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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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Orthopaedic

CASE 67: SuDDen CalF pain

history

A 31-year-old man attends the emergency department complaining of pain affecting his left calf. He was playing squash when he suddenly felt as though he had been hit on the back of the ankle. A loud snapping sound accompanied the pain.

examination

Examination of the left foot and ankle reveals no obvious deformity. There is tenderness over the calf and posterior aspect of the ankle. There is a full passive range of movement of the foot, ankle and knee joints. There are normal foot pulses, and neurological examination is unremarkable.

Figure 67.1 normal leg being tested.

Questions

•What clinical test is being demonstrated on a normal leg in Figure 67.1?

•What is the likely diagnosis in this patient?

•What investigation can be performed if the diagnosis is in question?

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100 Cases in Surgery

ANSWER 67

The clinical test that is being demonstrated is the ‘Simmonds test’. It describes the absence of ankle plantar flexion when the calf is compressed. This picture demonstrates normal plantar flexion with calf compression on the right leg.

Failure of plantar flexion indicates that the patient has ruptured his Achilles tendon. The history of sudden pain affecting the calf during sporting activity is typical. Other examination findings may include a palpable gap in the Achilles tendon and an inability to actively plantar flex the ankle (i.e. the patient is unable to stand on ‘tip-toes’). The latter feature may be misleading, as the deep flexors of the foot can compensate for this movement.

An ultrasound scan can confirm a gap in the Achilles tendon when the diagnosis is in doubt. Serial ultrasound scans can also be used to assess healing of the tendon. There is debate as to the best way to treat this injury. Non-surgical management involves immobilizing the leg in a plaster of Paris cast, with the foot initially in full plantar flexion. While this avoids the risks of surgery, it delays functional rehabilitation and results in a greater risk of the tendon re-rupturing. The tendon can be repaired surgically, which is thought to result in a stronger tendon repair. This may be more appropriate for patients who require a greater level of sporting activity.

KEY POINTS

•ultrasound can be used to detect damage to the achilles tendon.

•Simmonds test is diagnostic of an achilles tendon rupture.

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Orthopaedic

CASE 68: leFt Knee injury

history

A 22-year-old woman is brought to the emergency department by ambulance. Her friend says that they had been out drinking and that she had fallen off a 4-foot wall, landing directly on her left knee. Her knee swelled up immediately and she has not attempted to walk since the injury. She is normally fit and healthy. She takes a combined oral contraceptive pill, smokes 10–20 cigarettes a day and works in a supermarket.

examination

Her observations are normal. There is no evidence of a head injury. Her left knee is diffusely swollen and there is evidence of bruising. The skin is intact. The medial and lateral joint lines are not tender. The patient is unable to actively extend the knee. The knee feels otherwise stable. The hip and ankle joints are unremarkable, and the pedal pulses and foot sensation are normal.

INVESTIGATIONS

plain x-rays of the left knee are taken and are shown in Figures 68.1 and 68.2.

Figure 68.2 plain x-ray of the left knee.

Figure 68.1 plain x-ray of the left knee.

Questions

•What injury has this woman sustained?

•How should it be managed?

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100 Cases in Surgery

ANSWER 68

The x-rays show that the patient has a fractured patella (arrows in Figures 68.3 and 68.4).

Figure 68.4 patella fracture (lateral).

Figure 68.3 patella fracture (anterior-posterior).

This type of fracture typically occurs with direct trauma to the knee. It is possible, however, to sustain a similar injury by an indirect mechanism, such as by vigorous jumping that leads to rapid flexion of the knee against a fully contracted quadriceps muscle. An indirect injury tends to result in less displacement and comminution of the fracture.

The patella is a large sesamoid bone. The upper border is connected to the quadriceps tendon and the lower pole is connected to the patella tendon, which inserts into the tibial tuberosity. In order to actively extend the knee, the whole unit must remain in continuity. It is, therefore, very important when examining knee injuries to ensure the extensor mechanism is intact by feeling for any palpable gap and by getting the patient to actively extend the knee.

Patella fractures can be managed conservatively or operatively. If the extensor mechanism is disrupted and/or there is a greater than 3 mm gap in the fracture site, surgical fixation is often necessary. If the extensor mechanism is intact and there is a small gap in the fracture site, more common with the indirect injuries, then a cylinder plaster of Paris cast is more appropriate.

It is worth noting that a bipartite patella occurs in 1 per cent of the population, and it is not uncommon for patients to be misdiagnosed with a patella fracture. The diagnosis of a patella fracture is supported if there is a plausible mechanism of injury and the appropriate examination findings are present.

KEY POINT

•bipartite patella occurs in 1 per cent of the population, and can be mistaken for a patella fracture.

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