Evaluation of an injury to an extremity requires assessment of each structural element of the limb. Wounds that penetrate the skin should be obvious to circumferential inspection. The extent of closed soft tissue injuries is often obscure, though this may be suggested by the mechanism of injury: much more muscle damage occurs when a leg is crushed than when a fracture is produced by an indirect torsional force.

Swelling and loss of function provide hints. Firm induration may indicate pressure within muscle high enough to occlude capillary blood flow in the involved compartment (compartment syndrome), resulting in myoneural ischaemia and necrosis. Severely contused or degloved skin may not be evidently necrotic for several days. Fractured bones are often obvious, because of inappropriate motion, deformity, or crepitus. However, they may only be suggested by tenderness. Adequate radiographs are required for diagnosis. Injured joints may be unstable, have painful or limited motion, or have less obvious effusion or tenderness. Although injuries to subchondral bone and dislocations are evident on proper radiographs, a normal appearance does not exclude injuries to radiolucent structures such as ligaments, menisci, and articular cartilage. Distal pulses and adequate perfusion that is maintained over time must be confirmed for each injured extremity. Specific sensory and motor tests must be performed and documented for each regional peripheral nerve. The initial injury, its delayed complications, and occasionally treatment may result in altered neurological function. Repeated examination is necessary.

Restoration of normal anatomy and normal function is the goal of treatment. Fractured bones are realigned ("reduced") and held in position until healed with the traction, cast, or internal or external fixation.

With appropriate treatment, many musculoskeletal injuries heal with little loss of function. The prognosis depends upon the degree of energy absorption, and the location and morphology of tissue damage. An undisplaced tibial fracture may allow nearly normal activities with a short leg brace and heal with no disability. On the other hand, for a severely comminuted and displaced open tibial fracture with neurovascular injury treatment with early amputation, below knee prosthesis, and rapid rehabilitation gives better ultimate function, reduced risk of life-threatening infections, and lower socioeconomic cost.

Skeletal injuries may be associated with massive bleeding, accumulation of extravascular fluid, and hypovolaemic shock. Although distal closed fractures are rarely associated with loss of more than 500 to 1000 ml of fluid, patients with severe pelvic fractures may lose many times this amount. Patients with extremity fractures frequently suffer respiratory compromise, with measurable and clinically important hypoxaemia. This may be due to associated chest injuries, but is also caused by the so-called fat embolism syndrome, in which fat and other compounds released from the injured site produce impaired lung function. Unstabilized fractures continue to bleed and accumulate fluid. They are painful, and emit systemically active mediators that predispose to gut and nutritional disorders, a sepsis-like state, and multiple organ failure syndromes, with a high mortality rate.

Patients with fractures, especially those that produce immobility, have an increased risk of deep venous thrombosis, with potential for chronic venous insufficiency and/or potentially life-threatening pulmonary embolism. Prophylactic anticoagulation soon after fracture, particularly in patients with serious injuries, carries the risk of bleeding and may not prevent thromboembolic events.

Fractures heal slowly: several months may be required before healing is sufficient to permit function without risk of deformity. Prolonged bed rest, with traction or body-cast immobilization of the injured area, can maintain fracture alignment during bone healing. However such enforced rest has disadvantages, including cardiorespiratory deconditioning, osteoporosis from disuse, joint stiffness, pressure sores, and psychological challenges. Functional treatment is based on surgical stabilization and/or external support with casts or braces with encouragement of at least some use of the injured part. Properly carried out, such regimens provide rapid and often more complete rehabilitation. Such functional treatment regimens are also usually cost-effective. However, unless well planned, they may expose the injured patient to more serious risks than those associated with less aggressive treatment.

In addition to a thorough preoperative physical evaluation, patients with multiple injuries require radiographs of cervical spine, chest, and pelvis, head CT if neurological abnormality is present, peritoneal lavage or abdominal CT, and bladder catheterization. Aortography (to exclude aortic arch rupture), or other vascular imaging studies (e.g. femoral arteriogram to exclude a popliteal intimal flap) may be needed. Metabolic and cardiorespiratory dysfunction must be rectified: hypovolaemic shock, metabolic acidosis, and hypothermia may need correction. Normal blood clotting capacity must be present. Intracranial pressure must be kept within safe limits. Unstable spine injuries must be managed so as to avoid injury to the neural elements. If these principles are followed, early comprehensive fracture fixation can be beneficial. Judgements must be made initially and continuously, however, about the patient's overall suitability for skeletal surgery.

Most fractures unite without specific treatment, though the process may take several months. Displaced fractures of the intracapsular femoral neck, of the carpal scaphoid, and of the neck of the talus are notable exceptions: anatomical reduction and rigid internal fixation significantly improves the chance of union. In each of these examples, there is limited intraosseous blood flow that is disturbed by the injury. Furthermore, most of the injured bone is devoid of periosteum and is intra-articular, with a covering of synovium or articular cartilage.

Non-union of fractures is often ascribed to excessive motion, interposed soft tissue, devascularization, infection, or most importantly, a high-energy injury mechanism, which produces extensive disruption of not only the bone, but the surrounding soft tissues. However, it is rarely possible to ascertain a definite cause of non-union.

Diaphyseal fractures heal by a combination of osteochondral new bone formation within the fracture gap and periosteal bone formation at the periphery. The healing mesenchymal tissue, called fracture callus, is both peripheral, outside the injured bone, and medullary, within its marrow cavity. The metabolically active fracture site receives nourishment through local blood vessels recruited from the surrounding musculature. Cancellous bone heals by appositional new bone, laid down on the osseous trabeculae to bridge the fractured area. Rigid internal fixation is provided by forceful interfragmentary compression. In such a situation, little callus is formed, and the opposed bony surfaces are "welded" together by normal bone remodelling processes.

Strain (percentage change in length) is progressively less well tolerated by granulation tissue, cartilage, and bone. Motion at the fracture site causes the development of callus with endochondral bone formation. This has better strain tolerance, and progressively ossifies as it becomes stiffer, with less and less local strain.

Although treatment is not generally required to obtain bone union, it avoids malunion and deformity, as well as other local complications such as infection of open wounds, loss of mobility, unnecessarily delayed healing, and neurovascular injuries. Fracture treatment also seeks to minimize the systemic consequences of skeletal injuries. For example, surgical fixation of an intertrochanteric fracture of the proximal femur is not required for healing, which will occur within 2 or 3 months, or to allow the patient to walk, although the typical varus deformity produces a characteristic limp. It does, however, provide a faster, more comfortable recovery, a shorter hospital stay, and perhaps reduced mortality and morbidity from medical complications of prolonged bed-rest. With adequate medical care, however, even elderly patients with intertrochanteric fractures can tolerate traction treatment, and after rehabilitation most do as well as similar patients treated operatively. Except for socioeconomic issues there is room for debate about the best treatment for this common injury.

Displaced intra-articular fractures distort the joint surface and produce stiffness, pain, and post-traumatic arthritis, which may be disabling. Open reduction and rigid internal fixation provide the best opportunity for restoration of the normal contour of the injured joint, as well as for healing of the damaged articular surface. Joint function is further maximized by movement beginning in the early postoperative period. An operation that does not achieve satisfactory alignment or sufficient stability for early movement often has a poorer outcome than could be gained without surgery. If it is not possible to perform an operation that permits immediate mobilization, treatment may be better carried out with early motion in traction.

Open fractures threaten life and limb. The defect in the skin provides an entrance for any bacteria in the surrounding environment. The hypoxic haematoma and associated necrotic soft tissue offer a hospitable environment for micro-organisms, including anaerobes such as the ubiquitous clostridia. Gas gangrene, tetanus, and other serious infections are significant risks, especially when the volume of necrotic tissue or the size of the inoculum is large. Non-union and chronic osteomyelitis are common since infections interfere with fracture healing. Dead bone fragments, hypovascular scar, and retained foreign material decrease host resistance. If the fracture is open, the risk of infection is primarily dependent upon the status of the soft tissue. A surgical procedure that opens such a fracture increases the risk of complications.

Management of all open fractures should be carried out according to well accepted principles. Most important is thorough surgical debridement of all necrotic tissue and retained foreign material. This requires a formal operation with stepwise excision of obviously necrotic skin, injured and contaminated subcutaneous tissue, fascia, and muscle, devitalized bone fragments, and removal of all foreign material. This goal is accomplished by excision of visible debris, and copious irrigation of the wound with several litres of sterile Ringer's or normal saline solution (or clean water, if nothing else is available). Since open fracture wounds rarely provide adequate decompression for severely injured muscle compartments, fasciotomies must be part of this urgent operation. Major blood vessels and nerves must, of course, be preserved during open fracture debridement. Open fracture wounds should be left open, for delayed closure once host defences have been mobilized.

Important adjuncts to adequate open fracture debridement are antitetanus prophylaxis, parenteral antibiotics effective against likely contaminants, as well as good overall patient resuscitation, care, and nutrition.

Some form of fracture stabilization is required at the time of debridement to protect the soft tissues. Initial fracture treatment may be temporary (for example, external fixation), later replaced by definitive fixation.

Vascular injuries associated with fractures and dislocations may cause ischaemia, haemorrhage, or both. Occasionally the injury may be occult, with an intimal flap that results in delayed thrombosis: a classic example is seen when the popliteal artery is damaged by knee dislocation. Such injuries may result in irreversible ischaemia and amputation unless urgently repaired. In addition to obvious pallor, decreased temperature, and empty veins, any impairment of pulses, paraesthesia, paralysis, and pain persisting after fracture immobilization must be recognized as potential signs of limb-threatening ischaemia.

An arterial injury with limb-threatening ischaemia requires immediate repair or bypass. Irreversible muscle necrosis becomes important after 6 h of warm ischaemia. If revascularization is delayed much beyond this time satisfactory results are rare. While restoration of perfusion is most urgent, wound debridement, fracture reduction, and stabilization are also required. Distal fasciotomies are routinely required since postischaemic swelling causes compartment syndromes. Close collaboration between vascular and orthopaedic surgeons is required for an optimal result. Timing of vascular repair and other procedures should be individualized, with priority given to restoration of perfusion to ischaemic muscle and nerve. Occasionally a temporary arterial shunt permits fracture stabilization before definitive vascular repair. Restoration of skeletal alignment and stability can aid vascular repair, but must never delay it unless distal perfusion is sufficient. Rapid external fixation is often the best way to stabilize a fracture associated with an arterial injury. The extent of soft tissue and bone damage associated with combined arterial injuries and open tibial fractures is often such that a functional limb is rarely salvaged, even though perfusion may be restored to the foot. Serious consideration must be given to early amputation, which is preferable to prolonged fruitless attempts to save an irreparable limb.

Fractures and dislocations may be associated with injuries of any of the peripheral nerves that traverse the zone of injury. Potential injury mechanisms are contusion, traction, laceration, and continued compression of nerve. It is important to exclude compartment syndrome and arterial injury as causes of impaired motor power and sensation.

Unless an open wound is present or reduction manoeuvres precipitate the nerve deficit, expectant treatment is usually appropriate. Protective splinting and an active rehabilitation programme are often needed to maximize function and avoid contractures.

Muscles of the extremities, especially those of the forearm and leg, are surrounded by unyielding fascial envelopes. If swelling occurs within such a compartment, because of capillary leakage from any cause, interstitial fluid pressure rises to a level greater than that of the draining veins. These events establish a cyclic effect, with increasing capillary leakage and increasing pressure. Loss of capillary bed perfusion results in local muscle and nerve ischaemia, even though arterial trunk flow may persist. Tense swelling is evident on palpation of the involved compartment. Ischaemic pain increases by passive muscle stretch, altered or absent sensation, and loss of motor function soon follow. Pulses and distal skin perfusion are affected much later, and may appear normal while intracompartmental tissues undergo irreversible necrosis. Neuromuscular ischaemia lasting 4 h or more is commonly associated with at least some irreversible loss of tissue. Injured tissue has a reduced tolerance of ischaemia: sufficient muscle necrosis can occur to cause renal and metabolic problems due to release of myoglobin and potassium. The end result, Volkmann's ischaemic contracture, with shortened paralysed muscles and often impaired distal sensation, is severely disabling.

Open fracture wounds do not reliably decompress involved compartments, and may also be associated with compartment syndromes. Patients who are unconscious or have peripheral nerve injuries are especially at risk, as they show few signs of the problem other than local swelling.

Prompt fasciotomy is mandatory whenever a patient has convincing signs of a compartment syndrome. If the diagnosis is in question, intracompartmental pressure can be measured with a variety of techniques: this permits observation rather than fasciotomy in questionable cases. If pressure is greater than 30 to 40 mmHg below the mean arterial pressure, compartmental perfusion is probably impaired, and fasciotomy is advisable. Any associated fracture is then stabilized with external or internal fixation, and wound closure is postponed until swelling has resolved.

The initial task in evaluating an extremity injury is to identify immediately any limb-threatening injuries as soon as life-threatening disorders have been excluded or managed. The approaches taught in the American College of Surgeons Advanced Trauma Life Support course are valuable for the initial evaluation and treatment of the injured patient. Loss or severe functional impairment of a limb is threatened by arterial injuries, compartment syndromes, open fractures, and significant peripheral nerve lesions. An obvious injury is likely to interfere with the discovery of other, perhaps more serious, problems. Multiple injuries are frequent. A systematic physical examination, liberal, appropriate use of radiography, and a planned re-evaluation of the injured patient are the best means of detecting all injuries.

The entire limb must be examined for signs of ischaemia, swelling, wounds, deformity, and instability. Distal pulses must be confirmed by palpation, with pressure measurements if there is any asymmetry or diminution. Indurated swelling should be considered due to compartment syndrome until proven otherwise. A wound adjacent to a fracture or injured joint is assumed to communicate with it until proven otherwise by surgical exploration. Impaired passive mobility suggests an articular injury. Motion should not be forced until radiographs have been obtained. A fracture may coexist with a dislocation. If the patient is conscious and able to co-operate, voluntary motor function is assessed to check each peripheral nerve, and each muscle–tendon unit. The sensory area of each peripheral nerve must also be determined.

A pernicious limb-threatening upper extremity injury often associated with unimpressive fractures is scapulothoracic dissociation—essentially an incomplete avulsion of the entire limb. Neurovascular impairment is often obvious. Fractures and dislocations from the clavicle and scapula distally may also be associated with nerve and blood vessel injuries. Injuries commonly affect the axillary nerve at the shoulder, the radial nerve (humerus shaft fractures), the radial, median (including anterior interosseous), and ulnar nerves (elbow injuries), and the median nerve at the wrist.

Multiple fractures may follow a single isolated blow: a fall on the outstretched hand may cause fracture of the distal radius, radial head, and proximal humerus. Dislocations of proximal or distal radio-ulnar joints may be associated with a diaphyseal fracture of either bone: the joints above and below a fracture must be evaluated fully. While fractures tend to be fairly apparent on radiographs, dislocations may be more occult. Carpal fractures and dislocations are notoriously easy to miss; radiographs of a painful or swollen wrist must be examined with great care.

Only after a complete evaluation of the upper extremity is it appropriate to proceed with definitive treatment for identified injuries. Specific treatment for limb-threatening injuries assumes the highest priority. Dislocations should be reduced as soon as possible. Open fractures must be irrigated, debrided, and stabilized appropriately, within a few hours for optimal results. Most other fractures can be immobilized with a well-padded splint, though this may interfere with elevation to minimizing swelling of the injured extremity. Definitive treatment can then be provided as soon as consistent with the needs of the patient and the resources of surgical team.

Dislocations of the sternoclavicular joint are poorly visualized except with CT scans, but should be suspected when pain, swelling, and deformity are noted. Posterior dislocations, which often cause respiratory and/or circulatory compromise, should be identified and reduced promptly. Closed reduction is performed on the supine patient, with a rolled towel between the scapulae. Posteriorly directed pressure on both anterior shoulder regions distracts the dislocated joint. If this method does not reduce the deformity, anterior traction on the medial clavicle with a percutaneous stout towel clip may be required. The reduction is usually stable. Anterior dislocations that do not compress the mediastinum are less stable, and often recur after closed reduction. The reported complications after attempted open reduction and internal fixation has led many surgeons to accept such recurrences as inevitable. Deformity resulting from the prominent anteriorly displaced medial clavicle is not usually painful after restoration of range of motion and strength in the shoulder by physiotherapy. Persistent pain occasionally requires late resection of the medial clavicle. Since the medial clavicular growth plate fuses in the early twenties, many apparent sternoclavicular dislocations are actually growth plate fractures.

Clavicular fractures are very common, and usually benign, though early or delayed neurovascular compromise is occasionally seen. Healing, with some obvious deformity but unimpaired function, is the usual result after non-operative treatment with a figure-of-eight strap that maintains shoulder retraction, thus minimizing over-riding of the fracture. Pain on upper extremity motion can be minimized with a sling, but early shoulder motion is important to prevent stiffness. Clavicle fractures caused by high-energy trauma have a higher rate of non-union, which may be painful enough to require plate fixation and bone grafting.

Acromioclavicular joint injuries result in prominence of the distal clavicle, the degree depending on the extent of the capsular and coracoclavicular ligaments. The distal clavicle may also be fractured. When the distal clavicle is displaced, some surgeons advocate open reduction with fixation and/or ligament reconstruction. If the deformity is accepted, and early functional rehabilitation is emphasized, the result is usually serviceable, in spite of distal clavicular prominence.

Scapular fractures indicate appreciable regional trauma, often associated with serious thoracic injuries. The fractures themselves are of little importance if they are restricted to the body, but stiffness, or more significant shoulder joint disturbance may result if they involve the glenoid process or adjacent portions of the bone. While significant periarticular fractures should be considered for open reduction and internal fixation, early shoulder motion exercises suffice for most scapular fractures.

Shoulder dislocations may be obvious, causing pain, loss of motion, and the familiar deformity seen with anterior dislocation. An associated and unrecognized fracture may be present: confirmatory radiographs (auteroposterior and axillary lateral) are essential. Posterior dislocations are unusual and frequently missed. They cause little obvious deformity other than internal rotation of the arm. The anteroposterior radiograph may appear unremarkable as medial displacement of the humeral head is slight. An adequate lateral radiograph will confirm or disprove this diagnosis, which must be considered whenever a patient lacks normal external rotation of the shoulder.

Shoulder dislocations must be reduced promptly after evaluation and radiographic confirmation, using relaxation and traction in line with the humeral shaft. After successful reduction, the arm is immobilized by binding to the trunk with sling and swath. Neurological injury, particularly to the axillary (circumflex) nerve is common; lateral shoulder sensation, and voluntary contraction of the deltoid muscle must be confirmed as being present after reduction. Avulsion fracture of the greater tuberosity may be associated with anterior shoulder dislocation. This is usually satisfactorily reduced when the humeral head is returned to the glenoid, and if so will do well with closed treatment. If displacement persists or recurs, the tuberosity and attached rotator cuff tendon must be repaired. Younger patients with shoulder dislocations are especially at risk of recurrences, which, if sufficiently frequent, merit surgical repair. Treatment usually involves reattachment of a labral avulsion (Bankhart lesion) to the glenoid, or occasionally reefing of a redundant shoulder capsule, and/or capsulodesis or tenodesis to prevent motion of the shoulder into the range in which dislocation occurs.

Shoulder mobility, strength, and freedom from pain are important for normal function of the upper limb. The complex motion of the shoulder involves each articulation of the region, including the non-articular scapulothoracic "joint". The scapulohumeral rotator cuff muscles contribute significantly by stabilizing the humeral head in the shallow glenoid during motion. Their common tendinous attachment (rotator cuff) to the proximal humerus must move freely under the osteoligamentous arch composed of acromion and coracoacromial ligament, from which it is separated by the subdeltoid or subacromial bursa. Deformity of the proximal humerus, tendon rupture, and post-traumatic adhesions can all produce pain and limitation of motion. Treatment of shoulder injuries strives to restore anatomy and mobility to this region.

Proximal humerus fractures vary greatly in severity. Individual treatment is based primarily upon deform of displacement and fracture pattern. Four typical fragments are important components of the injury: humeral head, humeral shaft, and greater and lesser tuberosities. In any patient with proximal humerus fracture it is vital to determine the glenohumeral relationship: fractures with worse prognosis may be associated with glenohumeral dislocations. The axillary lateral radiograph is essential for identifying fracture-dislocations. Although avascular necrosis of the humeral head is not the common problem that it is for the femoral head, it may still be important for proximal humeral injuries that separate the intra-articular head from greater and lesser tuberosities. It is thus associated with anatomical neck fractures and comminuted proximal humerus fractures requiring extensive open reduction and internal fixation.

Undisplaced proximal humeral fractures are usually treated with protection and rest for a week or two, with early passive motion exercises to restore soft tissue gliding planes. Once skeletal healing is more advanced, exercises increase in vigour, with emphasis on strength and endurance. Displaced proximal humerus fractures must be evaluated carefully, as surgical treatment may be essential for optimal results. In older patients with more limited functional expectations, non-operative treatment may be more appropriate, though loss of motion, pain, and occasionally non-union may result.

Extra-articular unifocal proximal humerus fractures may be of two types. Displaced avulsions of the greater tuberosity, with its attached (supraspinatus, infraspinatus, and teres minor) rotator cuff tendons must be reattached securely to the proximal humerus to prevent bony impingement and/or loss of rotator cuff function interfering with glenohumeral motion. Displaced fractures through the proximal humeral metaphysis (surgical neck) separate the shaft from the proximal portion of the bone. Older individuals with these injuries have a risk of non-union, even though rather surprising degrees of deformity can be well tolerated if healing occurs. Healing following non-operative treatment is generally seen in adolescents and even young adults, in whom periosteum bridges the fracture gap and provides a source of healing bone.

Fractures of the shaft of the humerus can often be managed non-operatively; this is best suited for isolated injuries. This bone is surrounded by muscles, and is close to the major neurovascular structures of the arm, especially the radial nerve which spirals around the posterior surface of the humeral shaft with the profunda brachii vessels, under the deep head of triceps. The radial nerve emerges into the anterior distal arm between the branchioradialis and brachialis, where it can safely be identified surgically. It is especially at risk in fractures of the mid- and distal thirds of the shaft. Motor, sensation, and pulses should be carefully assessed, before and after fracture treatment.

Initial splinting of humeral shaft fractures is obtained with well-padded plaster splints—either posteriorly from shoulder to metacarpals, or a U-shaped splint wrapped around the elbow from axilla to acromion. In addition to the splint, the fractured humerus should be restrained to the chest with sling and swath to control rotation. Healing of most diaphyseal humerus fractures is fairly rapid and can be expedited with a cuff-like, adjustable fracture brace around the upper arm, from just below the axilla to the epicondyles. This brace is substituted for the initial splint after a week or two, once swelling and discomfort have diminished. Arm function, range of motion, and isometric elbow muscle exercises are encouraged in the brace, and a sling or collar and cuff are removed as the patient tolerates.

Healing with acceptable, though rarely anatomical, alignment usually occurs, with consolidation by 6 to 8 weeks. Bracing and protected use should be continued for another couple of weeks. Some humeral shaft fractures treated in this way fail to unite: these are usually identifiable by 12 weeks after injury. Progressive disuse osteoporosis and stiffness of elbow and/or shoulder joints compromise operative treatment of the non-united humerus fracture, and surgery should not be postponed long beyond this time. Surgical fixation of humeral shaft fractures has an important role in special indications: open fractures, multiply injured patients, especially those with significant ipsilateral or contralateral upper extremity injuries, associated vascular injuries, pathological fractures, and non-unions. A high incidence of complications is seen when humerus fractures are fixed urgently, especially by inexperienced surgeons. The thin cortex of the humerus provides less secure screw purchase, neurovascular structures are at risk, proximal entry sites for intramedullary nails may interfere with shoulder function, and loose intramedullary pins offer little rotational control. The decision to undertake operative treatment of a humeral shaft fracture must therefore be carefully considered, and precise technique is essential. In appropriate situations (such as transverse fractures, or those with significant displacement, suggesting soft tissue interposition), elective fixation can decrease the risk of slow healing or accelerate rehabilitation. Intramedullary nailing of a suitable humeral fracture may permit early transfers and crutch walking, though these activities would be delayed if plate and screw fixation were chosen.

Radial nerve palsy is reported to follow 0 to 16 per cent of humeral shaft fractures. The nerve injury is usually a neuropraxia or axonotmesis, and the prognosis for recovery is excellent. If recovery does not occur within 3 months or so, electromyography is indicated to determine whether subclinical recovery is occurring. Exploration of the nerve is indicated if such recovery is not evident. Patients with radial nerve palsy need appropriate wrist and hand splinting and therapy to maintain joint mobility.

Bone and joint injuries of the elbow may result in compromised function and appearance, pain, loss of motion, instability, and post-traumatic arthritis, and neurovascular injuries.

The elbow is a complex hinge, which permits two types of motion: rotation of the proximal forearm around the distal humerus, through an arc of 130° or more, and pronosupination of the forearm, in which the radius rotates around the ulna. In this movement, the radial head pivots freely from full supination (nearly 90°) to full pronation (70–90°), while it is restrained in the lesser sigmoid fossa of the proximal ulna by the orbicular ligament. Its slightly concave proximal surface rests against the convexity of the capitellum. Elbow stability is provided by the congruity of the articular surfaces, particularly the greater sigmoid fossa of the olecranon, the collateral ligaments, particularly medially, and to a certain extent, the tension of muscles crossing the joint. Disturbance of one or more of these structures can compromise function and comfort of the elbow. Complex injuries may affect more than one component. Until radiographs have revealed the precise nature of an elbow injury, it should be splinted in a neutral, somewhat flexed position, which gently corrects gross deformity but does not attempt any formal reduction. Formation of heterotopic bone around an injured elbow may be associated with severe soft tissue injuries, delayed or traumatic reduction attempts, and traumatic brain injury. This complication can compromise motion significantly, and may warrant resection after the precipitating condition has resolved.

In common with articular fractures in general, those of the distal humerus are classified as extra-articular (Type A), partial articular (Type B), and complete articular (Type C). In adults, these injuries can significantly interfere with elbow function; they pose challenges for operative treatment, and may cause neurovascular compromise. Two major categories of injuries are seen: high-energy injuries with significant soft tissue injuries in young individuals with normal bone, and low-energy injuries in osteopenic elderly patients. Those which distort the articular surface carry a worse functional prognosis. The best results are provided by anatomical reduction, rigid fixation, and early motion, as long as complications are avoided: fixation that does not provide sufficient stability for early joint motion may yield a worse result than non-operative management. Both osteopenia and comminution compromise fracture fixation, and demand surgical expertise for optimal results.

Neurovascular status and the condition of the surrounding skin and soft tissues should be assessed. It is crucial to determine the details of the fracture pattern prior to deciding upon a treatment plan: the location of fracture lines, and fixation techniques chosen will determine the required exposure. Failure to recognize intra-articular comminution may lead the surgeon to split the distal triceps tendon rather than performing an olecranon osteotomy. This may impair visualization of the fracture, and make reduction and fixation difficult. Less extensive approaches may be chosen with confidence if the fracture pattern is understood. An anteroposterior radiograph taken with the patient anaesthetized and manual traction applied to the forearm may be more useful than many radiographs taken through splints in the emergency department.

Undisplaced fractures can be managed satisfactorily with brief immobilization in a removable splint or hinged fracture brace and gentle active exercises. Displaced articular fractures usually require open reduction and internal fixation. Extra-articular fractures that can be held satisfactorily aligned in a cast or brace may be managed non-operatively, but if this method prevents joint motion for long (more than 3 weeks or so) significant loss of motion is possible. Widely displaced apophyseal avulsion fractures should be reattached. Medial epicondyle avulsion fractures are often the result of an elbow dislocation, and may indicate incompetence of the attached medial collateral ligament and elbow instability. Partial articular surface fractures should be reduced precisely and fixed stably with lag screws to permit early motion of the elbow.

An olecranon osteotomy, if necessary for adequate exposure, should be repaired with a tension band wire, as well as K-wires or an intramedullary ulnar screw. Postoperatively the elbow is splinted at a right angle in neutral pronosupination, and gentle active range of motion is begun within a few days during brief periods out of the splint. Such open reduction and internal fixation techniques produces excellent or good results in 76 per cent of patients. Comminution and patient age do not effect results. Poor outcome is more common in those with high energy injuries and multiple trauma. Most patients retain full pronation and supination; loss of extension is the most common restriction of motion.

Elbow dislocations may be associated with fractures, or may involve only disruption of the capsule and ligaments. Prompt closed reduction of an elbow dislocation, with distal traction and correction of deformity, should be followed by flexion to restore muscle tension. Although elbow dislocations are often stable after reduction, confirmation is required to enable post-reduction management to be planned. The best results are provided by active motion exercises within a few days, unless instability prevents this. In such cases immobilization in flexion for up to 3 weeks may restore adequate stability; active exercises can then be instituted. Ligament repair does not improve long-term results in patients with simple dislocations but may be necessary to maintain a very unstable joint. Whenever elbow instability is suspected, joint alignment must be monitored with radiographs taken with the limb in the splint. Redislocation may be occult, and is hard to treat if it is recognized late. Because rotation of the arm may redislocate an unstable elbow, the arm should be splinted securely to the patient's chest, and a warning against external rotation of the arm should be given.

In addition to dislocation of both proximal ulna and radial head from the distal humerus, isolated radial head dislocation may occur, either by itself, or together with a fracture of the ulna. It is important to recognize this injury complex, the so-called "Monteggia" fracture, so that both components of the injury are appropriately treated. Radiographs of the elbow must be obtained whenever it is injured or deformed, and especially whenever there is a forearm fracture. Two 90° opposed views are necessary. Careful interpretation is necessary: on any view, the long axis of the proximal radius must cross through the centre of the capitellum.

While closed management of Monteggia fractures is usually adequate for children, adults require anatomical open reduction and internal fixation of the ulnar fracture. This usually produces a closed reduction of the proximal radio-ulnar (and radiocapitellar) joint. If this does not occur, open reduction is required, often with repair of the orbicular ligament.

Fractures of the proximal radius may involve the head or neck. If undisplaced, only early motion is required. It may not be possible to repair displaced fractures of the head anatomically, so that early active motion can be prescribed. If this is the case, as with comminuted displaced fractures, radial head excision is better, but this may increase elbow instability if medial collateral ligament disruption is present. In this situation, a radial head prosthesis may improve stability, though currently available silastic prostheses may fail and cause an osteolytic response.

Diaphyseal fractures of the radius and ulna may occur singly or in combination. An apparently isolated displaced fracture of one bone is usually associated with a dislocation of either the proximal or the distal radio-ulnar joint. Displaced fractures of the radius with an intact ulna (Galeazzi fractures) are associated with disruption of the distal radio-ulnar joint. Fractures of both radius and ulna are commonly displaced in adults, although an isolated ulnar fracture with little if any displacement is not unusual. This is frequently due to a direct blow to the subcutaneous surface of the ulna ("nightstick" fracture).

A fractured forearm should be examined carefully for open wounds, which may be quite small. Compartment syndromes occasionally occur, and need urgent fasciotomy to release dorsal and volar muscle groups, and occasionally the mobile wad (brachioradialis and radial wrist extensors). Because individual forearm muscles have significant investing fascia, each muscle must be assessed for adequacy of decompression, and all potentially closed myofascial spaces must be released.

Unless an open wound or a compartment syndrome is present, forearm diaphyseal fractures can be grossly aligned and immobilized in a well-padded long arm cast, deferring definitive treatment until conditions are appropriate. Excessive delay, however, may compromise ultimate range of motion.

Non-operative treatment of displaced fractures, with closed reduction and a long arm plaster cast, is an effective treatment in children, but is often associated with poor healing, poor maintenance of reduction, impaired forearm motion and hand function, and, at the very least, prolonged disability in adults. Modern effective plate and screw fixation has now supplanted alternative therapies. It should be mentioned, however, that the rare, truly undisplaced forearm diaphyseal fracture can be satisfactorily treated without surgery. Rather than a long arm cast, functional bracing, applied once swelling and pain resolve, is advantageous, as it promotes not only function but healing. Internal fixation with compression plating gives a union rate of 98 per cent, and an excellent or satisfactory functional result in 92 per cent. Routine bone grafting is required for comminuted and open fractures. The infection rate is less than 3 per cent.

Open diaphyseal fractures of radius and ulna are a special case. If the wound is small and irrigation and debridement are performed promptly they can often be treated with plate and screw fixation, though with delayed wound closure. Badly contaminated wounds, those with extensive soft tissue defects, and those with significant delays before treatment may be better managed with external skeletal fixation. Once the soft tissue envelope has healed, delayed internal fixation may be considered. Autogenous cancellous bone grafting may be required if there is loss of bone or extensive comminution.

Fractures of the distal forearm or "wrist" usually affect the radius primarily. The radiocarpal and distal radio-ulnar joints, as well as the distal ulna, may or may not be involved. The distal radius, at risk from falls onto the outstretched hand, is a common site of injury, particularly in older, osteoporotic patients. Severe distal forearm fractures result from high-energy trauma in younger patients with normal bone. Prognosis is determined by the amount of energy absorbed, indicated by comminution and displacement, with implied soft tissue damage. The injury pattern, in particular the degree of involvement of the two above-mentioned joints, is also important. Chronic pain on activity, limited wrist and forearm motion, impaired hand function, and visible deformity are undesirable sequelae of wrist fractures. Residual articular surface incongruity of more than 2 or 3 mm is associated with development of osteoarthritis. Occasionally problems are due to associated injuries such as median nerve compression, forearm compartment syndrome, flexor or extensor tendon damage, carpal fractures and ligament disruptions, and reflex sympathetic dystrophy.

Distal forearm fractures are classified as extra-articular (Type A), partial articular (Type B), and complete articular (Type C). Problems and implications for treatment differ, but more severe injuries share elements of lesser ones: a severe Type C injury has proximal metaphyseal comminution, and may demonstrate dorsal or volar subluxation. Ulnar styloid process, and less obvious distal radio-ulnar joint injuries are often present.

Treatment of distal forearm fractures generally begins with a closed reduction, unless surgery is required because of an open wound or compartment syndrome. Anaesthesia and muscle relaxation can be obtained with general or regional techniques. If the injury is fresh (less than 12–24 h), sterile aspiration of the fracture haematoma and injection of 5 ml of 1 per cent lidocaine is often adequate. Distraction, occasionally manipulative disengagement of displaced distal radius fragments, and moulding into position with thumb and finger pressure are the usual stages of reduction, after which a moulded plaster cast or splint is applied over adequate padding. Three-point plaster moulding is accomplished, to resist redisplacement. While reduction of the typical dorsally displaced distal radius fracture is usually aided by pronation, some argue that supination is more helpful for retention or reduction. Whether or not to extend the cast or splint above the elbow to maintain a chosen position of pronosupination has been debated, but for most distal radius fractures this does not seem necessary. Post-reduction radiographs will document restoration of normal radial length, angulation of the distal radial articular surface on anteroposterior and lateral views, as well as correction of dorsal or palmar displacement of carpus and fracture fragments (lateral view). An inadequate reduction should be remanipulated, under improved anaesthesia.

The pelvis, an osteoligamentous ring, links the spine and lower extremities and houses genitourinary and visceral structures as well as neurovascular conduits. It provides a level platform for sitting, and includes the acetabular portion of the hip joint. Injuries of the pelvis are conventionally divided into those of the pelvic ring and those of the acetabulum, although they may coexist. Pelvic injuries are potentially lethal: a number of associated injuries require prompt identification and management. Pelvic injuries caused by high velocity trauma should be distinguished from those due to low-energy trauma, such as simple falls, which typically produce minimally displaced, stable injuries in elderly osteopenic patients.

Pelvic injuries are frequently occult: injured patients must be screened with an anteroposterior pelvic radiograph. Frequent problems associated with pelvic injuries include hypovolaemic shock due to bleeding from the pelvic fracture site or veins (rarely arterial) or other injuries, associated head and thoracoabdominal injuries, urological injuries, including torn urethra and ruptured bladder, neurological injuries to lumbosacral nerve roots, plexus, and any local peripheral nerve, genital injuries, rectal injuries, and open wounds around the fracture or affecting the pelvic contents. Detection of open wounds, which may be missed if they are small, or which involve rectum, vagina, or perineum, is especially important, since the mortality associated with open pelvic fractures approaches 50 per cent.

Bladder catheterization is undertaken routinely, but must be preceded by a retrograde urethrogram if blood from the urethral meatus or the prostate gland displacement is noted. A cystogram with at least two views is required to exclude the possibility of bladder rupture. Further definition of the pelvic injury is provided by 45° cephalad and caudad oblique radiographs (so-called inlet and outlet views) to demonstrate the shape of the pelvic ring. The posterior pelvis is seen better on computed tomography.

Treatment of pelvic ring trauma is determined by features such as uncontrolled local bleeding, mechanical instability, deformity, pattern of injury, and associated injuries. Unstable pelvic injuries involve at least two disruptions of the ring. Anteriorly there may be failure of the pubic symphysis or the rami. Posteriorly, the injury may involve sacrum, sacroiliac joint, ilium, or a combination. The sacroiliac joint may be totally disrupted or merely opened anteriorly, the stout posterior ligaments acting as a hinge.

About 90 per cent of haemorrhage from pelvic injuries is from fracture surfaces and venous lesions. It is best controlled by providing mechanical stability and replacing lost blood. Mechanically unstable pelvic injuries are often best stabilized with interiliac external skeletal fixation, using pins placed into the anterior iliac crest and connected with a frame that arches over the lower abdomen, but can be swung distally over the thighs if necessary. Alternatives are temporary use of a pneumatic compression garment, a spica cast, open reduction, and internal fixation of symphyseal disruption. Skeletal traction can be helpful if vertical instability is present. Direct surgical attempts to gain haemostasis are usually unwise. The prevailing philosophy is to tamponade low-pressure retroperitoneal bleeding by splinting the pelvis, and to provide blood transfusions, occasionally in massive amounts. If this is unsuccessful, arteriography and embolization of identified bleeding sites is occasionally helpful.

Open pelvic ring injuries require thorough irrigation and debridement, skeletal stabilization (usually external), diverting colostomy, and open wound management. The mortality rate is high.

Stable pelvic ring injuries usually require only symptomatic treatment, in addition to appropriate identification and management of any associated problems. Rotationally unstable injuries usually heal after 6 to 8 weeks, during which alignment can be maintained with anterior external or internal fixation and protection, ranging from limited weight-bearing to skeletal traction. Alignment following complete posterior pelvic ring disruption cannot reliably be held by anterior fixation. If satisfactory reduction of a posterior fracture has been gained, supplemental traction for approximately 6 weeks often allows anterior fixation to succeed. However, a posterior injury involving primarily the sacroiliac joint heals slowly. Even after 12 weeks of bed rest healing may be incomplete. Instability, non-union, and deformity are associated with disability due to gait disturbance and pain. Posterior interiliac bolts ("sacral bars") or plates are best for unstable sacral fractures. Complete disruptions of the sacroiliac joint are best fixed with short anterior plates, or with posterior lag screws. Iliac wing fractures can be fixed with lag screws and/or plates applied either posteriorly and laterally,or perhaps better through an anterior approach underneath the iliacus muscle. Disability after pelvic ring injury may also be due to lesions of the lumbosacral plexus or lower genitourinary tract.

Acetabular fractures are due to forceful impaction by the femoral head. Displaced fractures frequently result in disabling post-traumatic arthritis, unless anatomical reduction and rigid internal fixation are achieved. If articular surface congruity is present and there are no interposed osteocartilaginous fragments in the hip joint, non-operative treatment, usually with skeletal traction, is adequate.

Operative treatment of acetabular fractures requires particular skill. If an experienced surgeon is not available to treat a displaced acetabular fracture, consideration should be given to transferring the patient, or choosing non-operative treatment.

As with other pelvic fractures, haemorrhage and associated injuries must be identified and treated. The sciatic nerve, local soft tissues, and often the ipsilateral knee, are commonly damaged and must be evaluated. An acetabular fracture is suggested by pain, impaired motion, and often swelling or deformity. It should be evident on a routine anteroposterior radiograph of the pelvis, although some posterior fracture dislocations may not be obvious. Complete evaluation of an acetabular fracture requires 45° oblique (Judet) views of the involved innominate bone. Computed tomography provides additional valuable information. Since the obvious "acetabular dome" on a single radiographic projection is produced by a small area of bone, its apparent satisfactory relationship to the femoral head may mask the presence of major displacement or incongruity in other portions of the joint.

Criteria for significant displacement are important for deciding whether or not open reduction and internal fixation is warranted. Congruent coverage of the femoral head by at least a 45° arc of intact acetabulum on all three standard radiographic views (anteroposterior, internal or "obturator" oblique, and external of "iliac" oblique) is the minimum criterion for acceptable alignment. Fractures of the posterior wall deserve additional attention however, because roof arc measurements do not reliably indicate adequate femoral head coverage in this region. These fractures are better evaluated by CT and the obturator oblique radiograph. A displaced posterior wall fragment that is large or permits femoral head subluxation generally requires open reduction and internal fixation.

Initial treatment of an acetabular fracture begins with assessment and care of the entire patient. If persistent dislocation of the femoral head is present, a closed reduction, often under anaesthesia, will usually improve alignment, perhaps minimizing additional ischaemia and mechanical damage to the femoral head. Skeletal traction is advisable: this is the most effective splint, and protects the hip joint. Force 10 kg or more may be required.

Traction for 4 to 8 weeks is required for well-aligned fractures, as the powerful muscle forces across the hip joint may produce displacement. Open reduction and internal fixation, if necessary, is best delayed until the patient is haemodynamically stable and preparations for surgery are complete. Access can usually be obtained with a single incision. Greater exposure can be obtained by trochanteric osteotomy, or by extensile triradiate or iliofemoral incisions. Such approaches may be required for delayed treatment.

Neurological deficits may be a result of spinal cord, nerve root, or lumbosacral plexus injuries rather than of lower extremity wounds. Associated pelvic injuries are common: careful examination and a routine anteroposterior radiograph of the pelvis are essential, particularly when the femur is fractured. The deformity typical of hip dislocations and fractures is absent when the femoral shaft is disrupted.

Multilevel injuries must always be considered. Typical examples, usually due to high-energy trauma are knee injuries associated with acetabular fractures, femoral neck fractures (which may be undisplaced and occult) and femoral shaft fractures, and combined femoral and tibial fractures (floating knees) frequently associated with knee ligament injuries. An intimal flap tear of the popliteal artery is potentially life-threatening. It carries a significant risk of delayed thrombosis and may be associated with dislocations and fracture–dislocations of the knee. Foot fractures may be associated with more proximal injuries.

It is essential to assess the document distal pulses, to evaluate all open wounds, to check and follow motor and sensory function, and to watch for tense swelling or severe progressive pain, which may indicate ischaemia. Fractures are usually obvious on adequate radiographs; dislocations may be more subtle. Ligament injuries may be occult, and instability of each joint, especially the pelvis, knee, and midfoot, must be sought. Once the entire limb has been evaluated, priorities for treatment can be established.

The normal hip is a stable joint that requires appreciable force for dislocation. Patients with hip dislocation often have other serious injuries. Most dislocations are posterior, caused by force applied to the anterior aspect of the knee while the hip is flexed and somewhat adducted. If the hip is more abducted, the posterior lip of the acetabulum is fractured: the larger the fractured fragment, the more unstable the hip socket, and the more comminuted the fracture, the more difficult it is to gain stable surgical fixation. Anterior dislocations are much less common and result from forced abduction of the flexed hip.

Articular cartilage damage is commonly associated with dislocation. Interposed bone and cartilage fragments may prevent congruent reduction and compromise the outcome, as may associated fractures of the acetabulum or femoral head. Even in the absence of such findings, the prognosis after hip dislocation must be guarded, and post-traumatic arthritis is common in the long term (>20 years).

Any delay in treatment of a hip dislocation increase the risk of avascular necrosis of the femoral head. This leads to secondary segmental collapse during the revascularization phase, and often results in disabling post-traumatic arthritis. Hip replacement arthroplasty provides a satisfactory salvage option for the elderly and infirm. However, hip dislocations usually involve young individuals for whom replacement often fails within a relatively short time.

As with acetabular fractures, associated injuries are not uncommon. In particular, sciatic nerve palsy (especially of the peroneal division), knee injury, and occult proximal femur fracture must be sought. All patients with femoral shaft fractures must undergo anteroposterior radiography of the pelvis to exclude the possibility of hip injuries. Adequate radiographs are essential to exclude an undisplaced proximal femur fracture, which may become displaced when closed reduction of the hip is undertaken.

Hip dislocations are primarily characterized by direction. So-called "central dislocations" are invariably associated with an acetabular fracture, and are therefore considered and treated as above. Posterior hip dislocations may or may not be associated with a fracture of the posterior wall or lip of the acetabulum. A significant posterior lip fracture often prevents adoption of the normal adducted, shortened, internally rotated and slightly flexed position of the limb, any motion of which is severely painful. The rarer anterior dislocations produce an abducted, externally rotated deformity. They are often associated with an impaction fracture of the femoral head, which increases the risk of post-traumatic arthropathy.

When a hip dislocation is identified, reduction should be performed within an hour or two if at all possible, to restore the arterial blood supply to the femoral head. Closed reduction is usually possible following administration of analgesia and muscle relaxants, or perhaps general anaesthetic. Strong manual traction and flexion–rotation manipulation of the limb is performed while assistants stabilize the pelvis. If closed reduction is unsuccessful, open reduction is urgently required. After replacement of the femoral head into the acetabulum, stability must be assessed: skeletal traction is required if the hip readily redislocates, as is the case when a major posterior lip fracture is present. It is important to confirm congruent alignment, and to exclude interposed osteocartilaginous fragments or potentially unstable fractures, which require early elective open treatment. Alignment requires interpretation of post-reduction acetabular radiographs, and a CT scan. Following satisfactory stable reduction, the patient can resume protected walking as soon as comfort permits. After urgent replacement of the femoral head in the acetabulum, skeletal traction should be applied through the proximal tibia or distal femur if the joint is unstable or if arthrotomy will be required to remove intra-articular fragments. While such procedures can be delayed until the patient's condition is optimal, urgent open reduction is required when closed manipulation is unsuccessful.

Although the functional outcome after reduction of simple posterior hip dislocations is variable, excellent and good results are obtained in 70 to 80 per cent of patients. The majority of patients have minimal stiffness, slight pain with work, less than 25 per cent loss of motion, and minimal arthritic changes. Osteoarthritis develops in 15 to 20 per cent and avascular necrosis in 10 per cent of injured patients. Femoral head and acetabular fractures have poorer outcomes, with an increased risk of arthritis and avascular necrosis. Recurrent dislocations are rare.

Extra-articular proximal femur fractures (Type A) are those of the trochanteric region. Intracapsular femoral neck fractures (Type B) and those of the femoral head (Type C) carry a worse prognosis if they are displaced. Because of their differing prognosis and therapeutic needs, each of these injuries should be considered separately.

These rare injuries are associated with hip dislocations, and are easily missed unless pre- and post-reduction radiographs are carefully examined. Pipkin's classification is often used: split inferior to the ligamentum teres (Pipkin I), split cephalad to the ligamentum (Pipkin II), or impacted. Closed reduction of the hip often realigns a split femoral head fracture satisfactorily. If this is the case traction may be continued until healing, or open reduction and internal fixation may be undertaken via anterior approach, especially for the larger fragments, to permit earlier mobilization. Impacted femoral head fractures have a guarded prognosis, which may be improved by elevation and bone-grafting. The prognosis of a femoral neck fracture associated with a femoral head fracture (Pipkin III) is poor: primary arthroplasty is appropriate for older patients. Femoral head fractures associated with acetabular fractures (Pipkin IV) may require specific treatment, but management of the acetabular fracture assumes over-riding importance.

Femoral neck fractures are common in the elderly, and are occasionally seen in young individuals after high-energy trauma. Undisplaced fractures generally repair well, but in-situ fixation is advisable since non-operative treatment carries the risk of displacement. Non-union (5 to 15 per cent, or more) and avascular necrosis with segmental collapse (7 to 27 per cent) occur after displaced fractures with sufficient frequency to make primary replacement of the femoral head and neck advocated for elderly patients. Most authorities recommend urgent reduction and fixation for physiologically young patients, who will not be well-served by arthroplasty. Gaining an anatomical reduction is important for a good result. Femoral neck fractures are best fixed with three pins or screws. A closed reduction may suffice, but the capsule should be opened to decompress any taut hemiarthrosis that impairs head perfusion. If a satisfactory closed reduction is not achieved, an open reduction is indicated. For inactive, elderly patients, a simple hemiarthroplasty is successful. More active individuals have better pain relief and less frequent need for revision if a cemented bipolar prosthesis, or even a total hip arthroplasty is used, though complications are frequent when less experienced surgeons use total hip arthroplasty for primary treatment of a femoral neck fracture.

Intertrochanteric fractures (extra-articular) can be treated effectively with skeletal traction, but are usually internally fixed with a sliding screw or sliding nail device. Mechanical failure and non-union are rare, even in so-called unstable injuries with comminution of the lesser and greater trochanters. Elderly, osteoporotic people with subtrochanteric involvement pose potential problems for fixation, especially when the fracture line obliquity is reversed, with its lateral end more distal. Alternative reduction and fixation techniques may be helpful for such patients.

So-called subtrochanteric fractures are challenging to fix with simple nail plate implants, but with care and good reduction a stout modern sliding screw can be used, often with primary medial bone grafting. This technique may be preferable when the greater trochanteric region is comminuted. If this region is intact, these fractures should be treated as femoral shaft fractures. Closed intramedullary nailing, with locked devices that fix into the lesser trochanteric region, or the femoral head if the former is comminuted, provide the best reported results for operative treatment. Non-operative treatment has a high rate of malunion, non-union, and prolonged disability; skeletal traction should be considered if modern fixation techniques are not available. With closed nailing, the incidence of complications is little more than that seen with more distal femoral shaft fractures.

Fractures of the femoral shaft usually follow high-energy injuries, and are associated with all the real and potential problems of any patient with multiple trauma. A systematic search for associated injuries is necessary. The femur fracture itself must be promptly immobilized, optimally with a traction splint, as failure to do so increases local bleeding and soft tissue damage. Prompt surgical stabilization of femoral shaft fractures offers many systemic benefits for the patient. If definitive fixation must be delayed, skeletal traction should be applied, usually with a heavy threaded pin in the proximal tibia, unless local injuries contraindicate this.

Femoral shaft fractures usually unite with traction. This union takes 6 weeks in an adult, with a similar period in a spica cast, or perhaps a hinged cast brace, to prevent late progressive angulation of the consolidated but incompletely healed fracture. Prolonged disability, problems with malunion and knee dysfunction, and an increased incidence of adult respiratory distress syndrome are associated risks of such non-operative treatment.

Where available, closed intramedullary nailing offers the lowest incidence of complications and the fastest rehabilitation (Fig. 1) 2434,2435. Locking screws should be used routinely if there is comminution, significant obliquity, or a fracture outside the isthmus of the medullary canal. In a severely injured patient, especially one with associated vascular injury, plate fixation may be considered, but the risk of non-union is significant unless technique is flawless and early bone grafting is carried out. External fixation may reduce the risk of infection in serious open fractures of the femur.

Fractures of the distal femur pose many of the problems of femoral shaft injuries, but are unique because of their proximity to the knee. Radiographic assessment permits classification and planning of management, which for displaced fractures is optimally operative. Open wounds, torn knee ligaments, proximal tibial fractures, and nerve or arterial injuries may complicate these injuries.

As is the case with displaced articular surfaces generally, and perhaps more important for weight-bearing joints, the basic principles for articular fractures must be upheld. These include anatomical reduction, rigid fixation, and early motion of the joint, but delayed weight-bearing, with the goals of restoring alignment, mobility, muscle strength, and endurance, and avoiding post-traumatic degenerative arthritis. If the patient is a candidate for surgery, and if safe, effective surgical fixation can be accomplished, experienced surgical teams can gain optimal results.

Patellar fractures often involve disruption of the quadriceps mechanism with loss of knee extension. Ability to raise the extended leg from the bed is an important test for quadriceps continuity, and may also reveal rupture of the quadriceps tendon or patellar ligament when the patella is intact. A comminuted fracture that is undisplaced and has intact quadriceps function can be treated non-operatively, with early range of motion exercises, splinting during ambulation to prevent loading the flexed knee, and weight-bearing as tolerated with the knee fully extended. The occasional longitudinal fracture can be similarly managed, unless it is displaced enough to affect articular surface congruity. Transverse, displaced patellar fractures indicate quadriceps mechanism disruption: surgical repair is required to restore adequate knee extension strength. Displaced fractures should be fixed anatomically, preserving some or all of the patella if at all possible, with reattachment of quadriceps tendon or patellar ligament as indicated if a small proximal or distal fragment is excised. Re-attachment of the patellar ligament is protected with a heavy wire or equivalent patellotibial restraint. Transverse tears in the medial and/or lateral quadriceps expansions must be repaired, as they also transmit extensor force. A severely comminuted patellar fracture is often best excised to avoid disabling pain or post-traumatic arthritis, even though absence of the patella weakens knee extension.

Soft tissue injuries of the knee are important because of their frequency, consequences, and difficulties of diagnosis. A careful examination, perhaps under anaesthesia, diagnostic and therapeutic arthroscopy when indicated, and, when available, magnetic resonance imaging can elucidate most of these injuries. Knee ligament injuries associated with multiple trauma carry a guarded prognosis: optimal treatment is not always clear: significant rehabilitation is often required. Modification of activities may be an alternative to surgery for some individuals with residual functional instability.

Knee dislocations are associated with rupture of several ligaments; fractures may also be present. They are most important because of the high incidence of associated, often occult popliteal artery injury. Frequently these are intimal tears, with a gap that results in delayed thrombosis, occlusion, and irreversible distal ischaemia requiring amputation. A high-quality arteriogram is essential to occlude such injuries. If ischaemia is detected, urgent exploration and repair of the popliteal artery are required. Peroneal and/or tibial nerve injuries are frequent. Ligaments torn in a knee dislocation may be managed non-operatively with fairly good results, but primary repair is probably best for preservation of optimal function.

Dislocations of the patella (usually laterally) may recur, and are often due to congenital malalignment. Osteochondral or marginal avulsion fractures may be present. An initial acute patellar dislocation usually tears the medial retinaculum: this should be protected by maintaining knee extension during the 6 or so weeks required for healing.

Torn collateral ligaments of the knee may recover with appropriate non-operative treatment using a hinged brace and vigorous rehabilitation. If associated injuries are present, open repair and early range of motion and strengthening exercises within limits set by a hinged brace should be considered.

Torn cruciate ligaments do not heal with closed treatment or primary suture repair, unless they are avulsed from tibia or femur. If their absence results in functional instability, or is thought likely to, and if the patient is young and active and will co-operate with a careful, prolonged rehabilitation programme, augmented repair or replacement is indicated. Diagnosis can be aided by arthroscopy, but in acute injuries associated with capsular tears (dislocations, gross instability), arthroscopic irrigation fluid does not remain confined to the knee, and may cause excessive tissue swelling. Timing of surgery is critical to avoid knee stiffness. Full knee motion without significant swelling is required to assure maximal results. Either immediate reconstruction is performed, or surgery is delayed until soft tissues stabilize, and range of motion returns. Choice of graft for reconstruction depends on the extent of associated injuries with allograft tissues sometimes used to lessen donor site morbidity.

Meniscus tears that interfere with normal motion or cause pain are best treated arthroscopically. MRI provides an alternative, though costly, non-invasive approach to diagnosis. Tears of the meniscus are usually treated by partial meniscectomy; preservation of the meniscus is important to the longevity and function of the joint. Peripheral meniscus tears have potential for healing: they should be re-attached, and protected until the suture line has healed. A small undisplaced tear may heal with protection alone.

Tibial plateau fractures range from minor to major. Uncorrected articular surface displacement carries the risk of post-traumatic osteoarthritis, as well as chronic instability. If they involve the surface under the meniscus, undisplaced fractures usually need only to be protected during healing. More extensive injuries may produce instability: these are best managed by reduction and fixation. In split type injuries of the lateral plateau, the lateral meniscus may be incarcerated within the fracture line. Outcome is better following surgical treatment. Depressed segments of the plateau causing instability should be elevated and internally fixed, the resulting defect being filled with autogenous bone graft. Fixation should be secure enough to permit early motion of the joint, which promotes optimal recovery. Except for split fractures in bone of normal density, buttress plate fixation is necessary. An injured meniscus should be repaired and saved if at all possible. Torn collateral ligaments should also be repaired, but cruciate ligaments are not repaired primarily, unless an avulsion permits reattachment to bone and early motion is permissible. While early motion helps by preventing stiffness and promoting cartilage recovery, weight bearing must be delayed for several months, until fracture healing is mature.

Displaced bicondylar tibial plateau fractures (C2, C3) may cause such severe soft tissue damage that open reduction and internal fixation risks slough of the soft tissue flaps. Careful judgement regarding operability and timing of surgery is essential. Minimally traumatic techniques are necessary. Limited open reduction and internal fixation of the articular surface components, with temporary external fixation across the knee or skeletal traction may be safer for such injuries, especially since stable internal fixation may require an extensive exposure with application of plates to both medial and lateral cortices.

Treatment of displaced tibial plateau fractures with open reduction and internal fixation gives variable results: 50 to 90 per cent are excellent or good, depending on the severity of injury. Fractures of the medial condyle with lateral ligament disruption or bicondylar fractures have poorer long-term results but are best treated open. Following closed management of fractures with less than 10° of instability in full extension or less than 10 mm of joint depression 90 per cent of patients have good long-term results. Surgical and non-surgical treatment appear to be equally effective in treating these stable fractures.

Tibial diaphyseal fractures are common and are often associated with fibular shaft fracture. The distal or proximal tibiofibular joints are occasionally involved. Fractures may extend into the knee or ankle joints. Severe injuries have a greater risk of complications such as neurovascular compromise, delayed union, non-union, malunion, and (if open or opened) chronic infection. However, even relatively benign-appearing tibial fractures are not immune from these complications. Treatment should be chosen with regard to the severity of soft tissue and bone injury. Patients with low-velocity injuries usually do well with non-operative, functional treatment in a cast or brace. Severe tibial fractures benefit from a more aggressive approach. Operative care is mandatory if the fracture is open, especially if limb threatening ischaemia is caused by compartment syndrome or arterial interruption. The most severe open tibial fractures are best treated with early amputation, unless a functional leg can be salvaged without excessive risks for the patient.

The severity of a tibial fracture is indicated by several variables, which must be assessed independently. In general, the more energy absorbed by the soft tissues and bone of the leg, the more severe the injury. Indirect injuries, produced by torsional forces, are usually less severe than those produced by directly applied, and especially crushing forces. Factors that need to be assessed include the extent of devitalized skin and muscle, periosteal stripping from bone, arterial and neural injury, and wound contamination. The size of a skin wound is less important than the underlying soft tissue damage. Swelling sufficient to produce a compartment syndrome usually indicates a severe injury.

Associated fibular fractures may indicate more severe injuries, but do not necessarily affect the prognosis. An intact fibula may make non-operative management more difficult, with tendencies for varus malalignment and delayed union. Obvious diastasis between the two shafts requires longitudinal disruption of the interosseous membrane, and indicates a severe soft tissue injury.

Ellis reported a series of tibial fractures treated with non-operative fixation: 80 per cent of minor fractures healed by 12 weeks, and 80 per cent of those of moderate severity treated by 15 weeks. However, 27 weeks were required for healing of 80 per cent of severe fractures, and a number failed to heal at all. Initial care for a tibial shaft fracture must include careful evaluation, especially for vascular injuries, compartment syndromes, which may be delayed, and open wounds.

Open wounds require prompt surgical debridement with copious irrigation, and delayed closure unless they are minor. Compartment syndromes require fasciotomy. Arterial injuries that cause limb-threatening ischaemia must be repaired urgently, but results are poor, often because of the severity of all other injuries: many of these patients are best served by early amputation. Severe tibia fractures generally require stabilization with external, or occasionally internal, fixation.

Overall alignment should be restored, and the limb should be splinted, generally with a well-padded plaster cast, capable of being loosened to accommodate swelling. Provisional reduction, which may prove definitive for less severe injuries, is best achieved with the aid of gravity, the leg hanging over the edge of the examining table, and plaster being applied while an assistant holds the foot, correctly rotated and in neutral position. Gentle external moulding usually corrects any angulation. After the initial below-knee plaster has hardened, it is used to hold the limb horizontally, maintaining correct rotation, while the plaster is extended proximally, over adequate padding, about two-thirds the way up the thigh, with the knee flexed 10 to 15° so that rotation is controlled, but weight bearing is possible when the patient is sufficiently comfortable.

Definitive treatment for tibial shaft fractures is usually undertaken by external support in a weight-bearing cast. Although well suited to the common fractures caused by low-energy trauma, this approach may fail to maintain alignment and to achieve timely union for moderate and severe tibial fractures. The initial immobilization is with a long leg cast as described above. Early weight bearing is generally advocated (as soon as tolerated, and preferably before 6 weeks). Once swelling has resolved, a so-called patellar-tendon-bearing cast or brace may replace the long leg cast, for more stable fractures, to permit knee, and possibly ankle, motion. The majority of tibial fractures heal with satisfactory alignment and function within 4 or 5 months.

External fixation provides stable support for tibial fractures, without periosteal stripping or injury to intramedullary vessels. Bone vascularity is protected, and additional injury to the soft tissue envelope is minimal, with modern half-pin fixators placed anteromedially to avoid muscle penetration (Fig. 2) 2436. Extension of the fixator across the ankle into the forefoot provides temporary splinting of foot and ankle to prevent contractures and minimizes movement of injured soft tissues in the calf. Although external fixation provides an optimal environment for management of severe wounds, percutaneous pins may become loose or infected, at a rate that increases with time. Since severe tibial fractures heal slowly, especially after the radical debridement of devascularized soft tissue and bone necessary to minimize the risk of infection, external fixation is only one component of the comprehensive management required. Thorough, staged debridements, early wound closure using local or free muscle flaps as necessary, and delayed cancellous autografting are required for optimal results. Bone grafting should be performed as soon as the wound is securely healed, and not delayed until predictable problems with union become evident. Of 202 severe, open tibial fractures 93 per cent achieved union and 89 per cent satisfactory eventual function.

Intramedullary nailing is a valuable technique for managing selected tibial diaphyseal fractures, when proper equipment and experienced surgeons are available. Alignment, once achieved, can be reliably maintained with little or no external support. Significant function is often possible, long before full radiographic healing is complete. Important differences exist between intramedullary nailing techniques, which are still developing. The medullary canal of the tibia is often narrower in its central portion than at either end. Fixation with a standard nail is thus limited for proximal and distal fractures, and nail diameter is also restricted. Reaming of the medullary canal was introduced to obtain a longer zone of purchase by the nail in the medullary canal as well as to permit use of larger diameter nails (Fig. 3) 2437. However, reaming of cancellous bone devascularizes the tibial cortex, which receives most of its perfusion through the medullary arterial system and increases the risk of infection in open fractures. It does not appear to pose a clinically significant problem for closed injuries, especially if nailing is performed without opening the fracture site.

Fracture stability is improved by fixation with interlocking nails that rely on transosseous screws placed through proximal and distal portions of the nail. Length and rotation can be controlled for practically any tibial diaphyseal fracture, if proximal and distal purchase are secure (Fig. 4) 2438. This technique is well established with larger diameter reamed nails, but smaller diameter nails that can be placed into most tibias with little or no reaming do not provide fixation with the same durability. Nonetheless, non-reamed intramedullary tibial nails, with or without locking, produce results at least as good as other techniques of managing many open tibial fractures. Experience with their use in the most severe open tibial fractures is as yet limited, and caution remains appropriate.

While intramedullary nailing is very effective for treating well-aligned aseptic non-unions, its use after infection, including that associated with external fixation pins, risks development of serious infection extending throughout the medullary canal of the tibia. Protocols for use of intramedullary nailing after initial external fixation are not yet well accepted.

Although fixation of tibial fractures with plates yields satisfactory results, technique of both surgical approach and fixation is particularly important. Use of plates in the treatment of open fractures carries an increased risk of infection compared with external fixation. The necessary exposure risks wound slough. Comminution or loss of bone substance may require bone grafting to ensure union before plate failure. In general, plates are of greatest value for stabilizing metaphyseal tibial fractures, beyond the reach of locked intramedullary fixation.

The ankle region is frequently injured. Knowledge of the local anatomy and familiarity with the typical injury patterns are both essential: history of injury, pain, swelling, impaired function, and even deformity are non-specific. Localized tenderness, instability, specifically impaired function, and radiography are the keys to the proper definition of pathology. Integrity of skin, tendons, ligaments, and vascularity, as well as function of motor and sensory nerves must be assessed. Combinations of injuries are typical: the foot and leg may be involved in injuries affecting the ankle.

Most fractures are apparent on routine radiographs, but some, such as osteochondral lesions or lateral process fractures of the talus, or fractures of the foot (anterior process of calcaneus, base of fifth metatarsal, tarsometatarsal joint injuries) may be overlooked without appropriate radiographic projections. Injured ligaments are usually tender, painful and/or unstable when stressed, but may not be associated with pathognomonic bony displacement. Ruptured tendons are often tender, and a careful examination should demonstrate loss of specific function. Active plantar flexion is typically present when the tendocalcaneus is ruptured since the peroneus longus and brevis, and the deep posterior compartment flexors medially produce this movement, though with reduced strength.

The talocrural joint is a congruent hinge that permits dorsi and plantar flexion of the talus around an axis that connects the tips of medial and lateral malleoli. This joint does not normally allow rotation or inversion-eversion, although such movements do occur at the flexed knee and subtalar joint. The talus articulates with an osteoligamentous socket ("mortise") formed by the plafond and medial malleolus of the tibia, the tibiofibular syndesmotic ligaments, and the lateral malleolus. The lateral malleolus, securely attached to the distal tibia in a precisely normal location, will maintain the proper relationship of the talus to the tibial plafond. Restoring and maintaining this relationship is the goal of treatment for malleolar fractures. Ankle injuries that disrupt the normally congruent fit between talus and mortise pose a significant risk of post-traumatic osteoarthritis with pain, limited motion, and impaired gait. Most frequently, incongruence is due to a malleolar fracture caused by indirect forces that produce rotation of the talus relative to the tibia, primarily in the frontal or transverse planes, perpendicular to the ankle's more sagittally oriented plane of normal motion. Inversion (adduction) or abduction (eversion) in the frontal plane, and external rotation of the talus in the transverse plane are the movements that produce malleolar fractures. These usually occur when the foot is on the ground, and the body's momentum forces the tibia to move in an abnormal direction.

The common inversion injury involves adduction of the supinated foot ("supination–adduction"). This produces first a tension failure on the lateral side of the ankle, with either a lateral collateral ligament disruption ("sprain"), or a horizontal avulsion fracture of the lateral malleolus below the level of the tibial plafond. The second stage of this injury is a more or less vertical shearing fracture of the medial malleolus, with occasional medial plafond impaction.

External rotation of the supinated foot produces first a rupture of the anterior inferior tibiofibular ligament, then a spiral-oblique fracture of the lateral malleolus, primarily at the level of the plafond and most apparent on the lateral radiograph, with more or less proximal extension of the posteriorly directed fibular fracture line. The third stage is disruption of the posterior inferior tibiofibular ligament, often with avulsion of a larger or smaller fragment of the posterior lip of the distal tibia (the so-called "posterior malleolus"). The fourth and final stage is tensile failure medially of either the medial malleolus or the medial collateral (deltoid) ligament.

When the pronated foot is externally rotated the progression of stages is in the same sense, but begins one step more medially, with the medial malleolus or deltoid ligament failure first, followed by the anterior inferior tibiofibular ligament, then a different fibular fracture pattern entirely above the syndesmosis. This is usually a short spiral fracture extending from low medially to higher laterally; it is thus more visible on the anteroposterior of mortise radiograph than on the lateral view. The final stage is rupture of the posterior inferior tibiofibular ligament, which, as with injuries caused by external rotation of the supinated foot, may involve avulsion of more or less of the posterior tibial lip.

Undisplaced malleolar fractures are often stable, with intact bone and ligament on the opposite side of the ankle. There is no disturbance of the mortise relationships of the talus to the distal tibia, nor of the lateral malleolus to either distal tibia or to talus. Their prognosis is good with non-operative treatment. Displaced malleolar fractures should raise suspicion of an occult ligament disruption with ankle instability and loss of support for the talus. The most severe malleolar fractures are fracture dislocations, in which the talus is completely displaced from the tibial articular surface; this is most evident on the lateral radiograph. Prompt reduction of talus to tibia is necessary to minimize soft tissue compromise. A major posterior tibial lip fracture (usually >25–30 per cent) may render this reduction unstable, with recurrent posterior talar subluxation on lateral radiographs taken after reduction, in spite of apparently satisfactory plaster immobilization. Even in the absence of an intact medial collateral ligament, the talus is kept properly aligned with the tibial plafond by the lateral malleolus, but only if this malleolus is in its proper anatomical relationship with the distal tibia. Lateral malleolar length, rotation, and close, stable approximation to the distal tibia are all important. A mortise radiograph showing smooth subchondral bone density parallel to and equidistant from the talus and symmetrical with the uninjured ankle, indicates a satisfactorily congruent mortise. Though it is possible to hold the talus in proper alignment with a well-moulded cast, rarely does a closed reduction precisely restore the normal relationship of lateral malleolus to tibia. Displaced malleolar fractures are best treated by anatomical open reduction and stable internal fixation. An additional benefit of internal fixation is that immobilization in a non-functional position is avoided, and ankle motion and function can more rapidly be restored.

The precarious soft tissue envelope must be considered carefully in treatment of ankle fractures. When the soft tissues are intact and not excessively swollen, gentle technique should permit internal fixation electively. Open reduction and internal fixation within a few hours may permit surgery before soft tissue swelling becomes severe, but if this is not possible it is better to wait until soft tissue swelling has resolved, and skin wrinkles are again visible, even though this may require several days. The best possible closed reduction and well-padded cast or splint immobilization are essential during this waiting period. Elevation and observation for neurovascular compromise are also required.

Open fractures require prompt irrigation and debridement, adjunctive antitetanus therapy and antibiotics, fracture reduction, and stabilization, with delayed wound closure. Primary internal fixation is effective and safe for most of these injuries, but may be hazardous if significant additional soft tissue disruption is required for surgical exposure. In such cases, internal fixation of accessible fractures, combined with external fixation of the foot and ankle, may be safer. The external fixator may be retained through fracture healing, or exchanged for staged internal fixation once the soft tissues permit.

Medial malleolar fractures are approached through a straight or curved incision, which should also provide access to the medial ankle joint. Fractures are fixed with lag screws perpendicular to the fracture line, or with K-wires and "tension-band" wires if small and/or comminuted. Avulsion fractures (Type B and Type C injuries) are generally transverse. Screws are placed obliquely. Type A injuries with vertical fracture lines require horizontal screws, and may need reduction of impacted plafond components. If the medial component of an unstable malleolar injury is ligamentous, surgical repair is not required, since anatomical fibular repair is both necessary and sufficient. Occasionally medial exposure may be required, however, since medial tendon interposition prevents reduction of the talus in the mortise.

Small posterior malleolar fractures may not need additional treatment if they minimally involve the articular surface. If they are larger, anatomical reduction and stable lag screw fixation provide stability and a congruent articular surface of the plafond. Either the lateral or medial incision can be used to visualize reduction. Lag screws may be inserted from back to front, or from front to back through stab wounds if required, but should be preceded by provisional K-wire fixation and an intraoperative radiograph to confirm a satisfactory reduction.

After reduction and fixation of malleolar fractures, the ankle is initially splinted to permit soft tissue healing. It may then be treated with early motion, but resumption of unprotected weight bearing is delayed until after fracture healing. With such treatment, satisfactory long-term results should be anticipated in 80 per cent or more of injuries. Poorer outcomes are typical of more severe fractures, especially dislocations and those affecting more of the articular surface.

The distal tibial metaphysis is also referred to as the tibial "pilon". Fractures involving this region often extend into the transverse distal tibial articular surface, the "plafond" (ceiling) of the ankle joint. Often associated with severe soft tissue injury, these injuries occur through mechanisms that crush or impact because of axial loading, or those that shear the region apart, producing so-called "explosion" fractures. Anatomical restoration of axial alignment, articular surface, and mortise improves outcome, but only if it can be achieved without complications, primarily soft tissue slough.

Lateral collateral ligament sprains are common injuries produced by sudden, unprotected weight bearing on an inverted foot—the supination-adduction mechanism of Lauge-Hansen discussed above. The lateral collateral ligament of the ankle has three parts: the anterior and posterior talofibular ligaments, and the fibulocalcaneal ligament. Sprains usually involve the anterior talofibular and fibulocalcaneal components, which may be partially or completely torn. Diagnostic features include a history of acute inversion stress with lateral ankle pain, swelling, ecchymosis, and tenderness, usually best localized over the involved ligaments. Passive inversion usually increases the pain. Radiographs are essential to exclude other injuries, including osteochondral fractures of the talus and lateral process fractures of the talus.

Instability depends upon whether the ligaments have been minimally, partially, or completely torn. Since inversion is normally permitted by the subtalar joint instability is hard to assess, and stress radiographs are necessary to confirm this finding. Most inversion ankle sprains involve the anterior talofibular ligament, which also resists anterior displacement of the foot relative to the tibia, so that this "anterior drawer test" can be used to assess ligament stability. Dorsiflexion aligns the fibulocalcaneal ligament to resist inversion. Plantar flexion puts the anterotalofibular ligament in an appropriate position for this: inversion stress radiographs, if needed, should be obtained in both positions.

Inversion sprains interfere with walking and sports, and if undertreated, predisposes the patient to recurrent injuries. Protection from weight bearing, elevation, ice, and a supportive posterior or U-shaped well-padded splint provide appropriate initial treatment for all but the most trivial sprains. Once pain and swelling have improved, weight-bearing can usually be resumed in a stirrup splint, although a short leg weight bearing cast may be needed for more severe injuries. Rehabilitation should include peroneal muscle strengthening, balance exercises, and progressive resumption of activity, perhaps with a less restrictive stirrup splint. Chronic ankle inversion instability may require surgical ligament reconstruction.

Achilles tendon ruptures usually occur suddenly in middle-aged individuals during a push-off or jump, as in basketball or racket sports. Local pain, inability to continue the precipitating activity, and some degree of gait impairment are noted. Tenderness, a palpable defect in the tendon that becomes obscured by haematoma and swelling, and weak but persistent plantar flexion are noted. Compressing the calf while a patient kneels with his toes hanging freely normally produces passive plantar flexion (Thompson test). This response is absent or reduced when the tendocalcaneus is ruptured. Treatment can be either by immobilization in gentle equinus for 8 weeks, or by surgical repair with any of several techniques. Repair may have more complications, but produces better function with a lower rate of recurrence.

Functional results following surgical and non-surgical treatment of acute ruptures are equally good. Recurrence is more common following non-surgical treatment (12 per cent) than after surgical repair (4 per cent) but return to work is quicker (9 rather than 13 weeks) and infection rate is lower (zero compared with 4 per cent).

Posterior tibial tendon ruptures usually occur by attrition, perhaps preceded by pain posteroinferior to the medial malleolus. It is more common in patients with systemic arthritides. The actual rupture is rarely brought to medical attention, but the patient notices a progressive flat foot deformity that is usually painful. Tibialis posterior tendon rupture is a prime cause of adult onset flat foot. Early diagnosis may permit repair or augmentation in time to correct the problem, but otherwise triple or subtalar arthrodesis may be required to correct deformity and pain.

Foot injuries are often ignored or deferred "until later", especially when other more impressive fractures are present. This results in a chronically painful, deformed foot that is a significant cause of chronic disability, due to pain on weight bearing and impaired gait. Precise diagnosis of injuries and prompt, secure anatomical repair offer the best chance of successful rehabilitation for patients with serious foot fractures and dislocations.

Talus fractures occur in several varieties. Osteochondral fracture of the tibiotalar articular surface should be excised if the lesion is small. If they are large, reduction and internal fixation may be successful. A displaced fracture of the lateral process of the talus, which participates in both tibiotalar and subtalar joints, should be treated similarly. Talar neck fractures often extend into the body of the bone, though the latter fractures are customarily considered separately. Displaced talar neck fractures are associated with subtalar subluxation or dislocation. Tenuous skin cover and marked deformity often result in wound problems. Closed reduction is urgent, but often requires an anaesthetic; if unsuccessful, an open reduction is required. Anatomical reduction and rigid internal fixation with lag screws decreases the risk of avascular necrosis of the talar body, a more frequent complication of closed treatment. The incidence of this problem increases with the degree of displacement of the talar body from its sources of blood supply by the talar neck, the sinus-tarsi vessels, and the medial collateral ligament of the ankle. For optimal results, displaced talar fractures should be treated with anatomical alignment and delay of weight bearing until union has occurred.

Calcaneus fractures result usually from a fall from a height, with the patient landing on his heel. Associated axial loading injuries often include compression fractures of the thoracolumbar spine. With the typical calcaneal fracture, the talus is forced downward into the heel bone, driving the subtalar joint surface plantarward into the substance of the calcaneus, decreasing the height, but increasing the width of the bone. Subtalar comminution and deformity are present to a greater or lesser degree. Soft tissue damage may be severe enough to produce a skin slough, from swelling alone or in combination with skin tension over extreme bony deformity. Plantar nerve damage, and even compartment syndromes of the foot may develop. In addition to lateral, oblique, and axial radiographs, the true extent of calcaneal damage is often best shown by CT scans: coronally oriented sections are especially helpful, and aid preoperative planning. Surgical repair is becoming more popular for these disabling injuries. It remains to be seen whether or not it improves the outcome over that obtained with non-operative care emphasizing rest, elevation, active motion, and acceptance of deformity. Pain on weight bearing and loss of subtalar motion, especially noticeable when walking on uneven surfaces, are the typical sequelae of a calcaneus fracture. Closed reduction is rarely undertaken, and deformity persists without surgery. Symptoms tend to decrease gradually over many years following non-operative treatment.

Tarsal navicular fractures may be a consequence of fatigue or acute injury. Reduction of deformity and rigid internal fixation provide the best results, and help minimize chronic disability.

Tarsometatarsal fractures and dislocation (so-called Lisfranc joint injuries) frequently cause pain and disability. The best results are provided by precise, anatomical reduction, usually open, and rigid fixation, with screws for larger and less comminuted joints, and K-wires when this is not possible. Instability and tenderness of the forefoot or the midfoot must be sought whenever a foot injury is suspected. Slight loss of alignment of the medial three metatarsals with their cuneiforms, especially the recessed second metatarsocuneiform joint, is important, as is the alignment of the more mobile lateral two metatarsals with the cuboid. The overall configuration of the forefoot should be compared with normal, and especially with the patient's opposite foot, if it is not injured. Arthrodesis of chronically painful tarsometatarsal joints may improve symptoms and function. This is far easier if the foot is normally aligned.

Metatarsal fractures, if displaced significantly, may need open reduction and internal fixation with K-wires, or small plates and screws. Restoration of the normal distal plantar surface is necessary to provide normal weight distribution on the sole of the foot, and to avoid the pain resulting from an excessively prominent metatarsal head or bony deformity.

Toe dislocations should be reduced promptly with closed, or if these are unsuccessful, open techniques. Great toe fractures may benefit from open reduction and internal fixation if this is necessary to preserve overall alignment and dorsiflexion range of the first metatarsophalangeal joint. Lesser toes are less exposed to weight bearing. As long as fractures do not produce excessive deformity that will interfere with shoe wear or cause pressure on an adjacent digit, gross realignment is usually all that is required. Loose taping to adjacent toes is usually sufficient. Rarely, percutaneous K-wire fixation may be helpful, especially to stabilize an open injury.

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