736 \200 a m u a r t d n a s c i d e a p o h t r O Traction (see below & \201 g 2) may be used for eg femoral shaft fractures or spinal injury. Open reduction aids accuracy, eg before internal \201 xation. Methods of traction The nex t problem is to hold the re- duction in place by using traction or \201 xation during hea l- ing, which takes from 2 weeks (babies) to >12 weeks (p734). \200 Skin traction uses ad hesive strapping to attach the load to the limb. The problems are that the load cannot be v ery great, and that sensitivity to the adhesive may develop. \200 Fixed traction The Thom as \200\231 splint ( \201 g 1). Weight can be added over a pulley (at the foot end) to rel ieve pressure on ischial tuberosity. Skeletal traction Using a pin through bone, bigger forces can be employed (eg Steinmann or Denham pin in the distal femur/proximal tibia for femoral shaft fractures, Gardner \200\223 Wells tongs or Crutch \201 eld skull calipers for cerv ical spine traction). Balanced traction ( \201 g 2) The weight of the limb balanced against the load. This can e nable to patient to easily lift the leg off the bed, eg for a bed pan. Fig 1. Thomas \200\231 splint. Gallows traction ( \201 g 2) is suitable for children up to 2yrs of age. The buttocks rise just above the bed. The ward nurses will be experts at setting up and adjusting traction devices, so ask if you can watch and help. See BOX, p735 for methods of \201 xation. Fig 2. Traction: balanced traction, and gallows traction. 737 Smoking and tissue healing \200\224the consequences of a cigarette break Trauma patients ne ed to knit back together well, and they face a number of complications without adding tobac co into the physiological equation. Not only do smokers increase risk of perioperative comp lication \200\224such as venous thromboembolism, respiratory tract infection & cardiac isch aemia \200\224they also reduce their chances of healing well, potentially undoing all the h ard graft of the surgical team in theater (eg plastics, orthopedics, general surgery). What damage are smokers doing? Nicotine increases the time it takes for a fracture to unite and reduces quality of bone healing. Tobacco smoking also reduces tissue oxygenation and wound healing. This is particularly pertinent for operations on the lower extremities \200\224eg Achilles tendon repair (p712) or calcaneal fracture ORIF (p756) \200\224because of the pre carious local blood supply combined with a propensity for compartment syndrome, \200\207p7 38. Is it justi \201 able to withhold surgery from smokers?1 Perhaps \200\230yes \200\231 , if a given problem has a non-operative alternative with similar outcome yet potentially d isastrous complications exacerbated by smoking: eg a calcaneal ORIF spiral- ling out of con trol into an amputation. Also perhaps \200\230yes \200\231, if resources must be distribut ed across a population in whom smokers are shown to fare much worse with a given operative management. The ethical counterpoise would be from a discriminatory angle, both in terms of costs and the concept of self- in \202 icted harm \200\224eg in comparison to dangerous s porting activity. How to approach the issue? Careful informed consent will be vital, though whether scare tactics are allowed is another matter altogether. Abstaining for 6 to 8 week s prior to elective surgery will reduce many of the side-eff ects of smoking, but this is n ot a luxury aff orded to trauma patients, and for some the stresses of what has happened ma y be too much to place on top of stopping smoking.2 Do smokers mobilize more keenly in the post-op period in response to their craving to get off the ward for a cigarette? There appe ar to be no studies to answer this yet! For giving advice on stopping smoking, see p512. a m u a r t d n a s c i d e a p o h t r O Salter and Harris classi \201 cation of epiphyseal injury I II The commonest injury, with the fracture line above the growth plate III There is a dis placed fragment, with the fracture line through the growth plate IV Union across the growth plate may interfere with bone growth V Compression of the epiphysis causes deformity and s tunting Seen in babies or pathological conditions (eg scurvy) Fig 3. Salter and Harris classi \201 cation of epiphyseal injury. Injuries to and around t he growth plate can be very diffi cult to distinguish from normal appearances, especially w hen they are viewed obliquely. Most physes are in plane that makes it relatively easy to di agnose the injury (eg distal radius, and to a lesser extent proximal femur), whereas some c ross the plane of the x-ray at multiple angles (eg proximal humerus). With these trickier p hyses, it is wise to liaise with someone with experience. Also consider comparison with the contralat- eral side. 1 With pressure to provide a cost-eff ective and fair service in the NHS, there are strong arguments from both parties. The debate certainly does not allow for smoke without \201 r e \200 244 2 Though even stopping one day before surgery has been shown to improve outcome. Complications from fractures Complications Synopsis: see MINIBOX. Fat embo- lism: Typically arises on day 3 \200\22310. Signs: confusion, dyspnoea, pulse \200\200, PaO2 \200\201, \201 ts, coma, T \200\200, petechial rash. CXR/CT: small subpleural nodular opacities.245 \200 Take to ITU \200 Get expert help \200 Correct shock \200 Monitor CVP & urine outp ut \200 Treat respira- tory failure (OHCM p180). Aim for early mobilization. Early \201 xation of fractures is preventive. Mortality: 10 \200\22320%. Crush and compartment syndrom es are a cause of ischaemia. Fluid loss, DIC, and myoglobin re- lease cause renal tubular n ecrosis: dialysis may be needed. Correct hypovolaemia vigorously. Watch urine output & plas ma K+. A limb \200\231s dead weight when immobile or in coma may cause crush in- jury/compa rtment syndrome in a vicious cycle of pressure \200\203vascular occlusion \200\203hypoxia \200\203necrosis \200\203pressure \200\200. Look for tell-tale signs of red- ness, mottlin g, blisters, swelling, and pain on passive muscle stretching. \200 Compartment syndrome is limb- and life-threatening. problems caused by delay requires vigilance and perhaps intrac ompartmental pressure measurement (NB: diagnosis is clinical; normal values for interventio n are contro- versial). \200\207Prompt fasciotomy is life-/limb- saving.246 Late complicat ions \200 Wound sepsis: Early wound cleaning is vital. Infection arises in 8% of closed fractures if internal \201 xation is used. Cef- triaxone 2g IV1 at induction halves risk. 247 \200 Failure of \201 xation: eg plates or nails 738 \200 Complications Immediate: \200 Internal bleeding \200 External bleeding \200 Organ inj ury, eg brain \200 Nerve or skin injury \200 Vessel injury (limb ischaemia: OHCM p658) Later \200\224local: \200 Skin necrosis/gangrene \200 Pressure sores \200 Infection \200 Non- or delayed union Later \200\224general: \200 Venous or fat embolism \200 Pul monary embolism \200 Pneumonia \200 Renal stones a m u a r t d n a s c i d e a p o h t r O Haematoma Avoiding Vascular granulation tissue Subperiosteal osteoblast stimulation Bone matrix Endochondral ossi \201cation Deformable woven bone (callus) break, or dislodge. Joint stiffness, contractures, malalign- ment (=malunion). Lamellar bone (p701) CRPS: Joint stiff ness and patchy osteope- nia \200\224see OPPOSITE. Fracture union Psychological problems in mobilizing: eg \200\230compensation neurosis \200\231. Fig 1. Bone healing. Non-union (atrophic or hypertophic) This is said to have occurred when there is no evidence of progression towards healing, clinically or radiologically. Delayed union is when the fracture has not healed within the time reason- ably expected for that fracture (p734). Causes of delay: \200 A fracture in a bone which h as \201 nished growing. \200 Poor blood supply (eg lower tibia) or avascular fragment (e g scaphoid). \200 Comminuted/infected fractures, eg after open reduction/internal \201 x ation. \200 Generalized disease such as malignancy or infection. \200 Distraction of bone ends by muscle; open reduction internal \201 xation pre- vents this. NB: osteoporosis old age don \200\231t necessarily delay union. Managing non-union Broadly, a non-union occurs from inadequate or abnor- mal biology or mec hanics. Management is aimed at optimizing biology (infec- tion, blood supply, bone graft) o r the mechanics (skeletal stabilization). 739 Complex regional pain syndromes (CRPS) CRPS type I is a deranged sequel to limb trauma with out nerve injury (CRPS I \211\210 algodystrophy \211\210 re \202 ex sympathetic dystrophy , RSD). If nerve lesions are pre- sent, the term CRPS II (causalgia) is used. Here it is he lpful to bear in mind that after a partial nerve lesion there is \200\200activity in undam aged aff erent C \201 bres with neuropeptide release ( \200\230 vasodilatation within the ir innervation terri- tory). But CNS phenomena are important too. Animal studies show \200 \200expression of the N-methyl-D-aspartate (NMDA) receptors in models of neuropathic pain ( and NMDA receptor blockers such as memantine can improve symptoms).248 Another proof of cen tral eff ects is the \201 nding of substantial reorganization of somatotopic CNS maps \200\224leading to mislocalization of tactile stimuli.249 a m u a r t d n a s c i d e a p o h t r O CRPS type I is a \200\230complex disorder of pain, sensory abnormalities, abnormal blood \202 ow, sweating, and trophic changes in super \201 cial or deep tissues \200\231. The c entral event may be loss of vascular tone or supersensitivity to sympathetic neurotransmitt ers. Pathogenesis is obscure, the idea of exaggerated regional in \202 ammatory responses is supported by the fact that IgG labeled with indium (111In) is concentrated in the aff ec ted extremity.250 Causes Injury esp distal and esp upper limb \200\224eg fractures, carpal tunnel re- lease, ops for Dupuytren \200\231s, tendon release procedures, mastectomy, trans radi- al cardiac catheterization,251 knee surgery, crush injury, ankle arthrodesis, am- put ation, hip arthroplasty, rotator cuff injury, zoster, myocardial infarction, stroke, cancer , spontaneous/idiopathic. Presentation Typically patients have initial trauma \200\224commo nly in a hand or foot \200\224which may be trivial or severe. This is followed weeks or mon ths later by pain, allodynia/hyperalgesia, vasomotor instability and abnormal sweating. Pai n is often burning in nature and may extend to the whole limb. The limb may be cold and cya nosed, or hot and sweating (locally). T sen- sitivity may be heightened. The skin of the af- fected part may be oedematous, or, later, shiny and atrophic. Hyperre \202 exia, dysto nic move- ments, and contractures may occur. Symptoms are often worse after exercise, and m ay include weakness, hyperalgesia, clumsiness, inability to initiate movements, spasms, dys tonias, and allodynia (a stimulus not usually painful now hurts). There are no systemic sig ns (no fever, tachycardia, or lymphadenopathy). Imaging Radiographs: Patchy osteopenia grea ter than expected from disuse; joint space not narrowed (no thinned cartilage) \200\224see \201 g 2. Bone scintigraphy: Characteristic uniform up- take, with increased limb perfusi on on the dy- namic phase. \200 Treatment \200\207Refer to pain clinic/multidisciplinary team (physio + OT). \200 Encourage optimism and pleasurable things. Ultimately, with app ropriate Fig 2. CRPS type I, with diff use os- teopenia and destruction of the 2nd and 3rd metatarsa ls. Image Courtesy of Norfolk and Norwich University Hospital (NNUH) Radiology Department. care, CRPS is self-limiting. Avoid bad habits of trying to protect the aff ected by keeping it immobile, (leads to stiff ness). Educate on using the limb in activities of daily living. \200 Eff ective painkillers often have amitriptyline eg 25mg/d PO NSAIDs. Other treatments includ e: tricyclics; gabapentin; ketamine; clonidine ( \200 2- adrenoceptor agonist with anesthet ic and analgesic sparing eff ects); calci- tonin; postganglionic sympathetic blocks (guanet hidine; bretylium).252 Trauma to the arm Fracture of the clavicle Historically thought to be caused by a fall onto an outstretched hand, most seem to occur after a direct blow to the shoulder. Fractures ar e most common in the middle third. Management is typically a broad arm sling with follow up x-rays at 6 weeks to ensure union. Fractures at the lateral end may need internal \201 x ation if there is non-union ( \201 gs 1 & 2). \200\207Remember the possibility of neurova scular injury (brachial plexus; subcla- vian vessels) + pneumothorax as complications. Scap ula and acromion fractures These represent high-energy transfer inju- ries, so assess caref ully to exclude other injuries. Acromioclavicular (AC) joint dislocation The patient has a tender prominence over the AC joint. Adduction of the arm across the body will cause increa sed pain. Subluxation can be con \201 rmed by supporting the elbow and gently pushing down on the clavicle to improve the contour of the shoulder. On x-ray check for congruity of th e underside of the acromion with the distal clavicle. Radiography may be normal, so if susp icious, request bilateral weight-carrying views. These injuries rarely require anything mor e than sling support and early mobilization. A small number (<5%) have persistent symptoms and require surgery. Fracture of the proximal humerus may result in 2 \200\2234 fragments ( eg Neer classi \201 cation).253 Most are stable osteoporotic fractures in the elderly.254 Mini- mally displaced fractures may be managed conservatively. Open fractures, pathological fractures, 3 or 4 part fracture-dislocations or those with neuro- vascular injury (brachia l plexus/axillary artery) will need operative manage- ment.254 Prognosis and complications (eg avascular necrosis) worsen with \200\200 number of fragments. Fracture of the humeral shaft Often caused by a fall on an outstretched arm. Marked displacement may make the diagn osis easy. Non-operative man- agement is adequate for >90% of these fractures.255 Splinting with a humeral brace and gravity traction by means of a no. 1 \200\230collar and cuff \200\231 sling usually gives satisfactory reduction. Immobilize for 8 \200\22312 weeks. Sur gical options in- clude intramedullary nailing and compression plating. \200\207Radial ner ve injury may cause wrist-drop, but damage can also be a complication of surgery, so docume nt function pre-operatively. Anterior shoulder dislocation may follow a fall on an arm or s houlder ( \201 gs 4 & 5). Signs: Loss of shoulder contour ( \202 attening of deltoid), an anterior bulge from the head of the humerus, which may also be palpated in the axilla. \200\207Check pulses and nerves (including the axillary nerve supplying sensation over lowe r deltoid area) pre- and post-reduction. Before reduction, do radiography (is there a fract ure too?) \200\224unless this is a case of recurrent dislocation, when just a post-reductio n image may be needed. Relieve pain (eg intra-articular local anesthetic, parenteral opioid , Entonox through the procedure). Treatment: Simple reduction: Apply longitudinal tractio n to the arm in abduction, and re- place the head of the humerus by gentle pressure. Kocher \200\231s method: Flex the elbow to 90 , abduct the shoulder, externally rotate the shoul der/humerus and then abduct the upper arm back across the front of the body before internal ly rotating the shoulder. Risk: humeral #. Remember to obtain a radiograph post- reduction. Support the arm in internal rotation with a broad arm sling. Sur- gery may be needed eg if young/athletic, or recurrent dislocation (eg Bankart repair + capsular shift). Is there an underlying connective tissue disorder? Posterior dislocation of the shoulder is rare and p resents with a limitation of external rotation. It may be hard to diagnose from an anteropo sterior ra- diograph ( \200\230light-bulb \200\231 appearance of humeral head); lateral rad iographs are es- sential. Refer to an orthopedic surgeon. www.ncemi.org/cse/cse0905.htm Inf erior shoulder dislocation Rarer; from hyperabduction; high incidence of complication: neur ovascular injury, tuberosity avulsion, rotator cuff tear. 740 \200 a m u a r t d n a s c i d e a p o h t r O 741 Fig 3. Healed mid-clavicular fracture in a diff erent pa- tient \200\224note deformity. Oft en, surgical repair is not needed for clavicle fractures, as heal- ing and long-term functi on are good. a m u a r t d n a s c i d e a p o h t r O Fig 1. Comminuted distal cla- vicular fracture \200\224an injury requiring ORIF \200 Fig 2. \200 Hook plate repair of \201 g 1-type injury. Remember nearby vessels! Fig 4 \200\2236. Anterior dislocation of the shoulder ( \201 g 4)1 and a post-reduction im age ( \201 g 5 \200\224 copied and highlighted, \201 g 6). The dislocation can be painfu l, so positioning is diffi cult for the radiographer. These are attempted lateral views of the scapula. After reduction, the head of the humerus lies in the center of the \200\230Y \200\231 with the coracoid process anterior and the acromion posterior. Figs 1 \200\2233 courtesy of Norfolk and Norwich University Hospital (NNUH) Radiology Depar tment; Figs 4 \200\2236 courtesy of Professor Peter Scally. Fig 7. Types of anterior shoulder dislocation. 1 The humeral head can sometimes lie low in the glenoid fossa with surgical neck fractures, from \200\230deltoid inhibition \200\231 \200\224relaxation of the muscle from pain, caus ing subluxation; it is not a fracture-dislocation. Fractures of the elbow and forearm The humerus \200 Supracondylar fracture: is the most c ommon fracture of child- hood, with a peak incidence between the ages of 5 and 7 years.256 These frac- tures may compromise brachial artery, median (typically anterior interosseous b ranch), radial or ulnar nerve function so check neurovascular status. Keeping the elbow in extension after injury prevents exacerbating brachial artery dam- age from the time of inju ry. Management: Avoid \202 exing the elbow by >90 . Type I fractures (see box) can be ma naged with and above elbow back slab and sling. Type II fractures may require reduction und er sedation/GA. Type III fractures generally require ORIF (eg with K-wires).256 \200 Frac ture of the medial condyle: These may require surgery if a fragment is in 742 \200 the joint or if there are ulnar nerve compression symptoms. a m u a r t d n a Fracture of the lateral condyle: Surgical \201 xation may be required. Complica- tions include cubitus valgus and ulnar nerve palsy. T-shaped intercondylar humerus fracture: This is a supracondylar fracture with a break between the condyles. The elbow Imaging: Presence of an elbow fracture is suggested by an \200\230anterior sail sign \200\231 or \200\230posterior fat pad sign \200\231.1 Management: If no # obvious, bu t an eff u- sion is present, treat initially with a broad arm sling. Re-x-ray after 10d (# more easily seen): if clear, start mobilization. For fractures, internal \201 xation may be needed. Physiotherapy and early mobilization are vital in preventing stiff ness.257 Frac tures of the radial head The elbow is swollen and tender over the radial head; \202 exion /extension may be possible but pronation & supination hurt. Radi- ography often shows an ef f usion, but minor fractures are often missed. Undis- placed fractures can be treated in a collar and cuff sling \200\224if displaced or frag- ment prevents supination/pronation then internal \201 xation or excision of the radial head may be needed.258 Complications: 3 \200\22314% are associated with the terrible triad of radial head fracture, elbow disloca tion and coronoid process fracture \200\224resulting in joint instability and post traumati c complications.259 Radial nerve injury may occur with severe anterior displacement but is rare. Pulled elbow Typical patient: 1 \200\2234-yr-old who has been lifted by the arms in p lay, causing the radial head to slip out of the annular ligament ( \201 g 1; p667) The arm is held slightly \202 exed and twisted inwards. Reduction can be achieved through the ex aminer cradling the elbow, with thumb/fore \201 ngers over the ra- dial head and either hy perpronating or supinating and \202 exing the elbow. Hy- perpronation may be more success ful.260 Imaging is not needed. Caution par- ents not to pull arm of child, as this conditio n recurs in up to 25%. Elbow dislocation A fall on a not yet fully out- stretched hand, wit h elbow \202 exed, causes pos- terior ulna displacement on the humerus, and a swollen elb ow, \201 xed in \202 exion. Brachial artery and median nerve damage are rare. Reduction ( GA): Stand behind the patient; \202 ex the elbow to relax biceps brachii. With your \201 ngers around the epicondyles, push forwards on the olecranon with your thumbs, and do wn on the forearm. Hearing a clunk heralds success. This may be aided by trac- tion at the wrist. A post-reduction image is needed to exclude fractures. Immobilize in a backslab for 10 days. Complications: Stiff ness, instability, ec- topic ossi \201 cation, radio-ulnar j oint disruption.261 Olecranon fracture ORIF, eg tension band wiring, if displaced fracture. Elbow arthroplasty In comminuted distal humerus fractures, ORIF may be diffi cult, eg in o steoporotic bones. Hence the occasional use of total arthro- plasty as a primary procedure. 262 s c i d e a p o h t r O Fig 1. Displaced olecranon fracture needing \201 xation. Courtesy of Norfolk and Nor- wich University Hospital (NNUH) Radiology Department; 743 Gartland classi \201 cation of supracondylar fractures There are 2 chief categories: exten sion (95%) and \202 exion types. Type I Type II Angulated with an intact posterior cortex Type III Posterior displacement \200\224which is unstable263 Non-displaced fractures a m u a r t d n a s c i d e a p o h t r O IIIA is posteromedial and threatens the radial nerve \200 IIIB is posterolateral and thre atens the median nerve, esp. the anterior interosseous branch, which innervates deep \202 exors to the index \201 nger as well as \202 exor pollicis longus (pincer grip); it is an entirely motor nerve \200\224so injury is easily missed Falling children often get a buckle (ie torus) forearm fracture when the dorsal cortex crum ples on pressure through an outstretched arm. The volar cortex is intact (check carefully t o make sure). The distal fragment is angulated dor- sally. There is usually local tendernes s and swelling (torus is Latin for mound). As they are stable, a splint or short-arm cast f or 3 weeks may be suffi cient.264 In greenstick fractures, one cortex fails in compression and the other fails in bending or rotation. The deformation can continue to angulate with g rowth.265 NB: Monteggia/Galeazzi fractures See p650 & p644. Reduction of a fracture of the distal radius (Colles \200\231 type) \200 Ensure that ther e is adequate local or regional anesthesia (p744). Traction should be applied to the hand w ith an assistant to provide counter- traction at the elbow. The fracture can often be felt to disimpact with \200\230clunk \200\231. Fig 1. View before reduction (radius shown alone in lateral view only). Exaggerate dorsal angulation while main- taining distal traction to stop the inelastic dors al periosteum from preventing reduc- tion by longitudinal traction. Fig 2. Correct dorsal and radial angulation, again maintaining distal traction. Aim for anatomical alignment: Apply plaster of Paris (POP), molded to provide 3-point pressure \200\224this should mainta in the reduction in ulnar deviation and with some wrist \202 exion. Fig 3. Maintain traction while the POP is applied (get all the kit ready beforehand). This is most easily done by pulling on the thumb and 1s t \201 nger against counter-traction. This applies both palmar and ulnar deviation. Support in a sling, once a radiograph has shown a good position (dorsal tilt <10 , radial shortening <2mm ; radial inclination >15 ; articular step <2mm and distal radio-ulnar join t congruence). Split cast to allow for swelling \200 Check x-ray in 5d, when swelling has reduced; the p laster is then com- pleted. \200\207 Inability to get a good position may indicate soft tissue interpositioning. \200 \207 Finding good staff with experience saves remanipulating in theater. 1 The anterior fat pad can be seen on lateral elbow x-ray as a radiolucent triangle in fron t of the distal humerus. It can be present in a normal elbow, and is only abnormal when rai sed off the bone by an eff u- sion. A visible posterior fat pad is always abnormal. Absence of either of these signs makes a fracture very unlikely. Other things to check on the late ral x-ray: anterior humeral line (which should cross the anterior third of the capitellum) and alignment of the radial shaft with the capitellum (which it should bisect). Fractures and dislocations of the wrist Distal radial fractures \200\224eg Colles \200\231 type (common in osteoporotic post-men- opausal women who fall on an outstretched hand). The re is dorsal angulation and displacement producing a \200\230dinner-fork \200\231 wrist de formity (the \201 ngers are the prongs). Avulsion of the ulna styloid process may also oc cur. Treatment: For reduction, Bier \200\231s block method (= IV regional anesthesia) is be st \200\224but the young (<12) and elderly may not tolerate the prolonged time of cuff in \202 a- tion. The use of a double cuff is controversial \200\224a properly applied and chec ked tourniquet should suffi ce. 1 Place a loose tourniquet around the upper arm. 2 Place a small cannula on the back of the hand on the injured side, and a larger one in the antecubi tal fossa of the uninjured arm (in case you need to give rescue drugs). 744 \200 a m u a r t d n a 3 Empty the arm of blood either by raising above the heart for 1min or by the use of an Esmarch bandage.266 4 In \202 ate the cuff to 100mmHg above systolic BP. 5 Inject 30 \200\22340mL 0.5% priloca ine1 into the injured limb. \200\207Never use bupiva- caine for a Bier \200\231s block (cardiotoxic if cuff is accidentally de \202 ated). s c i d e a p o h t r O 6 Allow anesthetic to develop (5 \200\22310min), then manipulate the fracture (p743). 7 30m in after the injection de \202 ate the tourniquet, at which point the anaes- thesia will wear off .1 8 Other methods such as direct in \201 ltration of the haematoma (haematoma block) are les s eff ective.267,268 The alternative is GA. Complications: Median nerve symptoms (should re solve after good reduction); ruptured tendons (esp. extensor pollicis longus); malunion & n onunion; CRPS type I (p739). Smith \200\231s fracture Sometimes called a reverse Colles \200\231 fracture , in this inj ury the distal radius fractures with the fragment angled and displaced forward/ palmarly. F ixation is needed in these fracture more commonly than in Colles \200\231 fractures, as the fracture fragment tends to migrate palmarly. Bennett \200\231s fracture Carpometacarpal fr acture/dislocation of thumb. \201\227: Percu- taneous wire \201 xation. Good reduction r educes risk of future OA.269 Scaphoid fracture Common and easily missed on radiography; res ults from falls on the hand. Signs: Tender in anatomical snuff box and over scaphoid tuberc le, pain on axial compression of the thumb, and on ulnar deviation of the pronated wrist, o r supination against resistance. Imaging: Request a dedicat- ed \200\230scaphoid \200\231 series. If \200\223ve, and fracture is suspected MRI has been shown to be sensitive and co st-eff ective.270 CT is an alternative. If neither is available, cast and re-x-ray in 2 wee ks. Nondisplaced fractures involving the waist may be immobilized in a neutral forearm cast for several weeks until union. Percutane- ous cannulated screw \201 xation allows the pa tient to return to work earlier but does not aff ect the long-term outcome.271 Complication s: Avascular necrosis: the proximal pole relies on interosseous supply from the distal part . Wrist dislocation (eg scapholunate or lunotriquetral) May be anterior or pos- terior. Man ipulation and often open reduction, and plaster immobilization eg for 6 weeks. Median nerve compression may occur.272 \200\207Beware eponymity: See BOX, \200\230Today we have namin g of parts \200 \200\231 Fig 1. AP and lateral views of the left wrist. What type of wrist fracture is this: Colles \200\231, Smith \200\231s or Barton \200\231s? Courtesy of Norfolk and Norwich University H ospital (NNUH) Radiology Department. 745 a m u a r t d n a s c i d e a p o h t r O Fig 2. \200\230Today we have naming of parts \200 \200\231 Be careful in immediately la- belling a distal radial fracture as a Colles \200\231 fracture; a Smith \200\231s fracture has vol ar displace- ment and angulation, while a Barton \200\231s fracture is an intra-articular f racture involving the dorsal aspect of the distal radius ( \201 g 1 is a reverse Barton \200\231s, involving the palmar surface). Have a quick think before \201 ring off \200 \230Colles \200\231 fracture \200\231 and be better off for simply describing the fracture pattern that you see. Today we have naming of parts. Yesterday, We had daily cleaning. And tomorrow morning, We shall have what to do after \201 ring. But today, We have naming of parts \200 Henry Reed From the Dragon Book of Verse, OUP 1 To get 0.5% prilocaine, dilute the 1% solution with an equal volume of 0.9% saline. \200 \207NB: sudden early release of prilocaine into the circulation may cause seizures. Injuries to the hand \200\207There are no minor injuries to the hand. Any breach of the in tegument may be the start of a chain of events that leads to loss of our most useful append age. Contrary to beliefs of poets, our \201 ngers are not protected from accidents by an invisible ring of shining:* they are very frequently injured. Infections Staph aureus is th e most common bacteria associated with hand infection (80%). Others include Streps and Gram \200\223ves. Paronychia: infection under the eponychial fold. In the early stages, antibi otics may cure this, but once a collection forms, drainage is required. Occasionally part o f the nail needs to be removed. Felon: an infection in the pulp of the distal \201 nger. X-ray to look for a foreign body as the source of infection. Incise either into area of max imal \202 uctuance or a high lateral incision.273 Blunt dissection is needed to break up septae, and a drain left in place. Pyogenic \202 exor tenosynovitis Bacte- rial infection of \202 exor tendon sheath \200\224which can spread via the carpal tun- nel to the forea rm. Signs include swollen \201 ngers, with tenderness over \202 exor sheath, and pain o n extension of \201 ngers. Treat urgently with IV antibiotics and surgery (see \201 g 2 ). A chronic \200\230cold \200\231 abscess of the tendon sheath suggests tu- berculosis.27 4 Osteomyelitis: Infection in the bone occurs through direct spread from an open fracture o r contiguous spread following trauma. Haematoge- nous spread may occur in children, but is rare in adults. X-rays may show os- teolysis, periosteal reactions and sequestrum or involu crum (p697). Treatment requires IV antibiotics, and surgical debridement. Septic arthritis: Infection occurs within a joint space. Pain is severe with movement of the joint. Delay in treatment leads to destruction of cartilage. If possible obtain joint aspirates to help id entify the responsible organism. Treat with IV antibiotics and wash- out of the joint. Bite wounds: Bites from pets typically occur to children 5 \200\22310 and are often found on ha nds, feet and faces. Adults may get \201 ght bites \200\224 these occur when a \201 s t strikes the teeth of an opponent. They may appear to be unassuming lacerations found over the 4th and 5th metacarpals which can overlie fractures, deep fascia or tendon injuries. R igorous cleaning and irriga- tion is required. Give tetanus prophylaxis if needed. Most are allowed to heal be secondary intention. Antibiotic treatment (eg amoxicillin + clavulinic acid) is generally advocated.275 Nerve injury (p716 & p764) Examine sensory and motor funct ion. Nerves smaller than the digital nerve at the level of the DIP joint are rarely reparab le. Function is better if the injured nerve serves a single modality (motor or sen- sory). Let an expert decide the method of repair: primary, secondary, or nerve graft.276 Tendon in juries \200 Failure to extend the MCP joint \211\210 extensor tendon division. 75% are c losed injuries.277 \200 Failure to \202 ex the DIP joint against resistance \211\210 \202 exor digitorum profundus division. If this is intact but \202 exion of the PIP join t is aff ected, there is divi- sion of super \201 cialis. Flexor pollicis longus section l eads to inability to \202 ex the interphalangeal joint of the thumb. In general, \202 e xor tendon injuries are best treated by primary repair (most are open injuries). If there i s loss of tendon substance or delayed presentation, a staged repair with a silastic implant to keep the tendon sheath open, followed by a tendon graft, may be needed. Intensive hand physiotherapy with supervision is essential. 746 \200 a m u a r t d n a s c i d e a p o h t r O Bright clasp of her whole hand around my \201 nger My daughter, as we walk together now. All my life I \200\231ll feel a ring invisibly Circle this bone with shining \200 Stephen S pender To My Daughter 747 Limb surgery in bloodless \201 elds This can be achieved with pneumatic tourniquets, whic h must have adequate width and curve, and be applied for as brief a time as possible.278 \200\230Bruner \200\231s rules \200\231: These minimize risk of ischaemic limb changes. \200 Width of tourniquet: 10cm for the arm; 15cm for legs. \200 Apply to the upper arm, or mid/upper thigh. \200 Use \211 2 layers of orthopedic wool to provide adequate paddin g (make sure it does not get wet with the skin preparation \202 uid, which should be aque ous, so that if wetting happens inadvertently, \200\230chemical burns \200\231 do not occu r). \200 In \202 ation \200\224arm: 50 \200\223100mmHg above systolic BP; leg: double sy stolic BP. \200 De \202 ation \200\224must be within 2h. \200 Re-application after onl y brief reperfusion is inadvisable.279 \200 Avoid heating the limb (cooling is better, if feasible).280 \200 Apply only with the utmost caution to an unhealthy limb. \200 Ensur e the apparatus is calibrated weekly, and is well maintained. \200 Document duration and pressure of tourniquet use. a m u a r t d n a s c i d e a p o h t r O Fig 1. Procedure for the evacuation of a subungual haematoma. Hand incisions \200\224 \201 g 2 A: pulp space drainage; B & B1: lavage of \202 exor ten dons; C: drainage of radial bursa; D: drainage of the ulnar bursa; E & E1: for the mid-palm ar space; F: drainage of the thenar space. Fig 2. Fractures in the hand Metacarpal fractures The base of the 2nd and 3rd metacarpals (MCs) fo rm the functional center of the hand around which the movement of the hand is centered. Thu s, whilst malalignment and imperfect reduction may be tolerated in the 5th MC (<40o volar a ngulation), far less is permitted in the 2nd MC (<10o). The 5th metacarpal is most commonly involved, often from a punching injury. Managment may vary depending on whether the fractu re is in the head/neck/ shaft or base of the MC, however, stable closed fractures can be ma naged in a splint/cast for 2 weeks, with the wrist in partial extension (20 \200\22330 ), MCP joints in 70 \200\22390o \202 exion with \201 ngers in extension. Unstable fract ures may re- quire K-wires/ORIF.281 Longer periods of splinting in plaster or \200\230boxi ng glove \200\231 bandage can cause a stiff hand, eg from joint adhesions/contracture, \202 exor tendon \201 brosis and collateral ligament shortening. 748 \200 a m u a r t d n a Refer any fractures with obvious rotational deformity (a clinical, not a radio- logical dec ision), as this can be disabling. Rotational fractures disclose them- selves by producing a rotation of the \201 ngers \200\224see BOX; they usually require operative \201 xation (plate & screws), as do fractures of \211 2 metacarpals. \200\207Beware wounds overlying metacarpophalangeal joints (often from the teeth of the pu nched victim, as they are contaminated, and may communicate with the joint). Fractures of t he proximal phalanx Spiral or oblique fractures occurring at this site are likely to be ass ociated with a rotation deformity \200\224and this must be corrected (see BOX). Often, the only way to do this accurately is by open reduction and \201 xation, eg with a single com pression screw.282 Middle phalanx fractures Manipulate these; splint in \202 exion over a malleable metal splint, strapping the \201 nger to its neighbor ( \200\230neighbor strap ping \200\231). The aim is to control rotation, which interferes with later \201 nger \202 exion. Distal phalanx fractures may be caused by crush injuries and are often open. If closed, symptoms may be relieved by trephining the nail to reduce swelling. Rarely, split skin grafts from the thenar eminence may be needed for partial amputations of the \201 ng er tip.1 283 Mallet \201 nger The tip of the \201 nger droops because of avulsion of th e extensor tendon \200\231s attachment to the terminal phalanx or rupture of the terminal p art of the tendon. If the avulsed tendon includes a piece of bone, union is made easier \200\224using a special splint, eg with 0 of extension. Use for 6 weeks.284 Sur- gical in tervention may be indicated if the fracture fragment is >30% of the joint surface.285 Poore r outcome is associated with delay in splinting. Gamekeeper \200\231s thumb This is so-call ed because of the laxity of the ulnar col- lateral ligament of the metacarpophalangeal join t of the thumb during the forced thumb abduction that occurs when wringing a pheasant \200 \231s neck. The same injury is described in dry ski slope participants who fall and catch t heir thumb in the matting ( \200\230skier s thumb \200\231). Diagnosis can be diffi cult as the thumb is so painful to examine, but to miss this injury may condemn the patient to a w eak pincer grip \200\224inject 1 \200\2232mL 1% plain lidocaine around the ligament to faci litate examination. Diff erentiation of complete vs partial tears of the liga- ment is cruc ial because the treatment for complete tears is surgical. Radio- graphic evaluation will de tect a bony avulsion fragment. s c i d e a p o h t r O Partial tears (clinically stable), or those associated with undisplaced avul- sion fracture s of the proximal phalanx, can be adequately treated using simple short-arm thumb spica cas ting. 1 For \201 ngertip injuries in general, loss of <1cm2 \201 nger pulp skin should be abl e to heal by secondary intention. Fig 1. Nail avulsion. \200 If the nail margins are all intact, this is usually not needed . Look carefully at the dorsal nail fold, the nail root may have been avulsed then slipped back. \200 Warn the patient the nail may not re- grow (or may regrow improperly). Get con sent. 749 a m u a r t d n a s c i d e a p o h t r O Ring block the \201 nger and test it is numb.