Orthopaedics on call

Fractures, dislocations, joint and spine emergencies, and minor injuries.

• Fractures and dislocations: the essentialsPain relief, check nerves and pulses before and after anything you do, two views, and reduce urgently when the limb or the skin is at risk.
• Open fracturesIV antibiotics within an hour, tetanus, one photograph, a saline-soaked dressing and a splint. Then theatre on time.
• Hip (neck of femur) fractureAn elderly patient who fell and cannot walk, with a short, externally rotated leg. Pain relief and a nerve block early, find out why they fell, prepare for surgery within 36 hours, and prevent delirium.
• Compartment syndromePain out of proportion and pain on passive stretch. Split the plaster to the skin and call the senior. A pulse doesn't rule it out.
• Septic arthritisA hot, swollen, painful joint is septic until proven otherwise. Aspirate before antibiotics whenever it's safe.
• Back painMost back pain is mechanical. Your job is to find the few that aren't: cauda equina, cord compression, infection, spinal TB, AAA and fractures.
• Cauda equina syndromeBack pain with sciatica in both legs, numbness in the saddle area, or a change in bladder or bowel control is cauda equina until proven otherwise. Examine, bladder scan, emergency MRI, and spinal surgery the same day.
• Spinal cord compressionBack pain in someone with cancer is cord compression until proven otherwise. Act on the pain, before the weakness.
• Acute goutA hot, red big toe overnight with previous attacks is gout. Fever or an unusual joint means you must exclude infection first.
• Ankle and foot injuriesUse the Ottawa rules to decide on an X-ray, and don't miss the 5th metatarsal base, the Achilles tendon or the high fibula.
• Elbow injuriesAn adult who can fully straighten the elbow probably hasn't fractured it. Children need a lower threshold for X-ray.
• Hand and finger injuriesCheck rotation, every tendon and every digital nerve. A cut over a knuckle after a punch is a human bite into the joint.
• Knee injuriesA pop, swelling within 2 hours and giving way is an ACL tear until proven otherwise. Use the Ottawa knee rule for X-rays.
• Neck injuriesUse the Canadian C-spine rule in order, and never test neck rotation before excluding the high-risk factors.
• Rib injuriesPain relief is the treatment: it lets patients breathe deeply and cough. Older patients with several fractures do badly.
• Shoulder injuriesCheck the axillary nerve before and after any reduction. Look closely at the skin over a broken collarbone.
• Wrist injuriesSnuffbox tenderness means splint and follow-up, even if the X-ray is normal. Check the median nerve before and after any reduction.