CHAPTER 1
General Overview

Kapil Sugand1,2, Anita Khurwal2, and Chinmay M. Gupte1,3

1 MSk Lab, Charing Cross Hospital, Imperial College London, London, UK

2 North West London Rotation, London, UK

3 Imperial College Healthcare NHS Trust, London, UK

OVERVIEW

• Orthopaedics is one of the oldest surgical practices since ancient civilisations.
• With an ever‐growing and ageing population, there is a greater global clinical burden of trauma and elective orthopaedics.
• Fracture classifications can help with management plans, either nonoperative or operative treatment.
• Poor management of fractures and dislocations can lead to loss of function, long‐term disability, and chronic pain, as well as deterioration in quality of life.

Introduction

Trauma and orthopaedics is an ancient practice of surgery. Records from Ancient Egypt, for example, document the splintage of fractures, wound care, and the reduction of shoulder dislocation. The art and skill of managing musculoskeletal injuries depends on adequate history, thorough examination, patient selection, and meticulous operative technique. Orthopaedic surgeons are trained not only to manage fractures but also to treat deep‐seated infection, degenerative disease, tumours, and congenital deformities, as well as the repair of soft tissue like muscles, nerves, tendons, ligaments, and minimally invasive access surgery.

Epidemiology

There is an increasing demand for orthopaedic surgeons, owing to an ever‐growing population. Immigration patterns and an ageing population have further contributed to the clinical burden worldwide. The World Health Organisation (WHO) predicts that by 2020, trauma will be the third most common cause for the global burden of disease, and that one in two people in the world will require at least one orthopaedic procedure in their lifetime. Trauma services have been centralised in more economically developed countries, where specialist centres manage complex trauma effectively. However, there is a discrepancy in the infrastructure of the trauma services in less economically developed countries, which leads to increased mortality and chronic disability rates, which are potentially avoidable. Furthermore, specific registries have collated information including demographics, indications and complications, in order to improve the orthopaedic service provided to patients.

Definitions

Trauma and orthopaedics, like any other speciality, has its own jargon and terminology. There are 300 bones in newborns and 206 in adults, divided into the midline axial skeleton (head, spine, ribs, and pelvis) and the appendicular skeleton (limbs), seen in Figure 1.1a. Movements of the body are seen in Figure 1.1b.

Some popular terms include the following:

• Trauma: any injury, bony or soft tissue
• Joint: articulation between two or more bones
• Arthro‐: related to a joint
• Arthrocentesis: joint aspiration
• Arthroscopy: insertion of a minimally invasive camera into a joint
• Arthroplasty: joint reconstruction
• Arthrodesis: joint fusion
• Displacement: deviation of fracture fragment from original anatomical site
• Intra‐/extra‐articular: inside/outside joint
• Stable fractures: those able to withstand physiological loading, without further displacement (usually extra‐articular and minimally displaced)
• Open fracture: bone breaching soft tissue and skin, to be in contact with outside environment (as opposed to closed)
• Revision surgery: successive surgical attempts at achieving the desired result

Figure 1.1 (a) Human skeleton and (b) movement of the body

History

Taking a thorough history is the cornerstone of medical practice. It is important that as much information as possible about the patient’s symptoms and medical background is ascertained, in order reach a list of differential diagnoses and to offer optimal management options. It is said that 80% of the diagnosis is within the medical history. An orthopaedic approach to history taking is seen in Table 1.1.

Table 1.1 Orthopaedic history

Age Occupation and dominant side Pain (mnemonic – SOCRATES) Site Onset – sudden vs. progressively worsening? Character – sharp, dull, ache, stinging? Radiation Associations – any trauma, fever, swellings? Timing – at rest, night pain, constant or intermittent? Exacerbating/relieving factors – what position makes the pain better/worse? Severity – grade out of 10? Associated symptoms Stiffness, snapping, clicking, squeaking, deformity, numbness, weakness, locking, giving way, swelling Function How far can patient walk on a flat surface? Difficulty with stairs? Need any walking aids? Can patient participate in sports? Is patient able to work? Past medical and surgical history History of trauma Other joints affected Treatments already given (e.g. injection, physiotherapy etc.) Systems review Family history Social history

Examination

A systematic examination is essential in orthopaedic practice. The impression gained from the history is tested and further information is ascertained. The management options, and whether surgical intervention is necessitated, depends on the extent of disease and its consequent functional limitation and quality of life. As the idiom goes, a good surgeon knows when to operate, but the best surgeon knows when not to operate. The general principles of examining in orthopaedics are to (1) look, (2) feel, and (3) move as well as any (4) special tests (Figure 1.2).

Figure 1.2 Orthopaedic examination

Reading radiographs

Regardless of speciality, all doctors and medical students are expected to interpret basic orthopaedic plain radiographs (do not refer to them as X‐rays). Competency in reading radiographs is based on the following six points of information:

1. Anatomical site: which bone and which part of bone? Long bones are divided into proximal, middle, and distal thirds.
2. Number of fragments: simple (two‐part) vs. multifragmentary (formerly referred to as comminuted).
3. Fracture pattern: transverse vs. oblique (>30°) vs. spiral.
4. Is the fracture displaced vs. undisplaced (Figure 1.3)?
5. Is the fracture translated/ angulated/ rotated?
6. Extent of displacement/angulation/rotation/tilt in X/Y/Z planes.

Figure 1.3 Displacement in three planes

Examples of presenting radiographs

Figure 1.4 is “an AP and lateral radiograph of the right tibia and fibula of [patient name] taken on [date] at [time]. There is a two‐part transverse fracture of the junction between middle and distal third of the tibia, with 15% anterolateral translation and 10° angulation in the x plane.”

Figure 1.4 AP and lateral radiograph of the right tibia and fibula

Figure 1.5 is “an AP and lateral radiograph of the right tibia and fibula of a skeletally immature (growth plates present and not fused) patient, named [patient name], taken on [date] at [time]. There is a displaced multifragmentary fracture of the fibula and a minimally displaced two‐part oblique fracture of the tibia, both at the junction of middle and distal thirds of the diaphysis. Both have 20° valgus angulation and anterior tilt.”

Figure 1.5 AP and lateral radiograph of the right tibia and fibula of a skeletally immature patient

Note that angulation and translation is always described of the distal fragment, relative to the proximal fragment. Look for fracture dislocations near joints. Valgus refers to deviation away from the midline in the coronal plane, whereas varus is towards the midline. Malrotation is more common in the shoulder, hip, and ankle.

An aide‐memoire is vaLgus is Lateral to midline.

Common fracture classifications

There are numerous fracture classifications (Table 1.2) to describe the severity of injury, energy of trauma, and to guide your management options. Each classification has an eponymous name, often of the surgeon who developed it. The ideal classification describes the severity of injury in terms of anatomy, displacement, stability, and prognosis. Since most fall short of this ideal, it is up to the orthopaedic surgeon to not simply follow guidelines but to deliver optimal healthcare with a patient‐centred approach. It is the duty of every surgeon to offer the right treatment, to the right person, at the right time, and in the right place.

Table 1.2 Common fracture...