletal and soft tissue reconstruction, this should be converted to internal fixation within 72 hours.

Open fractures

The term open fracture refers to a disruption of the bony cortex associated with a breach in the overlying skin. Any wound that is present in the same limb as a fracture should be suspected as being representative of an open fracture. One of the main problems with open fractures is the associated injuries to the surrounding soft tissues. Whilst the skin is usually relatively resistant to trauma, underlying muscle can be damaged or devitalised, nerves, blood vessels and periosteum may all be disrupted the degree to which this occurs correlates with the severity of the injury and the outcome. These can be graded using the Gustilo and Anderson system (see below).

Grade Injury
1 Low energy wound <1cm
2 Greater than 1cm wound with moderate soft tissue damage
3 High energy wound > 1cm with extensive soft tissue damage
3 A (sub group of 3) Adequate soft tissue coverage
3 B (sub group of 3) Inadequate soft tissue coverage
3 C (sub group of 3) Associated arterial injury


In Type IIIc injuries, the mangled extremity scoring system (MESS) can help to predict the need for primary amputation.

Initial management should focus on careful patient examination to check for associated injuries, control of haemorrhage and the extent of injury. The area should be carefully imaged, distal neurovascular status established the wound covered with a dressing and antibiotics administered. Early debridement is the cornerstone of the management of open fractures. The aim of the debridement is to remove foreign material and devitalised tissue. In most cases the wound is left open. The wound should be irrigated, generally, 6 litres of saline is used. The fracture should be stabilised and an external fixator is often used in the first instance