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Trauma & Orthopaedics — Study Notes

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1. General Principles of Treatment of Patients

Goals of Trauma Management

• Primary survey: Airway, Breathing, Circulation, Disability (neurological), Exposure (ABCDE)
• Secondary survey: Head-to-toe examination after life-threatening injuries are stabilised
• Resuscitation: IV access, fluid resuscitation, blood products (1:1:1 ratio for massive haemorrhage — RBC:FFP:platelets)

Principles of Treatment

Wound Management

• Clean wounds: primary closure
• Contaminated/infected: delayed primary or secondary closure
• Tetanus prophylaxis for all traumatic wounds
• Antibiotics for open fractures (cefazolin ± aminoglycoside)

Haemorrhage Control

• Direct pressure, tourniquets for limb haemorrhage
• Damage control surgery: external fixation of pelvis/femur, packing, then definitive repair
• "Damage control resuscitation" — permissive hypotension (MAP 50–65 in penetrating trauma)

Neurogenic Shock (Spinal Injuries)

• Loss of sympathetic tone → bradycardia + hypotension without tachycardia
• Treatment: vasopressors (norepinephrine preferred), IV fluids
• Restore MAP >85 mmHg to minimise secondary cord ischaemia

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2. Classification and Complications of Fractures; Splints and Traction

Definition of a Fracture

General Descriptive Classification

AO/OTA Classification

Open Fracture — Gustilo-Anderson Classification

Complications of Fractures

• Haemorrhage / hypovolaemic shock
• Fat embolism syndrome (petechiae, hypoxia, confusion — classic triad; 12–72 h post long-bone fracture)
• Acute compartment syndrome (pain out of proportion, pain with passive stretch, pulselessness, paraesthesia, paralysis — the "6 Ps"; treat with fasciotomy)
• Neurovascular injury
• Infection (open fractures)

• Malunion (healed in abnormal position)
• Non-union (hypertrophic vs. atrophic — treat with bone graft ± fixation)
• Delayed union
• Avascular necrosis (AVN) — especially femoral head, scaphoid, talus
• Post-traumatic osteoarthritis
• Reflex sympathetic dystrophy (CRPS)
• Volkmann's ischaemic contracture (forearm compartment syndrome → flexor contracture)

Splints

• Posterior slab splint: ankle, Colles' fracture
• Thumb spica: scaphoid fractures, De Quervain's
• Ulnar gutter: 4th/5th metacarpal fractures (boxer's fracture)
• Sugar-tong: distal radius fractures (prevents supination/pronation)
• Long arm posterior: elbow/forearm fractures

Traction

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3. Traumatic Dislocations of Joints

General Principles

General Management

1. Analgesia + sedation (procedural sedation)
2. X-rays pre-reduction to identify associated fractures
3. Closed reduction (gentle in-line traction, manipulation)
4. Post-reduction X-ray to confirm congruence
5. Neurovascular check before and after
6. Immobilisation followed by rehabilitation

Shoulder (Glenohumeral) Dislocation

• Anterior (95%): arm in abduction/external rotation, mechanism = fall on outstretched hand (FOOSH)
  • Axillary nerve at risk (test sensation over deltoid patch)
  • Bankart lesion (glenoid labrum tear), Hill-Sachs lesion (posterolateral humeral head compression fracture)
  • Reduction: Cunningham (muscle relaxation), Milch, Stimson, FARES techniques
• Posterior (<5%): often missed; "lightbulb sign" on AP X-ray; seizures/electrocution mechanism
  • Reverse Hill-Sachs lesion

Elbow Dislocation

• Most common joint dislocated in children; posterior dislocation most common in adults
• "Terrible triad": elbow dislocation + radial head fracture + coronoid fracture
• Reduction: traction-countertraction with pronation/supination; immobilise in 90° flexion

Hip Dislocation

• Posterior (90%): hip flexed + adducted + internally rotated (dashboard injury)
  • Sciatic nerve at risk; AVN of femoral head if not reduced within 6 hours
  • Reduction (Bigelow/Allis manoeuvre): patient supine, traction in axis of deformity, then flex + adduct
• Anterior (<10%): hip extended + externally rotated + abducted
• Complication: post-traumatic osteoarthritis, AVN

Knee Dislocation

• High-energy injury; popliteal artery injury in 30–40% → mandatory vascular assessment (ABI, CT angiography or Doppler)
• Multi-ligament injury; peroneal nerve injury common
• Reduction then external fixation; vascular repair if needed

Patella Dislocation

• Lateral dislocation (almost always); usually young females
• Reduce with knee extension + medial push on patella
• Medial patellofemoral ligament (MPFL) typically tears

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4. Injury of Upper Limbs

Clavicle Fractures

• Most common in middle third (80%)
• Most treated non-operatively (arm sling 4–6 weeks)
• ORIF for: open, neurovascular compromise, shortening >2 cm, floating shoulder

Proximal Humerus Fractures

• Neer classification (4-part system: head, shaft, greater tuberosity, lesser tuberosity)
• 1-part (undisplaced): sling + early physio
• 2–3 part: ORIF or hemiarthroplasty (elderly)
• 4-part: high risk of AVN → hemiarthroplasty or reverse TSA

Humeral Shaft Fractures

• Radial nerve palsy (wrist drop) in ~18%; mostly recover spontaneously (humeral canal)
• Holstein-Lewis fracture (distal 1/3 spiral) = highest radial nerve risk
• Conservative: functional bracing (works well)
• ORIF if: open fracture, neurovascular injury, polytrauma, bilateral fractures

Supracondylar Humerus Fractures (Paediatric)

• Most common paediatric elbow fracture
• Gartland classification: Type I undisplaced, Type II partially displaced (posterior cortex intact), Type III completely displaced
• Anterior interosseous nerve at risk (can't make "OK" sign)
• Brachial artery at risk → "pink pulseless hand" → monitor closely
• Treatment: Type I → cast; Type II/III → closed reduction + percutaneous K-wire fixation

Forearm Fractures

• Both-bone forearm: ORIF with plate fixation (functional forearm = treat as joint)
• Monteggia: Ulna shaft fracture + radial head dislocation (RUINED mnemonic: Radial head, Ulna, INjured, Escaped)
• Galeazzi: Radial shaft fracture + distal radioulnar joint (DRUJ) dislocation ("fracture of necessity" → always needs ORIF)

Distal Radius Fractures

• Colles' fracture: extra-articular dorsal displacement/angulation; dinner-fork deformity; FOOSH in elderly
• Smith's fracture: volar displacement ("reverse Colles'"); FOOSH with wrist flexed
• Barton's fracture: intra-articular rim fracture of distal radius
• Management: closed reduction + cast for stable; ORIF (volar locking plate) for unstable/comminuted

Scaphoid Fractures

• Waist (70%), proximal pole (20%), distal (10%)
• Anatomical snuffbox tenderness = scaphoid until proved otherwise
• Risk of AVN of proximal pole (retrograde blood supply)
• If X-ray negative + snuffbox tenderness → immobilise + MRI/CT at 1–2 weeks
• ORIF with headless screw if: displaced, proximal pole, athlete

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5. Injury of Lower Limbs

Femoral Shaft Fractures

• High-energy; can lose 1–2 L blood into thigh
• Temporary skeletal traction (tibial pin) while awaiting surgery
• Definitive: intramedullary nail (IMN) — standard of care
• Complications: fat embolism (especially if delayed), mal-rotation

Tibial Plateau Fractures

• Schatzker classification (I–VI, increasing complexity)
• Schatzker IV = medial condyle fracture → knee fracture-dislocation; associated vascular injury
• Assessment: CT + MRI for soft tissue injury (MCL, LCL, menisci, cruciate)
• Treatment: ORIF for displaced; external fixation for high-energy open injuries

Tibial Shaft Fractures

• Most common open long-bone fracture (subcutaneous, high energy)
• Conservative (casting) for undisplaced stable
• IMN for displaced, open, or comminuted
• Complication: acute compartment syndrome (especially if associated fibular fracture is absent)

Ankle Fractures

• Weber/AO classification: A (below syndesmosis), B (at syndesmosis), C (above syndesmosis)
• Lauge-Hansen classification: based on mechanism (supination-adduction, supination-external rotation, pronation-abduction, pronation-external rotation)
• Maisonneuve: proximal fibula fracture + medial malleolus/deltoid ligament injury — easily missed; examine whole fibula
• Treatment: undisplaced → cast; displaced/unstable → ORIF

Calcaneal Fractures

• Fall from height; bilateral in 10%
• Sanders classification on CT
• Böhler's angle reduced (<20°) indicates significant comminution
• Conservative vs. ORIF (debate); minimally displaced → conservative

Femoral Neck Fractures

• Intracapsular: Garden classification (I–IV); Grade III–IV = displaced; high AVN risk
• Treatment: displaced → hemiarthroplasty (elderly), THR or ORIF (young)
• Undisplaced → cannulated screws
• Extracapsular (intertrochanteric): DHS (dynamic hip screw) or cephalomedullary nail
• Subtrochanteric: long cephalomedullary nail

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6. Spinal Injuries

Anatomy Review

• Anterior: anterior longitudinal ligament + anterior half of vertebral body/disc
• Middle: posterior half of vertebral body/disc + posterior longitudinal ligament
• Posterior: posterior bony arch + interspinous/supraspinous ligaments

Mechanisms of Injury

1. Flexion-compression: wedge fractures, burst fractures
2. Hyperextension: central cord syndrome (older patients with stenosis)
3. Flexion-distraction: Chance fracture (seat-belt injury) — horizontal fracture through posterior elements + vertebral body
4. Fracture-dislocation: high-energy; complete ligamentous disruption + cord injury

Classification

• AO Spine classification: Type A (compression), Type B (distraction/tension band), Type C (translation/rotation)
• TLICS (Thoracolumbar Injury Classification) — guides operative vs. non-operative
• ASIA impairment scale: A = complete injury, B-D = incomplete, E = normal

Incomplete Cord Syndromes

Management

• Immobilisation: cervical collar + spinal board
• Methylprednisolone: controversial; not routinely recommended (some guidelines abandoned this)
• Neurogenic shock: vasopressors; maintain MAP >85 mmHg
• Surgical indications: progressive neurological deficit, unstable fracture, failure of conservative treatment
• Cervical: tongs traction (Gardener-Wells), halo vest, anterior/posterior fusion
• Thoracolumbar: posterior pedicle screw fixation

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7. Pelvic Injuries

Anatomy

Classification

Haemorrhage Control

• Pelvic fractures can cause 3–6 L blood loss
• Pelvic binder (T-shirt, sheet, commercial) → immediate reduction of pelvic volume
• Angioembolisation for arterial bleeding (interventional radiology)
• Preperitoneal pelvic packing for venous/bony bleeding
• External fixation (anterior frame) for open-book injuries
• Definitive ORIF when patient stabilised (Day 3–5)

Acetabular Fractures

• Letournel classification: 5 elementary + 5 associated patterns
• Both-column (most common associated type)
• CT with 3D reconstruction for surgical planning
• Displaced: ORIF via Kocher-Langenbeck, ilioinguinal, or combined approach

Complications

• Urethral/bladder injury (blood at urethral meatus → retrograde urethrogram before catheter)
• Rectal injury
• Lumbosacral plexus injury
• DVT/PE (all pelvic trauma patients → VTE prophylaxis)

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8. Introduction to Orthopaedics; Methods of Investigation

What is Orthopaedics?

History Taking (Musculoskeletal)

• Pain: SOCRATES (site, onset, character, radiation, associated symptoms, timing, exacerbating/relieving, severity)
• Deformity, swelling, weakness, stiffness, instability
• Functional status (ADLs, walking distance, occupation)
• Past medical history, medications, smoking, family history

Physical Examination

• Look (inspection): skin (scars, sinuses, swelling, muscle wasting), alignment, deformity, gait
• Feel (palpation): temperature, tenderness (point/diffuse), crepitus, neurovascular status
• Move (ROM): active → passive → resisted; compare to opposite side
• Special tests: e.g., Lachman (ACL), McMurray (meniscus), Trendelenburg (hip abductors), Phalen/Tinel (CTS)

Investigations

• FBC, CRP, ESR — infection, inflammatory arthritis
• Uric acid — gout
• Rheumatoid factor, anti-CCP — RA
• ANA — connective tissue disease
• Bone profile (Ca, PO₄, ALP) — metabolic bone disease
• Blood cultures — septic arthritis, osteomyelitis

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9. Congenital Dislocation of the Hip (DDH); Torticollis (Stiffneck); Congenital Clubfoot

Developmental Dysplasia of the Hip (DDH)

• Ortolani test: hips flexed 90° + abducted → "clunk" of dislocated hip relocating = positive
• Barlow test: hips flexed + adducted + posterior pressure → dislocation provoked = positive
• Both tests become negative after 3 months (hip becomes "stuck")

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Torticollis (Wry Neck / Stiffneck)

• Most common; due to fibrosis of SCM (birth trauma/ischaemia during delivery)
• Presents in first weeks of life; palpable SCM "tumour" (fibrotic mass)
• Head tilts to affected side, face rotates away
• Plagiocephaly (skull asymmetry) develops if untreated

• Conservative (first line): physiotherapy — stretching exercises, positioning; 90% resolve by 1 year
• Surgery: SCM release (tenotomy) if >1 year, failed conservative; before age 4 for best results

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Congenital Clubfoot (Talipes Equinovarus)

• C — Cavus (high arch)
• A — Adductus (forefoot adduction)
• V — Varus (hindfoot varus/inversion)
• E — Equinus (plantarflexion; heel up)

1. Serial plaster casting (weekly; 5–7 casts) — corrects C, A, V sequentially
2. Percutaneous Achilles tenotomy (corrects equinus; 90% of cases)
3. Denis-Browne bar + boots — full-time for 3 months, then nights/naps until age 4 years (critical for preventing relapse)

• Relapse: common if bracing not maintained; treat with re-casting or anterior tibialis tendon transfer (TATT)
• Surgery (posteromedial release — PMR): reserved for resistant cases; higher complication rate

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10. Residual Consequences of Flaccid Poliomyelitis; Cerebral Palsy

Poliomyelitis

• Foot drop (tibialis anterior weakness) → toe drag, steppage gait
• Calcaneal foot (gastrosoleus paralysis) → heel walking
• Flail limb (complete LMN) → require bracing
• Leg length discrepancy (shortening due to growth arrest)
• Scoliosis (paraspinal muscle imbalance)
• Hip dislocation (hip abductor weakness)

• Bracing (orthoses): AFO (ankle-foot orthosis) for foot drop; KAFO for knee instability
• Tendon transfers: redirect functional muscle to replace paralysed one; must have donor grade ≥4/5
  • Tibialis posterior transfer through interosseous membrane → dorsiflexion (foot drop)
  • Foot drop: also posterior tibial tendon transfer anteriorly
• Arthrodesis (joint fusion): triple arthrodesis (subtalar + talonavicular + calcaneocuboid) for flail foot
• Osteotomy: correct bony deformity
• LLD correction: shoe raise, epiphysiodesis, limb lengthening (Ilizarov)

Cerebral Palsy (CP)

• By tone/movement: Spastic (most common, 70–80%), athetoid/dyskinetic, ataxic, hypotonic, mixed
• By topography: Hemiplegia, diplegia, quadriplegia
• GMFCS (Gross Motor Function Classification System): I–V (independent walking → wheelchair dependent)

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11. Scoliosis

Classification

Measurement — Cobb Angle

Risser Sign (skeletal maturity)

• Iliac crest ossification 0–5 (0 = immature, 5 = fused = mature)
• Risser 0–2 = high growth remaining = high progression risk

Treatment

Surgery

• Posterior spinal fusion with pedicle screw instrumentation (Harrington rods → modern CD systems)
• Goals: halt progression, improve curve magnitude, maintain sagittal balance
• Complications: infection, neurological injury (SSEP/MEP monitoring), adding-on, pseudarthrosis

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12. Osteomyelitis

Classification

• Acute: inflammatory changes; <2–4 weeks (some say: <6 weeks)
• Subacute: indolent presentation; Brodie's abscess (subacute metaphyseal abscess with sclerotic rim)
• Chronic: bone destruction, sequestrum, involucrum; >6 weeks

• Haematogenous: most common in children (metaphysis of long bones — rich capillary loops; sluggish flow)
• Contiguous: from adjacent soft tissue infection, diabetic foot
• Direct inoculation: post-surgical, open fracture, penetrating trauma

• I — Medullary (endosteal nidus)
• II — Superficial (cortical surface only)
• III — Localized (full-thickness cortex; stable bone)
• IV — Diffuse (circumferential; unstable bone)

• A — Good immune system/delivery (normal host)
• B — Locally (B-L) or systemically (B-S) compromised
• C — Not a surgical candidate (treatment risk > benefit)

Common Organisms

Clinical Features

• Acute: fever, malaise, point tenderness over affected bone, soft tissue swelling, refusal to weight-bear (child)
• Chronic: sinus tracts draining pus, sequestrum, pathological fracture

Investigation

Treatment

• IV antibiotics (empirical anti-staphylococcal: flucloxacillin; or vancomycin if MRSA risk)
• Switch to oral after clinical improvement + CRP normalisation (step-down)
• Duration: 4–6 weeks total
• Surgical drainage if: no response to 48 h antibiotics, abscess, subperiosteal collection

• Requires surgery + antibiotics
• Debridement: remove all infected/necrotic bone (sequestrectomy, saucerisation)
• Dead space management: local antibiotic beads (gentamicin-PMMA), calcium sulphate pellets, or muscle flap
• Bone grafting / reconstruction: Masquelet technique (induced membrane), bone transport (Ilizarov), vascularised bone graft
• Long-term antibiotics (often 6–12 weeks)

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