Fig. 40.1 X-ray features of osteoarthritis. Reproduced with permission from Wilkinson, Ian, et al, Oxford Handbook of Clinical Medicine 10e, 2016, Oxford University Press. Courtesy of Dr DC Howlett.
Trauma and orthopaedic surgery: overview
Trauma and orthopaedic surgery: in clinic
Trauma and orthopaedic surgery: in theatre
Trauma and orthopaedic (T&O) surgery is the branch of surgery concerned with the musculoskeletal (MSk) system. Orthopaedic surgeons treat MSk trauma, sports injuries, infections, tumours, and congenital and degenerative diseases. In some hospitals, they may also be involved in spine surgery (alt. neurosurgeons) and hand surgery (alt. plastics).
Most consultants are involved in trauma (injuries and fractures), however they also have one or two subspeciality interests:
• Arthroplasty (joint reconstruction).
• Neck of femur (NOF) fracture: intra/extracapsular
• Wrist (distal radius) fracture
• Osteoarthritis (OA (e.g. hip ± knee)
• Carpal/cubital tunnel syndrome
• Soft tissue knee injury (e.g. meniscal tear)
• Arthroscopy (mainly knee + shoulder)
• Arthroplasty (joint replacement).
• Manipulation under anaesthesia
• Intramedullary nailing (e.g. long bone fractures)
Factoid
Orthopaedic surgeons sometimes have the negative reputation of being simple minded, bone-centric, and interested only in private practice. You will hear it said that orthopods are strong as an ox and half as clever, however a multicentre prospective study found that orthopaedic surgeons were both stronger and more intelligent than their anaesthetic colleagues.1 In reality, most orthopods are enthusiastic, energetic, and approachable.
Reference
1. Subramanian P, Kantharuban S, Subramanian V, et al. (2011). Orthopaedic surgeons: as strong as an ox and almost twice as clever? Multicentre prospective comparative study. BMJ 343:d7506.
Not surprisingly, the T&O clinic is divided into trauma (fractures and injuries) and orthopaedic (elective conditions) clinics. Try to sit in on both types. This is an opportunity to practise your focused orthopaedic history and examinations. (See Table 40.1.)
The most common presenting complaint to an orthopaedic clinic is pain—either following an injury or through a degenerative process. If from an injury, what is the mechanism? The impact on quality of life and the level of disability caused must be established and therefore it is important to ask about hand dominance and occupation. Focus on conditions that may affect potential surgery in the PMHx. For instance, establish whether the patient has risk factors for undergoing anaesthesia. Diabetes, long-term steroid use, immunosuppression, and smoking are important as these are risk factors for poor wound healing. Any anticoagulant use should also be noted as this will need to be withheld prior to surgery. Finally, it is equally important to establish the patient’s goals and expectations. What activities would they like to return to? The treatment for a premiership footballer with an ACL rupture will be different to an elderly patient with a sedentary lifestyle with the same condition. The following cases are likely to form the mainstay of your clinic caseload.
Osteoarthritis (OA) is defined as degenerative arthritis (joint inflammation) predominantly affecting articular cartilage and subchondral bone. The overwhelming majority of arthritides are degenerative (OA).
Predisposing factors are age, weight-bearing (e.g. obesity and knee OA), and previous injury to the joint (e.g. infection/trauma/malalignment/damage to articular cartilage). Symptoms are predominantly pain and stiffness. The key to OA management is to understand this is not a life-threatening condition, and focus on improving quality of life. Initial treatment is lifestyle changes (weight loss, exercise) and analgesia. Later treatments include joint injections (steroid and local anaesthetic/hyaluronan), joint reconstruction (resurfacing/replacement), or fusion (arthrodesis). (See Fig. 40.1.)
Fig. 40.1 X-ray features of osteoarthritis. Reproduced with permission from Wilkinson, Ian, et al, Oxford Handbook of Clinical Medicine 10e, 2016, Oxford University Press. Courtesy of Dr DC Howlett.
• Rheumatoid arthritis (RA): a chronic multisystem disease with predominant MSk manifestations. It attacks synovial tissues, i.e. synovial joints, tendons and bursae, and 
deformities. Use of DMARDs has significantly reduced this.
• Carpal tunnel syndrome: entrapment of the median nerve at the wrist causing pain, paraesthesia, and numbness in the distribution of median nerve. Risk factors include pregnancy, diabetes, RA, hypothyroid, acromegaly. It is a matter of debate whether repetitive injury is associated with carpal tunnel syndrome. Treatment involves splinting, steroid injection, and surgical decompression.
• Rotator cuff (RC) pathology: affects the group of muscles that stabilizes the shoulder (supraspinatus, infraspinatus, subscapularis, teres minor). Common problems include RC tear, impingement, and RC arthropathy. Most are managed conservatively (e.g. physiotherapy, steroid injections). Refractory cases require surgery, usually arthroscopic.
• Bunions: hallux valgus (big toe) deviating laterally at metatarsophalangeal joint; associated with biomechanical forces typically related to wearing tight shoes or high-heels. Treatment involves pads, splints, wedges between toes, realignment surgery (e.g. scarf/Akin osteotomy), or arthrodesis in advanced cases.
Table 40.1 A favourite question is features of OA vs RA on X-ray
| Cardinal signs of OA (LOSS) | Cardinal signs of RA (LESS) |
| Loss of joint space | Joint space narrowing |
| Osteophytes | Erosions |
| Subchondral cysts | Soft bones (osteopenia) |
| Subchondral sclerosis | Soft tissue swelling |
• Soft tissue injury: tendon/ligament injuries and meniscal tears are common. Meniscal tears can be treated with physiotherapy and/or arthroscopy. Tendon ruptures can often be treated conservatively or with repair/reconstruction. Many soft tissue injuries can be treated with RICE (Rest, Ice, Elevation, and Compression).
• Fracture (fx or #): discontinuity in the cortex of a bone with an associated soft tissue injury (do not forget this important point).
See Fig. 40.2.
Fig. 40.2 Principles of orthopaedic management.
There are two main types of types of fracture fixation: fixation with absolute stability and relative stability (see Table 40.2).
Table 40.2 Difference between absolute vs relative stability
| Stability | Absolute | Relative |
| Movement | No movement at fracture gap | Limited movement, resulting in callus formation |
| Fracture gap | No gap | Small fracture gap |
| Bone healing | No callus (direct, hence primary) | Callus (indirect, hence secondary) |
| Examples | Lag screws, plate-and-screws (some) | Intramedullary nailing, plate-and-screws (some) |
This is the ‘classic’ four-stage method you will have read about:
1. Bleeding from bone ends creates a haematoma, generating an inflammatory reaction. Haematoma is gradually replaced by granulation tissue. Necrotic bone is removed.
2. Periosteal cells develop into chondroblasts and fibroblasts which form hyaline cartilage and woven bone. This culminates in a new mass of tissue known as soft callus.
3. The soft callus is converted into stronger hard callus.
4. The bone then remodels to the normal stresses it is placed under and returns to its normal shape over months to years.
Fixation by absolute stability ‘fools’ the body into thinking no fracture has occurred by obliterating the fracture gap. New bone is laid down without callus. These methods are used in different scenarios depending on the fracture pattern.
Top tips
• Attend the trauma meetings in the morning to learn how to present. It is not an X-ray, it is a plain radiograph!
• X-rays are like ECGs in the sense that you need (1) your own system, and (2) to see lots of normal to recognize abnormal. As an undergraduate it is usually enough to name the bones (common question), and recognize simple fracture patterns.
Never comment on a fracture based on one view, always ask for two orthogonal views (e.g. AP and lateral views); and remember the joint above and below may also need imaging.
The rate of bone healing is multifactorial, including which bone is affected, fracture pattern, blood supply, age and general health of the patient, and type of fixation (plaster vs plate etc.). Children heal much faster than adults.
Imagine you are on the phone describing the radiograph to your consultant who cannot see it:
• Pattern: spiral/oblique/transverse/impacted/avulsion/incomplete.
• Simple/comminuted (number of fragments).
• Dislocation: complete loss of congruity between the articular surfaces of a joint. Subluxation is partial loss of congruity between the articular surfaces of a joint. Both can be associated with fractures (‘fracture-dislocation’ and ‘fracture-subluxation’).
See Fig. 40.3 for an example.
Fig. 40.3 This is a plain radiograph of a 45-year old right hand dominant carpenter taken this morning, who fell onto his outstretched right hand today. He sustained a closed wrist fracture and is neurovascularly intact. This is a simple transverse fracture of the distal radius, which is extra-articular. There is 50% displacement, 1 cm shortening with dorsal angulation. There is also an associated ulna styloid fracture.
• Restricted range of movement.
• Overlying skin/soft tissue irritation.
When fractures heal, the fragments unite. However, this also depends on optimal conditions (see Table 40.3).
Table 40.3 Complications of orthopaedic surgery, fracture, and trauma
| Timeframe | |
| Short term | Medium to long term |
| Infection | Delayed/mal-/non-union |
| VTE and fat embolus | Joint stiffness |
| Compartment syndrome | Osteoarthritis |
| Haemorrhage | Avascular necrosis |
| Fracture blisters | Complex regional pain syndrome |
| Neurovascular and visceral injury | Myositis ossificans |
• Union: bone healing within an expected time frame (generally 6 weeks for children and 12 weeks for adults for long bones).
• Delayed union: failure to reach union in 6 months after fracture and fractures that take longer to heal.
• Non-union: an arrest in fracture repair due to infection, biomechanical instability, or poor vascularity (avascular necrosis/PVD). It is usually divided into atrophic vs hypertrophic.
• Malunion: fracture healing in a suboptimal and non-anatomic (abnormal) position.
• X-ray: uses a beam of electrons to pass through the body to generate an image on a photographic film. The vast majority of UK hospitals use an electronic version without need for films (e.g. picture archiving and communication system (PACS)).
• Ultrasound: uses high-frequency sound waves to visualize soft tissues (e.g. tendons). No ionizing radiation is used, but it is very operator dependent. It is faster, cheaper, and generally more readily available in hospitals than the following listed modalities.
• CT: takes X-rays of bones in 3D. It is mostly used to image complex fractures, but can also assess the degree of fracture healing.
• MRI: uses a strong magnetic field to generate images without radiation. It is used to image soft tissues but may also spot occult fractures. It is expensive, takes a long time, and can be difficult to get in district general hospitals. Metal inside the body (e.g. stents) is a contraindication to its use.
• Dual-energy X-ray absorptiometry (DXA): uses two beams of different densities to estimate bone mineral density. Used mostly in the context of fractured hips.
• Nuclear medicine scans (bone scan/scintigraphy): used to detect occult tumours, metastases, and stress fractures using radioisotopes such as technetium-99m.
‘The bone is a plant, with its roots in the soft tissue, and when its vascular connections are damaged, it often requires not techniques of a cabinet maker, but the patient care and understanding of a gardener.’ (Gathorne Robert Girdlestone, 1932)
You will see various methods of fracture fixation in theatre. Remember to (1) always wear a face mask according to the adage ‘you can sneeze into an abdomen but you cannot cough into a joint’ to minimize risk of infection, and (2) wear a lead gown when a C-arm is present to protect yourself from radiation.
These are thin, smooth wires driven into bone using a driver which pin fragments together. They act as blocking wires to stop further displacement of fracture fragments until healing begins. They are usually left protruding from the skin and need to be removed at a later date, usually in clinic.
Widely used for absolute stability but requires enough bone at either end of the plate to ensure screw fixation. It often requires a large incision and soft tissue stripping (risks compromising the periosteal blood supply to the bone) because the plate must be applied directly to the bone (e.g. ankle, wrist) through open reduction and internal fixation (ORIF).
For example, cannulated screws are used to fix the femoral head in situ in an undisplaced intracapsular fracture or in slipped upper femoral epiphysis (SUFE), or for fixing the medial malleolus. This is a minimally invasive technique that requires only a small incision.
IMN is essentially a rod placed through the centre of the bone (the medullary canal), usually for fractures of the diaphysis of long bones (humerus, tibia, and femur) through closed reduction and internal fixation (CRIF).
K-wires, screws, and IMN are inserted using small incisions using an image intensifier machine (called a C-arm) in theatre that provides fluoroscopic imaging, while plates require wide-open incisions allowing the entire plate to be visualized with the naked eye. Often a C-arm is used to confirm restoration of length, alignment, and rotation. The X-ray images can be stored for evidence of surgical outcomes and comparisons to preoperative planning in revision surgery.
This is an external device which acts as a scaffold to hold fractures from the outside of limbs. Protruding pins are driven into bone and connected by external bars. This has a wide range of indications:
• Heavily comminuted fracture.
• Polytrauma/temporary stability.
• Heavy soft tissue disruption.
Hip hemiarthroplasty is replacement of the fractured femoral head only, leaving the native acetabulum untouched (compare with total hip replacement (THR) where both are replaced). The usual indication is a displaced intracapsular fractured NOF where there is presumed disruption to the blood supply of the femoral head which will likely undergo osteonecrosis. Extracapsular fractures require a dynamic hip screw (DHS), which fixes the fractured femoral head onto the femoral shaft using a special plate-and-screws design such that weight-bearing compresses the fracture. Both options fulfil the goals of treatment which are to allow mobilization without restriction, preventing mortality and morbidity associated with being bed-bound.
This is minimally invasive surgery of a joint, typically knee and shoulder, and can be diagnostic or therapeutic (washout, reconstruction, repair, e.g. torn ligaments and menisci). Scars are 1–2 cm long, and usually two to four in number.
Honours
• Menisci are C-shaped discs of cartilage in the knee. They 
the congruency of the knee joint and act as shock absorbers.
• Tears are common in young, sporty patients who forcefully twist the knee on weight-bearing.
• Patients report ‘mechanical symptoms’ of pain, locking, and giving way of the knee.
• Examination may reveal joint line tenderness, reduced range of movement, and positive McMurray’s test (do with caution as this can be very painful!).
• Tears give characteristic MRI appearances.
• Physiotherapy is the mainstay of treatment but if it fails, patients undergo arthroscopy. Tears in the outer third where there is a blood supply are usually repaired with sutures; tears in the inner third have to be trimmed as they are not repairable. Menisci must be preserved as much as possible.
Almost every joint can be reconstructed or replaced; however, hip and knee are the most common, typically required for OA. These can be partial or total, and with or without bone cement. Research shows reduced pain, and improved quality of life and lifespan. The aim is to delay surgery until the last resort since every implant has a shelf life (~10–20 years on average) before it is inevitable to do revision surgery which becomes more complex and risky every time. Cement and implant loosening may be septic or aseptic.
Division of the skin fat superficial palmar fascia transverse carpal ligament (flexor retinaculum) in order to decompress the underlying median nerve. The flexor retinaculum contains four flexor digitorum profundus (FDP), four flexor digitorum superficialis (FDS) tendons, flexor pollicis longus (FPL), and median nerve. This is usually a day case procedure performed under local anaesthetic.
There are three main nerves supplying motor and sensory innervation to the upper limb: (1) median, (2) ulnar, and (3) radial nerves. The flexor retinaculum has four bony attachments: laterally, scaphoid tubercle and ridge of trapezium; medially, pisiform and hook of hamate. Guyon’s (ulnar) canal runs superficial and ulnar to the flexor retinaculum (outside the carpal tunnel) and contains the ulnar nerve and artery (hence ‘ulnar sparing’ in carpal tunnel syndrome). (See Fig. 40.4.)
Fig. 40.4 Cross-section of the carpal tunnel. Reproduced from https://commons.wikimedia.org/wiki/File:Carpal-Tunnel.svg, licensed under the Creative Commons Attribution-Share Alike 3.0 Unported license.
These nerves can become compressed at various sites along their course, especially where they travel between muscles and within tight tunnels. The most common is carpal tunnel syndrome, which constitutes compression of the median nerve as it travels through the carpal tunnel in the volar aspect of the wrist.
Compressive neuropathy produces typical symptoms:
• Pins and needles (paraesthesia).
Symptoms characteristically worsen at night and are relieved by shaking the hand or dangling it off the edge of the bed.
Most cases of carpal tunnel syndrome are idiopathic, however it can be caused by pregnancy, hypothyroidism, diabetes, and rarely by tumours within the carpal tunnel.
Can provoke the symptoms and add to the weight of clinical evidence:
• Durkan’s (pressure over tunnel).
• Tinel’s (tapping over the tunnel).
• Phalen’s tests (flat palms together in wrist hyper-flexion/extension).
Nerve conduction studies are useful to correlate with clinical findings but this is essentially a clinical diagnosis. MRI excludes space-occupying lesions within the carpal tunnel, which is rare.
Non-surgical management can be attempted with night splints and steroid injections around the median nerve. Definitive treatment is carpal tunnel decompression (via open vs endoscopic).
Sparing of sensation of the thenar eminence is due to its supply by the palmar cutaneous branch of the median nerve, which comes off the main nerve 5 cm proximal to the carpal tunnel. Symptomatic persistence ± recurrence can take 3 months to resolve. The commonest complication is scar sensitivity (pillar pain).
Trivia
It is a synthetic material which fills the free space between bone and implant. It is composed of a powder and a liquid which is mixed together. This generates an exothermic polymerization reaction to form polymethyl methacrylate (PMMA), commonly known as Plexiglas®.
Cement contains extract of chlorophyll to enable it to be seen easily.
Barium or zirconium is added to make cement radio-opaque.
Multiply injured patients in England are now triaged to major trauma centres, where they are looked after by a trauma team trained to deal with these complex injuries on a daily basis. The team includes ED, general surgery, vascular surgery, anaesthetics. and orthopaedics. It may also include neurosurgery and plastic surgery. Assessment and management of polytrauma patients are performed according to the ATLS® algorithm:
• A: airway with C-spine protection.
• B: breathing and ventilation control.
• C: circulation and haemorrhage control.
• D: disability/neurological assessment.
• E: exposure and environmental control.
Borrow a copy of the latest ATLS® manual; it is easy to read and will cover the whole scope of managing major trauma. It is beyond the scope of medical school but may be interesting/useful. Make sure you see a trauma call with primary and secondary surveys.
See Fig. 40.5 for types of hip fracture.
Fig. 40.5 Types of hip fractures. Reproduced with permission from Parker, M., Johansen, A., Hip Fracture, BMJ. 2006 Jul 1; 333(7557): 27–30.
This is a fracture communicating with an overlying skin wound. A fracture where the skin remains intact is a closed fracture. You cannot tell from a X-ray if the fracture is open or closed.
Use the six As to guide open fracture management:
• Assessment: ATLS® plus assessment of the neurovascular status of the limb, viability of soft tissues, photograph the wound.
• Antisepsis: remove gross contaminants, and seal with saline-soaked gauze and impermeable dressing.
• Alignment: align fracture and splint (for immobilization, analgesia, and haemorrhage control).
• Anti-tetanus: check status and immunize appropriately.
• Antibiotics: e.g. IV co-amoxiclav.
Tissue (osseo-fascial) pressure in a closed compartment exceeds the perfusion pressure resulting in ischaemia due to microvascular compromise and congested venous return. It is a clinical diagnosis and must be diagnosed promptly as the only treatment is immediate fasciotomy (in theatre) to save the limb. Complications include ischaemia/rhabdomyolysis necrosis contracture, chronic pain, dry and wet gangrene amputation.
Top tip
You will often hear and read that compartment syndrome is characterized by the six Ps which are actually signs of acute limb ischaemia. It is typified by pain out of proportionate to the underlying injury, especially on passive stretch of a tense compartment. Opioids have no effect!
This is often a low-energy injury in an elderly patient with osteoporosis. There are a number of fracture patterns; however, the classification that determines management is whether the fracture line is intra- or extracapsular. In general, the rule is fix/repair extracapsular fractures DHS, and replace intracapsular fractures hemiarthroplasty if displaced (or repair with cannulated screws/DHS if undisplaced).
Can involve medial, lateral, or posterior malleolar fractures. Lateral malleolar fractures are most common (Weber classification). Treatment will depend on whether the fracture is ‘stable’ or ‘unstable’ (displacement on full weight-bearing). Be on the lookout for (1) fracture dislocation (if obviously deformed, do not waste time waiting for an X-ray, just reduce it immediately), (2) talar shift, and (3) syndesmotic rupture which all add to instability and more complex surgery. Surgery is governed by Muller’s rule of 6: either operate within 6 hours or after 6 days to avoid swelling, in which case elevate on a Braun frame with ice compression and wait. Ankle ORIF is followed by 6 weeks of non-weight-bearing in plaster and VTE prophylaxis.
Usually occurs after high-energy trauma where most are anterior dislocation (>90%) > posterior (5%) > inferior (luxatio erecta <1%). Always check for axillary nerve function by checking the regimental patch. Reduce and re-X-ray. Patients aged <30 years have >90% dislocation rate and those aged >30 years have <10%. Initial management requires rest (polysling), physiotherapy, and ruling out rotator cuff injury. Recurrent dislocation requires arthroscopic stabilization.
This is septic arthritis until proven otherwise, as if missed will avoidable problems including septicaemia and hastened OA. Septic arthritis (pus in the joint due to infection) rapidly destruction of the articular cartilage and the joint itself. Causes are numerous, including:
Must exclude infection and gout using blood markers including WCC, ESR, CRP, and urate. Do a joint aspirate (arthrocentesis) for urgent MC&S and crystallography (gout/pseudogout). Always X-ray to look for erosive changes in septic, autoimmune, and gouty changes. Treat according to cause (proven septic arthritis requires antibiotics and washout in theatre). Do not start antibiotics blindly without sampling synovial fluid and blood cultures for MC&S for Gram-staining (only takes hours and can better guide specific antibiotic therapy).
This is a worrying presentation. Causes depend to some extent on age and include trauma, infection (septic arthritis, osteomyelitis), Perthes disease (idiopathic osteonecrosis of the femoral head, 5–10 years), SUFE (epiphysis slips through the growth plate in 10–15 years, half of which are obese), and transient synovitis.
This is usually a low-energy injury in an osteoporotic, elderly patient. They are also very common in children. Some eponymous names you may hear include:
Intra-articular fractures have a greater risk of being unstable, thus are likelier to require surgery. But there terms are fortunately largely obsolete. They can be immobilized in a cast, but unstable fractures require surgery (manipulation under anaesthesia K-wires ORIF with plates and screws).
Honours
• Gout and pseudogout crystals look different under polarized light: gout is needle-shaped and strongly negative birefringent; pseudogout is rhomboid-shaped and weakly positive birefringent.
• Damage control surgery (DTS) works on the principle that the primary insult (the injury) exerts metabolic damage which is worsened by prolonged complex surgery (secondary insult), death (via (1) coagulopathy, (2) hypothermia and (3) metabolic acidosis). DTS aims to stabilize the patient quickly with minimal additional insult, with the plan for further surgery when the patient is systemically stable. The alternative is early total care (ETC) where definitive surgery (often taking significant time) has become obsolete.
Clinical orthopaedic examinations are more difficult than those of other specialties as there is no single routine and lots of body parts! We urge you to ask a friendly registrar/consultant to show you how to examine a hip, knee, hand, shoulder, spine, and ankle/foot.
The good news is that all orthopaedic exams are a variation on look, feel, move, special tests, and imaging (see 
‘Orthopaedic examinations: general’ pp. 941–943). Remember, you have two limbs so you should always examine the normal side before the abnormal/painful side. You should also always offer to examine the joint above and below.
Like other specialties, you are unlikely to see emergency cases (e.g. fractured NOF, dislocations, septic arthritis). The most common cases are:
• knee/hip OA or arthroplasty postoperatively
• joint arthroscopy postoperatively
• shoulder impingement (in an actor).
Beware postoperative patients (of which there are many) with minimal scarring. It is common for candidates to be presented with a ‘normal’ knee; the majority will miss small arthroscopic port scars on the sides. When you look this is not just for show, it is important that you really look!
Also remember to look around the room for sticks, crutches, braces, etc. Ask the patient to remove their shoes and look at the soles for abnormal wear, and inside the shoes for insoles. These adjuncts will give you a clue as to what is wrong with the patient! Also remember that for lower limb joint examinations, stand the patient up and observe their stance and gait. This will allow you to thoroughly inspect all around and the back of the limb for any muscle wasting, scars, or deformities.
It is likely that you will be asked to comment on radiographs after the examination. Commonly this will be knee or hip OA (so know your radiographic features). Occasionally it may be a fracture (practise describing a fracture). Learn what THR, total knee replacement, DHS, hip hemiarthroplasty, plate-and-screws, and K-wires look like on X-ray.
