Handbook of Orthopaedic Traumatology

HANDBOOK OF
ORTHOPAEDIC
TRAUMATOLOGY
DEPARTMENT OF ORTHOPAEDICS AND
TRAUMATOLOGY
QUEEN MARY HOSPITAL
Content
Trauma
Fracture
Principles of management of fractures----------------1
Comprehensive classification of long bone fractures
2
Principles of management of multiple trauma
6
patients
Acromioclavicular joint dislocation-------------------9
Fracture of clavicle--------------------------------------19
Fracture of scapula--------------------------------------31
Fracture of proximal humerus-------------------------41
Fracture of humeral shaft-------------------------------47
Supracondylar fracture of humerus--------------------- 49
Fracture of distal humerus------------------------------- 57
Fracture of capitellum------------------------------------ 63
Fracture of radial head----------------------------------67
Olecranon fracture--------------------------------------71
Fracture of shaft of radius and
77
ulna--------------------Galeazzi fracture------------------------------------------ 78
Monteggia fracture--------------------------------------79
Fracture of pelvis----------------------------------------81
Fracture of acetabulum---------------------------------- 101
Fracture of proximal femur------------------------------ 113
i
Fracture of femoral neck--------------------------------- 116

Intertrochanteric fracture of femur--------------------- 121
Subtrochanteric fracture of femur---------------------Fracture of femoral shaft--------------------------------Supracondylar fracture of femur-----------------------Fracture of patella---------------------------------------Fracture of tibial plateau--------------------------------Fracture of proximal and distal
tibia-------------------Fracture of tibial shaft-----------------------------------Pilon fracture---------------------------------------------Malleolar fracture---------------------------------------Fracture calcaneum--------------------------------------Dislocation
Principle of management of dislocation--------------Shoulder dislocation------------------------------------Hip dislocation--------------------------------------------
ii
125
129
131
137
145
161
165
169
173
181
191
193
201
Surgical site infection (SSI) ----------------------------
Hand
Guidelines for hand
275
219
cases-------------------------------Compound hand fractures------------------------------Phalangeal fractures-------------------------------------Fracture of distal radius---------------------------------Acute tendon injuries-------------------------------------
223
225
227
239
Others
Compartment syndrome--------------------------------Necrotizing fasciitis--------------------------------------
250
253
Procedure
Principles of closed reduction--------------------------Principles of plaster technique-------------------------Intravenous regional block-----------------------------Tourniquet usage----------------------------------------Halo traction----------------------------------------------
255
256
259
261
263
Some useful classification

Gustilo and Anderson classification for open
fracture
Tscherne and Gotzen classification for soft tissue
injury------------------------------------------------------Injury Severity Score------------------------------------Hospital Trauma Index (Extremity Injury)-----------Mangled extremity severity score (MESS) ----------iii
Drugs
Recommended pre-operative antibiotic prophylaxisUse of methypredinisolone in traumatic acute spinal
cord compression----------------------------------------Drugs for CR under sedation---------------------------Telephone directory------------------------------------
267
269
271
272
273
iv
277
281
281
282
PRINCIPLES OF MANAGEMENT OF
FRACTURES
Closed vs open #
Assessment
site of # (e.g. humerus, radius;
intra-articular vs extra-articular)
Type of fracture (e.g. spiral vs transverse;
simple vs comminuted)
Associated neurovascular injury
Other concommitant injury
Treatment
1. Reduction if necessary
2. Immobilization if necessary
3. Rehabilitation always
Principle of fracture management
COMPREHENSIVE CLASSIFICATION OF
LONG BONE FRACTURE (Muller, 1990)
Diaphyseal Fracture Type
Metaphyseal / Diaphyseal segment
A:
B:
C:
Comprehensive classification of fracture
Simple
Wedge (2 main fragments still in direct
contact)
Comminuted (no direct contact between 2
main fragments)
Metaphyseal Fracture
A:
B:
C:
Extra-articular
Partial articular (part of the articular
surface is still in continuity with the
metaphysis)
Complete articular (no continuity
between metaphysis and articular surface)
PRINCIPLES OF MANAGEMENT OF
PATIENTS WITH SEVERE AND MULTIPLE
TRAUMA
Triage
sort patients with acute life threatening injuries
and complications from those whose life are not
in danger
1.
level of consciousness
2. Abnormal breathing / breathing difficulties
3. Signs of shock
Priorities
1. Support life (eg. CPR, fluid resuscitation)
2. Locate and control bleeding
3. Prevent brainstem compression and spinal cord
damage
4. Diagnose, evaluate and treat all other injuries
and complications
Basic Management Principles
1. Emergency assessment
A--Airway obstruction (eg. noisy breathing,
respiratory distress)
B--Breathing difficulty (eg. tachypnoea, mental
confusion, cyanosis, abnormal pattern of
breathing)
C--Circulatory shock (eg. cold periphery, delayed
capillary refill, low BP, rapid weak pulse)
2. Fluid resuscitation
If necessary, 2 or 3 large 14- or 16-gauge
intravenous cannula inserted
3. Oxygen therapy
Principle of management of multiple trauma
4.
5.
6.
High flow oxygen by mask ventilatory support

Cross-match blood
Analgesia
Urine output monitoring
Foley unless suspected rupture urethra(eg. blood
at urinary meatus, severe fractured pelvis)
7. Evaluation of other injuries
Evaluation of injuries
1. Head Injury
Glascow Coma scale and Neuro-observation q1h
Inspect for presence of CSF and/or blood in ears
and nose
SXR (3 views) +/- CT Brain
2. Facial Injury
Exclude bleeding into airway and severe
oro-pharyngeal edema (eg. from caustic burn),
which may lead to airway obstruction
SMV and OMV view
3. Suspected spinal injury
Immobilize until exclusion
signs of spinal cord injury (eg. paralysis,
diaphragmatic breathing, loss of vasomotor tone,
lax anal tone)
Cervical spine fracture or dislocation need to be
excluded in all patients with head injury (Xray
cervical spine AP and lateral; lateral Xray must
include C7 / T1 junction)
4. Chest
Look for haemothorax, pneumothorax, lung
contusion, flail chest
Clinical signs + CXR
5. Abdomen
Rupture viscera (eg. spleen, liver, mensenteries)
haemoperitoneum and peritoneal sign for rupture
bowel
Retroperitoneal haemorrhage (eg,. in # pelvis)
Renal injury with retroperitoneal haemorrhage,
leading to haematuria and loin pain
Clinical signs + AXR (E & S)
6. Pelvis #
Stability of Pelvis
Look for suspected ruptured bladder and urethral
bleeding
Clinical signs + XR pelvis (AP + inlet view +
outlet view)
7. Extremities
eg. long bone fracture, associated nerve or
arterial damage
ACROMIOCLAVICULAR JONT DISLOCATION

(C. Rockwook, Fractures in Adults, 4th ed., 1342-1413, 1996)
Anatomy
Mechanism of Injury
1. Direct forcepatient falling onto the point of shoulder

with the arm at the side in an adducted position
2. Indirect forcefall on outstretched hand
Classification (Rockwood)
Type I
Sprain of AC ligament
ACJ intact
CC ligament intact
Deltoid and trapezoid muscle intact
Stabilizer
1. Acromioclavicular ligament
2. Coracoclavicular ligamentconoid part and trapezoid part
3. Dynamic stabilizerdeltoid (anterior part) and trapezius
(upper portion)
Coracoclavicular interspace1.1 to 1.3cm (Bearden,

1973)
Acromioclavicular ligamenthorizontal
(anteroposterior) stability of ACJ
Coracoclavicular ligamentvertical stability of ACJ
Acromioclavicular joint dislocation
10
Type III
Type II
ACJ disrupted
ACJ wider: may be a slight vertical separation when
compared with the normal shoulder
Sprain of CC ligament
CC interspace might be slightly increased
Deltoid and trapezius muscles intact
AC ligaments disrupted
ACJ dislocated and the shoulder complex displaced
infreriorly
CC ligaments disrupted
CC interspace 25% to 100% greater than the normal
shoulder
Deltoid nad trapezius muscles usually detached from the
distal end of the clavicle
Type II Variants
1. Pseudodislocation through intact periosteal sleeve
2. Physeal injury
3. Coracoid process fracture
17
18
Type IV
ACJ dislocated and clavicle anatomically displaced
posteriorly into or through the trapezius muscle
CC ligaments completely disrupted
CC space may be displaced, but may appear same as the
normal shoulder
Deltoid an trapezius muscles detached from the distal
clavicle
17
Type V
CC ligaments disrupted
ACJ dislocated and grossly disparity between the clavicle
and the scapula (i.e. 100% to 300% greater than
the normal shoulder)
Deltoid and trapezius muscles detached from the distal
half of the clavicle
18
Type VI
CC ligaments disrupted in subcoracoid type and intact in
subacromial type
ACJ dislocated and clavicle displaced inferior to the
acromion or coracoid process
CC interspace reversed in the subcoracoid type (i.e.
clavicle inferior to the coracoid), or decreased in the
subacromial type (i.e. clavicle inferior to the acromion)
Deltoid and trapezius muscles detached from the distal
clavicle
17
Radiographical Assessment
1. Xray both ACJ (AP)
2. Zanca view100 to 150 cephalic tilt
18
3. Axillary lateral view

4. AP stress film
To 15 pounds are suspended from each arm with wrist
wrap
Treatment
1. Non-operative treatment
Rockwood 1 and 2 (minimally displaced)
Arm sling x2./52; then, early and gradual
rehabilitation
Heavy lifting or contact sports avoided for 8 to 12
weeks
2. Operative treatment
Rockwood 3 to 6
ACJ debridement
6MM transacromial K-wires
repair of CC ligament + Tevedek

reinforcement
o
Rehabilitationpendulum exercise x 6/52; then, r/o
K-wires at 6/52
5. Lateral stress film (Alexander view)

Patient is positioned as if a true
scapulolateral radiograph is taken
Patient is asked to thrust both
shoulder forward
6. Stryker notch view

demonstrate fracture base of coracoid
17
18
FRACTURE CLAVICLE
Anatomy
Fracture clavicle
ALLAM CLASSIFICATION
GROUP 1
middle third clavicular fracture
80/5 of all clavicular fracture
Proximal fragment: pulled superiorly and

posteriorly by sternocleidomastoid
Distal fragment: drops forward as a result of gravity

and pull of pectoralis
19
20
Fracture clavicle
GROUUP II
distal third clavicular fracture
12% to 15 % of clavicular fracture
sub classified according to the location of

coracoclavicular ligaments relative to the fracture
fragments
Neers Classification (Type I to Type III)
Type I
most common
Interligamentous fracture
occurring between the conoid and trapezoid / the

coracoclavicular and acromioclavicular ligament
minimal displacement
Type II
Coracoclavicular ligaments are detached from the
medial/proximal segment
Proximal fragment: no ligamentous attachment
Distal fragment: retained ligamentous attachment
Type IIA
Both conoid and trapezoid remain intact on the

distal fragment
Type IIB
Conoid ligament ruptured while trapezoid ligament

remains attached to the distal fragment (i.e. Distal
fragment: partial ligamentous attachment)
Thus, displacement is similar to Allam Group I

fracture
Fracture clavicle
21
22
Fracture clavicle
i.e. proximal fragment: pulled superiorly and

posteriorly
distal fragment: droops forward
Type IV (Craig)
Occur in children <16 years old
pseudodislocation of ACJ
Proximal fragment: ruptures through the thin

periosteum, may be displaced upward by muscular
forces
Coracoclavicular ligaments remain attached to the

periosteum or are avulsed with a small piece of
bone
Clinically and radiologically not distinguishable

from Grade III ACJ separation and Type II# distal
clavicle
Type III
Involve the articular surface of ACJ
No ligamentous injury
No displacement
Present with late degenerative arthrosis of ACJ
Fracture clavicle
23
24
Fracture clavicle
Type V (Craig)
Comminution
Neither the proximal nor distal fragments has

functional coracoclavicular ligament
Coracoclavicular ligament are intact and remain

attached to a small, third comminuted intermediate
segment
Displacement same as Group 1 # and Type II #

distal clavicle
More unstable than type II # distal clavicle

GROUP III
# medial third of clavicle
5 % to 6% of clavicular fracture
Craig: subdivided according to the integrity of

ligamentous structures
Type I: minimal displacement
Type II: significant displacement (ligaments

ruptured)
Type III: intra-articular (sterno-clavicular joint)
Type IV: epiphyseal separation (children and

young adult)
Type V: comminuted
Mechanism of Injury
1. Direct blow to shoulder
2. Fall on outstretched hand
5Fracture clavicle
25
Associated Injury
1. Associated skeletal injuries
Fracture dislocations of sternoclavicular or

acromioclavicular joints
Head and neck injuries
Fractures of first rib (ipsilateral and contralateral)
Floating shoulder (fracture of the clavicle and

scapula)
Rockwood
Treatment directed primarily at stabilization of

clavicle
For # scapula, conservative treatment unless

grossly displaced intra-articular or fracture of
glenoid fossae
2. Pneumothorax
3. Brachial plexus injury
Considerable trauma
Force usually come from above downward or from

the front downward
Traction injury
Direct injury ( with lesion directly by bone

fragments)(in direct injury, ulnar nerve is usually
involved)
4. Vascular injury
Unusual
Major trauma required
Potential vascular injury: laceration, occlusion,

spasm, acute compression
Most common vessels injured: subclavian artery
subclavian vein, internal jugular vein
26
Fracture clavicle
On admission, House Officer must examine

1. significant skin impingement
2. neurological deficit
3. vascular status (e.g. radial pulse, capillary refill)
4. whether breath sound is symmetrical bilaterally
Treatment
Conservative Treatment
1. Figure of eight bandage
X-ray
1. X-ray clavicle (AP)
2. X-ray clavicle: 450 cephalic view
Treatment
Conservative vs operative
Non-union: failure to show clinical or radiographic

progression of healing at 4 6 months
Conservative treatment: non-union: 0.1%
Operative treatment: non-union: 4.4%

Predisposing factors to non-union
1. Inadequate immobilization
2. Severity of trauma (with associated soft tissue
damage)
3. Re-fracture
4. Distal third fracture
5. Marked displacement
6. Primary open reduction
5Fracture clavicle
Principles of non-operative treatment

1. Brace the shoulder girdle to raise the outer fragment
upward, outward and backward
2. Depress the inner fragment
3. Maintain reduction
4. Enable ipsilateral elbow and hands to be used
27
2.
Arm sling (if patient cannot tolerated figure of eight

bandage)
Immobilization should be continued until union is
complete
Usual healing period of # of middle third of clavicle
(Rowe)
Infants:
2 weeks
Children:
3 weeks
Young adults:
4 to 6 weeks
Old adults:
>6 weeks
28
Fracture clavicle
Operative Treatment (if)

1.
skin impingement
2.
open #
3.
neurovascular compromise
4.
bilateral fracture clavicle
5.
floating shoulder
6.
multiple fracture
7.
non-union
8.
cosmesis
Treatment ORIF (PC Fix/3.5mm reconstruction
plate)
5Fracture clavicle
29
30
Fracture clavicle
Posterior surface of scapula
FRACTURE OF SCAPULA
(K.P. Butters, Fractures in Adults, 4th ed., 1996)
Anatomy
Anterior surface of scapula
Fracture scapula
31
32
Fracture scapula
Fractures
1. Body and spine
2. Glenoid neck
3. Intra-articular glenoid
4. Coracoid
5. Acromion
Mechanism of Injury
1. Indirect injury
through axial loading on outstretched arm
(fracture scapula neck)
2. Direct injury
From a blow or fall (# body) (often high energy
trauma)
Direct trauma to the point of shoulder (#
acromion and coracoid)
3. Shoulder dislocation
# glenoid
4. Traction injury
avulsion #
Associated Injury ( occur in 35% to 98% of
patients with scapular #)
1. Pneumothorax (11% - 38%) (Delayed in onset
from 1 to 3 days)
2. Ipsilateral fractured ribs (27% to 54%)
3. Pulmonary contusion (11% to 54%)
4. # clavicle (23% to 39%) (associated with #
glenoid or glenoid neck)
Fracture scapula
33
34
Fracture scapula
5. Brachial plexus injury (5% to 13%) (usually

supraclavicular type)
6. Arterial injury (11%)
7. Skull # (24%)
8. Closed head injuries (20%)
9. Fracture of thoracic spine, cervical spine, lumbar
spine
Glenoid Neck # (extra-articular)

1. Stable #
isolated glenoid neck #
conservative treatment
Xray Assessment
1. True AP view of shoulder
2. Transcapular view
3. Axillary lateral viewhow acromial and glenoid
rim #
4. Stryker notch view or cephalic tilt view--show
coracoid fracture
2. Unstable #
# glenoid neck associated with # clavicle or
disruption of coracoclavicular ligament
ORIF of # clavicle
Scapular body and spine #

examine for associated injury
conservative treatmenty with arm sling for
comfort and early mobilization exercise
Fracture scapula
35
36
Fracture scapula
Type I #
fracture of glenoid rim
> 25 % of intra-articular involvement
If displaced, predispose to instability of
gleno-humeral joint
1. Type IA
anterior type
ORIF
2. Type IB
posterior type
uncommon
Intra-articular Glenoid Fracture

Ideberg Classification
(Ideberg, Acta Orthop. Scand., 58:191-192, 1987)
Type II #
transverse or oblique fracture through the
glenoid with inferior glenoid as a free fragment
humeral head may subluxate inferiorly
If humeral subluxate
ORIF
Type III #
upper third of glenoid and includes coracoid
process
often accompanied by # acromion or clavicle or
acromioclavicular separation
(Gross, 1995) If intra-articular step > 5mm,
ORIF
Fracture scapula
37
38
Fracture scapula
radiologically (AP shoulder) a normal and

symmetric coracoclavicular distance
suspect # coracoid (base or through an epiphyseal
line)
Stryker notch view
if # coracoid process + ACJ separation
ORIF
Type IV #
horizontal glenoid # extending all the way
through the body to the vertebral border
if displaced, ORIF
Type V #
type II + type IV
If humeral head is well centred
Type VI #
badly comminuted #
conservative treatment with early motion
Acromion #
usually minimal displacement
DDx--os acromiale
1. If undisplaced
2. If displaced with subacromial space and
upward movement of humeral head
investigate rotator cuff lesion
Coracoid #
may occur with acromioclavicular dislocation
with coracoclavicular ligaments intact
clinical evidence of third degree
acromioclavicular separation with a high-riding
clavicle
BUT
Fracture scapula
39
40
Fracture scapula
FRACTURE OF PROXIMAL HUMERUS

(J. Schatzker, The Rationale of Operative Fracture
Care, 2nd ed., 1995, 51-82)
Anatomy
Four major fragments
1. Humeral head superior to anatomical neck
2. Lesser tuberosity
3. Greater tuberosity
4. Shaft of humerus
Unstable Fracture
movement between
the shaft and head
fragments
resulted from tension
or shear force
Stable vs Unstable Fracture

Stable Fracture
Impacted fracture
Shaft and head
moves as one piece
resulted from
compression force
Fracture proximal humerus
41
42
CLASSIFICATION OF FRACTURE TYPE

1. Stable Fracture
2. Unstable Fracture
A. Minimally displaced
(i. No segment displaced > 10 mm)
(ii.No segment angulated > 45 )
B Displaced
(C.S. Neer, JBJS, 52A: 1077-1089)
1. Two-part
a. Lesser tuberosity
b. Greater tuberosity
c. Surgical neck
d. Anatomical neck
2. Three-part--Surgical Neck
a. Plus Lesser tuberosity
b. Plus Greater tuberosity
3. Four-part--Anatomical Neck
Plus tuberosities
4. Fracture-dislocation
a. Two-part--with greater tuberosity
b. Three-part--Anterior, with greater
tuberosity
Posterior, with lesser
tuberosity
c. Four-partAnterior & Posterior
3. Articular
a. Head impaction(Hill Sachs)
b. Articular fractures
1. Humeral head split
2. Glenoid rim
43
44
TREATMENT
1. Stable Fracture
Early motion
2. Unstable, Minimally displaced Fracture
Collar and cuff x 3 weeks
then mobilization
3. 2-Part # (Displaced Unstable Fracture
Surgical Neck, Displaced Greater Tuberoisty)
& 3-Part #
CR + Percutaneous K-wire
If fail, OR + suture / wire
4. Fracture Anatomical Neck / Head Split /
4-Part #
Neers Hemiarthroplasty
45
46
FRACTURE OF THE HUMERAL SHAFT

most fractures can be treated successfully by
closed method
Acceptable alignment
1. < 20 angulation
2. > 50% bony overlap
To assess
Neurological function (esp. radial nerve)
Vascular condition
FRACTURES WITH ACCEPTABLE
ALIGNMENT
U-slab x 3 weeks; then, functional brace
Check Xray humerus (AP + lat) after application
of U-stab
FRACTURES WITH UNACCEPTABLE
ALIGNMENT
Attempt CR under sedation
U-slab x 3 weeks
Check for function of radial nerve after CR
Post-reduction Xray humerus to confirm
alignment
Fracture shaft of humerus
47
FRACTURES REQUIRING OPERATIVE

INTERVENTION
1. Fracture with unacceptable alignment despite
repeated CR (either due to failure to obtain a
satisfactory reduction or failure to maintain
reduction)
2. Open fracture
3. Comminuted / unstable fracture
4. Multiple fractures
5. Pathological fracture
6. Nerve palsy after manipulation
7. Humeral fracture with asssociated vascular
lesion
METHOD OF FIXATION
1. Proximal and Middle 1/3
Retrograde AO unreamed humeral nail
2. Distal 1/3
ORIF (plating)
3. Open #
AO nail / External fixator
48
Fracture shaft of humerus
SUPRACONDYLAR FRACTURE OF HUMERUS

(J. Schaztker, The Rationale of Operative Fracture
Treatment, 2nd ed., 1995, 103-111)
Anatomy
Supracondylar fracture of humerus
49
1. Articular Surface
Capitellum
covered by articular cartilage on its anterior
and inferior surface (not posterior)
articulate with radial head
Elbow in flexion: radial head articulate with
anterior surface of capitellum
Elbow in extension: radial head articulates
with inferior surface of capitellum
Trochlea
covered completely with articular cartilage
articulates with the trochlear notch of ulna
Elbow in Flexion
trochlear notch of ulna articulate with the
anterior aspect of trochlea
coronoid process of ulna rests in coronoid
fossa of humerus
radial head rests in radial fossa of humerus
Elbow in Extension
ulna articulates with inferior and posterior
aspect of trochlea
tip of olecranon lodges within the olecranon
fossa of humerus
Trochlea: corresponds the physiological
valgus tendency of elbow in full extension (ie.
Carrying angle, 170 )
50
2. At the level of olecranon fossa, the two columns of

bone on either side of the fossa
bone for fixation of implants
3. Longitudinal axis of lateral condyle makes a 60 angle
with the longitudinal axis of the shaft
reconstruction plate applied to the level of lateral
condyle must be bend to angle forward
Otherwise, extension deformity of distal fragment will
result
CLASSIFICATION
Riseborough and Radin Classification
(E.J. Riseborough and EL Radin, JBJS, 51A:130-141)
Type I
Non-displaced fracture
between capitellum and
trochlea
Type III
Separation of
the fragments
with rotational
deformity
Type IV
Severe
comminution
of the articular
surface with
wide separation
of the humeral
condyles
Type II
Separation of capitellum
and trochlea without
appreciable rotation of the
fragments in frontal plane
51
52
Comprehensive Classification
Mechanism of Injury
fall on the point of elbow
P/E
1. Closed vs Open
2. Associated vascular injury (Feel for radial pulse)
3. Associated compartment syndrome
4. Associated neurological complications
5. Associated fracture of humerus or radius and ulna
6. Concomitant injury
Aim of treatment
1. Accurate anatomical reduction of joint surfaces
2. Stable internal fixation
3. Early active motion
Recommended Treatment
1. Undisplaced
Conservative
2. Displaced and intra-articular
ORIF (+ olecranon osteotomy if intraarticular)
53
54
Immediate management
1. Exclude need for emergency operation (eg. open #,
associated vascular injury)
2. Long arm backslab for temporary immobilization
3. Elevation
Factors which influence success of surgical treatment
1. Patients age and degree of osteoporosis
2. Type of #
3. Degree of displacement
4. Degree of joint comminution
5. Whether trochlea can be reconstructed
6. If trochlea can be reconstructed
ORIF
7. If trochlea is beyond surgical reconstruction
conservative treatment (traction with early
mobilization); or
total elbow replacement (in active elderly
patients)
Rehabilitation
1. CPM
2. Indomethacin x 1/12
3. Hinged elbow brace
55
56
FRACTURE OF DISTAL END OF HUMERUS

Anatomy
FRACTURE OF EPICONDYLE
Treatment, 2nd ed., 1995, 95-97)
Fracture of Lateral Epicondyle
avulsion #
Adult
Rare
associated with posterolateral or posterior
dislocation of elbow(may be associated with #
medial epiconyle)
Children
lateral epicondyle is avulsed with varying
portion of capitellum
may turn no itself by 180
risk of non-union and deformity
When elbow is reduced, epicondylar fragment reduces
and heals in place
Prognosis: good
Fracture distal humerus
57
Fracture of Medial Epiconyle

most common in children
may be seen in adult
1. Direct injury
2. Avulsion
Treatment
1. Small and undisplaced
2. Displaced
ORIF to prevent ulnar nerve palsy
ORIF {4.0mm cancellous screw
{medial approach
{ulnar nerve protected +/- anterior
transposition
Prognosis: good
58
Fracture of Lateral Condyle
FRACTURE OF CONDYLES
(R.N. Hotchkiss, Fracture in Adults, 4th ed., 1996,
953-958)
capitellotrochlear sulcus divides the capitellar and

trochlear articular surfaces
lateral trochlear ridge: key to analyse humeral
condyle #
Milch Classification
(H. Milch, JAMA, 160: 529-539, 1956)
1. Type I #
lateral trochlear ridge remains with the intact condyle
elbow stable (medial to lateral)
2. Type II #
lateral trochlear ridge is involved in the fractured
condyle
elbow unstable (medial to lateral)
59
1. Type I #
lateral trochlear ridge remains intact
preventing dislocation of radius and ulna
2. Type II #
lateral trochlear ridge is a part of the fractured lateral
condyle
If + medial capsuloligamentous disruption
radius and ulna may dislocate
always extends medially and involve part of the
trochlea
Treatment
ORIF, then early mobilization
Lateral approach, 2 x 3.5mm cancellous screws
Prognosis
good
60
Fracture of Medial Condyle
1. Type I #
Lateral trochlear ridge intact
elbow stable
2. Type II #
lateral trochlear ridge is a part of fractured medial
condyle
If + lateral capsuloligamentous disruption
radius and ulna may dislocate medially on
humerus
Treatment
ORIF, then early mobilization
61
62
FRACTURE OF CAPITELLUM
(J. Schatzker, The Rationale of Operative Fracture Care,
2nd ed., 1995, 97-102)
Anatomy
smooth, rounded, knob-like portion of lateral condyle
of humerus
covered with articular surface only on anterior and
inferior surface (but not on posterior surface)
Elbow in Flexion
Head of radius articulated with the anterior surface of
capitellum (radial fossa, a depression on anterior
humerus just above the capitellum, accomodates the
margin of radial head when the elbow is acutely
flexed. Thus, radial fossa must be cleared of all #
fragments for the elbow to regain a FROM)
Elbow in Extension
Radial head articulates with the inferior surface of
capitellum
Always displaced antero-superiorly into the radial

fossa
limit elbow flexion
Occasionally, displaced posteriorly
limit elbow extension
Classification
Type I (Hahn-Steinthal) Capitellar #
Type II (Kocher-Lorenz) Capitellar #
1. Isolated injury
2. Part of comminuted supracondylar fracture
Isolated Injury
Mechanism
1. As the head of radius is forcibly driven against the
capitellum with the elbow in flexion
2. Direct blow to elbow when it is fully flexed
Becomes a free intra-articular osteochondral body
Fracture capitellum
63
64
Fracture capitellum
closed manipulation always fail
attempts at internal fixation five poor results
If the fragment is small
excision
If the fragment is sufficient large to allow stable
fixation
ORIF
1. Lateral approach
posterior fixation
capitellum held in place with a small hook; then,
provisionally fixed with K-wire; then,
3.5 mm cancellous screw from back to front
2. Fix the capitellum transarticularly

(head of screw must be countersunk below the level of
articular cartilage)
Fracture capitellum
65
66
Fracture capitellum
FRACTURE OF RADIAL HEAD

(J. Schtazker, The Rationale of Operative Fracture Care,
2nd ed., 121-125)
Aim
preservation of elbow flexion and extension,
pronation and supination of forearm
Mechanism of injury
Fall on outstretched hand(majority)
(may be associated with # capitellum)
Valgus force to elbow(occasionally)
(may be associated with fracture olecranon and torn
medial collateral ligament of elbow elbow
instability)
Treatment
Early active mobilization as pain allow
Otherwise,
1. OR + Bone wedge elevation + mini-screw; or
2. Radial head excision and spacer (if elbow is unstable)
Type I #
simple split wedge #
displaced vs undisplaced
Treatment
OR + lag screw
Permanent loss of motion

1. Bony block(due to displaced piece of bone)
Treatment: removal of block
confirm bony block by infiltration of the joint with 2%
lignocaine and test motion
2. Capsular and pericapsular scarring
Prevention: early mobilization
Conservative treatment
1. Displacement < 2mm
2. Fragment < 1/3 of radial head
3. In comminuted #, no associated elbow dislocation
4. No bony block
Fracture radial head
67
Type II #
impaction #
part of the head and neck remain intact
68
(usually the medial portion is intact because the injury

is usually the result of a valgus force with forearm in
supination)
variable comminution
Treatment
OR + Bone wedge elevation + mini-screws
69
Type III #
severely comminuted #
no portion of head and neck is in continuity
severe comminution
may be associated with torn medial collateral ligament
of elbow and fracture olecranon
1. If possible(esp. young patient)
OR + Bone wedge elevation + mini-screws

2. If irreconstructable,
excision of radial head (except with elbow
dislocation)
excision + prosthetic replacement (if elbow is
unstable)
70
OLECRANON FRACTURE
Treatment, 2nd ed., 1995, 113-119)
Fracture of olecranon with displacement
disruption of triceps mechanism
loss of active extension of elbow
CLASSIFICATION
Intra-articular Fracture
1. Simple Transverse Fracture
Assesment and Initial Management

1. Xray
Simple # vs comminuted #
Undisplaced vs displaced
2. For undisplaced fracture
test for ability to actively extend elbow against gravity
3. Long arm backslab for displaced fracture or with loss
of extensor mechanism
4. Elevation
Mechanism of injury
avulsion fracture and results from a sudden pull of
both the triceps and brachialis muscle
Direct fall on olecranon
Treatment
OR + TBW + K-wires
2. Complex Transverse #
1. Minimally displaced with intact extensor mechanism
Free mobilization
2. Displaced # +/- Ipsilateral elbow dislocation
ORIF
Olecranon fracture
71
Mechanism of injury
Direct force, such as a fall
comminution and depression of articular surface
Treatment
TBW + K-wire / Plate (in severe comminution) +/bone grafting
72
Olecranon fracture
3. Oblique #
Mechanism of injury
hyperextension injury of elbow
begins at the mid-point of trochlear notch and runs
distally
Treatment
OR + Lag screw(at right angle to the # line) + TBW
+/- K-wire
4. Comminuted # with associated injury
Mechanism of injury
high velocity direct injury to elbow, eg. with a
considerable fall directing on elbow
# lines are variable
Treatment
OR + Plate (3.5mm DCP) +/- bone grafting
certain features needed to be distinguished
a. Fracture involving coronoid process
Small fragment
unimportant
If the fragment is large
instability of elbow in extension
Olecranon fracture
73
Treatment
OR + Lag screw(to coronoid process) + plate +/- BG
b. Distal extent of fracture
if fracture extends distally past the midpoint of the
trochlear notch
disruption of triceps mechanism
compromise the stability of elbow in withstanding
varus or valgus force
Treatment
OR + lag screw + plate (3.5 mm DCP)
74
Olecranon fracture
c. Fracture or Dislocation of Radial head

associated with disruption of medial collateral
ligament
Treatment
ORIF of # (TBW + K-wires)
Repair of ligament
Radial head is reduced and fixed or replaced
by a prosthesis
Olecranon fracture
75
76
Olecranon fracture
Type III #
lateral or anterolateral dislocation of radial head +
fracture of ulnar metaphysis
MONTEGGIA FRACTURE
(R.R. Richards, Fracture in Adults, 4th ed., 1996,
914-925)
Fracture shaft of ulna + dislocation of radial head
< 5% of an forearm fracture
Bados Classification
(J.L. Bado, Clin. Orthop., 50: 71-86, 1967)
Type I (most common)
anterior dislocation of radial head + anterior angulated
fracture of ulna shaft
Type IV # (rare)
anterior dislocation of radial head + fracture of
proximal one third of both radius and ulna
Type II #
posterior dislocation of radial head + posterior
angulated fracture of ulna shaft
For Monteggia #,
must look for neurological injury, esp. radial nerve
(PIN), ulnar nerve injury has also been reported
Monteggia fracture
79
80
Monteggia fracture
FRACTURE OF SHAFTS OF RADIUS AND ULNA

Aim of Treatment
1. Anatomical reduction
2. Stable fixation
fracture of radius (junction of middle third and distal

third) + Dislocation / Subluxation of distal radio-ulnar
joint
Dislocation of DRUJ may occur at
1. initial injury
2. progressively during conservative treatment
Treatment must include reduction of DRUJ
Patients requiring operative treatment

1. All displaced #
2. Monteggia fracture and Galeazzi # with persistent
subluxed / dislocated proximal / distal radio-ulnar
joint
On admission
1. make sure Xray whole forearm(including both elbow
and wrist joint) is well taken(to rule out Monteggia
and Galeazzi #)
2. For undisplaced #
long arm pop
3. For displaced #
long arm backslab for temporary immobilization; and
work-up for OT
Operative Choice
1. Closed #
ORIF (PC Fix / LCDCP)
2. Open #
ORIF vs External Fixator
GALEAZZI FRACTURE
Fracture shaft of radius and ulna
77
78
Galezzi fracture
PELVIC FRACTURE
On admission
1. Follow principle of management of patients with
severe trauma
2. Assessment
Haemodynamic condition
Associated potential life threatening injuries (esp. in
high enery trauma, eg. severe RTA, fell from height,
etc)
eg. Head injuries
Cervical spine injuries
Chest injuries (eg. haemothorax,
pneumothorax)
Abdominal injuries (eg. haemoperitoneum,
torn abdominal viscera)
Torn vessels
3. Other associated injuries
eg. ruptured bladder
ruptured urethra
ruptured pelvic organ (eg. vagina, rectum)
peripheral nerve injuries
4. Fracture pelvis
Type and stability
Close vs open
5. Other associated muscoloskeletal injuries
Fracture pelvis
81
Haemodynamic instability due to

1. Bleeding from fracture site
Pelvis fracture: 1500 - 2000 ml
Fracture femur: 1000 ml
2. Torn pelvic vessels (arterial or veins), with
retroperitoneal haemorrhage
3. Other injuries(eg. rupture abdominal viscera,
haemothorax, etc)
For patients with haemodynamic instability / Associated
life threatening condition
1. NPO
2. Start Fluid resuscitation, as indicated
3. Start oxygen therapy (high flow oxygen +/intubation)
4. Insert 2 large bore iv line +/- CVP
5. Foley to BSB (uless suspect urethral injury)
6. Blood x cross-match
7. Routine blood test
8. Must examine patients neurology(to r/o severe head
injury and spinal injury), chest (for pneumothorax,
haemothorax) and abdomen (for haemoperitoneum )
9. Analgesics
82
Fracture pelvis
PELVIC FRACTURE
(M. Tiles, The Rationale of Operative Fracture Care, 2nd
ed., 1995, 221-270)
Anatomy
Pelvic ring
3 bones
Sacrum + 2 inominate bones (each consists of
ilium, ischium and pubis)
Stability
ability of pelvis to withstand physiological
force without significant displacement
depends mainly on surrounding soft tissues
1. Symphysis pubis
2. Posterior sacroiliac complex
3. Pelvic floor
Fracture pelvis
83
84
Fracture pelvis
SACROILIAC COMPLEX
Posterior sacroiliac complex(work like a suspension
bridge)
transfer weight bearing forces from the spine to the
lower extremities
1. Posterior sacroiliac interosseous ligaments
(strongest ligament in the whole body)
(maintain sacrum in position with pelvic ring)
2. Iliolumbar ligament
(from transverse process of L5 to iliac crest)
3. Interosseous ligament
PELVIC FLOOR
muscular layer covered by investing fascia
contains 2 major ligaments: sacrospinous ligament
and sacrotuberous ligament
1. Sacrospinous ligament
resists external rotation of the pelvis
2. Sacrotuber
ous
ligament
resists
vertical
shearing
force
Anterior sacroiliac ligament

resists external rotation and shearing force
Fracture pelvis
85
86
Fracture pelvis
TYPES OF INJURIES FORCE

1. External rotation force
2. Internal rotation force (lateral compression force)
3. Vertical shearing force
4. Complex force (as in high energy trauma)
External rotation force ( open book injury)

symphysis pubis disrupts
sacrospinous ligament and anterior sacroiliac
ligament open
impingement of the posterior ilium on sacrum
External Rotation Force

1. Direct blow to the PSIS
Internal Rotation Force (Lateral Compression)

1. Direct blow to iliac crest
upward rotation of the hemipelvis (bucket handle
injury)
2. Forced external rotation through hip joints unilaterally

or bilaterally
1. Through the femoral head, by a direct force against the

greater trochanter, often causing an ipsilateral injury
Internal rotation force / lateral compression
Fracture pelvis
89
90
Fracture pelvis
anterior structures, usually the rami, break and then

hemipelvis rotates internally
If the posterior ligament remain intact
anterior sacrum will compress
If the posterior ligament is torn,
stability is maintained by pelvic floor
1. External rotation and Vertical Shear force

Tearing of viscera and arteries
Traction injuries to nerves
2. Internal rotation
puncture viscera
compress nerve
Vertical Shearing Force

Vertical shearing force
marked displacement of bone gross disruption of soft
tissue structures
unstable pelvic ring with major anterior and posterior
displacement
CLASSIFICATION
Type A
Stable #
pelvic ring not displaced
Type B
Partially stable
retain posterior stability
cannot translate vertically ie. stable in vertical plane
1. Open book injury (external rotation force)
(Unstable in external rotation)
2. Lateral compression injury(internal rotation)
either unstable in internal rotation; or
rigidly impacted
Type C
Unstable
complete disruption of posterior arch, pelvic floor and
usually the anterior arch
Type A + B : 70 %
Type C : 30 %
Effects of Force on Soft Tissue
Fracture pelvis
89
90
Fracture pelvis
TYPE A--STABLE FRACTURES

pelvic ring is stable and cannot be disrupted by
physiological force
Type A1
avulsion # of innominate bone
not involve pelvic ring
usually in adolescent
Type A2
involve the iliac ring; or
anterir arch
no posterior injury
rare
Type A3
transverse # sacrum and coccyx
CLASSIFICATION OF PELVIC RING

DISRUPTION
Type A: Stable pelvic ring injury
A1: Avulsion of the innominate bone
A2: Stable iliac wing fracture or stable
minimally displaced ring fracture
A3: Transverse fractures of the sacrum and
coccyx
Type B: Partially stable
B1: Open book injury
B2: Lateral compression injury
B2.1: Ipsilateral type
B2.2: Contralateral type (buckethandle)
B3: Bilateral B injuries
TYPE B--PARTIALLY STABLE FRACTURE

Open Book Fracture (External Rotation)
First stage
disruption of symphysis pubis(< 2.5cm opening of
symphysis pubis)
Type C: Unstable (vertical shear)

C1: Unilateral
C1.1: Ilium
C1.2: Sacroiliac dislocation or fracture
dislocation
C1.3: Sacrum
C2: Bilateral, one side B, one side C
C3: Bilateral C lesions
Fracture pelvis
91
92
Fracture pelvis
Second stage
continuation of external rotation force will tear the
sacrospinous ligament and anterior sacroiliac
ligament
Signified by
1. Opening of pubis symphysis > 2.5cm
2. Avulsion fracture fo ischial spine
Lateral Compression Fracture (Internal Rotation)

Ipsilateral Injury
anterior and posterior lesion on the same side
direct blow to greater trochanter
superior and inferior pubic rami break + crush at
anterior part of SIJ
posterior ligamentous structures are intact
possible rupture of bladder +/- blood vessels
elastic recoil
strong posterior sacroiliac ligament remain intact(

stable in vertical force)
Third stage
external rotation force go beyond the yield point of
posterior ligament
posterior complex ruptures
unstable Type C # now (avulsion fracture of L 5
transverse process)
Fracture pelvis
93
94
Fracture pelvis
Contralateral Injury (Bucket-handle injury)

anterior fracture on the opposite side of posterior
lesion
(or all four rami may fracture anteriorly but the
anterior displacement is on the side opposite the
posterior lesion)
usually has major leg length discrepency (shortening
of the side of posterior lesion because of marked
internal rotation of hemipelvis)
posterior structures are firmly impacted
reduction require derotation of hemipelvis rather than
pure vertical traction
complete disruption of posterior sacroiliac arch +

rupture of pelvic floor(including the sacrospinous and
sacrotuberous ligaments)
Radiographic signs of Instability

1. Avulsion fracture of the transverse process of L5
vertebrae
(indicating rupture of ilio-lumbar ligament)
2. Avulsion fracture of ischial spine or avulsion of sacral
attachment of sacrospinous ligament (indicating
rupture of ischiospinous ligament)
3. > 1cm posterior or vertical translation
MANAGEMENT FO PELVIC #
Depends on
1. Personality of injury
2. Associated injuries
Management
Assessment
Resuscitation
Provisional stabilization
Definite stabilization
TYPE C--UNSTABLE FRACTURE
Fracture pelvis
95
96
Fracture pelvis
ASSESSMENT
General assessment
general assessment and management of a
polytraumatised patient
Specific Musculoskeletal assessment
Aim: Determine the stability of pelvic ring
Clinical Assessment
1. History
High-energy injury(eg.RTA, fell from height) vs
low-energy injury
2. P/E
Major bruising or bleeding from urethral meatus,
vagina, rectum (may signify an open fracture)
Rotatory deformity or limb shortening (may imply
unstable pelvic injury)
Test pelvic stability
apply both hands to ASIS and move the affected
hemi-pelvis (external rotation vs internal rotation)
apply one hand to the pelvic iliac crest and using
the other to apply traction to the leg (displacement
in vertical plane)
Radiological Assessment
Plain Xray
Xray pelvis (AP)
Xray Pelvis (inlet view)
direct Xray beam 60 from head to midpelvis
demonstrate posterior displacement
Xray pelvis (outlet view)
Fracture pelvis
97
Xray beam from the foot of patient to the

symphysis at an angle of 45
demonstrate superior or inferior migration
CT scan
Diagnosis of Pelvic Stability

1. Type C (Completely unstable)
Clinically, lack of a firm end-point in rotation or
traction
Radiologically,
displacement / gap (vertical displacement or
antero-posterior displacement)on Xray or CT >
1cm
Avulsion # of ischial spine or sacrum
2. Type B (Partially stable)
Clinically, firm end-point on palpation
98
Fracture pelvis
RESUSCITATION
Pelvic # hamorrhage (arterial, venous, bony)
Risk in unstable # > stable #
1. Massive fluid replacement, as indicated
2. Pneumatic antishock garment
3. Application of anterior external frame / Pelvic C
Clamp
in hypotensive patients / unstable #
pelvic volume
tamponade effect
help to stop venous and bony bleeding
4. Embolization of pelvic vessels
usually only help to control bleeding from a
small-bore artery
Small-bore artery bleeding may be asssumed if,
although the patient can be well controlled using the
above methods of fluid replacement, PASG, an
fracture stabilization, he or she goes into a shocked
state each time the fluid is slow down
5. Direct surgical control
rarely indicated and usually unsuccessful
PROVISIONAL STABILIZATION
Provisional stabilization by Anterior External Fixator
/ Pelvic C Clamp
Indications
those fractures with potential increase in pelvic
volume and patients with unstable haemodyname
condition
Wide open book injury (B1, B3)
Unstable pelvic fracture C
rarely required for lateral compression injuries (B2)
Fracture pelvis
99
Anterior External Fixator

2 pins percutaneously place in each ilium, at
approximately 45 to each other
one pin in ASIS
one in iliac tubercle
joined by an anterior rectangular configuration
Pelvic C Clamp
point of entry
4 finger breadth from PSIS on a line joining ASIS and
PSIS
Provisional stabilization with Skeletal traction
for patient with no haemodynamic instability
temporary skeletal traction pin in distal femur
5 - 20 kg of traction to prevent hemipelvis from
shortening
100
Fracture pelvis
ACETABULAR FRACTURE
(M. Tile, The Rationale of Operative Fracture
Treatment, 2nd ed., 1995, 271-324)
Aim of Treatment
anatomical reduction of hip joint without
operative complication
Major factors affecting prognosis
1. Degree of initial displacement
2. Damage to superior weight bearing surface of
acetabulum or femoral head
3. Degree of joint instability caused by posterior
wall fracture
4. Adequacy of reduction, either open or closed
5. Late complications
AVN of femoral head
Heterotropic ossification
Chondrolysis
Sciatic or femoral nerve injury
Anatomy
Fracture acetabulum
101
Mechanism of injury
pathological anatomy of the fracture depends on
the position of the femoral head at the moment of
impact
1. External rotation
of hip
anterior column #
2. Internal rotation
of hip
posterior column
#
3. Abduction of hip
Low transverse #
4. Adduction of hip
high transverse #
1. Direct blow on the acetabulum / upon the greater
trochanter
usually a transverse acetabular #
2. Dashboard injury (Flexed knee joint strikes the
dashboard of a motor vehicle, driving the femur
posteriorly on the acetabulum)
posterior wall or posterior column fracture or
fracture dislocation of hip joint
102
Fracture acetabulum
ASSESSMENT
Follow principles of assessment of polytrauma
patient
Specific assessment of # acetabulum
Xray pelvis (AP)
Important landmarks
1. iliopectineal line
denoting limit of anterior column
2. ilioischial line
denoting limit of posterior column
3. Anterior lip of acetabulum
4. Posterior lip of acetabulum
5. Tear drop
6. Superior dome
Fracture acetabulum
103
Iliac oblique view

45 external rotation of the affected pelvis
by elevating the uninjuried side on a wedge foam
Landmarks
1. best depicits the extent of posterior column
2. anterior lip of acetabulum
3. entire iliac crest
104
Fracture acetabulum
Obturator Oblique View

45 internal rotation of the affected hemipelvis
by placing a foam wedge under the affected hip
Landmarks
1. best shows the anterior column
2. posterior lip of acetabulum
3. best show displacement of iliac wing in the
coronal plane (because iliac crest is seen
perpendicular to its normal plane)
Classification
acetabulum consists
of 4 basic
anatomical areas
1. Anterior column
2. Posterior column
3. Anterior wall of lip
4. Posterior wall of lip
Fracture Types
1. Isolated Anterior
Column fractures
2. Isolated Posterior
Column fractures
3. Combined anterior
column and anterior
lip fracture
4. Combined posterior
column and
posterior lip
fracture
5. Transverse fracture
both anterior and posterior columns are broken
Fracture acetabulum
105
106
Fracture acetabulum
surface of the acetabulum remain attached to the

acetabulum
6. T Fracture
both columns are
broken and
separated from
each other
both transverse or
T fracture may be
associated with an
anterior or
posterior lip #
Transverse / T
fracture, a portion
of acetabular
dome is always
attached to the intact ilium
7. Both Column Fractures
both anterior and
posterior columns
are fractured and
separated from
each other
but the fracture in
the columns is
proximal to the
acetabulum in the
ilium
true floating
acetabulum
no portion of the
weight-bearing
Fracture acetabulum
Management (Depends on)

1. Fracture factor
2. Patients factor (age and bone quality, general
medical status, associated injuries)
Fracture factor
Non-operative management if
Hip stable and Congrous
Undisplaced fractures (all types)
require no skeletal traction
Minimally displaced # (displacement < 2mm)
Low anterior column # (# not involve major weight
bearing area)
Low transverse #
through the
acetabular
fossa area
(infratectal)
skeletal
traction
Low transverse
# (infratectal)
main portion of
the weight
bearing dome is intact
107
108
Fracture acetabulum
medial portion of the dome act as a buttress to the

femoral head, preventing redisplacement
c.f. High transverse

# (Supratectal,
tanstectal)
divides the
mid-portion of the
superior
weight-bearing
dome
medial fragment
remains displaced
and the femoral
head is congrous with that portion rather than the
dome portion
Both column fractures without major posterior
column displacement
true floating acetabulum
no portion of the weight bearing dome attached
to the axial skeleton
exhibit secondary congruence (Letournel, 1980)
skeletal traction
Fracture acetabulum
109
Operative management
indicated for unstable and/or incongruous hip
joint
Instability
hip dislocation associated with
1. Posterior wall or column displacement (posterior
instability)
2. Anterior wall or column displacement (anterior
instability)
Incongruity
1. Fractures through the roof of the dome
displaced dome fragement
High transverse or T types # (transtectal)
Both-column types with incongruity (displaced
posterior column)
2. Retained bone fragments
3. Displaced fractures of femoral head
4. Soft tissue interposition (usually posterior
capsule)
Other operative indications
1. development of a sciatic or femoral nerve palsy
after reduction of the acetabular # (possible
entrapment of the nerve)
2. Presence of a femoral artery injury associated
with an anterior column fracture of the
acetabulum
110
Fracture acetabulum
3. Fracture of the ipsilateral femur / disruption of

ipsilateral knee, which makes closed treatment of
acetabulum virtually impossible
Fracture acetabulum
111
112
Fracture acetabulum
FRACTURE OF PROXIMAL FEMUR

*For patients < 60 years old presenting with acute
intracapsular fracture neck of femur (both displaced
and undisplaced), need EOT x CR + IF (AO screw)
Care, 2nd ed., 1995, 323-340)
Anatomy
Neck shaft angle: 125 - 135
Blood Supply of Femoral Head

1. Via retinacular vessels in the posterior capsule of
hip joint
Common femoral artery
medial circumflex femoral artery
posterior superior retinacular vessels and
posterior inferior retinacular vessels
posterior superior retinacular artery gives rise
to lateral superior epiphyseal vessels
Femoral artery
(Lateral femoral circumflex artery
anterior retinacular vessels
not contribute to blood supply of head
Fracture proximal part of femur
113
114
2. Via ligamentous teres (supply a small portion of

head close to their site of entry)
3. Intraosseous blood supply
Attachment of capsule of hip joint
1. Front
along the intertrochanteric line
2. Back
attach to the neck only halfway to the
intertrochanteric crest
115
Fracture Proximal Part of Femur

1. Intracapsular
Subcapital # neck of femur
Transcervical # neck of femur
In these fractures, capsule may be torn
blood supply of femoral head is at risk
2. Extracapsular
Fracture basal neck of femur
Intertrochanteric fracture of femur
Subtrochanteric fracture of femur
In these fractures, capsule is intact
Femoral head is not at risk of AVN
Intracapsular Fracture Neck of Femur
Garden Classification (1964)
use the relationship of medial trabeculae
(compression trabeculae) in the head and pelvis
as an index of displacement
undisplaced # (Garden I and II) vs displaced #
(Garden III and IV)
1. Undisplaced Fracture
capsule is less likely to be injuried
lower incidence of AVN
2. Displaced Fracture
capsule is likely to be torn
higher incidence of AVN and higher
incidence of failure of fixation and nonunion
116
Fracture neck of femur
Garden I
head impacted in
valgus
Garden IV
completely
displaced #
Garden II
undisplaced #
History
simple fall with pain over groin +/- inability to
walk
P/E
R/O concomittant injury (eg. head injury, # distal
radius)
Affected leg shortened and externally rotated
Pain on manipulation of the affected leg
Garden III
partially displaced
#
Treatment
1. For all young patients (< 60 years) with
intracapsular fracture neck of femur (both
displaced and undisplaced #)
need EOT x CR + IF
2. For patients > 60 years
for elective OT uless medically unfit
Undisplaced intracapsular Fracture (Garden I
and II)
AO screws +/- AMA
117
118
Displaced intracapsular fracture (Garden III

and IV)
AMA / Cemented Thompson
CR of intracapsular fracture neck of femur

Femoral head usually displaces into varus and
retroversion
femoral shaft externally rotates
Methods of CR (under Image Intensifier)
1. Longitudinal traction (bring the head out of varus
position)
2. Gentle internal rotation of the limb (correct
retroversion)
Acceptable alignment(Schatzker)
1. Anatomical reduction or one with the head in
slight valgus position
2. Head in neutral version or minimally anteverted
repeated attempts of CR increase risk of AVN
119
120
INTERTROCHANTERIC FRACTURE OF
FEMUR
Care, 2nd ed., 1995, 340-348)
Fracture of proximal femur in the region joining
the greater and lesser trochanter
extra-capsular
Calcar (Postero-medial fragment in the bone
around lesser trochanter)
important to the weight bearing capacity of
femur
calcar is involved
Kyles I
stable non-displaced fracture without
comminution
Kyles II
stable with minimal comminution
Kyles Classification (1979)

1. Stable fracture (Kyles I and Kyles II)
calcar is not involved
2. Unstable fracture (Kyles III and Kyles IV)
121
122
Kyles III
unstable and has a large postero-medial
comminuted area
Treatment
all #TOF require elective OT for internal fixation
with DHS (dynamic hip screw)
look for assicated injuries (eg. head injury,
fracture distal radius)
work-up for OT
Kyles IV
fracture with subtrochanteric extension
highly unstable
123
124
SUBTROCHANTERIC FRACTURE
Care, 2nd ed., 1995, 349-366)
Subtrochanteric segment--extends from lesser
trochanter to the junction of proximal and middle
third of the diaphysis
Factors important for stability (in order of

importance)
1. Degree of comminution
2. Level of fracture
3. Pattern of fracture
Degree of comminution
1. irreconstructable medial cortex comminution
(shattered medial cortex)
2. irreconstructable segmental comminution
Biomechanical
consideration
subtrochanteric
region is
subjected to:
1. axial load
2. bending force
because of
eccentric load
application to
the femoral head
medial
cortex--loaded
in compression
lateral
cortex--loaded
in tension
Level of fracture
1. Closer the fracture to the lesser trochanter
shorter the lever arm and the lower the
bending moment
2. Involvement of greater trochanter
difficult to keep the intramedullary nail within
the proximal fragment
better to fix the fracture with an angled device
(eg. angled blade plate)
3. Involvement of lesser trochanter
lock proximally within the femoral neck and
head (eg. AO unreamed femoral nail + spiral
blade locking)
Pattern of fracture
determine the mode of internal fixation
125
126
Comprehensive Classification of Fractures

(Muller, 1990)
Type A #
simple
transverse / oblique / spiral
Type B #
wedge #
can still be reconstructed to yield a stable
structure
lateral wedge
medial wedge
Type C #
comminution to a degree that a stable unit cannot
be achieved
Indications for surgery

all subtrochanteric fracture of femur needs
operative treatment
On admission
1. r/o associated injury
2. skeletal traction
3. work-up for OT
Surgery
AO unreamed intramedullary nail with spiral
blade locking
127
128
FRACTURE SHAFT OF FEMUR

result of high energy trauma
rule out associated injury
follow management of polytrauma patient
Type C
complex #
C1--spiral
C2--segmental
C3--irregular
Comprehensive Classification of Fracture

(Muller, 1990)
Type A
simple #
A1--long oblique
A2--short oblique
A3--transverse
Treatment
All adult femoral fracture
Closed #
O unreamed femoral nail
Open #
xternal fixator
On admission
Follow management of polytrauma patient (if
applicable)
Skeletal traction
work-up for operation
Type B
wedge fracture
Fracture shaft of femur
129
130
Fracture shaft of femur
SUPRACONDYLAR FRACTURE OF FEMUR

Care, 2nd ed., 1995, 387-413)
1. Younger patient
high energy trauma
severe fracture with greater intra-articular
disruption or segmental comminution
possible association with open wound, multiple
fractures, ligamentous injury
2. Older patients
low energy trauma (eg. slip an fell)
associated with severe osteoporosis
Aim of treatment
1. accurate anatomical reduction of Joint surface
2. Stable internal fixation of the articular surface
3. Restoration of normal axial alignment and
length
4. Buttressing of metaphysis
5. Early mobilization
6. thus, operaive treatment for all patients
On admission
Follow management of polytrauma patient (if
applicable)
Skeletal traction
work-up for OT
Supracondylar fracture of femur
131
Comprehensive Classification of Fractures

(Muller, 1990)
Type A
extra-articular
A1--extra-articular, simple
A2--extra-articular, metaphyseal wedge
A3--extra-articular, metaphyseal complex
Type B
partial articular
part of the articular surface intact and in contact
with the diaphysis
B1--partial articular, lateral condyle, sagittal
B2--partial articular, medial condyle, sagittal
B3--partial articualr, frontal
132
Type C
complete articular
articular surfaces are fractured and have lost
continuity with the diaphysis
C1--cmplete articular #, articular simple,
metaphyseal simple
C2--complete articular #, articular simple,
metaphyseal multifragmentary
C3--complete articular #, multifragmentary
ORIF (May plate +/- Bone grafting +/- Cement

augmentation)
Surgical Anatomy
1. Anatomical axis:
in valgus
with sagittal plane
(79 to 82 ) with the
knee joint axis
(parallel to ground)
2. Mechanical axis:
line projected
through the centre
of femoral head,
knee joint an ankle
joint
with sagittal plane
with anatomical axis
of femur
Treatment
133
134
Lateral view
when posterior cortex of the shaft is projected
distally, it divides the epiphysis into an anterior
and posterior half
Anterior position of condyles appear as a
continuation of shaft
thus, blade of a condylar plate / screw of a DCS
should be placed into the anterior part of
condyle; or the plate will not fit the femur
135
Cross Section
distal femur appear as a trapezoid
anterior and posterior surfaces are not parallel
medial and lateral walls are inclined (medial wall
inclined at 25 to the vertical)
important in selecting the length of compression
screw
136
FRACTURE PATELLA
Care, 2nd ed., 1995, 415-418)
Anatomy
seasmoid bone within the tendon of quadriceps
muscle
displacement with disruption of quadriceps
mechanism
loss of active extension of knee and loss of ability
to lock the knee in extension
Patella is bound
1. proximally to quadriceps tendon
2. distally to infrapatellar tendon
3. on either side to retinacular expansion which are
adherent to the capsule
Classification
Transverse fracture
Fracture patella
137
result from sudden, violent contraction of the

quadriceps (eg. when a person tries to stop a fall)
may disrupt quadriceps mechanism
may result in avulsion of quadriceps tendon, or
infrapatellar tendon, or transverse fracture of
patella
associated with a tear into retinacular expansion
If undisplaced # with intact extensor mechanism
long leg cylinder x 6 weeks and FWB walking
For all displaced fracture
open reduction + TBW / Cerclage wiring
138
Fracture patella
Stellate fractures / Vertical fractures

result from a direct blow to patella
quadriceps mechanism is undisturbed and
retinacula is not torn
Fracture is stable and will not displace under
normal physiological stress of active motion
surgery is not necessary
On admission
1. Test for integrity of extensor
mechanism--inability to maintain the knee in
extension against gravity
2. For undisplaced # with intact extensor
mechanism
long leg cylinder
3. For all displaced #
long leg backslab for temporary
immobilization and work-up for OT
Surgical Option
Tension Band Wiring
Osteochondral fracture
result of lateral dislocation of patella
usually involve portion of medial facet and
subjacent bone
# is visualized in skyline view
Surgery is required
1. remove the intra-articular loose body
1. repair quadriceps mechanism to prevent
recurrences of the dislocation
Fracture patella
139
140
Fracture patella
Dynamic compression (by TBW)

TBW applied to the anterior surface of patella
absorbs the distracting force
In flexion, patella is pulled against the
K-wire
provide rotational and lateral stability
must be inserted parallel (otherwise, block the
interfragmental compression by TBW)
Lag screws
provide interfragmental compression
must be protected by TBW
Cerclage Wiring
unable to neutralize the pull of quadriceps and
infrapatellar tendon
under load, such as flexion of knee, the fracture
gaps anteriorly and stability of the fracture and
congruity of the patella are lost
intercondylar groove
Fracture closes with the fragments under
axial compression
Fracture patella
141
142
Fracture patella
Partial patellectomy
Fracture patella
143
144
Fracture patella
TIBIAL PLATEAU FRACTURE

Care, 2nd ed., 1995, 419-438)
History
Mechanism of injury(S/F, RTA, Fell from
height)
High velocity injury vs Low velocity injury
Direction of force
Patients expectation and level of function
required
P/E
Soft tissue condition (open wound, swelling,
bruising, etc)
Site of Local tenderness (may indicate possible
disruption of collateral ligament)
Neurological deficit
Vascular deficit
Compartment syndrome
Management
1. Rule out concomitant injury
2. Rule out patients requiring EOT (eg. open
fracture, vascular injury, acute compartment
syndrome)
3. Long leg backslab for temporary immobilization
Fracture tibial plateau
145
Tibial Plateau Fracture

about 50 % patients get satisfactory results (both
closed and open treatment)
Causes of failure of treatment
1. Residual pain
2. Stiffness
3. Instability of knee joint
4. Deformity
5. Recurrent effusions
6. Giving way
Mechanism of Injury
usually a combination of vertical thrust and
bending
Aims of Treatment
1. Stable Joint
2. Congruent articular surface
3. Correct axial alignment
4. Satisfactory range of movement
146
TREATMENT
1. Undisplaced Fracture (< 5mm depression, no
splaying of condyles)
hinged knee brace x 6 weeks
+ protected weight bearing
(NWB walking x 6/52
PWB walking x 6/52
FWB walking)
2. All others / Open Fracture / Fracture
associated with acute compartment syndrome
/ Fracture associated with vascular or
neurological injury (vascular injury is most
often associated with type IV tibial plateau
injury)
i. OR + Buttress Plate + Bone Graft
ii. CR + Ilizarov +/- Mini-open technique + bone
graft
Schatzker Classification of Tibial Plateau

Fracture
Rehabilitation
early mobilization
147
148
1. Undisplaced
Hinged knee brace x 6/52; protected weight
bearing
2. Displaced
ORIF +/- bone graft
(Young people: lag screw
Old people : lag screw + buttress plate)
3. Minor displacement
may need arthroscopy to make sure that the
meniscus is not trapped in the fracture
Type I Fracture
Prognosis
excellent if the joint is carefully reconstructed
1.
2.
wedge fracture of lateral tibial plateau

Undisplaced
Displaced with lateral wedge fragment
spread apart from the metaphysis
broadening of joint surface
Depressed
Both spread and depressed
(For fracture with significant displacement,

lateral meniscus may be trapped in the #)
Mechanism
result of bending and shearing force
Age
usually young people < 30 years (because of
dense cancellous bone of lateral tibial plateau)
Treatment
149
150
1.
2.
3.
Type II Fracture
wedge fracture + depression adjacent weight

bearing portion of lateral tibial plateau
Depressed fragment may be anterior, central,
posterior, or a combination of all three
Undisplaced and Depression < 5mm

Hinged knee brace x 6/52
Protected weight bearing
Displaced fracture
ORIF (buttress plate) + Bone graft
Displaced Fracture with contraindication to
surgery
CR + Hinged knee brace x 6/52 + Protected
weight bearing
Prognosis
1. Poor results if residual joint depression,
incongruity, joint instability
2. Significant knee stiffness if prolonged
immobilization
Mechanism
result of bending and shearing force
Age
> 50 years
Treatment
151
152
Treatment
1. Depression < 5mm and No knee instability
Hinged knee brace x 6/52 + Protected weight
bearing
2. Depression > 5mm
ORIF (Buttress plate + Lag screw below the
elevated portion of tibial plateau + Bone graft)
Type III Fracture
Prognosis
excellent
most common but least serious tibial plateau

fracture
Depression of articular surface of the lateral
tibial plateau without an associated lateral wedge
fracture
Mechanism
result of smaller force exerting its effect on
weaker bone
Age
> 55 years
153
154
Type IV Fracture
fracture medial tibial plateau

carry worst prognosis
1. High velocity injury

Younger individual
medial plateau splits as a simple wedge with an
associated fracture of the intercondylar eminence
and adjacent bone with the attached cruciate
ligament
may be associated with a posterior split wedge of
medial plateau
femoral condyle subluxate posteroirly on
flexion
frequently a concomitant disruption of the lateral
collateral ligament complex (tear through the
155
substance of ligament or avulsion of bone, such

as the proximal fibula)
possible stretching or rupture of the peroneal
nerve (as a result of traction)
occasionally, damage to popliteal vessels
represents a subluxation or a dislocation of knee
which has been reduced
Poor prognosis--because of associated soft tissue
injury and other complications, such as
compartment syndrome, Volkmans contracture,
footdrop
2. Trivial Low Velocity Injury

elderly with marked osteoporotic bone
medial tibial plateau crumbles into an
irreconstructable mass of fragments
Poor prognosis--because of joint incongruity and
instability
156
Treatment
1. Undisplaced with No significant soft tissue
injury
Hinged knee brace x 6/52 + Protected weight
bearing
2. Displaced and/or associated ligamentous or
neurovascular lesion
Open repair of ligamentous injury
ORIF--buttress plate to medial plateau + BG
Avulsed intercondylar #:
Fixed with lag screw or wire loop
Posterior split wedge fracture
2nd buttress plate posterio-meduially
CR + Ilizarov External Fixator +/- Mini-open
technique + bone grafting
157
Type V Fracture
bicondylar fracture, which consists of a wedge

fracture of the medial and lateral tibial plateau
No assiciated depression of the articular surface
Intra-articular vs Extra-articular (when the
fracture lines begins in the intercondylar
eminence)
associated with limb shortening
Mechanism
equal axial thrust on both plateaux
Treatment
ORIF (buttress plate on both sides)
Prognosis
depends whether # is intra- or extra-articular
158
Type VI Fracture
Treatment
ORIF + BG (Two buttress plates, one strong
narrow 4.5mm DCP to bridge the diaphysis and
act as neutralization or compression plate)
CR + Ilizarov External Fixator +/- Mini-open
technique + Bone grafting
Prognosis
80% with satisfactory result (Schatzker, 1979)
most complex type of tibial plateau #

Fracture which separates the metaphysis from
the diaphysis
Fracture pattern of the articular surface is
variable
can involve one or both tibial condyles and
articular surfaces
associated with marked displacement and
depression of the articular fragments
Mechanism
High velocity injury
159
160
FRACTURE OF PROXIMAL AND DISTAL

TIBIA (JUXTA-ARTICULAR)
in the region of metaphysis and transition
between metaphysis and diaphysis
Mechanism of Injury
1. Compressive force
# are crushed and axially malaligned
closed reduction of this type often leave a gap at
the site of crush, with a tendency for the fracture
to redisplace into it
disimpaction of the # changes it from a stable to
an unstable one
2. Shear forces (tensile force)
may be direct trauma or indirect trauma
(torsional force)
markedly unstable
For young patient, usually result of high energy
trauma
For closed #
1. Undisplaced # without significant soft tissue
injury nor swelling
long leg pop x 6/52; then, Sarmiento brace x
6/52
NWB walking x 6/52; then, PWB walking x
6/52; then, FWB walking
2. Undisplaced # with significant soft tissue injury
or swelling
long leg backslab for temporary immobilization
change to long leg pop once soft tissue condition
allow
3. Displaced #
Ilizarov external fixator
For open #
Follow principle of management of open #
Book EOT x Debridement +/- # stabilization (if
necessary)
On admission
Closed vs open
Degree of soft tissue injury
exclude compartment syndrome
exclude associated vascular injury
Treatment
Fracture proximal and distal tibia
161
162
Fracture proximal and distal tibia
Safe Corridor for insertion of Ilizarov K-wires in tibia
FRACTURE SHAFT OF TIBIA

On admission
1. Closed vs Open (Gustilo classification for open
#)
2. Determine degree of soft tissue injury
(Tscherene classification for closed #)
3. Must r/o compartment syndrome
4. Measure compartment pressure if any doubt
5. Look for associated vascular injury
Treatment
For closed #
1. Undisplaced # without significant soft tissue
injury nor swelling
long leg pop x 6/52; then, Sarmiento brace x
6/52
2. Undisplaced # with significant soft tissue injury
or swelling
long leg backslab for temporary
immobilization
elevate the fracture limb
For long leg pop after soft tissue condition
improve
3. Displaced fracture / multiple #
elective OT for AO unreamed intramedullary
nailing
work-up for OT
long leg backslab for temporary immobilization
Fracture shaft of tibia
165
For open #
Follow principle of management of open fracture
Book EOT x Debridement + # Fixation (if
necessary)
# Fixation
1. AO unreamed intramedullary nailing
2. External fixator (Gustilo IIIC)
For confirmed compartment syndrome
Book EOT x Fasciotomy +/- # stabilization
High Energy Trauma (e.g. RTA)
transverse # / comminuted # / marked
displacement
significant soft tissue injury
Low Energy Trauma
spiral # with minimal displacement and minimal
comminution
mild soft tissue damage
166
External Fixator Safe Corridors for inserting

Schanz screw in tibia
167
168
PILON FRACTURE
(M. Tile, The Rationale of Operative Fracture Care,
2nd., 1995, 491-521)
metaphyseal injury of distal tibia, extending into
ankle joint
Mechanism of Injury
Compressive Injury (e.g. fell from height)
Tibia
1. Articular cartilage
impaction of articular surface
marked comminution
2. Metaphysis
severe impaction of metaphyseal bone
axial malalignment
when reduced by closed reduction
extremely large peri-articular gap is formed
thus, redisplacement possible
Fibula
may remain intact
With an intact fibula, ankle is often driven into
varus with severe impaction of medial part of
tibial plafond
Shear (Tension) Force (e.g. skiing injury, RTA)
Tibia
1. Articular cartilage
may spare articular surface / minor cracks at joint
surface
severe impaction is rare
Pilon fracture
169
2. Metaphysis
unstable injury with disrupted soft tissue envelop
Fibula
always fractured
usually transverse / short oblique with a butterfly
fragment
occasionally comminuted
Combined Axial compressive force and Shearing
force (e.g. severe high energy trauma)
On admission
Closed vs open #
State of soft tissue injury
Elevate the injuried limb always
Treatment
1. For undisplaced fracture with minimal swelling
short leg pop x 6/52
2. For displaced fracture
Short leg backslab x temporary immobilization
elevate injuried limb
Ilizarov + mini-open technique + Bone grafting
170
Pilon fracture
Type B
partial articular
B1--pure split
B2--split depression
B3--multifragmentary depression
Aim of treatment
1. Anatomical reduction of articular surface
2. Correct axial alignment
3. Bone grafting
Classification
Type A
extra-articular
A1--metaphyseal simple
A2--metaphyseal wedge
A3--metaphyseal complex
Type C
complete articular
C1--articular simple, metaphyseal simple
C2--articular simple, metaphyseal
multifragmentary
C3--complete articular #, multifragmentary
Pilon fracture
171
172
Pilon fracture
MALLEOLAR FRACTURE
(W.B. Geissler, Fractures in Adults, 4th ed., 1996,
2201-2266)
Anatomy
Tibia and fibula forms a mortise, providing a
constrained articulation for the talus
Stability of ankle joint depends on

1. Bony architecture (mortise formed by tibia and
fibula)
2. Joint capsule
3. Ligaments
Syndesmotic ligament maintains integrity
between distal tibia and fibula
resists axial, rotational and translational
forces that attempt to separate these two
bones
consists of
anterior tibiofibular ligament
posterior tibiofibular ligament
transverse tibiofibular ligament
interosseous ligament
Malleolar fracture
174
173
Malleolar fracture
Medial Collateral Ligament

superficial deltoid ligament
deep deltoid ligament
Lauge-Hausen Classification
Basic mechanism of injury
Lateral Collateral Ligament

anterior talofibular ligament
posterior talofibular ligament
calcaneofibular ligament
Malleolar fracture
Supination-adduction injury pattern
175
176
Malleolar fracture
Pronation-external rotation injury pattern
Supination-external rotation injury pattern
Vertical loading injury pattern
Pronation-abduction injury pattern
Malleolar fracture
177
178
Malleolar fracture
Treatment
1. Undisplaced #
short leg pop x 6/52;
2. Displaced #
short leg backslab for temporary immobilization
elective OT x ORIF
3. Fracture with Dislocation / Subluxation of ankle
joint
immediate CR under sedation to improve
alignment
short leg backslab for temporary immobilization
elevate involved limb
Weber Classification
Weber A--infra-syndesmotic lesion
Weber B--trans-syndesmotic lesion
Weber C--supra-syndesmotic lesion
the higher the fibular #, the more extensive the

damage to the tibiofibular ligaments
the greater the damage, the greater the danger of
ankle mortise insufficiency
Malleolar fracture
179
180
Malleolar fracture
FRACTURE CALCANEUM
(M. Tile, The Rationale of Operative Fracture Care,
2nd ed., 1995, 589-603)
fracture through sustentaculum tali is a constant

feature of all os calcis fracture
If not anatomically restored, will interfere with
medial arch
Mechanism of Injury
direct axial load
1. Fell from height
2. Motor vehicle injury
1. Superior surface of calcaneum has 3 articular

surfaces:
Posterior facet
articulates with talus
middle one third of calcaneum supports
the posterior facet
Middle facet
Anterior facet
Both articulates with cuboid
supported by anterior one third of
calcaneum
2. Sustentaculum tali
articulates with talus
supported by the complex medial arch structures,
including insertion of tibialis posterior tendon
and spring ligament (key soft tissue of medial
arch)
Fracture calcaneum
181
Primary Fracture Line

constant medial fragment containing the
sustentaculum tali
rotation of heel into varus
182
Fracture calcaneum
Secondary Fracture Line

1. may involve the joint itself in a single or in
multiple fragments (Joint Depression Type
Fracture)
2. may be a single horizontal fracture line, resulting
in Tongue-Type Fracture
2. Three-part fracture
Tongue-type fracture
Joint depression type fracture
On admission
Closed # vs open #
R/O other injuries (eg. burst # lumbar spine)
short leg backslab for temporary immobilization)
Elevate injuried limb
XR calcaneum (lateral + axial)
Book CT calcaneum (axial cut)
Classification (Sanders Classification)
CT classification
1. Two-part fracture
Primary fracture line through sustentaculum tali
Fracture calcaneum
183
184
Fracture calcaneum
3.
Four-part fracture
may involve more than four parts
additional fracture of lateral wall of calcaneum
fracture line often extend forward into the cuboid
articulation
Assessment
Xray
lateral and axial view
determine number of primary and secondary
fracture line
Bohler angle: 25 to 40
Crucial angle of Gissane--135
Fracture calcaneum
185
CT
axial cut
3-D reconstruction
Conservative Treatment
walking with calcaneal brace (NWB walking) x
6/52; then, PWB walking x 6/52; then, FWB
walking
Operative Treatment
If # is constructable
ORIF + BG
lateral approach (Hockey stick or wavy) +/medial approach
Timing: 5 - 14 days pot-injury
time for revascularization of
subcutaneous skin and allow
fracture blisters to resolve
lateral approach
186
Fracture calcaneum
medial approach
1.
2.
3.
4.
5.
Application of traction
Elevation of depressed intra-articular fragment
Bone grafting
Lag screw fixation (3.5mm cancellous screw)
Buttress plate to lateral cortex (1/3 tubular or
3.5mm reconstruction plate)
Fracture calcaneum
187
188
Fracture calcaneum
If fragments within the posterior facet of os calcis

is too comminuted and irreducible
Primary subtalar fusion
Prognosis
poor for those fractures with multi-fragmentation
of joint surface, widening of heel an poor soft
tissue
Indications for surgery
1. Displaced fracture, which deforms and widens
the os calcis, esp. with the lateral fragment
impinging on the lateral malleoli
2. Depressed and altered articular surface of the
posterior facet
Causes of long term pain

1. secondary arthritis
2. residual deformity, causing lack of a plantigrade
foot
3. widening of heel, causing impingement at the
lateral malleolus to all soft tissues, esp. the
peroneal tendon
4. injury to heel pad
Fracture calcaneum
189
190
Fracture calcaneum
DISLOCATION
1. All acute dislocations require urgent reduction
2. Assessment before reduction
site of dislocation (e.g. shoulder, elbow, hip,
knee, etc)
direction of dislocation (e.g. anterior, posterior,
inferior,etc)
associated fractures (e.g. fracture greater
tuberosity in anterior dislocation of shoulder)
associated neurological injury
e.g. shoulder joint--axillary nerve
posterior dislocation of hip joint--sciatic nerve
associated vascular injury
look for signs of vascular insufficiency
(e.g. pallor, prolonged capillary refill,
absent pulse, etc.)
look for signs of compartment syndrome
(esp. for knee dislocation)
Other committant injury
3. Reduction
attempt closed reduction in ward under sedation
immediately (valium 10 mg iv, pethidine 50 mg
iv) preferably under image intensifier guide
(Patient must be fully sedated.
CR under sedation must be gently performed
If any difficulty encountered during CR under
sedation, for CR under GA)
Inform MO and book EOT x CR under GA +/OR

4. After Reduction
must reassess neurovascular status
If there is deterioration in neurovascular
condition, may need EOT x urgent exploration
Must take post-reduction Xray to confirm
alignment
Test for post-reduction stability
Dislocation
1. Acute dislocation
2. Chronic dislocation
3. Recurrent dislocation
For failed CR under sedation
Dislocation
191
192
Dislocation
SHOULDER DISLOCATION
(C. Rockwood, Fractures in Adults, 4th ed., 1996,
1193-1302)
1. Anterior dislocation (common)
2. Posterior dislocation
3. Inferior dislocation
4. Superior dislocation
ANTERIOR DISLOCATION
Mechanism of Injury
1. Direct traumae.g. a blow directed at the
proximal humerus
2. Indirect force (most common) combination of
abduction, extension and external rotation forces
applied to the arm
Xray
AP Thorax vs True AP view of shoulder
P/E
very painful (acute dislocation)
muscle spasm
humeral head palpated anteriorly
hollow beneath acromion
arm is held in slight abduction and external
rotation
shoulder incapable of complete IR and abduction
associted nerve injury esp. axillary nerve
Shoulder dislocation
193
193
Transcapular view (True lateral view of

shoulder)
Hippocratic technique
Method of Closed Reduction

Modified Stimson Technique
195
196
note that heel of physician is not in patients

axilla
Modified Hippocrates Method
POSTERIOR DISLOCATION
Mechanism of Injury
1. Violent muscle contraction by electrical shock or
convulsive seizures
2. Direct force applied to anterior shoulder
Post-reduction Care
1. Shoulder immobiliser x 3/52
2. Check for neurovascular status
3. Check Xray for post-reduction alignment (AP +
transcapular view)
4. Test for stability
197
3. Indirect posterior force applied through the arm

up to the shoulder
198
P/E
1. severe pain and muscle spasm
limited ER of shoulder (< 0
3. limited elevation of arm (< 90 )
4. posterior prominence and rounding of the
shoulder compared with the normal side
5. flattening of the anterior aspect of shoulder
6. prominence of coracoid process on the dislocated
side
Treatment
1. Adequate muscle relaxation (preferably GA with
muscle relaxant)
2. patient supine
axial traction supplied to the adducted arm in the
line of deformity
gentle lifting of the head back into the glenoid
fossa
NOT to force the arm into external rotation
3. If locked posterior dislocation (Pre-reduction
Xray head is locked on the posterior glenoid)
distal traction of arm + lateral traction of upper
arm
199
200
HIP DISLOCATION
(J.C. DeLee, Fractures in Adults, 4th ed.,
1996,1756-1825)
usually result from high energy trauma
thus, follow principle of management of
multitrauma patient (r/o life threatening injuries)
need urgent CR under sedation
if fail, for CR under GA as EOT
Hip Dislocation
1. Anterior dislocation
2. Posterior dislocation
ANTERIOR DISLOCATION
10 % to 15 % of traumatic dislocation of hip
Superior dislocation (Pubic type)--femoral head is

palpable in the groin region
Inferior dislocation--fullness in the region of
obturator foramen
4. Circulatory status--damage to femoral artery and
vein
5. Neurologial status--damage to femoral nerve
Epstein Classification
(H.C. Epstein, Clin. Orthop., 92:116-142, 1973)
Type ISuperior dislocation (including pubic and
subspinous dislocations)
Type IA
no associated # (simple dislocation)
Mechanism of injury
RTA (when the knee strikes the dashboard with
the thigh abducted)
Falls from height
Secondary to a blow to the back of patient while
in a squatted position
P/E
1. involved limb slightly shorten
2. Superior dislocation--hip is extended and ER
Inferior dislocation--hip is abducted, ER and in
varying degree of flexion
3. Superior dislocation (Subspinous type)--femoral
head is palpable in vicinity of ASIS
Hip dislocation
dislocation
201
202
Hip
Type IB
associated # of the head (transchondral or
indentation type) and/or neck of femur
Type II--inferior dislocation (includes obturator,

thyroid, and perineal dislocations)
Type IIA
no associated # (simple dislocation)
Type IC
associated # of the acetabulum
Hip dislocation
Type IIB
associated # of the head (transchondral or
indentation type) and/or neck of femur
203
204
Hip dislocation
Type IIC
assocated fracture of the acetabulum
Allis Maneuver
patient supine
knee flexed (relax hamstring)
assistant stabilize pelvis and apply a lateral
traction force to the side of thigh
longitudinal traction is applied in line with the
axis of femur
Hip is slightly flexed
surgeons gently abducts and IR the femur to
achieve reduction
Treatment
Closed Reduction--preferably under GA / SA
Gravity method of Stimson
Hip dislocation
205
206
Hip dislocation
Reversed Bigelow Maneuver

patient supine
hip partially flexed and abducted
Lifting method
firm jerk applied to the flexed thigh
Traction method (if lifting method fail)
traction in the line of deformity
hip is then adducted, sharply IR and extend
gentle reduction due to risk of #NOF
POSTERIOR DISLOCATION
common
Mechanism of injury
force applied to the flexed knee with the hip in
varying degree of flexion
P/E
Involved limb shortened, IR and adducted
associated sciatic nerve injury (10 % to 14 %)
Post-reduction care
1. Check for neurovascular status
2. Check for post-reduction Xray
3. Skin traction with hip in slight flexion and IR
Hip dislocation
207
208
Hip dislocation
Thompson and Epstein Classification

(V.P. Thompson and H.C. Epstein, JBJS, 33A:746)
Type I
with or without minor fracture
Type II
with a large single # of posterior acetabular rim
Hip dislocation
209
Type III
with comminution of the rim of acetabulum with
or without a major fragment
Type IV
with fracture of acetabular floor
210
Hip dislocation
Type II
posterior dislocation of hip + # of the femoral
head cephalad to fovea centralis
Type V
with fracture of femoral head
Pipkin Subclassification of Epistein type V

(G. Pipkin, JBJS, 39:1027-1042, 1957)
Posterior dislocation of Hip (with # femoral head)
Type I
posteror dislocation of hip + # of femoral head
caudal to the fovea centralis
Hip dislocation
211
Type III
type I and type II with associated # of femoral
neck
212
Hip dislocation
Type IV
Type I, II, III with acetabular fracture
Type I (Posterior dislocation without fracture)

urgent CR within 12 hours
Gravity method of Stimson
Treatment
reduction (closed vs open) within 12 hours of
0injury
Immediate CR
Open reduction is reserved for
failed CR unstable reduction
Fracture fragments are trapped between the
joint
neurovascular injury after reduction
Hip dislocation
213
Allis maneuver
1. patient supine
2. pelvis stabilized
3. axial traction in line of deformity
4. gentle hip flexion to 90
5. Hip is gently rotated internally and externally
with continued longitudinal reduction is
achieved
214
Hip dislocation
Allis maneuver
Hip dislocation
Bigelow
maneuver
supine
pelvis
stabilized
longitudinal
traction along
line of
deformity
adducted and
IR thigh is then
flexed 90 or
more on the
abdomen
While traction
is maintained,
femoral head is
levered into
acetabulum by abduction, external rotation and
extension of hip
risk of #
215
216
Hip dislocation
Post-reduction
Check for neurovascular injury (e.g. sciatic
nerve)
Check post-reduction Xray
Skin traction / Skeletal traction with hip in
abduction, extension and external rotation
Hip dislocation
217
218
Hip dislocation
GUIDELINES FOR HAND CASES

Basic Operative Technique
1. Anaesthetic
Metacarpal blocks (No digital ring block)
Intravenous regional anaesthesia
2. Antibiotics
Ampicillin and Cloxacillin (po/iv if necessary
and not contraindicated eg. allergy)
3. Tourniquet
Cotton wool should be wrapped around the limb
before its application
4. Skin grafts
Donor site for split skin grafts should have
xylocaine jelly applied after graft taking
5. Skin closure
Tourniquet must be released and haemostasis
checked before closure
6. Drain
If in doubt, put in a drain
7. Suture material
Silk and catgut has no place in hand surgery
For tendons, atraumatic prolene
For nerves, 8/0 atraumatic prolene or 8/0
atraumatic fine nylon
Guideline to hand cases
219
Post-operative
1. Dressing
Everyone should know how to put a
boxing-glove dressing +/- a volar pop slab
2. Elevation
for all cases
3. Check circulation
of finger tips hourly x 8 hours for doubtful cases
4. If patient complains of excessive pain, must
remove all dressing and examine the wound
5. Rheomacrodex
To improve micro-circulation:
500 ml q8h/q6h at most 1 bottle per day, for at
most 3 days
Open Hand Injuries
1. Aim is to achieve skin healing by the end of 2
weeks
2. Physical examination:
If necessary, give pethidine 50mg 1ml 30 min.
prior P/E
Done in treatment room
In detail (both you and the patient sit down. Use
a trolley to support the hand)
3. X-Rays
Should be available for all crush injury cases
4. Surgical toilet
If operation delayed for some reasons,
preliminary toilet can be done in the treatment
room under pethidine coverage
220
Irrigation with plenty of normal saline (3-6

bottles) can be done in the treatment room under
pethidine coverage
And sterile swabs soaked with hibiscrub instead
of peviscrub
Nails should be cleaned with a brush
This most important procedure may take up to
half of the operating time
5. Debridement
Done with tourniquet inflated and then again
after deflated
Wound closed after tourniquet is released and
haemostasis secured
6. Dressing
Sufratulle
Then a layer of wet normal saline gauze swab
Then outter dressing
7. Nerves
All digital nerves to be repaired if possible,
unless the wound is heavily contaminated
8. Bone
9. Tendons
For extensor tendons
: Primary repair
For flexor tendons : Primary repair if possible
10. Finger-Tip Injury
No skin grafting
All treated by bone shortening and open method
For thumb tip loss proximal to middle of
proximal phalanx, consult your senior
221
11. All amputated finger or hands for replantation

should be wrapped in sterile cloth or gauze and
then put in a well sealed plastic bag which should
then be put in a basin with ice and water
Others
1. Amputation
No primary emergency ray amputation
2. Infection
Generous incision
Squeeze all pus out during I & D until fresh
blood appear
Hand is then immobilised with boxing glove
dressing + elevation + iv antibiotics
If in doubt, institute close-irrigation system for
frank tendon sheath infections
3. Mallet fingers
Closed Mallet fingers should be referred to
Occupational Therapist for a mallet finger splint
after wound has healed up
For open mallet fingers, Primary repair + axial
K-wire
222
COMPOUND HAND FRACTURES

Suggested emergency management
1. Management of soft tissue
wound debridement and lavage
approximate skin edges
raw area covered with acriflavine gauze
2. Management of fracture
debridement of contaminated fragment
reduce fracture to improve alignment
subcutaneous K-wire to splint fracture
immobilize in boxing glove for phalangeal or
metacarpal fracture
immobilize in short arm pop for carpal fracture
definitive fixation if soft tissues allows or in
cases with neurovascular bundle injury
Definitive treatment
1. Stable fracture
active mobilization programme
2. Unstable fracture / unacceptable alignment
definitive fixation within 7 days if the plan is
operative or
splintage / pop as definitive treatment
Compound hand fractures
223
224
Compound hand fractures
PHALANGEAL FRACTURE(D/P, M/P, P/P)

AIM
1. Early active mobilization
2. Convert fracture alignment to acceptable
configuration by CR or OR, if indicated
3. Convert unstable # to stable # by ORIF / External
Fixator
4. Avoid unnecessary immobilization
DEFINITIONS
1. Stable Fracture
The fracture is stable enough for mobilization
programme
The range of active movement of adjacent joints
> 30% of normal range
Flexion and extension views of Xrays required
2. Acceptable Alignment
Determined by Xrays
AP view : angulation < 10
True lateral: angulation < 10 at shaft
angulation < 20 at base and
proximal end
angulation < 45 at neck of 4th and
5th metacarpals
Area of contact > 50%
No obvious visible rotation
3. Significant soft tissue injuries
simple skin laceration is not counted as
significant soft tissue injury
Phalangeal fractures
225
defined as flexor tendon, extensor tendon, digital

nerve injuries or a large skin defect that requires
reconstructive procedures eg. skin graft or flaps
4. Splintage
Intra-articular # D/P with mallet finger
deformity: short mallet splint for 6 weeks
# proximal half of P/P, stable on flexion, unstable
on extension: MP block splint for 3 weeks
Condylar fracture of M/P, P/P with acceptable
alignment: IPT extension splint for 6 weeks
CLOSED FRACTURE
1. Stable fracture with acceptable alignment
free active mobilization
2. Fracture with acceptable alignment and stable on
spints under study
splintage
3. Fracture with unacceptable alignment
CR
4. Unstable fracture / Fracture with failed CR /
Re-displaced fracture
Operative fixation (ORIF, CR + ext. fix., CR
+ percutaneous absorable K-wires, Ext. fix. +
limited ORIF)
226
Phalangeal fractures
FRACTURE OF DISTAL RADIUS

(W.P. Cooney, Fractures in Adults, 4th ed., 1996,
769-791)
1. Colles #
2. Smiths #
3. Bartons #
COLLES #
most common
involves distal metaphysis of the radius, which is
dorsally displaced and angulated
within 2 cm of the articular surface
may extend into distal radiocarpal joint or DRUJ
Dorsal angulation (silver fork deformity)
Dorsal displacement
Radial angulation
Radial shortening
may have an accompanying fracture of ulnar
styloid
may signify avulsion of TFC insertion
Classification
1. Frykman classification
2. Melones classification
3. Mayo classification
Fracture of distal radius
227
Frykman Classification of Colles Fracture
Fractures
Extra-articular
Intra-articular
involving
radiocarpal
joint
Intra-articular
involving distal
radioulnar joint
Intra-articular
involving both
radiocarpal and
distal
radioulnar joint
228
Distal Ulnar Extension

Absent
Present
I
II
III
IV
VI
VII
VIII
Type III
additional
fracture
component
from the shaft
of radius that
can project
into the
flexor
compartment
Melones Classification
four basic components
1. Shaft
2. Radial styloid
3. Dorsal medial
4. Palmar medial
Type I
Non-displaced and
minimally comminuted
Type IV
transverse
split of the
articular
surfaces with
rotational
displacement
Type II (Die punch fracture)

moderate to severe
displacement
comminution of anterior
cortex unstable
1. anterior displacement
2. posterior displacement
229
230
Mayo Classification for intra-articular fractures

of distal radius
Type I
intra-articular, undisplaced
Type IV
displaced
involving both the
radioscaphoid and
lunate joints and the
sigmoid fossa of
distal radius
comminuted
always includes a
fracture component
into the DRUJ
Type II
displaced
involving radioscaphoid
joint
associated with scaphoid
lunate ligament tears
significant dorsal
angulation and radial
shortening
Type III
displaced
involving radiolunate
joint
die-punch or lunate
load fracture
often irreducible by
traction alone
231
232
SMITHS FRACTURE
reversed Colles fracture
volar angulated fracture of the distal radius
garden spade deformity
Hand and wrist displaced forward or volarly with
respect to the forearm
BARTONS FRACTURE
fracture-dislocation or subluxation in which the
rim of distal radius is displaced dorsally or
volarly
1. Dorsal Barton fracture
2. Volar Barton fracture
Modified Thomas Classification

Type I : Extra-articular
Type II : Intra-articular, cross into the dorsal
surface
Type III: Enters the radiocarpal joint (equivalent to
volar Barton's fracture-dislocation)
233
234
FRACTURE WITH ACCEPTABLE

ALIGNMENT
1. No reduction required
2. Apply pop
Age < 60 years: complete long arm pop x 3
weeks;
then, short arm pop x 3 weeks
Age > 70 years: short arm backslab x 4 - 6
weeks
3. Check XRay wrist to confirm alignment (AP +
Lat)
NORMAL ALIGNMENT
1. Coronal plane (XRay AP)
ulnar inclination 22
22
FRACTURE WITH UNACCEPTABLE

ALIGNMENT
1. CR under sedation
2. Apply pop
3. Check XRay wrist (AP + Lat)
2. Saggital plane (XRay lateral)

volar tilt 14
14
4. Failed CR x 2 times
ACCEPTABLE ALIGNMENT
1. Coronal plane (XRay AP)
Intra-articular gap < 2 mm
Intra-articular step < 2 mm
Radial shortening < 2 mm (compared with
normal side)
2. Sagittal plane (XRay lateral)
dorsal angulation < 10 to ventral angulation <
20
235
ORIF
*For patient with severe swelling

Backslab for temporary immobilization
Elevate the involved limb
Definite treatment after swelling subside
236
emergency operation without waiting for 3D

CT
POSITION OF IMMOBILIZATION OF
FRACTURE
1. Colles fracture
wrist in palmar-flexion and slight ulnar deviation
2. Smiths fracture
wrist in dorsi-flexion
3. Volar Barton fracture
wrist in palmar-flexion
4. Dorsal Barton fracture
wrist in dorsi-flexion
STUDY PROTOCOL
Inclusion criteria
1. Age 16 - 60 years
2. Type C3 intra-articular fracture (complex
articular and metaphyseal facture)
Protocol
1. CR under Fluroscan on day of admission to
improve alignment +/- second CR under
Fluroscab when edema subsides
2. 3D CT scan of wrist within one week (CT
booking form attention to Dr. W Peh)
3. If alignment acceptable,
long arm pop for 3 weeks
then, short arm pop for 3 weeks
4. If alignment not acceptable / redisplacement
within 3 weeks post-injury
ORIF
5. For compound #, compartment syndrome,
vascular surgery
237
238
FLEXOR TENDON INJURY

(J.P. Leddy, Operative Hand Surgery, 2nd ed., 1988,
1935-1968)
ZONES
1.
2.
Zone I
Distal to FDS insertion in M/P
FDP only
Zone II
From distal palmar skin crease to insertion of
FDS
synovial sheath
FDP + FDS
3. Zone III
From distal to carpal tunnel to distal palmar
crease
where lumbrical arise
4. Zone IV
Within carpal tunnel
5. Zone V
From distal one third of forearm (at
musculo-tendinous junction) to just proximal to
carpal tunnel
Acute tendon injury
239
SYNOVIAL SHEATHS
240
Acute tendon injury
PULLEYS
PULLEYS ON THUMB
1.
2.
3.
A1 pulley
located at MPJ
Oblique pulley
located on P/P
insertion of adductor pollicis
A2 pulley
near insertion of FPL
A1 and oblique pulley are more important
thickened areas
within flexor tendon
sheath
1. A pulley: Annular
pulley
prevent bowstringing
of flexor tendon
during finger flexion
A2: arise from P/P
A4: arise from M/P
A1: arise from
MCPJ
A3: arise from PIPJ
A5: arise from DIPJ
A2 and A4 most
important
2. C pulley: Cruciate
pulley
thinner than A pulley
concertina on flexion
entry point of blood vessels
Acute tendon injury
241
242
Acute tendon injury
ARRANGEMENT OF FDS AND FDP IN

FINGERS
WOUND EXTENSION
TEST FOR FDP
TEST FOR FDS
Acute tendon injury
243
244
Acute tendon injury
1.
2.
3.
4.
5.
SUTURE METHOD
1. Core suture
Modified Kessler (4/0 prolene)
2. Epitendinous suture
running stitch (6/0 prolene)
systematic
one step by one step
Passive positioning
Distal joints (first)
Proximal joints (then)
Milking technique
Tendon retriever
used only if you can see the cut end of the tendon
gentle handling of the tendon
Proximal skin incision
Infant feeding tube technique (Find the tendons
in the proximal incision first)
side-by-side
end-to-end
If step 1 - 3 fails, proximal stump of tendon may
retract to
In fingers,
around / proximal to A1 pulley
never to the wrist because of the attachment of
lumbricals
In thumb,
Vincula intact: around / proximal to A1
Vincula rupture: can retract to carpal tunnel or
even to the wrist
PARTIAL TEAR
no need for repair if < 50% cut without any
impingement
TECHNIQUE OF TENDON RETRIVAL
Acute tendon injury
245
246
Acute tendon injury
EXTENSOR TENDON
SIX COMPARTMENTS OVER WRIST
1ST: APL + EPB
2nd: ECRL + ECRB
3rd: EPL
4th: EDC + EI
5th: EDM
6th: ECU
POST-OPERATIVE CARE
follow flexor tendon programme
Acute tendon injury
247
248
Acute tendon injury
ZONES OF EXTENSOR TENDON INJURIES

Zone
Finger
Thumb
DIPJ
IPJ
I
M/P
P/P
II
PIPJ
MPJ
III
P/P
MC
IV
MPJ
CMCJ
V
MC
-VI
Dorsal wrist
-VII
retinaculum
Distal forearm
-VIII
-Middle and
IX
proximal
forearm
ARRANGEMENT OF EXTENSOR
EXPANSION
Acute tendon injury
250
249
Acute tendon injury
COMPARTMENT SYNDROME
Causes
1. Crush injury
2. Tibial fracture
3. Vascular comprimise, eg. after dislocation of knee
4. Compression within a complete pop
Signs
1. Exaggerated pain on passive stretching of the muscle
group involved
2. Parathesia
3. Paralysis
4. Pulseless
5. Perishing cold
6. Pallor
All confirmed compartment syndrome require urgent

fasciotomy
1.
2.
3.
4.
5.
NPO
IVF as appropriate
Elevate involved limb
Inform MO
Book EOT x Fasciotomy, Debridement +/- Fracture
fixation
6. Consent
7. Pre-op. Antibiotic, if indicated
8. May require urgent bedside fasciotomy if situation is
critical
Compartment pressure
< 40 mmHg within all compartments
251
252
NECROTIZING FASCIITIS
Risk Factors
1. Elderly patients
2. Liver cirrhosis
3. DM
4. Immunocomprimised, eg. steriod taking
5. Marine organism injury/contact
Organisms
1. Vibrio
2. Group A haemolytic Streptococcus
3. Others, mixed organisms
Diagnosis
1. +/- septic patients
2. Rapidly progressing cellulitis in hours (which
spread proximally in an abnormal rapid manner)
3. (Thus, need frequent assessment)
4. Clinical signs
Bullae or blisters
Patchy cyanosis of skin
Initially painful, but later become painless or
numb (despite ongoing cellulitis)
Superficial venous thrombosis
5. Aspirate subcutaneous plane with an
angiocatheter and send the tip of angiocatheter
for urgent Gm smear
Necrotizing fasciitis
253
Management
1. NPO
2. IVF +/- Fluid resuscitation
3. Close monitoring (BP/P q1h, u/o q1h, T , +/CVP, +/- Hstix)
4. Urgent inform MO
5. Urgent consult microbiologist
6. iv antibiotics (Penicillin G + Ciprofloxacillin)
7. Book EOT x Debridement +/- Amputation
8. Consent major +/- minor
9. Routine pre-op. work-up
10. T & S; blood products(FFP, Platelet concentrate)
if indicated
11. Blood culture
254
Necrotizing fasciitis
PRINCIPLE OF CLOSED REDUCTION

identify the
direction of force
leading to the
fracture
identify the intact
periosteum, which
can act as soft
tissue hinge
Technique
1. Traction: to
disimpact the
fracture
Exaggerate initial
fracture
configuration(if
necessary): to get
clear of any
jamming
periosteum or bone
spike
Reduction by
reversing the direction of forces which initially
leading to the fracture and maintain the fracture
in a slightly over-corrected position (to put the
intact soft tissue hinge in tension)
PRINCIPLE OF PLASTER TECHNIQUE

Plaster of Paris
a layer of cotton wool is interposed between the
skin and plaster
the wet plaster bandage is rolled around the limb
To immobilize a fracture satisfactory, one joint
above and one joint below the fracture are
included.
Molding: plaster bandage is pressed and
pushed round the limb by the pressure of the
thenar eminence of the surgeon
Principle of
Three-point
fixation:
1. Identify soft tissue
hinge
2. Two of the three
points are those
where the surgeon
hands molded the
plaster while setting;
one is applied to the
proximal fragment
while the other is
applied to the distal
fragment
3. The third point
extends over a diffuse
area at the proximal part of the cast
If a fracture slips in a well padded plaster, then

the fracture was mechanically unsuitable for
treatment by plaster and another mechanical
principle should have been chosen
WEDGING
Opening wedge vs closing wedge
Correct angulation of #
Intravenous regional block / Bier block

(Stewart, Traction and Orthopaedic Appliances,
1983Ed.)
For operations < 2 hours in the region of hand /
forearm
Dilute lignocaine without adrenaline to 0.5%
Apply double pneumatic cuff:
For operations in hand- forearm cuff
For operations in forearm- cuff over region of
arm
Insert a small intravenous cannula (22G) into a
superficial vein, preferably over dorsum of hand
Exsanguinate the limb by elevation for four
minutes or applying Esmarch bandage
Inflate the distal cuff to a pressure of 250 mmHg
and maintain this pressure during the duration of
operation
Inject the required dose of 0.5% lignocaine
slowly
Cuff over forearm: 25 ml
Cuff over arm
: 35 ml
(Maximum dose: < 3 mg lignocaine per kg
body weight)
Wait for analgesia to work. About 4 - 6 minutes.
Remove the cannula
On completion of the operation, deflate the cuff.
The cuff should be kept inflated for at least 30
minutes after injecting the local anaesthetic
agent
Sensation will usually return within 8 minutes
Allow patient to recover under supervision
Complications of tourniquet: refer to chapter on

tourniquet
Complications of overdose of LA:
Mild: palpitation, dizziness, blurred vision,
nausea, vomiting, tinnitus, peri-oral
numbness
Severe: arrhythmia, tremor, convulsion,
cardiac arrest
TOURNIQUET(Stewart, Traction and

Orthopaedic Appliances, 1983Ed.)
It is used to provide a bloodless field after
exsanguinating blood from the limb
Contra-indications to the use of tourniquet:
1. Peripheral vascular disease
2. Severe crushing injuries
3. Sickle cell disease
Contra-indications to expressive exsanguination:
1. Infections and tumor
2. Proven or suspected deep vein thrombosis
Methods of exsanguination:
1. Elevate the limb as vertically as possible for four
minutes
2. Apply Esmarch bandage
Tourniquet pressures:
1. Upper limb-250 mmHg } At least twice the
systolic blood
Lower limb-300 mmHg } pressure
Tourniquet time:
< 2 hours
Dangers of tourniquet:
1. Dangers from exsanguination by applying
Esmarch bandage
a. Skin damage
b. Embolisation of deep vein thrombosis,
malignant tumor and infection
c. The heart may be overloaded
2. Dangers from the pressure in the tourniquet cuff
Tourniquet paralysis syndrome (Tourniquet

palsy)(Moldaver, Archieves of Surgery, 1954)
- caused by pressure
Motor paralysis with hypotonia or atonia but
without appreciable atrophy
Sensory dissociation--Touch, pressure,
vibration and positional sense: absent
Pain sensibility is rarely lost. Hyperalgesia.
Heat and cold sensation: preserved
The colour and temperature of skin are normal.
Peripheral pulses are normal
Recovery from full paralysis takes more than
three months
3. Dangers from ischaemia
- The tissues distal to the cuff become anoxic,
acidotic and loaded with metabolites
Post-tourniquet syndrome (Bruner, JBJS, 1951)
- due to ischaemia and its duration
Puffiness of the hand and fingers
Stiffness of the joints in hand to a degree not
otherwise explained
Colour changes in the hand which is pale when
elevated and congested when dependent
Subjective sensations of numbness without true
anaesthesia
Objective evidence of weakness of muscles in
the hand and forearm without real paralysis
4. Dangers from bleeding after closure of the
wound
5. Dangers from failing to remove the tourniquet
HALO-TRACTION
Indications
1. Reduce a dislocation or fracture dislocation of
cervical spine
2. Immobilize an unstable cervical spine fracture or
dislocation
3. Maintain position of cervical spine before and
after operative fusion, if indicated
4. Shave the scalp 5 cm around each pin site

5. Slip the halo ring over the skull and ask an
assistant to hold it in correct position
6. Advance the positioning pins (about 3) so that
the halo ring lies evenly around the skull
7. Infiltrate the site of insertion of fixing pins with 2
- 3 ml lignocaine
8. Ask the patients to close his eyes
9. Advance the four fixing pins until finger tight
Procedure
1. Choose a halo ring of appropriate size
2. Patient lie supine

3. Identify sites of
the four fixing pins
1 cm above the
lateral one third of
eyebows in the
shallow grooves
on the forehead
between the
supra-orbital ridges and frontal protuberances
1 cm above the tops of the ear in the line with the
mastoid process
Halo traction
263
10. Using torque-limiting screw-drivers, further

advance the pins in diagonally opposite pairs at
the same time (avoid side to side drifting of the
halo ring)
11. Torque limit:
Adult
6 lb/inch
Children < 4 lb/inch (use 6 pins in children)
12. Remove the positioning screws
13. Apply traction, if indicated
14. Start with 2 kgf
15. Elevate the head of bed to provide counter
traction
264
Halo traction
Management of Skull Traction

1. Apply minimum traction weight
Recommended tracton weights (Crutchfield, 1954)
Level
Minimum
Maximum
weight
weight
C1
5 lb
10 lb
(2.3 kg)
(4.5 kg)
C2
6 lb
10 - 12 lb
(2.7 kg)
(4.5 -5.4 kg)
C3
8 lb
10 - 15 lb
(3.6 kg)
(4.5 - 6.7 kg)
C4
10 lb
15 - 20 lb
(4.5 kg)
(6.7 - 9.1 kg)
C5
12 lb
20 -25 lb
(5.4 kg)
(9.0 - 11.3 kg)
C6
15 lb
20 - 30 lb
(6.7 kg)
(9.0 - 13.5 kg)
C7
18 lb
25 - 35 lb
(8.2 kg)
(11.3 - 15.8 kg)
2. Check alignment with X-Ray / mini-C arm
3. For trauma cases, if reduction has not been
obtained, gradually increase traction weight
4. Repeated clinical and radiological assessment.
Make sure that the reduction can be achieved
within a few hours
5. Stop increasing traction weight if there is
increase in neurological symptoms or if X ray
reveal over-distraction
6. For OR if closed reduction with traction fail
Important: Check daily that

1. Neurological examination of patient has not been
changed
2. Check the tightness of fixing screw by using a
torque limiting driver
1st week
: daily
st
after 1 week: twice each week
3. Watch out for pin tract infection
Halo traction
266
265
Halo traction
GUSTILO (& ANDERSON) CLASSIFICATION

(for open fracture)
(R.B. Gustilo and J.T. Anderson, JBJS,
58A:453-458, 1976)
Type I : Open fracture with a clean wound < 1cm
long
Type II : Open fracture with a laceration more
than 1 cm long (1-10cm), without
extensive soft tissue damage, flaps or
avulsion
Type III : Open fracture with extensive soft tissue
damage (laceration > 10 cm)
III A
: Adequate coverage of the fracture bone
despite extensive soft tissue lacerations,
flaps; or
high energy trauma regardless of the size
of the wound
III B
: Extensive soft-tissue injury with
periosteal stripping and bony exposure,
usually associated with massive
contamination
III C
: Open fracture with associated vascular
damage requiring repair
Gustilo and Anderson classification
267
268
TSCHERNE AND GOTZEN CLASSIFICATION

(1984)
classification of soft tissue conditions in closed
fractures
Grade 0
little or no soft tissue
injury
Grade III
extensive
contusion or
crushing of
skin or
destruction of
muscle; also
subcutaneous
avulsions,
decompensated compartemnt syndrome, or rupture of a
major blood vessel
Grade I
significant abrasion
or contusion
Grade II
deep contaminated
abrasion with local
contusional damage
to skin or muscle
Tscherne Classification
269
270
Tscherne Classification
INJURY SEVERITY SCORE (ISS)

(S. Baker, J. Trauma, 14:187-196, 1974)
for evaluation of multiple trauma patient
evaluate 6 body system
Abbreviated Injury Scale Defined Body Area
1. Soft tissue
2. Head and neck
3. Chest
4. Abdomen
5. Extremity and/or pelvis
6. Cardiovascular
1.
2.
3.
4.
5.
non-fatal injury based on a rating system 0 (no

injury) to 5 (critical)
Severity Code
Minor
Moderate
Severe (non-life threatening)
Severe (life threatening)
Critical (survival uncertain)
Overall mortality in the presence of associated
injury to a second or third body system, but
injury to a forth system has little effect on
survival (Baker, 1974)
ISS = A2 + B2 + C2
(i.e. Sum of the squares of the three highest
Abbreviated Injury Scale Grades)
Minimum ISS = 0
Maximum ISS = 75
Injury Severity Score
271
HOSPITAL TRAUMA INDEX EXTREMITY

INJURY
(Am. Coll. Surg., 65:31-33, 1980)
Injury
No injury
Minor sprains and
fractures--no long bones
Simple fractures: humerus,
clavicle, radius, ulna, tibia,
fibula, single nerve
Fractures: multiple
moderate, compound
moderate, femur(simple),
pelvic(stable), dislocation
major, major nerve
Fractures: two major,
compound femur, limb
crush or amputation,
unstable pelvis
Fractures: two severe,
multiple major
Class
No injury
Minor
Index
0
1
Moderate
major
Severe
Critical
272
Hospital Trauma Index
MANGLED EXTREMITY SEVERITY SCORE

(MESS)
(K. Johansen, J. Trauma, 30:568-573, 1990)
Skeletal / soft tissue injury
Low energy (stab, simple fracture,
1
low-velocity gunshot wound)
Medium energy (open or multiple
2
fractures, dislocation)
3
High-energy (close-range shotgun or
high-velocity gunshot wound, crush
injury
Very high energy (above plus gross
4
contamination, soft tissue avulsion)
Limb ischaemia
Pulse reduced or absent but perfusion
1
normal
Pulseless; paresthesias, diminished
2
capillary refill
3
Cool, paralysed, insensate
*score doubled for ischaemia > 6
hours
Shock
Systolic blood pressure always > 90
1
mmHg
Hypotension transiently
2
Persistent hypotension
3
Age
< 30 years
1
30 - 50 years
2
> 50 years
3
Score < 7 points: limb salvage
MESS
273
274
SURGICAL SITE INFECTION (SSI)

Risk Factors
1. ASA (American Society of Anaesthesiology) 3,
4, 5
2. Dirty-infected wound and contaminated wound
3. Prolonged duration of operation
Risk index
0
: no risk factor present
1
: any one of the above risk factors present
2
: any two of the above risk factors present
3
: all of the above three risk factors present
*( ): Figure reported in National Nosocomial

Infections Surveillance System (Jan 1987 - Dec
1990)(Am Journal of Med. 91 3B: 152S-157S)
American Society of Anaesthesiology (ASA)
1. Healthy
2. History of medical disease, no disabling
3. Major medical disease, high risk if not well
controlled
4. High risk to operation, not contraindicated for
life saving procedure
5. Pending death within 24 hours
SSI Rates in UOU QMH Jan 96 - Dec 96

Classification of wound
Risk
Index
Limb
Amputation
Spinal
Fusion
Open
reduct-i
on of #
Hip
prosthesis
Others
0%
(3.9%)
0%
(4.6%)
5.9%
(5.5%)
8.3%
(7%)
6.3%
(0.7%)
0.3%
(1.0%)
6.3%
(1.9%)
2.3%
(1.8%)
10%
(4%)
0%
(3.5%)
-(50%)
-(3.7%)
1.4%
7.1%
4.2%
--
0%
(0.4%)
3%
(0.7%)
9.3%
(2.3%)
-(0%)
Surgical site infection
275
Clean wound
Clean-contaminated
wound
Contaminated wound
Dirty-infected wound
276
Infection Rate
2.1 %
3.3 %
6.4 %
7.1 %
Surgical site infection
RECOMMENDATIONS ON USE OF
ANTIBIOTIC PROPHYLAXIS IN
ORTHOPAEDIC SURGERY
1a
1b
Non-traumati
c
No foreign
body
Excluding:
immunocom
promised
open
intra-articula
r procedure
spine surgery
with grafting
Non-traumati
c
No foreign
body
immunocom
promised
open
intra-articula
r procedure
spine surgery
with grafting
Non-traumati
c implants
Antibiotics
eg.
Arthroscopy
Tendon
transfer
Posterior
diskectomy
eg.
Arthrotomy
ASF
Non-traumati
c prosthesis
eg.
Total joint
replacement
Close
Traumatic
No FB
Close
Traumatic
Implants
Close
Traumatic
Prosthesis
Soft tissue
wound
No #
eg.
Repair of
tendo
Achilles
eg.
Malleolar #
DHS
eg.
AMA
No
Antibiotics
Cefazolin 1g
iv on
induction
In cefazolin
sensitivity,
use
gentamycin
1.5 mg/kg
6
7
8
eg.
Osteotomy
Spinal
instrumentation
Cefazolin 1g
iv on
induction
In cefazolin
sensitivity,
use
gentamycin
1.5 mg/kg
277
278
Gustilo I & II
compound #
eg.
Laceration of
Tendo
Achilles
Cefazolin 1g
iv on
induction
In cefazolin
sensitivity,
1g slow iv
vancomycin
infusion on
induction
Cefazolin 1g
iv on
induction
In cefazolin
sensitivity,
use
gentamycin
1.5 mg/kg
Cefazolin 1g
iv on
induction
Cloxacillin
1g q6h iv
Gentamycin
1.5mg/kg
q8h
for 3 days
For farm
injury, add
Flagyl
500mg q8h
Antibiotics
Gustilo III
compound #
10
Diabetic foot
Antibiotics
As above for
3 days and
individualized thereafter
according to
sensitivity
Augmentin
375 mg tds
po or 1.2g iv
on induction
Duration
individualized
279
280
Antibiotics
ACUTE SPINAL CORD COMPRESSION (2 to

acute trauma)
high dose of iv methylprednisolone
start within 8 hours of injury
loading dose
: 30 mg/kg iv within 1 hour
maintenance dose : 5 mg/kg/hour x 23 hours
and then stop
covered with Zantac 50 mg iv q8h
DRUGS FOR CR UNDER SEDATION
valium 10 mg iv
pethidine 50 mg iv
decrease dose in elderly patients, paediatric
patients
watch out for respiratory depression
Drugs
281

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HANDBOOK OF

Fracture of femoral neck--------------------------------- 116

Surgical site infection (SSI) ----------------------------

cases-------------------------------Compound hand fractures------------------------------Phalangeal fractures-------------------------------------Fracture of distal radius---------------------------------Acute tendon injuries-------------------------------------

Some useful classification

Principle of fracture management

Diaphyseal Fracture Type

Metaphyseal / Diaphyseal segment

Comprehensive classification of fracture

Comprehensive classification of fracture

Comprehensive classification of fracture

Comprehensive classification of fracture

Principle of management of multiple trauma

High flow oxygen by mask ventilatory support

Principle of management of multiple trauma

Principle of management of multiple trauma

ACROMIOCLAVICULAR JONT DISLOCATION

1. Direct forcepatient falling onto the point of shoulder

Coracoclavicular interspace1.1 to 1.3cm (Bearden,

Coracoclavicular ligamentvertical stability of ACJ

Acromioclavicular joint dislocation

Acromioclavicular joint dislocation

Deltoid and trapezius muscles intact

Acromioclavicular joint dislocation

Acromioclavicular joint dislocation

Acromioclavicular joint dislocation

Acromioclavicular joint dislocation

Acromioclavicular joint dislocation

Acromioclavicular joint dislocation

3. Axillary lateral view

6MM transacromial K-wires

repair of CC ligament + Tevedek

5. Lateral stress film (Alexander view)

Acromioclavicular joint dislocation

6. Stryker notch view

Acromioclavicular joint dislocation

middle third clavicular fracture

80/5 of all clavicular fracture

Proximal fragment: pulled superiorly and

Distal fragment: drops forward as a result of gravity

distal third clavicular fracture

12% to 15 % of clavicular fracture

sub classified according to the location of

occurring between the conoid and trapezoid / the

Both conoid and trapezoid remain intact on the

Proximal fragment: no ligamentous attachment

Conoid ligament ruptured while trapezoid ligament

Proximal fragment: no ligamentous attachment

Thus, displacement is similar to Allam Group I

i.e. proximal fragment: pulled superiorly and

Occur in children <16 years old

Proximal fragment: ruptures through the thin

Coracoclavicular ligaments remain attached to the

Clinically and radiologically not distinguishable

Present with late degenerative arthrosis of ACJ

Neither the proximal nor distal fragments has

Coracoclavicular ligament are intact and remain

Displacement same as Group 1 # and Type II #

More unstable than type II # distal clavicle

Craig: subdivided according to the integrity of

Type I: minimal displacement

Type II: significant displacement (ligaments

Type III: intra-articular (sterno-clavicular joint)

Type IV: epiphyseal separation (children and