EXAMINER: A 38-year-old left-hand dominant lady fell on to her right arm when out drinking and attended the accident and emergency department the next day at 4 pm as the pain in the right shoulder had not settled down. These are the X-rays of her right shoulder (Figure 12.1a). What is your diagnosis?

CANDIDATE: Anterior dislocation of the right shoulder with an associated greater tuberosity (GT) fracture. Complete loss of joint congruence is demonstrated on the AP view, while the anterior displacement is best demonstrated on the axial view. There is no visible evidence of fracture through the anatomical neck, although this occurs in about 10% of cases. This pattern of injury is more in keeping with this patient’s age than surgical neck fracture, which is more typically seen in an older demographic.¹

EXAMINER: How will you manage this condition?

CANDIDATE: Assess the patient according to ATLS protocol and exclude any neurovascular injury because brachial plexus injury is part of a recognized pattern comprising the ‘terrible triad’ of the shoulder.² If there was suspicion of an undisplaced neck fracture, I would obtain an emergency CT to confirm and then plan for open reduction and fixation of both the neck and GT fractures. I would perform a neurovascular examination of the shoulder and document my findings in the case notes before attempting manipulation. I would reduce the shoulder dislocation under sedation using the scapular manipulation technique, as this is the most successful and least painful method with no reported incidences of fracture. This involves the patient lying prone with a weight applied to the arm while the tip of the scapula is rotated medially and upward. I would immobilize the limb in a shoulder immobilizer. After manipulation I would obtain anteroposterior and axial radiographs and repeat a neurovascular examination of the involved limb.

EXAMINER: What are the risks and complications you anticipate?

CANDIDATE: During reduction there is a risk of displacing an unseen humeral neck fracture or propagating the GT fracture through the neck. Other risks are injury to axillary nerve and artery, brachial plexus and rotator cuff injury.³

EXAMINER: Attempted closed reduction in the accident and emergency department has failed and it is 7 pm now. What will you do next?

CANDIDATE: I will take into account availability of space on the emergency list, presence of neurological symptoms, the patient’s level of pain and level of anaesthetic risk. If it is safe and within a reasonable time frame, I would take the patient for closed reduction under general anaesthetic. After reduction I would reassess the neurovascular status. If there was a new neurovascular deficit, this may be due to nerve entrapment. In this situation, I would plan for a shoulder surgeon to explore the nerve and perform an open reduction in the morning. If there was going to be a delay in taking the patient to theatre for reduction, as long as there was no neurovascular compromise I would plan for emergent reduction and/or fixation by a shoulder surgeon on the next available list.

EXAMINER: What manoeuvre would you perform to achieve shoulder reduction?

CANDIDATE: Under complete muscle relaxation, I will use the traction/countertraction method given that scapular manipulation has failed. This is the second most effective technique and the associated discomfort will not be felt by the anaesthetized patient.⁴ Because failure of reduction may be due to head impaction on the anterior glenoid, this technique also allows controlled external rotation to disengage this.

EXAMINER: What other factors may prevent a closed stable reduction of the dislocation?

CANDIDATE: A large rotator cuff tear or axillary nerve injury may prevent the shoulder from remaining in joint. On occasion, the long head of the biceps may get caught up posterior to the humeral head and prevent reduction. The stability of the joint may also be affected by a structural deficit such as a bony or soft-tissue Bankart lesion or a Hill–Sachs lesion.

EXAMINER: Next day in theatre, closed reduction is achieved (Figure 12.1b). What will you do next?

CANDIDATE: I will assess the greater tuberosity fracture reduction. If it is less than 5 mm superiorly displaced, I will treat it non-operatively with a polysling for 3 weeks with serial X-rays on a weekly basis and if there is no fracture displacement, I will start shoulder mobilization under physiotherapy care.⁵

EXAMINER: X-ray of right shoulder one week later is shown in Figure 12.1c. What will you do?

CANDIDATE: I will arrange a CT scan of the shoulder to assess the degree and direction of displacement as this is useful in borderline cases.⁶

EXAMINER: The CT scan (Figure 12.1d) of the right shoulder shows no humeral neck fracture but significant displacement of the greater tuberosity. What will be your management strategy?

CANDIDATE: If the greater tuberosity fragment has posterosuperior displacement more than 5 mm,⁷ I would offer the patient reduction and fixation. Arthroscopic fixation with a double row of anchors may be possible – it is less invasive than ORIF and has demonstrated superior postoperative range of motion.⁸

EXAMINER: What are the risks of non-operative management of displaced greater tuberosity fracture?

CANDIDATE: Non-union, malunion, which effectively narrows the subacromial space, leading to mechanical impingement and consequent rotator cuff atrophy.⁹

EXAMINER: A 24-year-old man fell down the last few steps of a flight of stairs and sustained an injury to his right wrist. His X-rays are shown in Figure 12.2a. What is this injury?

CANDIDATE: There is a displaced radial styloid fracture, which is classically termed a ‘chauffeur’s fracture’.³⁹ In addition, there is radiocarpal dislocation. This is demonstrated by more than 50% of the lunate having subluxed ulnarly from its fossa. This pattern would be classified by AO as type B2.3 and its pathomechanism is suggested to be an avulsion of the styloid by the radioscaphocapitate ligament.¹⁰ On these images there is no visible scaphoid fracture or evidence of scapholunate ligament disruption; however, this would be a common association.

EXAMINER: What other injuries have occurred in addition to the radial styloid fracture?

CANDIDATE: Rupture of volar capsule and radiolunate ligaments, while the radial collateral and volar radiocarpal ligaments are attached to the fragment, allows subluxation of the radiocarpal joint.¹¹ The distal part of the brachioradialis insertion is typically 17 mm from the tip; therefore, with this relatively distal fracture, there is no stabilizing force from the brachioradialis.¹²

EXAMINER: How will you manage this injury?

CANDIDATE: Assuming it is an isolated closed injury, I will attempt closed reduction under sedation in casualty, apply a below-elbow moulded dorsal plaster slab, check the distal neurovascular status and get a repeat X-ray of the wrist. Given that this is a type B injury with a high-energy mechanism, I would also arrange a CT to assess for any associated carpal fracture as well as articular reduction.¹³

EXAMINER: Figure 12.2b shows a post reduction X-ray. How will you manage this injury?

CANDIDATE: Post reduction X-rays show that the fracture is well reduced, and the radiocarpal alignment is satisfactory. Given that the CT demonstrated < 2 mm articular disruption, no carpal fracture and radiocarpal congruency, I would treat this in a moulded plaster and weekly radiographic follow-up. If there was evidence of instability, I would offer ORIF of the radial styloid alone, as this should restore radiocarpal stability.¹⁴ If there was evidence of further instability, repair of volar radiocarpal ligaments may be necessary. Neurovascular decompression, joint debridement and management of inter- and transcarpal injuries may also be addressed.

EXAMINER: A motor bike rider came off his bike at around 80 miles/hour and has sustained an isolated injury to his right elbow. X-rays in casualty are shown in Figure 12.3a.

CANDIDATE: This X-ray of the right elbow demonstrates a bicolumnar distal humerus fracture. It is intra-articular, complete articular and there is comminution of the articular surface. There is evidence of a well-healed distal humerus diaphyseal fracture which was stabilized with an intramedullary nail. The dressings around the elbow suggest a possible open injury. I will assess the patient according to ATLS protocols and assess neurovascular status. I will also check if it is an open fracture.

EXAMINER: How are these injuries classified?

CANDIDATE: Intra-articular fractures can be divided into partial or complete according to the AO classification. In type B fractures, a single column is involved while the articular surface of the other column remains in continuity with the diaphysis – this is ‘partial articular’. In type C fractures, both columns are involved and there is no continuity between any part of the articular surface and the diaphysis – this is ‘complete articular’. The severity of these fractures depends on whether their articular and metaphyseal components are simple or multifragmentary.

EXAMINER: This is an open fracture. How will you deal with the wound in casualty?

CANDIDATE: According to BOAST 4 and NICE guidance 37, in conjunction with Orthoplastics input, I will remove gross contamination but not irrigate the wound. I will document and photograph the wound for size and tissue loss then dress with saline-soaked gauze and an occlusive dressing and splint the limb. I will check the patient’s tetanus status and give a booster dose if required and analgesia. I will start the patient on intravenous co-amoxiclav which will continue until 72 hours after initial debridement or wound closure.

EXAMINER: What will be the definitive management and its timing?

CANDIDATE: This will depend upon vascular status and orthoplastics input. If there is vascular compromise, this would necessitate immediate appropriate surgery. If there is evidence of compartment syndrome, this would warrant immediate fasciotomy.

Otherwise, the patient should be taken to theatre by a senior plastic and orthopaedic surgeon on a scheduled trauma list within 24 hours but ideally within 12 hours for high-energy injuries such as this. Initial debridement consists of excising wound edges and extending the wounds in conjunction with plastics to ensure that this will not compromise their plans for soft-tissue coverage. I will deliver the bone ends and excise devitalized bone and ensure the medullary cavity is clean, which in this case may necessitate removal of the humeral nail. I would then irrigate the wound with 6 litres of gravity-assisted normal saline.

If the patient is systemically stable and immediate soft-tissue coverage was possible then I would progress to definitive internal fixation or hemiarthroplasty. Otherwise I would perform limited fixation of the articular fragments, apply a negative-pressure dressing and span the zone of injury with an external fixator.

EXAMINER: If the wound is satisfactory and definitive stabilization is planned, how will you go about it?

CANDIDATE: In an appropriately marked, consented and anaesthetized patient, I would position in a lateral decubitus position. My approach would be posterior under guidance of plastics, likely incorporating the existing defect. An olecranon osteotomy would aid visualization of this intra-articular fracture.

If the nail is still in situ, I would plan my fixation around this, although as the old fracture is well healed, removing the nail is an option if this would make fixation or arthroplasty of the new fracture easier. Principles of fixation are anatomical reduction and rigid fixation of the articular fragments and functional alignment and relative stability of the metaphyseal and diaphyseal sections. According to the principles set out by O’Driscoll,¹⁵ I would initially reduce the articular fragments and stabilize with K-wires. I would use one pre-contoured locking plate on each column.

EXAMINER: How will you stabilize the olecranon osteotomy?

CANDIDATE: With a traditional apex distal chevron osteotomy, I will use a 6.5-mm partially threaded screw with a washer in a pre-drilled hole as this has been demonstrated to give the highest rate of union and lowest rate of implant removal.¹⁶ However, there is increasing evidence that an extra-articular step-cut osteotomy may produce a more stable construct with a much higher bone contact surface area.¹⁷

EXAMINER: This is the postoperative X-ray (Figure 12.3b). What will be your postoperative management?

CANDIDATE: There is stable anatomical fixation of the distal humerus. The olecranon osteotomy has been fixed with a partially threaded screw; however, there is a gap at the osteotomy site.

I would allow active assisted mobilization of the elbow and monitor for displacement of the osteotomy. If there were signs of radiological displacement or clinical non-union, I would revise the fixation using a screw with a washer.

I would consider the use of prophylaxis for heterotopic ossification.

EXAMINER: Why not plate the osteotomy?

CANDIDATE: That would be my plan B if the screw and washer failed to achieve compression. I would initially try to avoid plate fixation as there is already a significant amount of metalwork around the elbow.

EXAMINER: A cyclist was knocked over by a car and he landed on his elbow. This is an isolated injury. His X-rays are shown in Figure 12.4a.

CANDIDATE: This is a Monteggia fracture–dislocation. The ulna has a comminuted metaphyseal fracture with apex posterior and the radial head is dislocated posteriorly as is seen most commonly in adult injuries. This would be classified by Bado as a Type 2 with disruption at the proximal radioulnar joint. The fracture may extend across the base of the coronoid, although this is undisplaced and the greater sigmoid notch appears to be preserved. A radial head fracture is associated with this pattern of injury and should be carefully examined for.

As with all high-energy injuries I would assess the neurovascular status for wounds indicating an open injury.

EXAMINER: How will you manage this?

CANDIDATE: I will reduce the fracture in A&E, apply an above-elbow backslab then reassess the neurovascular status and check position with a plain radiograph. I will then offer the patient open reduction and internal fixation.

EXAMINER: Can this fracture be treated non-operatively?

CANDIDATE: Unless there was an absolute contraindication such as the patient being unfit for surgery or refusing surgery, I would treat this operatively. The fracture is comminuted and is therefore unstable and will allow further dislocation of the joint with limitation of range of motion. There may be loose fragments within the joint which will cause locking. The lateral ulnar collateral ligament is commonly injured with this pattern and may result in instability even if bony alignment is restored. Fixation allows early mobilization and reduced stiffness.

In an appropriately marked and consented patient, I would position the patient lateral decubitus with the arm over a support. I would use the posterior approach and assess for displacement of a coronoid fragment. If this was present I would reduce and stabilize this through a split in the flexor-pronator mass. I would use a pre-contoured locking plate to bridge the comminuted region and restore length and alignment. Stabilization of the coronoid fragment may be achieved via a screw through the plate. I would then assess the range of motion and stability. If the radial head is fractured I would consider fixation or metallic replacement.

EXAMINER: What are the causes for the radial head continuing to sublux after ulna fracture stabilization?

CANDIDATE: Malreduction of ulna fracture – either malalignment or shortening. Capsuloligamentous, coronoid or radial head deficiency. For posterolateral instability, injury to the lateral ulnar collateral ligament is most likely to play a role. Annular ligament interposition is uncommon. If the elbow remained unstable after addressing all of the above, then I would use a temporary static external fixator.

EXAMINER: This is the postoperative X-ray (Figure 12.4b). What will be your postoperative management?

CANDIDATE: I will protect wound healing with a back-slab for 2 weeks then start physiotherapy with active movement as tolerated to prevent stiffness and follow-up the patient to make sure the wound and fracture have healed along with good functional outcome. I would consider the use of prophylaxis for heterotopic ossification as this is common after elbow trauma. I would also monitor for joint subluxation, loss of fixation, non-union and progressive arthrosis.

EXAMINER: A 23-year-old male while on a night out fell on to his left hand and has come to casualty with pain and deformity. The X-ray of his left distal forearm is shown in Figure 12.5.