Surgey: Trauma and orthopaedics

• Fracture basics: Fracture Principles | Fracture Complications | Open Fractures
• Upper limb: Shoulder and Clavicle Injuries | Elbow and Forearm Injuries | Wrist Fractures | Hand Injuries and Hand Conditions
• Lower limb: Hip Fractures | Femur and Knee Injuries | Ankle and Foot Injuries
• Infection, spine and children: Septic Arthritis and Osteomyelitis | Back Pain and Spinal Emergencies | Children's Orthopaedics
• Elective orthopaedics: Osteoarthritis and Joint Replacement | Shoulder Pain | Elbow, Knee and Foot Soft Tissue Problems | Bone Tumours
• Revision: Orthopaedic Conditions at a Glance | Spot the Diagnosis | Exam-style Scenarios | Key Points | Guidelines and Further Reading

🩺 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?

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

• 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

• 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

• 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

• 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).