Surgey: Trauma and orthopaedics

🩺 Trauma and orthopaedics -page 10 of the Surgery chapter. Orthopaedics covers injuries to bones and joints (trauma) and long-term problems such as arthritis (elective). For every injury, check the skin (open fracture?), the nerves and the blood supply beyond the injury, and think about compartment syndrome. Hip fractures in older people are one of the commonest reasons for emergency surgery. Major trauma resuscitation is on the Major Trauma page; inflammatory arthritis and bone metabolism are in the Rheumatology and Bone Medicine chapters.
Your four questions for every patient: Is the limb at risk -open wound, nerve or vessel injury, compartment syndrome? What exactly is the injury (describe it properly from two X-ray views)? Does it need reduction, fixation, or neither? What about the whole patient -analgesia, VTE, falls, bone health, safeguarding and rehabilitation?

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Fracture Principles

• Describe a fracture:
  • Patient and X-ray -name, age, date, which bone and side, views (always at least two views at right angles -"one view is no view"), include the joint above and below.
  • Open or closed (skin broken over the fracture).
  • Site -diaphysis (shaft), metaphysis, epiphysis; intra-articular (into the joint).
  • Pattern -transverse, oblique, spiral (twisting), comminuted (more than two fragments), segmental, avulsion, greenstick and buckle (children).
  • Displacement -translation (shift), angulation, rotation, shortening -described by the position of the distal fragment.
• Pathological fractures -through abnormal bone after little force -osteoporosis (fragility fractures -wrist, hip, vertebrae), metastases (breast, prostate, lung, kidney, thyroid), myeloma, Paget's disease, osteomalacia.
• Stress fractures -repeated loading (runners, soldiers -metatarsals, tibia, femoral neck); X-ray may be normal early -MRI.
• Principles of management -reduce (if displaced), hold (cast, splint, traction, internal or external fixation), rehabilitate (move and strengthen).
• Fixation:
  • Plaster casts and splints -most simple fractures; check circulation; warn about swelling and tightness.
  • Open reduction and internal fixation (ORIF) -plates and screws; intra-articular or unstable fractures.
  • Intramedullary nails -long bone shaft fractures (femur, tibia).
  • External fixators -contaminated open fractures, damage control, soft tissue problems.
  • Joint replacement -some fractures near joints in older people (hip).
• Healing -haematoma, soft callus, hard callus, remodelling; about 6–8 weeks for upper limb and 12 weeks for lower limb in adults (faster in children; slower with smoking, diabetes, NSAIDs, poor blood supply).

Fracture Complications

Timing	Complications
Immediate	Bleeding and shock (pelvis, femur), nerve injury, vascular injury, skin injury (open fracture), injury to organs (ribs -pneumothorax)
Early (days)	Compartment syndrome, VTE (DVT, PE), fat embolism, infection, rhabdomyolysis, pressure sores, plaster problems, delirium and pneumonia in older people
Late (weeks to years)	Delayed union and non-union, malunion (healed in a bad position), avascular necrosis (scaphoid, femoral head, talus), joint stiffness, post-traumatic osteoarthritis, complex regional pain syndrome (CRPS), growth disturbance in children, osteomyelitis

• Compartment syndrome -pain out of proportion and pain on passive stretch; tibial and forearm fractures, tight casts -split the cast to skin, urgent fasciotomy (see the Vascular Surgery page).
• Nerve injuries to remember:
  • Axillary nerve -shoulder dislocation and humeral neck fracture -numb "regimental badge" patch, weak deltoid.
  • Radial nerve -humeral shaft fracture -wrist drop.
  • Median nerve (anterior interosseous) and brachial artery -supracondylar fractures in children.
  • Ulnar nerve -medial epicondyle fractures.
  • Sciatic nerve -posterior hip dislocation.
  • Common peroneal nerve -fibular neck fracture, knee dislocation, tight casts -foot drop.
• Avascular necrosis -scaphoid (proximal pole), femoral head (intracapsular neck of femur fracture), talus neck.
• Complex regional pain syndrome -burning pain, swelling, colour and temperature changes, stiffness out of proportion after an injury (often the wrist) -early mobilisation, physiotherapy, pain team.
• VTE prophylaxis -follow NICE NG89 (e.g. LMWH for lower limb immobilisation where risk exceeds bleeding risk; hip fracture patients routinely).

Open Fractures

• A fracture with a wound that communicates with the bone -high risk of infection (osteomyelitis) and non-union -an orthopaedic emergency.
• Immediate management (BOAST -Open fractures):
  • Primary survey; control bleeding; check and record neurovascular status.
  • IV antibiotics as soon as possible -ideally within 1 hour of injury (e.g. co-amoxiclav or cefuroxime per local policy; add gentamicin at surgery).
  • Tetanus prophylaxis.
  • Photograph the wound, remove gross contamination only, cover with a saline-soaked dressing and an occlusive film -don't keep re-examining.
  • Realign and splint the limb; re-check pulses.
• Surgery -debridement in theatre by both orthopaedic and plastic surgeons (orthoplastic approach): within 12 hours for high-energy injuries, within 24 hours for others, immediately for heavily contaminated (agricultural, marine, sewage) wounds or with vascular injury.
• Gustilo–Anderson classification:
  • I -clean wound under 1 cm.
  • II -1–10 cm, moderate soft tissue damage.
  • III -over 10 cm or high energy (IIIA -bone can still be covered; IIIB -needs a flap; IIIC -vascular injury needing repair).
• Definitive soft tissue cover within 72 hours (and ideally at the same time as fixation).

Shoulder and Clavicle Injuries

• Clavicle fracture -fall onto the shoulder; usually the middle third; broad arm sling for most; surgery for marked displacement, skin tenting, open fractures, neurovascular injury, or non-union.
• Acromioclavicular joint injury -a step at the end of the shoulder; most managed in a sling; surgery for severe displacement.
• Anterior shoulder dislocation (over 95%):
  • Fall on an outstretched hand or forced external rotation; arm held slightly away from the body; loss of the shoulder's rounded contour ("squared off").
  • Check the axillary nerve (sensation over the badge area) before and after reduction.
  • X-ray before reduction (exclude a fracture) and after; reduction under sedation or analgesia (e.g. Kocher's, external rotation, Milch technique); broad arm sling; physiotherapy.
  • Associated injuries -Hill–Sachs lesion (dent in the humeral head), Bankart lesion (labral tear), greater tuberosity fracture, rotator cuff tear (older people).
  • Recurrence is common in young people -stabilisation surgery.
• Posterior dislocation -seizures and electric shocks; arm held internally rotated; "light bulb sign" on the AP X-ray -easily missed (get a lateral view).
• Proximal humerus fracture -older people with osteoporosis after a fall; most managed in a sling with early movement; surgery (fixation or replacement) for severe displacement in fit patients.
• Humeral shaft fracture -check the radial nerve (wrist drop); usually managed with a functional brace; most nerve palsies recover.

Elbow and Forearm Injuries

• Supracondylar fracture of the humerus (children, about 5–7 years, fall onto an outstretched hand):
  • Swollen elbow; check radial pulse and hand perfusion (brachial artery) and nerves (anterior interosseous -can't make an "OK" sign; median, radial, ulnar).
  • Gartland classification -I undisplaced (cast), II angulated, III completely displaced (closed reduction and K-wire fixation).
  • A pulseless, poorly perfused hand -emergency reduction; watch for compartment syndrome (Volkmann's ischaemic contracture).
• Radial head fracture -adults, fall on an outstretched hand; pain on rotating the forearm; "sail sign" (fat pad displaced by an effusion) may be the only X-ray clue; sling and early movement for most.
• Elbow dislocation -usually posterior; check nerves and vessels; reduce urgently.
• Olecranon fracture -fall onto the elbow; displaced fractures need fixation (tension band wiring or plate).
• Pulled elbow (radial head subluxation) -toddlers (1–4 years) lifted or swung by the arm; won't use the arm, holds it slightly bent and pronated; no X-ray needed if typical; reduce by supination and flexion (or hyperpronation).
• Forearm fractures:
  • Monteggia -fracture of the ulna with dislocation of the radial head.
  • Galeazzi -fracture of the radius with dislocation of the distal radio-ulnar joint.
  • ("MUGR" -Monteggia Ulna, Galeazzi Radius.) Always X-ray the joints above and below; adults usually need ORIF.

Wrist Fractures

Fracture	Features	Management
Colles'	Distal radius, dorsal displacement ("dinner fork" deformity); fall on outstretched hand; older women with osteoporosis	Manipulation under haematoma block or regional anaesthesia, cast; ORIF if unstable; bone health assessment
Smith's	Distal radius, volar (palmar) displacement ("garden spade"); fall on a flexed wrist	Usually unstable -often ORIF
Barton's	Intra-articular distal radius fracture with carpal subluxation	ORIF
Buckle (torus)	Children -bulge in the distal radius cortex	Removable splint for about 3 weeks, no follow-up needed
Scaphoid	Young adults; fall on an outstretched hand; tenderness in the anatomical snuffbox, scaphoid tubercle or on thumb compression; X-ray may be normal	Splint; scaphoid X-ray views; if normal but suspected -MRI (or repeat X-ray at 10–14 days); cast or fixation; risk of non-union and avascular necrosis (proximal pole)
Perilunate and lunate dislocations	High-energy wrist injury; median nerve symptoms; easily missed on X-ray ("spilled teacup" on lateral)	Urgent reduction and surgery

• Complications of distal radius fractures -median nerve compression (acute carpal tunnel syndrome), malunion, extensor pollicis longus rupture (weeks later -can't lift the thumb), CRPS, stiffness.
• Fragility fracture at any site in someone over 50 -assess for osteoporosis (FRAX, DEXA), falls risk, and offer treatment (see the Bone Medicine chapter).

Hand Injuries and Hand Conditions

• Boxer's fracture -fifth metacarpal neck after punching; check for rotation (fingers should point to the scaphoid when making a fist) and wounds over the knuckles.
• "Fight bite" -a wound over a knuckle from a tooth -high risk of joint and tendon sheath infection -explore and wash out, co-amoxiclav.
• Flexor tendon sheath infection -Kanavel's signs -finger held flexed, fusiform swelling, tenderness along the sheath, pain on passive extension -urgent washout and IV antibiotics.
• Tendon injuries:
  • Mallet finger -the fingertip droops (extensor tendon avulsion at the DIP joint) -continuous mallet splint for 6–8 weeks.
  • Cut flexor tendons -can't bend the finger -surgical repair by a hand surgeon.
• Gamekeeper's (skier's) thumb -ulnar collateral ligament injury of the thumb MCP joint; weak pinch; splint or surgery.
• Carpal tunnel syndrome -median nerve compression; tingling of the thumb, index, middle (and half the ring) finger, worse at night, shaking the hand helps; Phalen's and Tinel's tests; thenar wasting late; causes -pregnancy, hypothyroidism, diabetes, rheumatoid arthritis, acromegaly, obesity; night splints, steroid injection, carpal tunnel release.
• Cubital tunnel syndrome -ulnar nerve at the elbow; tingling in the little and ring fingers, weak hand muscles.
• Dupuytren's contracture -thickening of the palmar fascia pulling the ring and little fingers into flexion; family history, men, alcohol, diabetes, epilepsy drugs; treat when the hand can't be laid flat (table-top test) -needle fasciotomy or fasciectomy.
• Trigger finger -the finger catches or locks in flexion (A1 pulley); steroid injection, surgical release.
• De Quervain's tenosynovitis -pain over the radial wrist; Finkelstein's test positive; new mothers; splint, injection, release.
• Ganglion -a smooth cystic swelling on the back of the wrist; usually leave alone (often resolves).

Hip Fractures

• Neck of femur fractures -usually older people after a fall from standing height; about 70,000 a year in the UK; 30-day mortality about 6–7%.
• Features -hip or groin pain, unable to weight bear, leg shortened and externally rotated (displaced fractures). If X-rays are normal but a fracture is suspected -MRI (or CT if MRI unavailable within 24 hours).
• Classification and surgery (NICE CG124):

  Fracture	Operation
  Intracapsular, undisplaced (Garden I–II)	Internal fixation (cannulated screws) -or arthroplasty if unfit or frail
  Intracapsular, displaced (Garden III–IV) -blood supply to the femoral head is cut off (risk of avascular necrosis)	Arthroplasty -total hip replacement if walking independently outdoors with no more than a stick, not cognitively impaired, and medically fit; otherwise hemiarthroplasty
  Extracapsular -trochanteric (intertrochanteric)	Sliding hip screw (dynamic hip screw); intramedullary nail for subtrochanteric or reverse oblique fractures
  Subtrochanteric	Intramedullary nail

• Standards (NICE CG124 and the National Hip Fracture Database):
  • Surgery on the day of or day after admission.
  • Early analgesia -paracetamol, opioids, fascia iliaca or femoral nerve block.
  • Orthogeriatric assessment within 72 hours; delirium prevention and screening.
  • Mobilise the day after surgery; allow full weight bearing.
  • Fluids, nutrition, pressure care, VTE prophylaxis, falls and bone health assessment (most need osteoporosis treatment).
• Don't delay surgery unnecessarily -correct reversible problems quickly (anaemia, fluids, electrolytes, anticoagulation -DOACs and warfarin need a plan; aspirin and clopidogrel are not a reason to delay).
• Complications -delirium, pneumonia, VTE, AKI, pressure sores, dislocation (after hemiarthroplasty), infection, bone cement implantation syndrome (sudden hypoxia and hypotension during cemented arthroplasty -rare), loss of independence.

Femur and Knee Injuries

• Femoral shaft fracture -high energy in young adults (can lose 1–1.5 L of blood); traction splint (pain relief and reduces bleeding), femoral nerve block; intramedullary nailing; watch for fat embolism. In children under walking age -consider non-accidental injury.
• Hip dislocation -usually posterior (dashboard injury -knee hits the dashboard); leg shortened, flexed, adducted and internally rotated; sciatic nerve injury; urgent reduction (avascular necrosis risk). (Hip replacement dislocation -similar position.)
• Ottawa knee rules -X-ray if any: age 55 or over, isolated patella tenderness, fibular head tenderness, can't flex to 90°, can't weight bear for 4 steps (both immediately and in ED).
• Knee injuries:

  Injury	Features	Management
  Anterior cruciate ligament (ACL)	Twisting injury (football, skiing), a "pop", rapid swelling (haemarthrosis within hours), giving way; positive Lachman's and anterior drawer tests	MRI; physiotherapy; reconstruction for active people or instability
  Meniscal tear	Twisting injury, swelling over hours to a day, locking (can't fully straighten) or clicking, joint line tenderness	MRI; physio; arthroscopy for locked knee (bucket handle tear -urgent repair)
  Medial collateral ligament	Blow to the outside of the knee; medial tenderness; pain on valgus stress	Brace, physio (usually heals without surgery)
  Patellar dislocation	Young women, twisting; patella displaced laterally	Reduce by straightening the knee; physio
  Extensor mechanism rupture (quadriceps or patellar tendon, patella fracture)	Can't straight-leg raise; palpable gap	Surgical repair
  Tibial plateau fracture	Valgus force in older people or high energy; haemarthrosis	CT; ORIF if displaced; watch for compartment syndrome
  Knee dislocation	High energy; very unstable knee	Vascular emergency -popliteal artery injury (ABPI, CTA); common peroneal nerve

• Tibial shaft fracture -the commonest open fracture; high risk of compartment syndrome; intramedullary nail.

Ankle and Foot Injuries

• Ottawa ankle rules -ankle X-ray if pain in the malleolar zone plus any of: bone tenderness at the posterior edge or tip of the lateral or medial malleolus (distal 6 cm), or unable to weight bear for 4 steps both immediately and in ED. Foot X-ray if pain in the midfoot plus tenderness at the base of the fifth metatarsal or navicular, or unable to weight bear.
• Ankle sprain -usually the lateral ligaments (inversion); rest, ice, compression, elevation, early mobilisation and physio.
• Ankle fractures -Weber classification (fibular fracture relative to the syndesmosis):
  • Weber A -below the syndesmosis -stable -boot or cast, weight bear.
  • Weber B -at the level of the syndesmosis -may be unstable (check for medial injury and talar shift).
  • Weber C -above the syndesmosis -unstable -usually ORIF.
  • Bimalleolar and trimalleolar fractures, and any talar shift -unstable -ORIF.
• Fracture-dislocation of the ankle -reduce immediately (in ED, under sedation) if the skin is tented or the foot is pale -don't wait for X-ray if the foot is threatened.
• Maisonneuve fracture -a high fibular fracture with ankle ligament injury -examine the whole fibula.
• Achilles tendon rupture:
  • Sudden pain in the back of the heel ("kicked" feeling) during sport (middle-aged "weekend warriors"); also fluoroquinolones and steroids.
  • Palpable gap, weak plantar flexion, positive Simmonds' (Thompson's) test -squeezing the calf doesn't plantar-flex the foot.
  • Ultrasound if unclear; functional bracing in equinus (pointed toes) with early rehabilitation or surgical repair -similar results.
• Calcaneal fracture -fall from height onto the heels -check the spine (lumbar fractures) and the other heel.
• Fifth metatarsal fractures -avulsion of the base (inversion -boot and weight bear) versus Jones fracture (proximal shaft -slow healing -non-weight-bearing or fixation).
• Lisfranc injury (tarsometatarsal joint) -midfoot pain and plantar bruising -easily missed -weight-bearing X-rays or CT; usually needs surgery.

Septic Arthritis and Osteomyelitis

• Septic arthritis -an orthopaedic emergency (joint destruction within days):
  • Hot, swollen, very painful joint with marked loss of movement; fever (not always); usually the knee or hip.
  • Organisms -Staphylococcus aureus (most common), streptococci, gonococcus (young sexually active adults -with skin pustules and tenosynovitis), gram-negatives (older, IV drug users), Kingella kingae (young children).
  • Risk factors -existing joint disease (rheumatoid arthritis), prosthetic joints, diabetes, immunosuppression, IV drug use, recent joint injection.
  • Aspirate the joint before antibiotics (if this doesn't delay treatment) -Gram stain, culture, crystals, cell count; blood cultures; CRP.
  • IV antibiotics (e.g. flucloxacillin, or per local policy -add vancomycin if MRSA risk; ceftriaxone for gonococcus) and joint washout (arthroscopic or open).
  • Crystals don't exclude infection -both can coexist.
• Prosthetic joint infection -early (wound problems, fever) or late (pain, loosening); joint aspiration in theatre conditions -don't give antibiotics blindly; surgery (washout with implant retention -DAIR, or one- or two-stage revision).
• Osteomyelitis:
  • Children -blood-borne, metaphysis of long bones (femur, tibia); fever, limp, refusal to use the limb.
  • Adults -from an open fracture, surgery, a diabetic foot ulcer (contiguous spread), or blood-borne to the spine (vertebral osteomyelitis and discitis -IV drug users, endocarditis, TB -Pott's disease).
  • MRI is the best test (X-ray changes take 10–14 days); bone biopsy for culture; prolonged antibiotics (at least 6 weeks); surgery to remove dead bone (sequestrum).
  • Salmonella osteomyelitis -in sickle cell disease.

Back Pain and Spinal Emergencies

• Most back pain is non-specific (mechanical) and settles -stay active, simple analgesia (NSAIDs), physiotherapy, exercise; avoid prolonged rest; no imaging without red flags (NICE NG59).
• Red flags:
  • Cancer -age over 50, past cancer (breast, prostate, lung, kidney, thyroid), weight loss, night pain, thoracic pain.
  • Infection -fever, IV drug use, immunosuppression, recent infection or surgery.
  • Fracture -significant trauma, osteoporosis, long-term steroids.
  • Inflammatory -young, morning stiffness, improves with exercise (axial spondyloarthritis).
  • Neurological -progressive weakness, bladder or bowel symptoms, saddle anaesthesia.
• Cauda equina syndrome -a surgical emergency:
  • Compression of the nerve roots below the cord (usually a large central disc).
  • Saddle (perineal) numbness, bladder dysfunction (retention, overflow, reduced sensation), bowel dysfunction, sexual dysfunction, bilateral sciatica or leg weakness, reduced anal tone.
  • Emergency MRI (whole spine or lumbar per local pathway) -surgical decompression urgently.
  • Give patients with sciatica written "safety-netting" advice about these symptoms.
• Metastatic spinal cord compression -back pain (often thoracic), leg weakness, sensory level, bladder problems in someone with cancer -dexamethasone 16 mg, whole-spine MRI within 24 hours, radiotherapy or surgery (see the Oncological Emergencies chapter).
• Sciatica (radiculopathy) -leg pain worse than back pain, following a dermatome (L5 -big toe and dorsum of foot; S1 -sole and lateral foot, reduced ankle reflex); usually settles; neuropathic pain drugs (not gabapentinoids for sciatica per NICE), epidural injection or discectomy if persistent.
• Spinal stenosis -neurogenic claudication (leg pain on walking, eased by sitting or bending forward); decompression surgery for severe cases.
• Osteoporotic vertebral fractures -sudden back pain, height loss, kyphosis; analgesia, bone protection; vertebroplasty rarely.

Children's Orthopaedics

Condition	Key features	Management
Developmental dysplasia of the hip	Newborns -risk factors: breech, family history, first-born girls; Barlow and Ortolani tests; later -limp, leg length difference, asymmetric skin creases	Ultrasound (under about 4–6 months); Pavlik harness; surgery if late
Transient synovitis ("irritable hip")	Age 3–10, limp after a viral illness, well, mild or no fever	Rest, NSAIDs; exclude septic arthritis
Septic arthritis of the hip	Unwell, fever, can't weight bear (Kocher criteria -fever over 38.5°C, non-weight bearing, ESR over 40, WCC over 12)	Urgent aspiration, washout, IV antibiotics
Perthes disease	Age 4–8, boys, avascular necrosis of the femoral head; limp, hip or knee pain	X-ray, MRI; physio, bracing or surgery depending on age and severity
Slipped upper femoral epiphysis (SUFE)	Age 10–15, overweight boys, hip or knee pain, limp, loss of internal rotation; may be bilateral; hypothyroidism	Frog-leg lateral X-ray; non-weight bearing and urgent surgical pinning
Osgood–Schlatter disease	Active teenagers; painful bump on the tibial tuberosity	Rest, ice, settles with growth
Talipes equinovarus (club foot)	Newborn -foot pointed down and in, can't be corrected passively	Ponseti method -serial casts, Achilles tenotomy, boots and bar
Scoliosis	Adolescent girls (idiopathic); rib hump on bending forward (Adam's test)	Observe, bracing, surgery for severe curves; red flags -pain, neurological signs, left thoracic curve

• Knee pain in a child may come from the hip -always examine the hip (SUFE, Perthes).
• Salter–Harris fractures (through the growth plate) -I straight across, II above (commonest), III lower (into the joint), IV through everything, V crush -types III–V risk growth problems ("SALTR" -Straight, Above, Lower, Through, Ruined).
• Non-accidental injury -fractures in non-mobile babies, metaphyseal corner fractures, posterior rib fractures, multiple fractures at different stages of healing, story not matching the injury -safeguarding referral and skeletal survey; consider osteogenesis imperfecta.
• A limping child with fever, night pain or a very unwell appearance -exclude septic arthritis, osteomyelitis, leukaemia and bone tumours.

Osteoarthritis and Joint Replacement

• Osteoarthritis -loss of cartilage with bone changes; pain worse on use, brief morning stiffness (under 30 minutes), crepitus, bony swelling; X-ray -Loss of joint space, Osteophytes, Subchondral sclerosis, Subchondral cysts ("LOSS").
• Diagnose clinically (NICE NG226) -age 45 or over with activity-related joint pain and no or brief morning stiffness -imaging isn't needed to diagnose.
• Treatment -exercise (strengthening and aerobic) and weight loss are core; topical NSAIDs (knee and hand), oral NSAIDs (with a PPI) for short periods; avoid routine paracetamol alone, strong opioids, glucosamine; intra-articular steroid injections for short-term relief.
• Joint replacement -when symptoms substantially affect quality of life despite non-surgical treatment (don't use age, weight, smoking or comorbidities alone as barriers):
  • Total hip replacement -very successful; risks -dislocation (avoid extreme flexion and internal rotation early on), leg length difference, sciatic nerve injury, fracture.
  • Total or partial knee replacement -more persistent pain and stiffness than hips; risks -stiffness, common peroneal nerve injury.
• Complications of all joint replacements -infection (about 1% -devastating), VTE (LMWH, aspirin or DOAC for 2–5 weeks), bleeding, wound problems, aseptic loosening (pain years later), periprosthetic fracture, implant wear, need for revision.
• Dental and other procedures -routine antibiotic prophylaxis isn't needed for people with joint replacements.

Shoulder Pain

Condition	Features	Management
Subacromial pain (impingement, rotator cuff tendinopathy)	Pain on lifting the arm sideways -"painful arc" (about 60–120°); pain at night lying on it; full passive movement	Physiotherapy, NSAIDs, subacromial steroid injection
Rotator cuff tear	Weakness and pain, especially after injury or in older people; can't start or hold abduction; can't hold the arm out (drop arm)	Ultrasound or MRI; urgent repair for acute traumatic tears in younger patients; physio for degenerate tears
Frozen shoulder (adhesive capsulitis)	Age 40–60, diabetes; painful then stiff then thawing over 1–3 years; loss of external rotation (active and passive)	Analgesia, physio, steroid injection, hydrodilatation; surgery rarely
Glenohumeral osteoarthritis	Older people; pain and stiffness in all directions	Physio, injections, shoulder replacement
Acromioclavicular joint pain	Pain on top of the shoulder; pain on moving the arm across the body	Injection, physio
Calcific tendinopathy	Sudden severe pain; calcium in the tendon on X-ray	Analgesia, injection, barbotage

• Don't miss referred and serious causes -cardiac pain (left), diaphragmatic irritation (gallbladder, spleen, subphrenic abscess), cervical radiculopathy, Pancoast tumour (with Horner's), polymyalgia rheumatica (both shoulders, stiffness, raised ESR), septic arthritis, an unreduced posterior dislocation after a seizure.

Elbow, Knee and Foot Soft Tissue Problems

• Lateral epicondylitis (tennis elbow) -pain over the outer elbow on gripping and lifting; worse on resisted wrist extension; rest, physio, brace; most settle within a year.
• Medial epicondylitis (golfer's elbow) -pain over the inner elbow on resisted wrist flexion.
• Olecranon bursitis -a swelling over the back of the elbow; aspirate if infection is suspected (hot, red, painful -antibiotics).
• Prepatellar bursitis ("housemaid's knee") -kneeling; septic bursitis needs antibiotics.
• Baker's (popliteal) cyst -a swelling behind the knee with knee arthritis; rupture mimics DVT (calf pain and swelling -ultrasound).
• Patellofemoral pain -young active people; pain around the kneecap on stairs and squatting; physio.
• Plantar fasciitis -heel pain worse with the first steps in the morning; stretching, insoles, weight loss; most resolve.
• Morton's neuroma -burning pain and numbness between the 3rd and 4th toes, worse in tight shoes; wider shoes, injection, excision.
• Hallux valgus (bunion) -big toe deviates outwards; wider shoes; surgery if painful.
• Achilles tendinopathy -pain and thickening of the tendon; eccentric exercises; avoid steroid injections (rupture); caution with fluoroquinolones.
• Gout -acute hot red big toe joint (first MTP); can mimic septic arthritis -aspirate if in doubt (see the Rheumatology chapter).

Bone Tumours

• Bone metastases are far more common than primary bone cancers -from breast, prostate, lung, kidney and thyroid ("BLT with a Kosher Pickle") and myeloma.
  • Bone pain (night pain), pathological fractures, high calcium, spinal cord compression.
  • Mirels' score estimates fracture risk in a long bone metastasis -prophylactic fixation if high risk; radiotherapy, bisphosphonates or denosumab.
• Primary bone cancers (sarcomas -rare; refer to a specialist sarcoma centre before biopsy):
  • Osteosarcoma -teenagers and young adults; around the knee (distal femur, proximal tibia); "sunburst" pattern and Codman's triangle on X-ray; also older people with Paget's disease.
  • Ewing's sarcoma -children and teenagers; diaphysis of long bones and pelvis; "onion skin" periosteal reaction; fever and raised inflammatory markers (mimics infection).
  • Chondrosarcoma -older adults; pelvis, femur, shoulder.
• Benign bone lesions -osteoid osteoma (young people, night pain relieved by NSAIDs), osteochondroma (bony lump near a joint), giant cell tumour (epiphysis, "soap bubble" -locally aggressive), simple bone cysts (may fracture), enchondroma (hands), fibrous dysplasia.
• Refer urgently (NICE NG12) -children and young people with unexplained bone swelling or pain -very urgent X-ray; X-ray suggesting sarcoma -suspected cancer pathway; persistent unexplained bone pain at night.

Orthopaedic Conditions at a Glance

Condition	Key clues	Management
Open fracture	Wound over a fracture	Antibiotics within 1 hour, photo, dressing, splint, theatre debridement
Compartment syndrome	Pain on passive stretch after tibial fracture	Split cast, urgent fasciotomy
Anterior shoulder dislocation	Squared-off shoulder; check axillary nerve	X-ray, reduce, sling
Supracondylar fracture	Child, swollen elbow, check pulse and nerves	K-wires if displaced; emergency if pulseless
Colles' fracture	Dinner fork deformity, older woman	Manipulate and cast; bone health
Scaphoid fracture	Snuffbox tenderness, normal X-ray	Splint and MRI
Displaced intracapsular hip fracture	Short externally rotated leg	Hemiarthroplasty or THR on the day of or after admission
Extracapsular hip fracture	Trochanteric fracture	Sliding hip screw (nail if subtrochanteric)
ACL rupture	Pop, rapid swelling, giving way, Lachman's	MRI, physio, reconstruction
Weber C ankle fracture	Fibular fracture above the syndesmosis	ORIF
Achilles rupture	Kicked feeling, positive Simmonds' test	Equinus boot or repair
Septic arthritis	Hot swollen joint, can't move it	Aspirate, IV antibiotics, washout
Cauda equina syndrome	Saddle numbness, bladder dysfunction	Emergency MRI, decompression
SUFE	Overweight teenager, knee pain, loss of internal rotation	Non-weight bearing, urgent pinning
Osteosarcoma	Teenager, knee pain at night, sunburst X-ray	Sarcoma centre referral before biopsy

Spot the Diagnosis

Clue	Diagnosis
Numb patch over the deltoid after a shoulder dislocation	Axillary nerve injury
Shoulder pain after a seizure with a "light bulb" humeral head on X-ray	Posterior shoulder dislocation
Wrist drop after a humeral shaft fracture	Radial nerve injury
Child can't make an "OK" sign after a supracondylar fracture	Anterior interosseous nerve injury
Toddler won't use the arm after being swung by it	Pulled elbow
Ulnar shaft fracture with radial head dislocation	Monteggia fracture
Elbow pain with a raised anterior fat pad and normal-looking bones	Occult radial head fracture
Snuffbox tenderness with a normal X-ray	Suspected scaphoid fracture -MRI
Can't lift the thumb 6 weeks after a distal radius fracture	Extensor pollicis longus rupture
Rotated little finger after punching a wall	Boxer's fracture with malrotation
Swollen flexed finger, painful passive extension	Flexor tendon sheath infection
Night-time tingling in thumb and index finger in pregnancy	Carpal tunnel syndrome
Fingertip droops after catching a ball	Mallet finger
Short, externally rotated leg after a fall in an 85-year-old	Neck of femur fracture
Short, flexed, adducted, internally rotated leg after a dashboard injury	Posterior hip dislocation
Sudden hypoxia and hypotension during cemented hemiarthroplasty	Bone cement implantation syndrome
Pop and knee swelling within 2 hours playing football	ACL rupture
Knee locks and can't fully straighten after a twist	Bucket handle meniscal tear
Can't straight-leg raise after a fall onto the knee	Extensor mechanism rupture
Foot drop after a fibular neck fracture	Common peroneal nerve injury
Ankle injury with a tender proximal fibula	Maisonneuve fracture
Midfoot pain with plantar bruising after a fall	Lisfranc injury
Calf squeeze doesn't move the foot after a "kick" in the heel	Achilles tendon rupture
Heel pain worst with first steps in the morning	Plantar fasciitis
Fever, hot swollen knee and gram-positive cocci on aspirate	Septic arthritis (S. aureus)
Hot knee, pustules and tenosynovitis in a sexually active 22-year-old	Disseminated gonococcal infection
Bone infection in a child with sickle cell disease	Salmonella osteomyelitis
Saddle numbness and urinary retention with back pain	Cauda equina syndrome
Limp and knee pain in an overweight 13-year-old with reduced hip internal rotation	SUFE
Well 5-year-old limping after a cold, mild hip pain	Transient synovitis
Posterior rib fractures of different ages in a 3-month-old	Non-accidental injury
Painful shoulder with loss of external rotation in a woman with diabetes	Frozen shoulder
Night pain in the tibia relieved by ibuprofen in a 16-year-old	Osteoid osteoma
Onion-skin periosteal reaction in a 12-year-old with fever	Ewing's sarcoma

Exam-style Scenarios

1. An 84-year-old woman falls at home and can't stand. Her right leg is shortened and externally rotated. X-ray shows a displaced intracapsular neck of femur fracture. Before the fall she walked to the shops with a stick and has no cognitive impairment.
Answer: Displaced intracapsular hip fracture in an active, independent patient.

• Analgesia (paracetamol, opioid, fascia iliaca block), fluids, bloods, ECG, group and save; check anticoagulants.
• Total hip replacement (walks independently outdoors with a stick, cognitively intact, fit) -surgery on the day of or day after admission.
• Orthogeriatric review, delirium prevention, mobilise the day after surgery, VTE prophylaxis, falls assessment and bone protection.

2. A 26-year-old motorcyclist has a tibial shaft fracture with a 3 cm wound over the bone. He was given oxygen and morphine at the scene.
Answer: Open tibial fracture.

• Primary survey; IV antibiotics within 1 hour (e.g. co-amoxiclav or cefuroxime); tetanus; record neurovascular status.
• Photograph the wound, remove gross contamination, saline-soaked dressing and film cover; realign and splint.
• Orthoplastic debridement in theatre (within 12 hours for high energy); fixation and soft tissue cover within 72 hours; watch for compartment syndrome.

3. A 7-year-old boy fell off a trampoline onto his outstretched arm. His elbow is very swollen; the hand is cool and pale with no radial pulse. X-ray shows a completely displaced supracondylar fracture.
Answer: Gartland III supracondylar fracture with vascular compromise.

• Analgesia; splint the arm in about 20–40° of flexion (not tight); check and document nerves (anterior interosseous, radial, ulnar, median).
• Emergency closed reduction and K-wire fixation -pulse often returns after reduction; explore the brachial artery if the hand remains poorly perfused.
• Observe closely for compartment syndrome (pain on passive finger extension).

4. A 68-year-old man with a right knee replacement 4 years ago has 2 days of a hot, swollen, painful knee and a temperature of 38.6°C. CRP 220.
Answer: Prosthetic joint infection.

• Urgent orthopaedic referral; blood cultures; joint aspiration by the orthopaedic team under aseptic conditions before antibiotics if he is not septic.
• If septic -Sepsis Six and start IV antibiotics after cultures.
• Surgery -washout with implant retention (DAIR, early infection) or revision (one- or two-stage); prolonged targeted antibiotics.

5. A 13-year-old overweight boy has had a limp and left knee pain for 3 weeks. Knee examination is normal; left hip internal rotation is reduced and the leg rotates outwards when the hip is flexed.
Answer: Slipped upper femoral epiphysis.

• Examine the hip in any child with knee pain; AP and frog-leg lateral hip X-rays (both hips).
• Non-weight bearing (crutches or wheelchair) and urgent orthopaedic referral for surgical pinning (in situ screw fixation).
• Watch the other hip (bilateral in up to a third); check TFTs if atypical; complications -avascular necrosis and early osteoarthritis.

Key Points

• Two X-ray views at right angles, including the joints above and below.
• For every injury, check skin, nerves and blood supply -and think compartment syndrome.
• Open fractures -antibiotics within 1 hour, photograph, dressing, splint, debridement by an orthoplastic team.
• Shoulder dislocation -check the axillary nerve; posterior dislocations follow seizures.
• Supracondylar fractures -check the radial pulse and the anterior interosseous nerve.
• Monteggia -ulna fracture, radial head dislocation; Galeazzi -radius fracture, DRUJ dislocation.
• Scaphoid -snuffbox tenderness with a normal X-ray means splint and MRI.
• Any fragility fracture over 50 -assess for osteoporosis.
• Hip fracture -surgery on the day of or after admission; orthogeriatric care; mobilise the next day.
• Displaced intracapsular -arthroplasty (THR if active and fit); extracapsular -sliding hip screw.
• Ottawa rules guide knee and ankle X-rays.
• Weber A stable; Weber C and bimalleolar fractures need fixation; reduce a dislocated ankle with a threatened foot immediately.
• Simmonds' test -Achilles rupture.
• Septic arthritis -aspirate before antibiotics if possible; crystals don't exclude infection.
• Cauda equina -saddle numbness and bladder symptoms -emergency MRI.
• Examine the hip in a child with knee pain -SUFE and Perthes.
• Posterior rib and metaphyseal corner fractures in babies -non-accidental injury.
• Osteoarthritis -exercise and weight loss first; joint replacement when quality of life is affected.
• Bone metastases are far commoner than primary bone tumours; refer suspected sarcomas before biopsy.

Guidelines and Further Reading

• NICE CG124: Hip fracture -management; National Hip Fracture Database (NHFD)
• NICE NG38: Fractures (non-complex) -assessment and management
• NICE NG37: Fractures (complex) -assessment and management
• BOAST (British Orthopaedic Association Standards for Trauma): Open fractures; Supracondylar fractures in children; Compartment syndrome; Fragility fractures of the ankle
• NICE NG59: Low back pain and sciatica in over 16s
• Getting It Right First Time (GIRFT) and NHS England: National suspected cauda equina syndrome pathway
• NICE NG226: Osteoarthritis in over 16s -diagnosis and management
• NICE NG157: Joint replacement (primary) -hip, knee and shoulder
• NICE NG89: Venous thromboembolism in over 16s -reducing the risk
• British Society for Rheumatology: Management of the hot swollen joint in adults
• NICE NG12: Suspected cancer -recognition and referral (sarcoma)
• BNF -for current doses