Fig. 21.1
Describing fractures
Which bone is fractured?
Where in the bone is the fracture?
What is the fracture pattern?
What is the degree of comminution, angulation or displacement?
How severe is the overlying soft tissue injury? Is it an open (wound in continuity with fracture) or closed (skin intact) fracture?
Is there an associated neurological or vascular injury or compartment syndrome?
Fracture patterns are often described according to their appearance on a radiograph. The pattern of a fracture may indicate the nature of the causative trauma, the stability of the fracture and can guide the best method of reduction. For example, a transverse fracture is commonly a result of an angulation force, as opposed to a twisting force, which usually leads to a spiral fracture. Greenstick fractures are exclusive to children, especially in those aged 10 years or younger. The soft and relatively flexible bones characteristically bend and crack, similar to the branches of a young tree.
In terms of displacement, this commonly occurs following a complete fracture of the bone due to the force of the injury, gravity or the pull of muscles attached to it. Displacement is described in terms of shift (usually as less than 50 % and more than 50 %). It is important to remember that displacement can occur in any plane (sagittal, coronal or transverse).
Soft tissue damage is dependent on the energy involved in the fracture. Low-energy fractures usually cause only limited soft-tissue damage, such as a closed spiral fracture. High-energy fractures such as segmented or comminuted fractures can cause severe damage, whether it is an open or closed wound. The soft tissue damage has a significant effect on fracture healing and hence it is important to comment on it when describing a fracture.
Management of Fractures Can Best Be Remembered by the three R’s
- 1.
Reduction: manipulating the fracture into a better position or reducing a dislocated joint.
- 2.
Restriction: immobillising the limb with a backslab, full cast or traction.
- 3.
Rehabilitation: exercises, physiotherapy and occupational therapy if appropriate.
Core Operations
Pre-operative Management
It is important to ascertain if there has been any previous trauma to the affected joint as this may accelerate any degenerative process. Blood tests should be performed (ESR, CRP, FBC, Us & Es, LFTs, clotting, and rheumatoid factor) to exclude infection, systemic conditions e.g. rheumatoid arthritis and systemic functioning prior to surgery. A group and save should be performed. X-rays (AP and lateral) of the joint should also be performed. A chest X-ray and ECG is useful for exclusion of other co-morbidities. Further investigations may be required which are specific to the procedure.
The four cardinal signs of osteoarthritis (OA) on x-ray are:
- 1.
Loss of joint space.
- 2.
Bone cyst formation.
- 3.
Subchondral sclerosis.
- 4.
Osteophytes.
Total Hip Replacement
Total hip replacements (THR) are usually performed when there is degeneration of the joint most commonly due to OA or rheumatoid arthritis (RA). THR’s are also being advocated in neck of femur (NOF) fracture patients who are active and medically stable. For elective patients requiring a THR, they commonly present with progressive pain in the groin, which is worse on movement. Night pain is also common and adoption of a waddling Trendelenberg gait is often seen. Advanced disease may cause significant degeneration of the joint leading to shortening of the leg.
Relevant Clinical Anatomy
Bryant’s triangle (also known as the iliofemoral triangle) quantitatively measures supratrochanteric shortening which can be an indication of degeneration at the hip. True and apparent leg length discrepancy may also be suggestive. An understanding of the bony landmarks of the greater trochanter and the hip joint in the groin is essential for a THR procedure.
Step-by-Step Summary: Total Hip Replacement
- 1.
A general anaesthetic or spinal anaesthesia with sedation is given along with broad spectrum prophylactic antibiotics.
- 2.
The patient is placed in a lateral position.
- 3.
The site is prepared and draped.
- 4.
A posterior or antero-lateral approach may be used.
- 5.
The incision is made through various layers until the bone is reached: skin, fat, fascia, tensa fascia lata, muscle, capsule and joint.
- 6.
The femoral head is dislocated from the acetabulum and removed from the femoral shaft.
- 7.
The acetabulum is reamed to create a smooth socket for the acetabular cup.
- 8.
The inside of the femur is cleared and a prosthesis is placed into its shaft.
- 9.
Implants are fixed into place cautiously using cement.
- 10.
Evaluate the leg for stability, mobility and length.
- 11.
Wash and close wound in layers.
Complications
Peri-operative:
DVT, PE, MI, CVA, pneumonia.
Leg length discrepancy.
Infection.
Bleeding.
Nerve injury.
Aseptic loosening.
Death (rare).
Peri-prosthetic fracture.
Prolonged pain and/or stiffness.
Dislocation.
Non-union and/or malunion leading to secondary OA.
Femoral head avascular necrosis and secondary OA.
Follow Up
Routine blood tests are repeated and X-rays are performed post-operatively whilst the patient is in hospital. Physiotherapy and occupational therapy are organised and the patient is seen by their GP at 2 weeks for a wound check and then at 6 weeks in the orthopaedic clinic.
Total Knee Replacement
The majority of patients having a TKR are elective patients who suffer significant, disabling pain caused by severe arthritis. They also present with progressive pain in the associated joint which is worst on movement. Night pain, the feeling of the knee ‘giving way’ and an inability to fully straighten the knee (flexion deformity) are often noted. In some cases, the bone disease is restricted to one side (most commonly the medial compartment) of the knee and other devices are also commonly used e.g. unicondylar or patella-femoral knee replacement
Relevant Clinical Anatomy
The key bony landmarks around the distal femur and proximal tibia are important to know. This includes the medial and lateral condyles of the femur and tibia as well as the tibial tuberosity anteriorly. You should also appreciate the normal position of the patella. Furthermore, a clear understanding of the important ligaments and their attachments is key. This includes the anterior and posterior cruciate ligaments and the medial and lateral collateral ligaments.
Step-by-Step Summary: Total Knee Replacement
- 1.
A general anaesthetic or spinal anaesthesia with sedation is given along with prophylactic broad spectrum antibiotics.
- 2.
The patient is placed in a supine position with the knee in flexion.
- 3.
A tourniquet is applied to allow for a bloodless field.
- 4.
The site is prepared and draped.
- 5.
Access is achieved through a medial parapatellar incision.
- 6.
Bone cuts made to the distal femur and proximal tibia perpendicular to the mechanical axis.
- 7.
Implants are selected and placed in situ and cemented.
- 8.
Wash the joint.
- 9.
Wash and close wound in layers.
Complications
Peri-operative complications (as above).
Particle debris.
Injury to the popliteal vessels and nerves.
Follow-Up
Follow-up is the same as for a THR.
Fractured Neck of Femur
Fractured neck of femur (NOF) is a common presentation with over 70,000 hip fractures occurring each year in the UK. Amongst the elderly, there is a 10 % mortality rate within 1 month and 30 % within 1 year. The need for effective emergency treatment and rehabilitation into the community is vital for subsequent management of this patient group.
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