ORTHOPAEDIC
CASE 65: a Fall onto the outStretCheD hanD
history
A 76-year-old woman is brought to the emergency department having fallen on some ice. She remembers slipping over and stretching out her right hand in order to ‘save her fall’. She describes significant pain around her right wrist. Fortunately, her only other injury is a minor graze on her forehead. She says she has previously had a heart attack in her 60s. She takes atenolol, ramipril, simvastatin and aspirin. She also has a history of essential hypertension and she had a hysterectomy for menorrhagia when she was 40 years old. She is the sole caregiver for her husband who suffered a stoke 2 years ago and is bed-bound. She is anxious to get back home to look after him.
examination
Her vital observations are stable. She has an obvious deformity of her right wrist. There is already bruising evident. There is no distal neurovascular deficit.
INVESTIGATIONS
anterior-posterior (ap) and lateral x-rays of her wrist have been performed and are shown in Figure 65.1.
Figure 65.1 plain x-rays of the right wrist.
Questions
•What injury has this woman sustained?
•How should it be managed?
•Are there any other considerations before this woman is sent home?
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100 Cases in Surgery
ANSWER 65
This woman has sustained a Colles’ fracture. This term is often applied to any distal radial fracture. The correct definition of this injury comes from Abraham Colles in 1814, who originally described a low-energy extra-articular fracture of the distal radius occurring in elderly individuals. The typical mechanism of injury has been given in this scenario, which is a fall on the outstretched hand resulting in forced extension at the wrist. The distal fragment is dorsally angulated and displaced, giving a ‘dinner-fork deformity’ appearance (arrows in Figure 65.2).
Figure 65.2 Colles’ fracture (anteriorposterior and lateral).
As with all injuries, it is important to assess the distal neurovascular status. In this injury, it is not uncommon to develop symptoms associated with compression of the median nerve.
A Colles’ fracture can usually be managed by closed reduction and immobilization. A number of techniques have been described. Adequate analgesia can be provided locally with lidocaine injected into the fracture site, a so-called haematoma block, or regional anaesthesia is used.
The latter is thought to provide better pain control as well as allowing more accurate fracture reduction and a better functional outcome.
To achieve fracture reduction, the distal fragment is further dorsally angulated in order to disengage it from the fracture site. Longitudinal traction is then applied while trying to manipulate that fragment in a distal and volar direction, thereby restoring the normal position and length to the radius. A backslab is applied with the wrist held in slight flexion and ulnar deviation. X-rays should be performed to check that there has been an adequate fracture reduction. The patient should be brought back to the fracture clinic in a few days in order to complete the cast and check that the fracture has not slipped out of position.
This case also illustrates the secondary consequences of significantly injuring a limb. It is unlikely that this woman will be able to cope at home, looking after her incapacitated husband. Most hospitals and general practitioners (GPs) have access to a ‘rapid response team’, which is ideally suited to provide extra community-based social, nursing and physiotherapy support on a short-term basis.
KEY POINT
• in all fractures the distal neurological and vascular status should be assessed.
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Orthopaedic
CASE 66: ChroniC Knee pain
history
A 67-year-old woman presents to her GP with a history of progressive pain affecting her left knee. Over the past 3 months she has required increasing amounts of painkillers to control the pain. The pain gets worse throughout the day, particularly if she has been very active, and it often keeps her awake at night. There is no history of significant trauma and she denies any other joint symptoms. She is otherwise fit and does not take any regular medication other than analgesics.
examination
Examination of her left knee demonstrates a moderate swelling with a palpable effusion. The medial joint line is tender. The passive range of movement, which is painful, is restricted to an arc of 75°, and crepitus is felt throughout. The knee is intrinsically stable. The hip and ankle joints both have a full pain-free range of movement, and examination of her back is normal.
INVESTIGATIONS
an x-ray of the knee is taken, and is shown in Figure 66.1.
Figure 66.1 plain x-ray of the left knee.
Questions
•What is the diagnosis?
•What are the typical x-ray findings in this condition?
•What are the treatment options?
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100 Cases in Surgery
ANSWER 66
The AP radiograph of the left knee demonstrates osteoarthritis (Figure 66.2).
Figure 66.2 osteoarthritis of the left knee (anterior-posterior).
The characteristic radiological features of osteoarthritis in any joint are:
•Reduction in joint space
•Osteophytes
•Subchondral cyst formation
•Periarticular sclerosis
In this x-ray there is loss of the joint space on the medial side and periarticular sclerosis (arrow in Figure 66.2).
Primary osteoarthritis is a common degenerative condition predominantly affecting the elderly population. The condition typically affects the weight-bearing joints, i.e. knee, hip, cervical and lumbar spine, and ankle. The other common sites are the distal interphalangeal joints of the hands.
Radiological evidence of osteoarthritis is common, with 80 per cent of individuals over 80 years demonstrating some evidence of the condition. The symptoms of the disease do not, however, directly correlate with the radiological findings. A significant number of individuals remain symptom-free despite radiographs showing extensive joint destruction. The commonest symptoms are pain, a reduction in mobility, and deformity of the affected joint. Diagnosis is made on a combination of clinical and radiological grounds. It is important when assessing the patient to examine the joints above and below as referred pain must be considered. Blood tests add little value if the history is typical.
Management is wide ranging and crosses many disciplines. Surgical intervention should be considered if conservative measures fail and the condition significantly impairs the patient’s quality of life.
•Physiotherapy: muscle-strengthening exercises, walking aids
•Occupational therapy: handrails, stairlifts, kitchen aids
•Medical treatment (non-invasive): simple analgesics, non-steroidal anti-inflammatory drugs
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Orthopaedic
•Medical treatment (invasive): steroid joint injection, hyaluronan injections
•Surgical intervention: arthroscopy, osteotomies, arthroplasties
KEY POINTS
•osteoarthritis primarily affects the weight-bearing joints.
•management requires a multi-disciplinary team approach.
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