Clinical Outcomes

Discuss the basic epidemiology, presentation, investigation, management, complications and prognosis of fractures - with focus on the main fracture presentations including hip/femur, knee, shoulder, wrist, scaphoid, tibia and ankle

Ankle fractures (1)

• Commonly a low-energy fracture of either the lateral and/or medial malleolus
• Includes fracture of the posterior malleolus
• Vascular compromise is rare

• Over 65/older women 1.5-5.3 per 1000 people

• Highest frequency is white women and lowest being non-white men

• Proper immobilisation, analgesia and timely orthopaedic referral can greatly enhance patient comfort and ensure optimal outcome

• Displaced fractures commonly treated with an open reduction and internal fixation

• Open fractures (bone pierces skin) require emergency treatment by surgeons

• Diagnostic factors: Recent trauma, ankle pain and swelling, inability to weight-bear

• Other factors: Ankle deformity, crepitus (joint movement sounds), tenderness of the proximal fibula

• Risk factors: Low-energy fall, osteoporosis, multiple falls, inversion injury to ankle

• Ottawa ankle rules: Help decide when to order x-rays, if there is posterior lateral or medial bony tenderness within 6cm of the distal aspect of the fibula or tibia or inability to weight bear 4 steps at the scene then ankle x-ray should be ordered.
  First investigation to order is a plain x-ray

Hip fracture (2)

• Occur predominantly in older people as risk increases significantly with age

• In younger patients, they usually result from higher energy trauma

• Associated commonly with low-energy injury (e.g. a fall) and osteoporosis

• Treatment is most commonly surgical

• Any fracture of the femur distal to the femoral head and proximal to a level a few cm below the lesser trochanter

• 76'000 hip fractures each year

• Occupy 4'000 NHS beds at any one time

• History of fall/trauma

• Pain in the affect hip, groin or thigh

• Inability to bear weight or move hip

• Shortened, externally rotated leg

• Risk factors: Osteoporosis/osteopenia, old age, falls, low BMI
  First investigations to order are plain radiographs, full blood count, urea and electrolytes and glucose

Wrist fracture (3)

• Non-displaced fractures do not have any deformity and are treated with immobilisation in a splint or cast

• Displaced fractures present with a 'dinner fork' deformity and require closed reduction and possible surgical fixation

• Fractures that affect the distal ends of the radius, ulna and carpus. Distal radius are one of the most common injuries

• Incidence of distal radius fractures is 36.8/10'000 in women and 9.0/10'000 in men over 35

• Women of any age - 170.2/100'000

• Men of any age - 83.9/100'000

• Presence of risk factors

• Wrist pain

• Tenderness over the distal radius

• Swelling

• Deformity - 'dinner fork'
  

• Risk factors: Trauma, osteopenia, osteoporosis
  First investigation to order is plain x-rays of the wrist

Long bone fracture

• Long bones defined as humerus, radius, ulna, femur, tibia and fibula

• At least 2 90${}^{\circ }$ orthogonal x-rays (sagittal, transverse, coronal) should be obtained with inclusion of joints proximal and distal to site

• Incidence of fractures in Britain is about 3.6%, 1.8M fractures in England each year

• Tibia is most frequently fractured, 6.6% of all fractures

• Pain

• Soft-tissue swelling

• Ecchymosis - bruise

• Altered nerve sensation

• Impaired motor function

• Risk Factors: Direct/indirect trauma, osteoporosis and chronic renal failure
  First investigations to order are x-ray limb, full blood count blood typing and cross-matching

Describe the radiological principles behind diagnosing and describing fractures

Ottawa ankle rules (1)

• Help decide when to order x-rays
• Ankle x-rays should be ordered if there is posterior lateral or medial bony tenderness within 6cm of the distal aspect of the fibula or tibia or inability to weight bear 4 steps
• Ankle fractures are diagnoses mainly from plain x-rays in orthogonal planes

Hip fractures (2)

• Order plain radiographs with both sagittal and coronal views
• Radiography is the definitive test to confirm the diagnosis
• If radiograph does not show a fracture but strong suspicion of one, request MRI
• Classify fractures radiographically into intracapsular (in joint capsule) or extracapsular (out of join capsule) to determine surgical managemetn

Wrist fractures (3)

• Order plain x-rays in all patients
• Order MRI if there is suspected scaphoid fracture

Long bone fractures (4)

• Order plain x-rays in all patients with suspected lower limb fracture

Discuss the basic epidemiology, presentation, investigation and management of compartment syndrome

Compartment syndrome of extremities (5)

• Incidence of acute compartment syndrome is difficult to ascertain because concrete diagnostic criteria are elusive

• 0.7 per 100'000 women, 7.3 per 100'000 men

• Presence of risk factors (fractures, osteoporosis)

• Pain

• Pressure (muscle tightness)

• Paraesthesia - abnormal skin sensation

• Paralysis

• Risk factors: Trauma, bleeding disorder, compression support and thermal injury

First investigation to order is compartment pressure measurement

• Significant muscle necrosis - amputation may need to be considered
• Casts or dressings should be split completely

Describe the common joint dislocations and their complications and management - with focus on the main dislocation presentations including shoulder, elbow, hip, knee and ankle

Joint dislocation (6)

• Complete separation of 2 articulating bony surfaces

• Common sites: shoulder, finger, patella, elbow and hip

• Partial/incomplete dislocation - subluxation

• Glenohumeral joint is the most mobile joint - vulnerable to dislocation
  

• Anterior shoulder dislocations account for more than 95% of shoulder dislocations and the most common discloation

• Incidence has bi-modal peaks: men between adolescence and 30 years and women aged 61-80

• 23.9 per 100'000 people in general population

• Presence of risk factors

• Characteristic posturing of joint

• Pain

• Inability to move joint

First investigations to order are plain x-rays of suspected dislocated site

Discuss the methods of imaging bone and the advantages and disadvantages of each

X-ray (11)

• Fly through many kinds of matter
• X-rays collide with electrons: sometimes transfers all its energy and gets absorbed, or transfers some energy and the rest scatters
• Frequency of outcomes depends on the number of electrons hit
• Collisions more likely for dense material or elements of higher atomic number
• Bones are dense - absorb x rays well
• Soft tissue are less dense - absorb less, is penetrated

Magnetic Resonance Imaging (MRI) (7)

• MRIs use protons which is abundant in the human body
• Protons spin which creates a small magnetic charge
• When a strong magnetic field is introduced the protons align with the field
• Radiofrequency pulse is introduced which disrupts the protons into a 90$\mathrm{°}$ or 180$\mathrm{°}$ realignment
• When radiofrequency is turned off the protons realign with the field
• This releases electromagnetic energy and the MRI detects this energy and differentiates between tissues based on the quickness of release

Computer Tomography (CT) (10)

• Creates cross-sectional images with the help of computer processing
• CT uses a motorised x-ray source that shoots narrow beams of x-rays as it rotates
• Digital x-ray detectors opposite the x-ray source which transmit to a computer
• Images individually are 2D but stacking them together can create a 3D image
• Computers use iterative reconstruction which uses forward projections detected by the CT to create an image
• Python code tutorial

Positron Emission Tomography (PET) (8)

• Tiny tracers with specifically designed radioactive molecules
• PET tracks the position of trackers
• Reveals activity in 3D
• Tracer can be any molecule (sugar, protein, hormone) each are tailored to a specific function in the body
• Radioactive atom on tracer loses radioactivity which releases a positron
• Positron + Electron they combine and destroy each other which releases energy as two gamma rays that travel out and in opposite directions
• PET scanner is like a geiger counter (radioactivity detector)
• This detects the two gamma rays and can calculate where the tracer must be

Functional MRI (fMRI) (9)

• Images of activity
• Observation of the response of protons
• Determine properties of the tissue the signal came from
• Differences in the magnetic properties of oxygenated vs deoxygenated blood

Ultrasound

• High frequency sound waves emitted from a probe
• Sound waves bounce back off tissues - echo
• Echoes detected and translated to image
• No radiation

Advantages/disadvantages

Discuss the indication for prescribing Paracetamol

Indication (12)

• Mild to moderate pain
• Pyrexia (fever)
• Acute migraine

Discuss the efficacy, safety, suitability and routes of administration for Paracetamol

Routes of administration (12)

• Mouth
• Intravenous infusion
• Rectum

Safety information

• No evidence that taking paracetamol during pregnancy causes autism in children
• Multiple incidents of overdose for adult inpatients with low body-weight (<50kg)

Side-effects

• Thrombocytopenia (low platelet count)

In Lakia's case she was given paracetamol for the pain

• 0.5-1g every 4-6 hours. Maxes out at 4g for a day
  In Billy-Joe's case he was given paracetamol for the pain
• 480-500mg every 4-6 hours. Maxes out at 4 doses a day

Quiz

Connections

Reference/s

1. bestpractice.bmj.com. (n.d.). Ankle fractures - Symptoms, diagnosis and treatment | BMJ Best Practice. [online] Available at: https://bestpractice.bmj.com/topics/en-gb/385?q=Ankle fractures&c=suggested [Accessed 2 Oct. 2026].
2. MFS (2026). Hip fractures - Symptoms, diagnosis and treatment | BMJ Best Practice US. [online] Bmj.com. Available at: https://bestpractice.bmj.com/topics/en-gb/387 [Accessed 2 Oct. 2026].
3. Bmj.com. (2025). Wrist fractures - Symptoms, diagnosis and treatment | BMJ Best Practice US. [online] Available at: https://bestpractice.bmj.com/topics/en-gb/392 [Accessed 2 Oct. 2026].
4. Bmj.com. (2025). Long bone fracture - Symptoms, diagnosis and treatment | BMJ Best Practice US. [online] Available at: https://bestpractice.bmj.com/topics/en-gb/386 [Accessed 2 Oct. 2026].
5. bestpractice.bmj.com. (n.d.). Compartment syndrome of extremities - Symptoms, diagnosis and treatment | BMJ Best Practice. [online] Available at: https://bestpractice.bmj.com/topics/en-gb/502 [Accessed 2 Oct. 2026].
6. Bmj.com. (2026). Joint dislocation - Symptoms, diagnosis and treatment | BMJ Best Practice US. [online] Available at: https://bestpractice.bmj.com/topics/en-gb/583?q=Joint dislocation&c=suggested [Accessed 2 Oct. 2026].
7. NIBIB (2013). How Does an MRI Scan Work? Available at: https://www.youtube.com/watch?v=1CGzk-nV06g [Accessed 3 Oct. 2026].
8. Imperial College London (2016). How does a PET scan work? YouTube. Available at: https://www.youtube.com/watch?v=yrTy03O0gWw [Accessed 3 Oct. 2026].
9. Neuroscientifically Challenged (2019). 2-Minute Neuroscience: Functional Magnetic Resonance Imaging (fMRI). YouTube. Available at: https://www.youtube.com/watch?v=rJjHjnzmvDI [Accessed 3 Oct. 2026].
10. NIBIB gov (2017). How Does a CT Scan Work? YouTube. Available at: https://www.youtube.com/watch?v=l9swbAtRRbg [Accessed 3 Oct. 2026].
11. TED-Ed (2015). How X-rays see through your skin - Ge Wang. Available at: https://www.youtube.com/watch?v=gsV7SJDDCY4 [Accessed 3 Oct. 2026].
12. British National Formulary (2025). Paracetamol. [online] NICE. Available at: https://bnf.nice.org.uk/drugs/paracetamol/ [Accessed 3 Oct. 2026].