Fracture Description Picture Monteggia Fracture of ulna shaft with
dislocation of proximal
Galeazzi Fracture of radial shaft with
dislocation of distal radioulnar
Mnemonic: Medics Under Pressure Get Really Drunk
Monteggia: Ulnar shaft + Prox Radio-ulnar Joint; Galleazzi = Radial shaft + Distal RUJ
Colles’ and Transverse fracture of radius Smith’s within 2.5 cm of wrist
In Smith’s there is palmar (or
volar) displacement of the
distal fragment (Pic to right)
In Colles there is dorsal
displacement of the distal
fragment (bottom right and
Scaphoid 75% of all carpal fractures
Tenderness in snuffbox
Pos prox avascular necrosis
Request scaphoid x-ray
Fractured Hip (Fractured neck of femur)
Classically, this is a fracture of old age, affecting women in their eighth or ninth decade of life.
Usually the bone has been weakened by underlying disease - most commonly, osteoporosis but also osteomalacia, diabetes, alcoholism and other conditions associated with osteopenia. There is usually a history of trauma but in severely weakened bone, direct injury may be trivial or absent. There is a debate as to whether "patients fall because they fracture or fracture because they fall".
Rarely, fractures of the femoral neck are seen in children.
Generally the fracture is displaced and unstable. If some of the fragments have been impacted then the patient may be able to walk with some pain and discomfort.
Femoral neck fractures most commonly follow a fall or blow on the greater trochanter which
may be quite trivial. In severely osteopenic bone, the femoral neck may fracture on weightbearing, for example, on rising from a chair. Rarely, a femoral neck fracture follows severe traumatic injury in a child.
Differentials and clinical features
Posterior dislocation Yes Int Add Yes Common in drivers / Rotation
passengers of head-on
collision Adduction/ Anterior dislocation No Ext Abd Yes Rare adduction Neck of femur fracture Yes Ext Abd Yes May be able to stand
Blood supply poor
Mal / non-union common Flexion Avascular necrosis risk
Intertrochanteric fracture Yes Ext + Abd Yes Cannot stand
Cannot raise leg
Blood supply good
Rare avascular necrosis
Subtrochanteric fracture Yes Ext Abd Yes Swollen thigh
Investigations ； X-ray Pelvis ； CT if doubtful
； X-ray femoral shaft + knee ； Scintigram
Ligamentum teres: a branch of the obturator
artery (absent in 20% of the population) – this
artery is insufficient to supply the head of
the femur in adults.
； One enters posteriorly from the Medial
femoral circumflex artery which is a
branch of femoral artery – greatest
supply of blood to the femoral head
； Two enter anteriorly from the Lateral
femoral circumflex artery which is a
branch of femoral artery – lesser (but
important) supply of blood to femoral
Nutrient artery: This is a branch of profunda
femoris and supplies the shaft of the bone.
In the subcapital fracture the main arterial In the intratrochanteric (pertrochanteric)
supply is lost to the head – this is likely to fracture the main arterial supply to the head
result in avascular necrosis of the head. is intact.
Management may be via replacement of the Management may be via internal fixation e.g.
head (hemiarthroplasty). with a dynamic hip screw.
Any fracture is, almost by definition a trauma and there are certain protocols to follow:
When these are done the limb itself can be assessed
； Blood supply is the most important factor to confirm ； Neural function should be next
If the fracture is open then the following need to be considered (SATS)
Immediate washout with sterile Saline ；
； Antibiotic cover (usually augmentin)
； Tetanus booster ? tetanus immunoglobulin ； Surgical wound debridement under anaesthesia (reduces infection risk)
There are three principles to fracture management (The 3 R’s)
； Reduction: Via traction
； Retention (or fixation) – this is the most effective pain relief in fracture.
； Rehabilitation (intended to preserve function of joints above and below)
Non-operative management Operative management
Internal Fixation External Fixation
Mnemonic: COT Nail (through shaft of long bone) A quick procedure performed in
damage control orthopaedics for
Cast / backslab Interlocking nail (a nail fixed by polytrauma. SE include poor (backslab – plaster of Paris or screws to limit movement) cosmesis and infection risk.
fibreglass – former is more
moldable while latter is lighter) Screw (brings bone pieces into Can also be used when increasing
tight opposition) bone length and correcting
(e.g. callipers, knee brace, collar Plate (resists forces of rotation –
& cuff, sling, corset) often used with screw) Fine wire frames
Traction Pin – e.g. K-wire (small bones,
(Skin – if <24 hours and little wt; little weight bearing)
Nerve Damage – upper limb
Nerve Mechanism Motor Sensory Upper brachial plexus Excessive forceful Erb-duchenne palsy Lateral side of arm
displacement of head and (waiters tip) ； Suprascapular N.
shoulder away from each ； Subclavius
other (e.g. from a Limb hangs limp, ； Axillary
motorcycle injury) medially rotated with ； Musculocutaneous forearm pronated. Traction or tearing of
C5 and C6 roots
Lower brachial plexus Traction from excessive All small nerves of the Medial side of arm
abduction of arm (e.g. hand – clawed appearance. ； First thoracic nerve
clutching at object when
falling from a height)
Long thoracic Radical mastectomy Paralysis of serratus
Blow or pressure to anterior – difficulty in
posterior triangle of neck raising arm above head.
Axillary Badly adjusted crutch in Impairment of abduction ‘Regimental patch’
axilla. of arm (now done just by
Shoulder dislocation. supraspinatus).
Fractured surgical neck of Muscle wasting and loss
humerus. of shoulder contour.
Radial (in axilla) Badly adjusted crutch in Unable to extend elbow
axilla. joint, wrist joint and
Falling asleep with arm fingers.
over back of chair. Wristdrop – disabling as
Fracture or dislocation of it prevents a tight grip
proximal humerus. with the hand concerned.
Radial (in spiral groove) Fractured shaft of If beyond branch to Lateral dorsal surface of
humerus or involved in triceps and anconeus: hand and up to DIP on
the callus during repair. Unable to extend wrist latera 3.5 digits (dorsal)
joint and fingers.
Musculocutaneous Rarely injured as Biceps and Sensory loss on lateral
protected by biceps. coracobrachialis paralysed side of forearm
Flexion preserved via
brachialis (also supplied
by radial nerve) and
Median (at wrist) More common than at Paralysis and wasting of Dorsal aspect lateral 3.5
elbow due to stab wounds thenar eminence leading digits and lateral half of
or broken glass. to loss of ability for palmar aspect
between thumb and
fingers – disabling.
Nerve Mechanism Motor Sensory
Median (at elbow) Supracondylar fracture Pronators and long flexors Dorsal aspect lateral 3.5
of forearm (except FCU digits and lateral half of
and medial FDP). Forearm palmar aspect
is kept supine and wrist
flexion is weak and
adduction. No flexion at
IP joints of index and
Paralysis and wasting of
Ulnar Medial condyle fractures FCU and medial half of medial 1.5 fingers.
FDP are paralysed.
Flexion of wrist joint Froment’s sign
results in abduction.
Unable to adduct and
Small muscles of hand
except LOAF will be
paralysed – unable to
Claw’ deformity ‘
Nerve Damage – lower limb
Nerve Mechanism Motor Sensory
Femoral Knife or bullet wound – Quadriceps muscle Anterior and medial thigh,
complete division rare. paralysed – cannot extend medial leg, medial foot to
knee (aided in walking by base of great toe.
Sciatic Badly placed IM Footdrop due to paralysis All in below knee except
injections. of all lower leg muscles. as supplied by femoral
Penetrating wounds Hamstrings paralysed but nerve.
Fractures of pelvis weak flexion of knee
Dislocation of hip. possible by sartorius and
Common peroneal Fracture of neck of fibula Footdrop due to paralysis All in below knee except
(e.g. car bumper) of muscles in anterior and as supplied by femoral
Pressure from casts or lateral compartments of nerve.
Tibial Rarely injured – deep and Sole of foot – trophic Dorsiflexion and
protected under soleus. eversion of foot from ulcers usually develop.
paralysis of muscles in
back of leg and sole of
Obturator Rare – anterior hip disloc. All adductor muscles Minimal on medial side of
fetal head during birth. except one head add mag. thigh.
Diseases of Bone
Osteoporosis Paget’s disease Rickets / osteomalacia Osteogenesis imperfects Definition Low bone mass and enhanced A focal disorder of bone Inadequate mineralisation of Defects in type I collagen
fragility. remodeling – excessive bone matrix (osteoid) resulting in fragile and brittle
Mineralisation occurs as normal absorption followed by bones
compensatory abnormal new
Risk factors Female, increasing age, Genetic (gene on 18q) Vitamin D deficiency or Genetic – defects in one of the
Caucasian or Asian race, resistance Type I collagen genes
early menopause, small frame,
lack of exercise, smoking, Deficient diet
excess alcohol, Poor sun exposure (shift work,
low calcium intake. dress style, sun block, staying
Clinical features Fracture is only cause of Mostly asymptomatic. Adults (osteomalacia): vague Fragile and brittle bones
symptoms. Vertebral crush bone or muscle pain –
fractures may lead to pain, Pathological fractures possibly a ‘waddling’ gait. Type I:
increasing kyphosis, height Nerve compression: CN II, V, Mild bone deformities
loss and protuberant abdo. VII and VIII (deafness) Children (rickets) blue sclera
Bone pain (esp spine / pelvis) Defective dentine
Colle’s fracture and fractured Joint pain Early-onset deafness
head of femur more common Hypermobility of joints
Heart valve disorder Investigations Radiographs for fractures ; Alkaline phosphatase with ; Alkaline phosphatase
DXA scan for bon density normal calcium and phosph. Serum 25-OH-vit D low 3
(except in Vit D resistant
Notes Prevention vis: diet, exercise, Rarely may be due to low More severe forms may present
smoking cessation, and fall phosphate (hypophosphatemic with multiple fractures and
reduction rickets) gross deformities
Pathological disorders of Joints
Osteoarthritis Ankylosing Spondylitis Rheumatoid arthritis Juvenile polyarthritis Presentation Nodular arthritis Pain and back stiffness Bilateral, symmetrical Typically
Assymetrical polyarthritis temporomandibular +
Affects DIP Affects spine and cervical spine
Osteophytes on x-ray sacroileac joints PIP, MCP, wrists Sometimes mirrors RA Prevalence up to 0.2% 1 – 3% 1/1000 Male : Female 1 : 1 2-10: 1 1: 3-4 1 : 1 Age of onset 40s – 50s 15 – 25 40s – 50s Usually below 6 yrs RF present (anti IgG) - - 80% 15% Course Load too much for Genetic susceptibility Genetic susceptibility
cartilage (load high,
cartilage weakened or Inflammation, granulation Immunologic reaction
subarticular bone and bone erosion focused on synovial tissue
Fibrosis of granulation Inflammatory reaction in
Progressive cartilage tissue joints and tendon sheaths
Capsular fibrosis Ossification of fibrous anti IgG produced
tissue ； ankylosis
Perpetuation of Four X-ray signs
inflammatory reaction Subarticular cyst
Articular cartilage Sclerosis of surrounding
destroyed bone (white edges)
Reduction in joint space
Notes Increase in water content 90% HLA-B27 +ve RF is not diagnostic but it This is a rare subtype of
of cartilage – stress on does indicate a worse juvenile chronic arthritis
collagen network prognosis
The Shoulder Joint
Stability is provided by:
； The rotator cuff muscles (the most important factor)
； The glenoid labrum
； The joint capsule and tendons
； The long head of biceps
； The long head of triceps (reinforces inferior margin)
Painful arc syndrome:
Adhesive capulitis (frozen shoulder):