Orthopaedics
Trauma and orthopaedics for the Indian MBBS final-year exam — fractures, dislocations, bone and joint infection, tumours, the spine, arthritis, paediatric and regional orthopaedics. Full-length explanation-first answers with diagrams.
The Gartland classification of the extension-type supracondylar fracture (95–98% of cases) drives management: type I is undisplaced and needs only a cast; types II and III are displaced and are treated by closed reduction and percutaneous K-wire fixation. The danger lies in what sits in front of the forward-driven fragment — the brachial artery and the median nerve (particularly its anterior interosseous branch) — so every child must have a documented neurovascular examination before and after reduction. WHY THIS FRACTURE MATTERS
The supracondylar fracture is the commonest fracture around the elbow in children (peak age 5–8 years), and it is important out of all proportion to its frequency because the complications — not the fracture itself — are what threaten the limb. The distal humerus here is a thin, flat sheet of bone between the coronoid and olecranon fossae, and immediately in front of it run the brachial artery and the median nerve. In the common EXTENSION type (95–98%) — caused by a fall on the outstretched hand with the elbow extended — the distal fragment is pushed backwards and the sharp proximal spike is driven forwards into these structures. The rare FLEXION type follows a fall on the point of a flexed elbow and displaces the distal fragment forwards.
CLINICAL FEATURES AND THE CARDINAL RULE OF EXAMINATION
The child presents with a painful, grossly swollen elbow held in slight flexion, with an S-shaped deformity. The great danger is that swelling masks a vascular injury. The single most important step is to document the neurovascular status BEFORE any manipulation and again AFTER: the radial pulse, the colour, warmth and capillary refill of the hand, and the function of all three nerves — the ANTERIOR INTEROSSEOUS branch of the median nerve is the commonest nerve injured (tested by the 'OK' sign — flexion of the interphalangeal joint of the thumb and the distal interphalangeal joint of the index finger). A pink, pulseless hand after reduction may be observed closely, but a white, pulseless hand is a surgical emergency.
⚠️The three feared complications are VOLKMANN'S ISCHAEMIC CONTRACTURE (from untreated forearm ischaemia — the most catastrophic), neurovascular injury at presentation, and CUBITUS VARUS (gun-stock deformity) — a cosmetic malunion that is the commonest LATE complication and is due to malunion, not growth arrest.RADIOLOGY
Two views (AP and a true lateral) are essential. In an undisplaced fracture the only clue may be a POSTERIOR FAT-PAD (sail) sign, indicating a joint effusion. On the lateral view, the anterior humeral line should pass through the middle third of the capitellum — in an extension injury the capitellum falls behind it. Baumann's angle (on the AP view) is used to judge reduction and to detect the coronal tilt that produces cubitus varus.
MANAGEMENT — DICTATED BY THE GARTLAND TYPE
Type I (undisplaced): an above-elbow cast in about 90° of flexion for 3 weeks. Type II (displaced, posterior cortex/hinge intact) and Type III (completely displaced): closed reduction under anaesthesia and percutaneous K-wire fixation, followed by an above-elbow slab. The reduction is held with lateral (or crossed) K-wires; crossed wires are biomechanically stronger but risk the ulnar nerve. Open reduction is reserved for an irreducible fracture, an open fracture, or vascular compromise that does not resolve with reduction. The classic error — flexing the elbow beyond 90° in a cast to 'hold' an unstable fracture — obstructs the already-compromised circulation and invites Volkmann's contracture, which is exactly why fixation, not forced flexion, is used.
💡A pulseless but well-perfused (pink) hand that stays pink after a good reduction can be watched — the collateral circulation around the elbow is rich. A pulseless AND pale/cold hand, or one that becomes so after reduction, needs urgent exploration of the brachial artery.Gartland type Displacement Management Type I Undisplaced Above-elbow cast Type II Displaced, posterior cortex intact Reduction + K-wire Type III Completely displaced Closed / open reduction + K-wire Key risk Brachial artery, median (AIN) nerve Check pulse and nerves 🔑KEY POINTS TO REMEMBER- Commonest elbow fracture in children (5–8 yr). EXTENSION type (95–98%) from a fall on the outstretched hand; the proximal spike is driven FORWARDS into the brachial artery and median nerve.
- ALWAYS document the neurovascular status BEFORE and AFTER manipulation. The ANTERIOR INTEROSSEOUS nerve (median) is the commonest nerve injured — test the 'OK' sign.
- Gartland I = undisplaced → above-elbow cast. Gartland II & III = displaced → closed reduction + percutaneous K-wire fixation. Open reduction only if irreducible, open, or vascular compromise persists.
- Fat-pad (sail) sign, anterior humeral line through the middle third of the capitellum, and Baumann's angle assess an undisplaced fracture and the reduction.
- Feared complications: VOLKMANN'S ISCHAEMIC CONTRACTURE (untreated ischaemia), neurovascular injury, and CUBITUS VARUS (gun-stock) — the commonest LATE complication, due to MALUNION not growth arrest.
📚SOURCES: Maheshwari's Essential Orthopaedics; Apley & Solomon's System of Orthopaedics and Trauma; AO Principles of Fracture Management.A Colles' fracture is an extra-articular fracture of the distal radius (about 2.5 cm from the wrist) in which the distal fragment displaces dorsally, radially, is impacted and supinated — producing the classic dinner-fork deformity. Reduction aims to restore the three normal parameters (volar tilt, radial inclination and radial length), and the commonest complication is malunion. DEFINITION
A Colles' fracture is a fracture of the distal end of the radius, about 2.5 cm proximal to the wrist joint, with DORSAL displacement and angulation of the distal fragment. It is classically extra-articular. It is the commonest fracture of the upper limb, occurring typically in the elderly, osteoporotic woman who falls on the outstretched hand (FOOSH) with the wrist in dorsiflexion. The same injury in a young adult implies much higher energy and is more often comminuted or intra-articular.
THE SIX DISPLACEMENTS AND THE DEFORMITY
Understanding the deformity is understanding the reduction. The distal fragment displaces in six ways: (1) dorsal displacement, (2) dorsal angulation (loss of the normal 11° volar tilt), (3) radial displacement, (4) radial tilt (loss of the normal 22° radial inclination), (5) proximal impaction (radial shortening), and (6) supination of the fragment. The dorsal displacement and angulation together produce the classic 'dinner-fork' (or 'bayonet') deformity seen from the side, while the radial shift produces the 'lateral' prominence of the radial styloid seen from the front.
CLINICAL FEATURES
There is pain, swelling and the dinner-fork deformity, with tenderness over the distal radius. Always examine and record the median nerve (sensation over the radial three-and-a-half digits), as acute carpal tunnel compression can occur, and check the distal radioulnar joint for tenderness (an associated ulnar styloid fracture is common).
RADIOLOGY AND THE THREE PARAMETERS OF REDUCTION
AP and lateral views confirm the fracture and quantify the displacement. The reduction is judged by restoration of the three normal radiological parameters: the VOLAR TILT (≈ 11°), the RADIAL INCLINATION (≈ 22°) and the RADIAL LENGTH (≈ 11–12 mm, i.e. the radial styloid should lie about 11 mm distal to the ulnar articular surface). Loss of these is what defines an unacceptable position.
MANAGEMENT
Undisplaced fractures are treated in a below-elbow cast for about 6 weeks. Displaced fractures are treated by closed reduction under anaesthesia (haematoma block, Bier's block or general anaesthesia) — the manoeuvre is disimpaction by traction, followed by flexion, pronation and ulnar deviation of the hand — and the position is held in a dorsal below-elbow slab/cast (the Charnley position: slight palmar flexion and ulnar deviation), with a check X-ray. The cast must never encircle a swollen limb completely at first, and the fingers, elbow and shoulder are mobilised from day one. Unstable, comminuted, markedly displaced or intra-articular fractures, and those that redisplace, need operative fixation — usually a volar locking plate, or K-wires or an external fixator.
COMPLICATIONS
Early: median-nerve (acute carpal tunnel) compression, and circulatory embarrassment from a tight cast. Late: MALUNION (the commonest complication — a dinner-fork deformity that heals uncorrected), delayed rupture of extensor pollicis longus (from attritional/ischaemic damage as the tendon runs around Lister's tubercle — it typically ruptures weeks later, even after an undisplaced fracture), stiffness of the fingers and shoulder, Sudeck's atrophy / complex regional pain syndrome (a painful, swollen, stiff hand with patchy osteoporosis), and subluxation of the distal radioulnar joint with loss of forearm rotation.
🔑KEY POINTS TO REMEMBER- Colles' = extra-articular fracture of the distal radius ~2.5 cm from the wrist, with DORSAL displacement/angulation. Commonest in elderly osteoporotic women after a FOOSH; produces the DINNER-FORK deformity.
- Six displacements: dorsal displacement, dorsal angulation (loss of volar tilt), radial displacement, radial tilt (loss of radial inclination), impaction (shortening) and supination.
- Reduction restores the THREE parameters: volar tilt (~11°), radial inclination (~22°) and radial length (~11–12 mm).
- Undisplaced → below-elbow cast. Displaced → closed reduction + Charnley cast. Unstable/comminuted/intra-articular → volar locking plate, K-wires or external fixator.
- Complications: MALUNION (commonest), acute carpal tunnel/median-nerve compression, DELAYED EPL rupture (around Lister's tubercle), Sudeck's/CRPS, stiffness and DRUJ subluxation.
📚SOURCES: Maheshwari's Essential Orthopaedics; Apley & Solomon's System of Orthopaedics and Trauma; AO Principles of Fracture Management.The anterior dislocation is the commonest large-joint dislocation. The arm is held abducted and externally rotated with loss of the deltoid contour (squaring); the axillary nerve must be tested before and after reduction. Reduction (Kocher, Hippocratic, Stimson or Milch) is followed by a sling. Recurrence is driven by the Bankart lesion (labral avulsion) and the Hill–Sachs lesion (humeral head impaction). INTRODUCTION
The shoulder is the most commonly dislocated large joint in the body because its stability is sacrificed for mobility — a large humeral head articulates with a small, shallow glenoid. Over 95% of dislocations are ANTERIOR, and of these the sub-coracoid position is the commonest. The mechanism is a fall on the outstretched hand with the arm in ABDUCTION and EXTERNAL ROTATION, or a direct blow to the back of the shoulder.
CLINICAL FEATURES
The patient supports the injured arm and holds it slightly ABDUCTED and EXTERNALLY ROTATED, resisting any movement. The normal rounded contour of the shoulder is lost — the deltoid appears flattened and the acromion becomes prominent, giving the characteristic 'SQUARING' of the shoulder. There is an anterior fullness where the humeral head can be palpated below the coracoid. Dugas' test is positive — the patient cannot place the hand of the affected side on the opposite shoulder. Before and after reduction, the AXILLARY NERVE must be tested by checking sensation over the 'regimental badge' area on the lateral aspect of the upper arm (and, once pain allows, deltoid contraction), as it is the nerve most commonly injured.
⚠️Two structures at risk: the AXILLARY NERVE (regimental badge area — always test and document it) and, in the elderly, the AXILLARY ARTERY. In older patients an anterior dislocation is often accompanied by a fracture of the greater tuberosity or a rotator-cuff tear, which must be looked for on the X-ray.RADIOLOGY
An AP view plus a second view at right angles (an axillary or a scapular 'Y' view) is essential — a single AP can miss a POSTERIOR dislocation, which is the classic exam trap (seen after epileptic seizures or electric shock, giving the 'light-bulb' sign of the internally rotated head). Radiographs also confirm reduction and exclude an associated fracture.
MANAGEMENT — REDUCTION
The dislocation is reduced as an emergency, under sedation or general anaesthesia and with muscle relaxation. Several techniques exist: KOCHER'S method (traction in the line of the arm, then external rotation, adduction across the chest, and finally internal rotation — effective but with a risk of humeral fracture if done forcibly), the HIPPOCRATIC method (traction and counter-traction), the STIMSON technique (the patient lies prone with a weight hanging from the wrist, allowing gentle spontaneous reduction), and the MILCH manoeuvre. After reduction the neurovascular status is rechecked, a confirmatory X-ray is taken, and the arm is rested in a sling for about three weeks, followed by graded rotator-cuff and deltoid rehabilitation.
RECURRENT DISLOCATION
Recurrence is common, especially in young, active patients (the younger the patient at first dislocation, the higher the risk). It is driven by two lesions produced at the first dislocation: the BANKART lesion — an avulsion of the antero-inferior glenoid labrum with its capsule (the 'essential lesion' of recurrent anterior instability) — and the HILL–SACHS lesion — a compression (impaction) fracture of the postero-lateral humeral head where it strikes the glenoid rim. The apprehension test (the patient becomes apprehensive when the shoulder is abducted and externally rotated) is diagnostic of instability. Established recurrent instability is treated surgically — a Bankart repair (arthroscopic or open reattachment of the labrum), or a bone procedure (Latarjet) where there is significant glenoid bone loss.
💡Never accept a single AP film. A posterior dislocation can look almost normal on the AP view and is missed in up to half of cases — always get an axillary or scapular-Y view, and suspect it after a seizure or electric shock.🔑KEY POINTS TO REMEMBER- The shoulder is the commonest large joint to dislocate; >95% are ANTERIOR (sub-coracoid commonest), from a FOOSH in abduction–external rotation.
- Signs: arm held abducted/externally rotated, loss of deltoid contour (SQUARING), anterior fullness, Dugas' test positive. ALWAYS test the AXILLARY NERVE (regimental badge) before and after reduction.
- Get an AP PLUS a second view (axillary or scapular-Y) — a single AP misses POSTERIOR dislocation (seizure/shock; light-bulb sign).
- Reduce under sedation/anaesthesia: Kocher's, Hippocratic, Stimson or Milch; then sling ~3 weeks + confirmatory X-ray. Look for greater-tuberosity fracture in the elderly.
- Recurrence (high in the young) is driven by the BANKART lesion (antero-inferior labral avulsion — the essential lesion) and the HILL–SACHS lesion (humeral-head impaction); apprehension test positive → Bankart/Latarjet repair.
📚SOURCES: Maheshwari's Essential Orthopaedics; Apley & Solomon's System of Orthopaedics and Trauma; AO Principles of Fracture Management.BOTH-BONE FOREARM FRACTURES — WHY REDUCTION MUST BE ANATOMICAL
The radius and ulna function as a parallelogram that allows pronation and supination; the radius rotates around the fixed ulna about the radial bow. It follows that a forearm-shaft fracture is a joint injury in disguise — if length, angulation and above all ROTATION and the radial bow are not accurately restored, forearm rotation is permanently lost. This is why, unlike many diaphyseal fractures, both-bone forearm fractures in the ADULT require ANATOMICAL reduction and rigid internal fixation — typically open reduction and plating (compression plates) of both bones. In CHILDREN, whose remodelling potential is large, most are managed by closed reduction and an above-elbow cast, accepting minor angulation but never malrotation.
CLINICAL AND RADIOLOGICAL ASSESSMENT
There is pain, deformity and loss of forearm rotation. The cardinal rule of forearm and elbow trauma applies: a fracture of one forearm bone with shortening or angulation is almost always accompanied by a fracture or a DISLOCATION of the other, because the two bones are bound together by the interosseous membrane and the two radio-ulnar joints. Therefore the X-ray MUST include both the elbow AND the wrist — an isolated 'ulna fracture' that also shows a dislocated radial head is a Monteggia injury, and missing it is a classic and costly error.
MONTEGGIA AND GALEAZZI FRACTURE-DISLOCATIONS
These two named injuries embody that rule — a fracture of one bone with dislocation of the radio-ulnar joint at the other end of the forearm. The MONTEGGIA fracture-dislocation is a fracture of the proximal ulna with dislocation of the radial head (classified by Bado on the direction of the radial-head dislocation). The GALEAZZI fracture-dislocation is a fracture of the distal radius with dislocation of the distal radio-ulnar joint. They are compared below.
Feature MONTEGGIA GALEAZZI Fracture Proximal third of the ULNA Distal third of the RADIUS Dislocation Head of the RADIUS (proximal radio-ulnar joint) Distal radio-ulnar joint (DRUJ) Mnemonic MUGR — Monteggia = Ulna #, Radial head out GRUM — Galeazzi = Radius #, Ulna (DRUJ) out Nerve at risk Posterior interosseous nerve (PIN) Usually none (DRUJ instability) Adult treatment ORIF of the ulna → radial head usually relocates ORIF of the radius + stabilise DRUJ MANAGEMENT OF THE FRACTURE-DISLOCATIONS
In the ADULT both are treated operatively. In a Monteggia injury, anatomical fixation of the ulna (plating) usually allows the radial head to reduce spontaneously; the radial head is checked and, if it does not reduce, the annular ligament or an interposed structure is dealt with. In a Galeazzi injury, the radius is plated and the DRUJ is then assessed and stabilised (the Galeazzi is sometimes called the 'fracture of necessity' because non-operative treatment in the adult reliably fails). In CHILDREN, both are often amenable to closed reduction. The PIN (posterior interosseous nerve) must be examined in every Monteggia injury.
COMPLICATIONS
Early: the forearm is a common site of compartment syndrome — a high-energy both-bone fracture, a tight cast or a crush injury must raise this suspicion, and pain on passive finger extension is the key early sign. Nerve injury (the PIN in Monteggia) may occur. Late: MALUNION with loss of the radial bow → permanent loss of pronation/supination (the functional penalty this whole injury is about); NON-UNION (favoured by the tenuous blood supply of the mid-forearm and by soft-tissue stripping at surgery); and radio-ulnar CROSS-UNION (synostosis) — a bony bridge between the two bones that abolishes rotation, seen especially after high-energy injuries, when both fractures are at the same level, or after excessive surgical dissection.
⚠️The commonest reason a Monteggia or Galeazzi injury is missed is a radiograph that does not include the joint above and below the fracture. Never accept a forearm film that stops short of the elbow or the wrist.Always image the joint above and below a forearm fracture. 🔑KEY POINTS TO REMEMBER- The forearm is a rotating parallelogram — restoring LENGTH, ANGULATION, ROTATION and the RADIAL BOW is essential, or pronation/supination is lost.
- ADULT both-bone forearm fractures need ANATOMICAL reduction + rigid plating of both bones; CHILDREN are usually managed by closed reduction and an above-elbow cast.
- ALWAYS X-ray the elbow AND the wrist — a fracture of one forearm bone is commonly accompanied by dislocation of the other radio-ulnar joint.
- MONTEGGIA (MUGR) = proximal ULNA fracture + RADIAL HEAD dislocation; risk to the POSTERIOR INTEROSSEOUS NERVE. Treat by ORIF of the ulna; the radial head usually reduces.
- GALEAZZI (GRUM) = distal RADIUS fracture + DRUJ dislocation; the adult 'fracture of necessity' → ORIF of the radius + DRUJ stabilisation.
📚SOURCES: Maheshwari's Essential Orthopaedics; Apley & Solomon's System of Orthopaedics and Trauma; AO Principles of Fracture Management.The radial nerve winds around the spiral groove of the humeral shaft, so a mid-shaft fracture may cause a radial-nerve palsy (wrist drop). Most palsies are neurapraxia and recover spontaneously, so a palsy present before reduction is observed; a palsy that appears after manipulation, or accompanies an open fracture, is explored. Most humeral shaft fractures unite with a functional brace. THE FRACTURE AND ITS SPECIAL RELATIONSHIP
The shaft of the humerus is a common site of fracture, from a fall, a direct blow or (in the elderly) a low-energy injury through osteoporotic or metastatic bone. Its clinical importance rests on one anatomical fact: the radial nerve winds around the back of the humerus in the SPIRAL (radial) GROOVE, in close contact with the bone at the junction of the middle and lower thirds. Hence a fracture at this level may injure the radial nerve, producing a WRIST DROP. The Holstein–Lewis fracture — a spiral fracture of the distal third — is particularly associated with radial-nerve entrapment.
CLINICAL FEATURES
There is pain, swelling, abnormal mobility and shortening of the arm, with crepitus. The essential additional step is to examine the radial nerve: a palsy produces inability to extend the wrist, the fingers at the metacarpophalangeal joints, and the thumb (wrist drop), with sensory loss over the dorsal aspect of the first web space. Grip is weak because the wrist cannot be stabilised in extension. The distal circulation is also checked.
MANAGEMENT OF THE FRACTURE
The humeral shaft has an excellent capacity to heal and tolerates a surprising degree of angulation without functional loss, so MOST fractures are treated CONSERVATIVELY. The limb is supported initially in a U-slab or a hanging cast, and after a week or two converted to a functional (Sarmiento) brace, which controls the fracture while allowing shoulder and elbow movement — union is expected in 8–12 weeks. Operative fixation (compression plating or intramedullary nailing) is indicated for: open fractures, polytrauma, segmental fractures, a 'floating elbow' (with a forearm fracture), bilateral fractures, pathological fractures, vascular injury, and established non-union.
MANAGEMENT OF THE RADIAL-NERVE PALSY — THE CRUCIAL RULE
Most radial-nerve palsies associated with a humeral shaft fracture are a NEURAPRAXIA (a stretch injury) that recovers spontaneously over 3–4 months. Management therefore depends on WHEN the palsy is noticed: a palsy present at the time of injury (before reduction) is OBSERVED — the wrist and fingers are supported with a cock-up splint to prevent stiffness, and recovery is awaited (if there is no clinical or electrophysiological recovery by about 3–4 months, exploration is considered). A palsy that appears AFTER manipulation or is associated with an OPEN fracture should be EXPLORED, because the nerve may have become trapped in the fracture or been lacerated.
💡Because the radial nerve supplies the wrist and finger EXTENSORS but not the intrinsic hand muscles, a radial-nerve palsy weakens grip only indirectly — the flexors work, but with the wrist dropped they cannot generate power. Splinting the wrist in extension immediately restores much of the grip and prevents a fixed flexion contracture while recovery is awaited.🔑KEY POINTS TO REMEMBER- The radial nerve lies in the spiral groove against the bone at the mid/lower-third junction, so a shaft fracture there may cause a radial-nerve palsy (WRIST DROP). The Holstein–Lewis (distal spiral) fracture is classically associated.
- Radial-nerve palsy = loss of wrist, finger (MCP) and thumb EXTENSION + sensory loss over the dorsal first web space; grip is weak because the wrist cannot be stabilised.
- MOST humeral shaft fractures unite with CONSERVATIVE treatment: U-slab/hanging cast → functional (Sarmiento) brace.
- Surgery (plating/nailing) for: open, polytrauma, segmental, floating elbow, bilateral, pathological, vascular injury or non-union.
- Radial-nerve palsy present BEFORE reduction → OBSERVE (usually neurapraxia; splint and wait 3–4 months). Palsy appearing AFTER manipulation, or with an OPEN fracture → EXPLORE.
📚SOURCES: Maheshwari's Essential Orthopaedics; Apley & Solomon's System of Orthopaedics and Trauma; AO Principles of Fracture Management.The scaphoid receives its blood supply retrogradely, the vessels entering distally, so a fracture of the waist or proximal pole risks avascular necrosis and non-union of the proximal fragment. Snuffbox tenderness with a normal initial X-ray must be treated as a fracture until proven otherwise. IMPORTANCE AND MECHANISM
The scaphoid is the commonest carpal bone to fracture, typically in a young adult who falls on the outstretched, dorsiflexed hand. It matters because of its peculiar RETROGRADE blood supply: the nutrient vessels (from the radial artery) enter the bone distally and run proximally, so a fracture through the WAIST (the commonest site) or the PROXIMAL POLE deprives the proximal fragment of its blood supply — leading to avascular necrosis and non-union.
CLINICAL FEATURES AND THE DIAGNOSTIC PITFALL
The hallmark is tenderness in the ANATOMICAL SNUFFBOX, with pain on axial compression of the thumb and on wrist movement. The crucial pitfall is that the initial X-ray is frequently NORMAL even when a fracture is present. Therefore any patient with snuffbox tenderness after a fall is treated as having a scaphoid fracture: the wrist is immobilised in a scaphoid (thumb-spica) cast and the X-ray is repeated at 10–14 days (by which time bone resorption at the fracture line makes it visible), or an MRI is obtained for early definitive diagnosis.
MANAGEMENT
Undisplaced fractures are treated in a scaphoid (thumb-spica) cast for 6–12 weeks. Displaced fractures, and most proximal-pole fractures, are treated by internal fixation with a compression (Herbert) screw, which also allows earlier mobilisation. Complications are non-union, avascular necrosis of the proximal pole, and — if untreated — a pattern of secondary wrist osteoarthritis (SNAC wrist: scaphoid non-union advanced collapse).
🔑KEY POINTS TO REMEMBER- Commonest carpal fracture; FOOSH in a young adult; commonest site is the WAIST.
- RETROGRADE blood supply (vessels enter distally) → waist/proximal-pole fractures risk AVASCULAR NECROSIS and NON-UNION of the proximal fragment.
- Snuffbox tenderness with a NORMAL initial X-ray = treat as a fracture: scaphoid cast + repeat X-ray/MRI at ~2 weeks.
- Undisplaced → thumb-spica cast; displaced or proximal-pole → Herbert screw fixation. Untreated non-union → SNAC-wrist osteoarthritis.
📚SOURCES: Maheshwari's Essential Orthopaedics; Apley & Solomon's System of Orthopaedics and Trauma; AO Principles of Fracture Management.SMITH'S FRACTURE — THE 'REVERSE COLLES''
A Smith's fracture is a fracture of the distal radius with VOLAR (palmar/forward) displacement of the distal fragment — the exact opposite of a Colles' fracture, hence 'reverse Colles'. It results from a fall on the back of a flexed wrist (or a backward fall on the palm). It produces a 'garden-spade' deformity. Crucially, it is an UNSTABLE fracture that tends to redisplace in a cast, so although it can be reduced closed, it frequently requires operative fixation with a volar buttress (locking) plate.
BARTON'S AND CHAUFFEUR'S FRACTURES
A BARTON'S fracture is an INTRA-ARTICULAR fracture of the distal radius (the volar or dorsal rim) with SUBLUXATION or dislocation of the carpus along with the fragment — it is really a fracture-subluxation, is inherently unstable, and needs a buttress plate. A CHAUFFEUR'S (Hutchinson's) fracture is an intra-articular fracture of the RADIAL STYLOID, often from a ligamentous avulsion.
HOW THEY DIFFER FROM COLLES'
The distinction is essentially the direction of displacement and whether the joint is involved, which in turn determines stability and therefore treatment — the volar and intra-articular patterns are unstable and lean towards surgery, whereas the classic Colles' is often managed by reduction and a cast.
Fracture Displacement of distal fragment Deformity / nature COLLES' DORSAL (backward) + radial, impacted Extra-articular; 'dinner-fork' SMITH'S (reverse Colles) VOLAR (forward/palmar) 'Garden-spade'; unstable BARTON'S Intra-articular rim + subluxation of the carpus Volar or dorsal; a fracture-subluxation CHAUFFEUR'S Fracture of the radial STYLOID Intra-articular; ligament avulsion ⚠️The practical message: a VOLAR-displaced (Smith's) or an intra-articular fracture-subluxation (Barton's) is UNSTABLE and usually needs a volar buttress plate — do not expect a plaster cast to hold it.Direction of displacement of the distal fragment names the fracture. 🔑KEY POINTS TO REMEMBER- SMITH'S = distal radius fracture with VOLAR displacement ('reverse Colles'), from a fall on the flexed wrist; 'garden-spade' deformity; UNSTABLE → usually volar plate.
- BARTON'S = intra-articular rim fracture of the distal radius with SUBLUXATION of the carpus (a fracture-subluxation) → buttress plate.
- CHAUFFEUR'S (Hutchinson's) = intra-articular fracture of the RADIAL STYLOID.
- Direction of displacement (dorsal vs volar) and joint involvement determine stability and treatment; Colles' (dorsal, extra-articular) is often cast, the others often need fixation.
📚SOURCES: Maheshwari's Essential Orthopaedics; Apley & Solomon's System of Orthopaedics and Trauma; AO Principles of Fracture Management.SITE AND MECHANISM
The clavicle is one of the most commonly fractured bones, and the commonest site is the junction of the middle and outer thirds — the point where the bone changes its curvature and is weakest. The usual mechanism is a fall on the outstretched hand or on the point of the shoulder (rarely a direct blow). In children it is a frequent birth injury and a common greenstick fracture.
CLINICAL FEATURES
The patient supports the arm and tilts the head towards the injured side to relax pull on the muscles. There is a visible and palpable prominence at the fracture, with the medial fragment pulled UP by sternocleidomastoid and the lateral fragment pulled DOWN by the weight of the arm. Although rare, the underlying subclavian vessels and the brachial plexus must be checked, and the skin inspected for tenting.
MANAGEMENT
The great majority are treated conservatively — a broad arm sling (or a figure-of-eight bandage) for comfort, for about 3 weeks, followed by mobilisation. The clavicle unites reliably, and even a moderate bump usually remodels and causes no functional loss. Operative fixation (a plate) is reserved for: an OPEN fracture, neurovascular injury, skin tenting/threatened skin, severe displacement or marked shortening, a 'floating shoulder' (with a scapular neck fracture), and established non-union.
COMPLICATIONS
These are uncommon but examinable. MALUNION (with a visible bump and, if there is marked shortening, some functional loss) is the most frequent. NON-UNION is rare and is seen mainly after severely displaced or comminuted fractures, open injuries and over-vigorous early movement. Neurovascular injury to the underlying subclavian/axillary vessels and the brachial plexus, and injury to the apex of the lung (pneumothorax), are rare but serious and must be excluded in a high-energy injury. Late compression of the neurovascular bundle by exuberant callus (thoracic-outlet-type symptoms) can occur.
💡A visible lump after a healed clavicle fracture is callus, not a failure of treatment — it usually remodels over months, and the parents of a child (or an anxious adult) can be reassured. Function, not the radiograph, is what matters.Sternocleidomastoid elevates the medial fragment. 🔑KEY POINTS TO REMEMBER- Commonest site = junction of the middle and outer thirds; usual mechanism is a FOOSH or a fall on the point of the shoulder.
- Medial fragment is pulled UP by sternocleidomastoid, lateral fragment pulled DOWN by the arm's weight; the patient tilts the head to the injured side.
- MOST are treated conservatively with a sling/figure-of-eight for ~3 weeks; union is reliable and a bump remodels.
- Surgery for: open fracture, neurovascular injury, threatened/tented skin, severe displacement or shortening, floating shoulder, or non-union.
📚SOURCES: Maheshwari's Essential Orthopaedics; Apley & Solomon's System of Orthopaedics and Trauma; AO Principles of Fracture Management.PRINCIPLE
Every upper-limb fracture carries a risk to a specific nerve because of the close anatomical relationship of nerve to bone. Recognising the pattern of motor and sensory loss localises the lesion and guides whether to observe or explore. Most closed traction (neurapraxia) injuries recover; a deficit appearing after manipulation, or with an open or penetrating wound, is explored.
Nerve Typical injury Motor loss / deformity Sensory loss RADIAL Humeral shaft fracture; 'Saturday-night' palsy WRIST DROP — loss of wrist/finger/thumb extension Dorsal first web space MEDIAN Supracondylar fracture; wrist laceration; carpal tunnel 'Ape thumb' (loss of opposition); 'pointing index' on making a fist Radial 3½ digits (palmar) ULNAR Medial epicondyle fracture; elbow/wrist injury 'Claw hand' (ulnar 2 fingers); wasting of intrinsics Ulnar 1½ digits BEDSIDE TESTS WORTH KNOWING
RADIAL: ask the patient to extend the wrist and fingers — a wrist drop is unmistakable; sensation is tested in the dorsal first web space. MEDIAN: test abduction/opposition of the thumb (abductor pollicis brevis); the 'pointing index' appears on trying to make a fist (the index cannot flex); Ochsner's clasp test. ULNAR: Froment's sign (the patient flexes the thumb IP joint to grip paper because adductor pollicis is weak) and the card (Egawa) test for the interossei; a low ulnar lesion gives a more marked claw (the 'ulnar paradox').
GRADING AND RECOVERY (SEDDON)
The prognosis depends on the severity of the nerve injury, described by Seddon: NEURAPRAXIA (a conduction block from stretch or pressure — the commonest, and it recovers fully in days to weeks), AXONOTMESIS (axons divided but the sheath intact — recovers slowly by axonal regrowth at roughly 1 mm/day), and NEUROTMESIS (the nerve is completely divided — it will not recover without surgical repair). A closed traction injury is usually neurapraxia or axonotmesis and is watched, with splinting to prevent contractures and physiotherapy to keep the joints supple; recovery is monitored clinically (an advancing Tinel's sign) and by nerve-conduction studies at about 6 weeks if there is doubt.
⚠️A nerve deficit that appears AFTER manipulation of a fracture, or one that accompanies an open or penetrating wound, should be explored — the nerve may be trapped or divided. A deficit present at the time of a closed injury is usually a neurapraxia and is observed.Level of the lesion determines which muscles escape. 🔑KEY POINTS TO REMEMBER- RADIAL → humeral shaft fracture → WRIST DROP + sensory loss over the dorsal first web space.
- MEDIAN → supracondylar fracture / carpal tunnel → 'ape thumb', 'pointing index', loss of thumb opposition; sensory loss over the radial 3½ digits.
- ULNAR → medial-epicondyle / elbow injury → 'claw hand' of the ulnar two fingers, wasted intrinsics, Froment's sign positive; sensory loss over the ulnar 1½ digits.
- Most closed (neurapraxia) injuries recover; a deficit appearing AFTER manipulation, or with an open wound, is EXPLORED.
📚SOURCES: Maheshwari's Essential Orthopaedics; Apley & Solomon's System of Orthopaedics and Trauma; AO Principles of Fracture Management.THE INJURY AND THE NEER CLASSIFICATION
Fractures of the proximal humerus are common in the elderly osteoporotic patient after a fall on the outstretched hand, and in younger patients after high-energy trauma. They are classified by NEER, which divides the proximal humerus into FOUR anatomical 'parts' — the humeral head (articular segment), the greater tuberosity, the lesser tuberosity and the shaft. A 'part' counts as displaced only when it is separated by more than 1 cm OR angulated more than 45°. The fracture is then described as one-, two-, three- or four-part, which reflects both the severity and the risk to the head's blood supply.
CLINICAL FEATURES AND ASSESSMENT
There is pain, swelling and bruising (which characteristically tracks down the arm and chest wall a few days later), with restricted, painful shoulder movement. The AXILLARY NERVE must be tested (regimental-badge sensation), as it is at risk. Imaging is with an AP and an axillary or scapular-Y view (CT for complex patterns).
MANAGEMENT
The majority are minimally displaced (one-part) and are treated CONSERVATIVELY — a collar-and-cuff or sling, with early pendulum exercises within 1–2 weeks to prevent a stiff shoulder. Displaced two- and three-part fractures are often treated by internal fixation (locking plate or intramedullary nail). Four-part fractures and head-splitting fractures in the elderly, in which the head's blood supply is lost, are treated by arthroplasty (hemiarthroplasty or reverse total shoulder replacement).
COMPLICATIONS
AVASCULAR NECROSIS of the humeral head is the most important — its risk rises with the number of parts (highest in four-part and head-splitting fractures), because the anterior circumflex humeral artery and its ascending branch, which supply the head, are torn. Shoulder STIFFNESS is the commonest problem overall and is why early pendulum exercises matter. Others are MALUNION (especially of the greater tuberosity, causing impingement), axillary-nerve injury, and non-union.
💡The bruising that tracks down the arm and onto the chest wall a few days after the injury alarms patients but is expected — it is simply the fracture haematoma gravitating under the skin, not a sign of a new problem.Most are minimally displaced and treated conservatively. Part Structure 1 Humeral head (articular segment) 2 Greater tuberosity 3 Lesser tuberosity 4 Humeral shaft Criterion for a 'part' Displaced more than 1 cm OR angulated more than 45° 🔑KEY POINTS TO REMEMBER- Common in elderly osteoporotic patients after a FOOSH; test the AXILLARY NERVE.
- NEER classification uses FOUR parts — head, greater tuberosity, lesser tuberosity, shaft — a part being 'displaced' if >1 cm apart or >45° angulated.
- MOST are minimally displaced (one-part) → conservative (sling + early pendulum exercises to avoid stiffness).
- Displaced 2/3-part → internal fixation (locking plate/nail); 4-part or head-splitting in the elderly → arthroplasty.
📚SOURCES: Maheshwari's Essential Orthopaedics; Apley & Solomon's System of Orthopaedics and Trauma; AO Principles of Fracture Management.MECHANISM AND CLINICAL FEATURES
Injuries of the acromioclavicular (AC) joint usually follow a fall directly onto the point of the shoulder with the arm adducted. There is tenderness and swelling over the AC joint, and in higher grades a visible 'step' deformity as the outer end of the clavicle rides upward. The 'piano-key' sign — the clavicle springs back up when pressed down — indicates disruption. Stability depends on two ligament groups: the acromioclavicular ligaments (horizontal stability) and the coracoclavicular ligaments (vertical stability).
CLASSIFICATION AND MANAGEMENT (ROCKWOOD)
The Rockwood classification grades the injury by which ligaments are torn and the degree of displacement, and this determines treatment.
Rockwood type Ligament injury Treatment I AC ligament sprain only; joint stable Conservative — sling, analgesia II AC ligaments torn, coracoclavicular (CC) intact; slight subluxation Conservative III Both AC and CC torn; clavicle rides up Controversial — usually conservative; surgery for high-demand patients IV–VI Severe displacement (posterior / marked superior / inferior) Operative reconstruction IMAGING
An AP view of both shoulders allows comparison of the coracoclavicular distance and the joint alignment with the normal side; an increase indicates a torn coracoclavicular ligament (type III or above). Weighted ('stress') views, once used to unmask subtle subluxation, are now rarely needed. Higher-grade or posteriorly displaced (type IV) injuries may need an axillary view or CT to define the displacement.
PRINCIPLE OF TREATMENT
Low-grade injuries (I–II) are treated conservatively with a sling and early mobilisation, and the great majority do well. Type III is controversial and most are managed non-operatively — a residual bump may persist but function is usually good — with surgery reserved for young, athletic or heavy-manual patients. The severe types (IV–VI) require operative reduction and reconstruction of the coracoclavicular ligaments.
Grades I–II conservative; higher grades may need fixation. 🔑KEY POINTS TO REMEMBER- AC joint injury follows a fall onto the point of the shoulder; features are AC tenderness, a 'step' deformity and a positive 'piano-key' sign.
- Stability = AC ligaments (horizontal) + coracoclavicular ligaments (vertical).
- Rockwood I–II (CC ligaments intact) → conservative. Type III (both torn) → usually conservative, surgery for high-demand patients.
- Rockwood IV–VI (severe displacement) → operative reconstruction.
📚SOURCES: Maheshwari's Essential Orthopaedics; Apley & Solomon's System of Orthopaedics and Trauma; AO Principles of Fracture Management.WHAT IT IS
'Pulled elbow' (nursemaid's elbow) is a subluxation of the head of the radius from under the annular ligament, occurring almost exclusively in young children aged about 1–4 years. The mechanism is a sudden longitudinal pull (traction) on the PRONATED forearm — classically a carer lifting or swinging the child by the hand, or a sudden tug. At this age the radial head is small and not yet fully formed, so it slips out from the annular ligament, which then becomes partly interposed in the joint.
CLINICAL FEATURES
The child suddenly refuses to use the arm and holds it slightly flexed and PRONATED, and cries if it is moved. There is usually no swelling, no deformity and no bruising, and often no clear history of a fall — which is the key point that distinguishes it from a fracture. Tenderness, if any, is over the radial head. Because the picture is so benign, radiographs are usually normal and are not routinely required when the history is typical.
WHY IT HAPPENS ONLY IN SMALL CHILDREN
The injury is confined to this age group for an anatomical reason: in the toddler the radial head is still largely cartilaginous and almost the same width as the radial neck, so the annular ligament that encircles the neck can slip up over the head when the arm is pulled. As the child grows, the radial head enlarges and becomes bulbous, and the ligament can no longer ride over it — which is why pulled elbow essentially disappears after the age of about five.
MANAGEMENT
Treatment is a simple closed reduction manoeuvre: the elbow is held and the forearm is fully SUPINATED and then flexed (alternatively, hyperpronation), during which a click is often felt over the radial head. The child starts using the arm again within minutes, and no immobilisation is needed. Parents should be reassured but advised to avoid pulling the child by the hand, as recurrence is common until the child is older.
⚠️If there IS a history of a fall, swelling or point tenderness over bone, do NOT assume a pulled elbow — obtain radiographs to exclude a supracondylar or other fracture before manipulating the elbow.Supination-flexion manoeuvre reduces it instantly. 🔑KEY POINTS TO REMEMBER- Pulled (nursemaid's) elbow = subluxation of the radial head from under the annular ligament, in a child 1–4 years old.
- Mechanism: a sudden longitudinal PULL on the PRONATED forearm; the child refuses to use the arm and holds it flexed and pronated, with NO swelling or deformity.
- X-rays are usually normal and not needed with a typical history; obtain them if there is a fall, swelling or bony tenderness (to exclude a fracture).
- Reduce by SUPINATION + flexion (or hyperpronation) — a click is felt, the child uses the arm within minutes, and no immobilisation is required.
📚SOURCES: Maheshwari's Essential Orthopaedics; Apley & Solomon's System of Orthopaedics and Trauma; AO Principles of Fracture Management.