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Orthopaedic

Orthopaedics is a branch of medicine addressing injuries and disorders of the skeletal system and its related joints, muscles and ligaments.

This section of our website provides detailed information about the different types of upper and lower-limb orthopaedic injuries that may occur and the various forms of treatment, care and rehabilitation available.

Lower-limb injuries

Lower-limb orthopaedic injuries may include one or more of the following:

  • Pelvis injuries

  • Hip injuries

  • Leg injuries

  • Knee injuries

Pelvis injuries

The pelvis plays a very important, functional role in the human skeletal system.

A basin-shaped structure connects the lower region of the spine (the sacrum) to the legs via a network of fused bones and strong connective tissues known as ligaments.

On both sides of the pelvis, there is a concave region of bone called the acetabulum which act as sockets for the hip joints, and each hipbone itself is made up of three sections: the ilium, ischium, and pubis.

Digestive and reproductive organs are located within the pelvis, and large nerves and blood vessels also run through it into the legs. Additionally, the pelvis acts as a focal point for muscles that extend down into the legs and up into the abdomen.

Given its location and structural importance, a serious pelvis injury has the potential to cause devastating consequences.

Most pelvis injuries are the result of high impacts such as in road accidents, industrial crushes or falls. The most severe pelvic fractures are often associated with serious head, chest and leg injuries and can be life-threatening, requiring urgent surgical intervention.

By nature, a pelvic fracture is extremely painful, but it can also cause further problems such as nerve damage, dislocation of the lower back joint, bladder ruptures, internal organ damage and heavy bleeding, which itself can cause the injured person to go into shock.

Serious pelvis and hip injuries may also cause secondary effects and debilitating conditions such as problems with bladder and bowel control, sexual dysfunction and hip deformities.

If medical staff suspect a pelvic fracture after an accident, X-rays and usually CT scans are taken to confirm whether any bones have been displaced.  It is also necessary for the injured person to undergo examinations of blood vessels and nerves in their legs to check for further complications.

Some injuries such as stable fractures are relatively minor. A stable fracture is where the broken areas of the bone remain in place and generally, they heal without any need for surgery. For example, a ‘pelvic avulsion fracture’ is where trauma causes a fragment of bone to come away from the pelvis.

In such cases, medics will usually prescribe rest for up to three months (or until the bones are healed) to avoid putting excess weight onto one or both legs. Pain relief and possibly blood thinning medication may also be necessary during this recovery period, and keeping the hip or knee bent in a specific position may help to avoid aggravating the pain.

Conversely, an unstable fracture is a much more serious type of bone fracture and is one that requires a greater level of medical treatment. In most cases, unstable fractures need surgical treatment to realign the bones, and this is the case for major pelvic fractures.

One of the most common practices is to use a device called an external fixator. This is inserted into the bone on each side via long screws and is connected to a frame outside the body. This provides the fractured pelvis with structural support and also enables treatment for any injuries to internal organs.

Unstable fractures may also require traction or the insertion of plates or screws, but usually an external fixator will be appropriate.

Ordinarily, pelvic fractures heal well. However, in some cases there may be subsequent problems such as chronic pain, impaired mobility and sexual dysfunction. These symptoms are usually the result of damage to nerves and organs caused by the pelvic fracture.

Serious pelvic fractures include:

  • Fracture dislocation involving bones called the ischial and the pubic rami causing impotence

  • Traumatic myositis ossificans: an unusual condition where a blunt trauma to the soft tissue in the hip area causes bone to form within it (a process also called ectopic calcification)

  • Fracture of the acetabulum bone, which leads to degenerative changes and leg instability. This may require surgery to shorten, lengthen or realign the acetabulum (a process called an osteotomy) and there is an increased likelihood in requiring a future hip replacement

  • Fracture of an arthritic femur (thigh bone) or hip necessitating a hip replacement

  • Fracture resulting in a hip replacement which is only partially successful so that there is a clear risk of the need for revision surgery

  • Fracture of the pelvis severe enough to require a leg amputation

Hip injuries

The hip is a ball-and-socket joint that enables the upper leg to bend and rotate at the pelvis.

Hip fractures are usually the result of a fall or trauma to the side of the hip, and they occur when there is a break to the top of the thighbone (femur). However, if the injury is a break to the hip socket, then it is not classed as a hip fracture.

As a result of a hip injury, pain is usually felt in the outer upper thigh region or groin area, and further great discomfort is felt whenever the hip is flexed or rotated.

Urgent medical attention in essential for a serious hip injury, and clinicians believe that the sooner an operation for a hip fracture takes place, the better. First, X-rays of the hip and femur are needed to determine whether the hip has sustained a fracture and in some cases, magnetic resonance imaging (MRI scans) may be recommended to identify any hidden fractures that may have otherwise been missed by X-ray.

Surgery may not be required for a stable impacted fracture (fractures that have not displaced or moved the bone) but regular X-ray assessments will be required to ensure that the bone remains in place throughout the recovery phase and until fully healed.

The following are the three main types of hip fracture that can be sustained, and in serious cases, more than one may occur at the same time:

1. Intracapsular fracture

This is a fracture to the very top of the thighbone, alternatively described as the neck and head of the femur. Due to the positioning of this type of fracture, the socket (or acetabulum) is often also broken.

An intracapsular fracture is usually corrected by the application of screws, and it is an injury where damage to the cartilage (the flexible, shock-absorbing tissues situated between the joints) will also require surgical repair.

In some cases, the blood supply to the head of the femur can become compromised causing painful arthritis in the hip joint. This may later require a surgical procedure known as a hemiarthroplasty, which replaces the ball or head of the femur. In serious cases, both will be replaced by surgery called a total hip replacement.

2. Intertrochanteric fracture

This is another type of fracture that occurs near the top of the thighbone, between its ‘neck’ and a small protruding region beneath it on the inner thigh called the lesser trochanter.

Intertrochanteric fractures can be treated with a compression hip screw. This acts to stabilise the fractured hip and is attached to the outside of the bone through a plate fixed into position by a series of ‘bone screws’ (cortical and cancellous screws) and a large secondary screw (lag screw) into the neck and head of the femur.

Alternatively, an intramedullary nail may be used to treat the fracture, though this is also referred to as an intramedullary rod. It is inserted into the bone marrow in the broken bone’s central cavity to strengthen its weight-bearing capacity.

3. Subtrochanteric fracture

This type of fracture occurs beneath the protruding lesser trochanter area of the inner-femur, and may potentially be extended further down the thighbone.

Subtrochanteric fractures are usually treated like some intertrochanteric fractures in that a long intramedullary nail is inserted into the central cavity of the femur, as well as inserting a large lag screw, or alternatively, ‘bone screws’.

Occasionally a plate may be used instead of a nail, similar to that used with a compression hip screw.

Hip injuries such as the above three have the potential to cause a condition called spondylolisthesis. This is where a bone in the spine (known as a vertebra) slips out of its position and onto the bone beneath it. This can cause excruciating pain, but can be treated by a surgical procedure called a spinal fusion to join two or more vertebra together.

After surgery, a stay in a rehabilitation unit to undergo therapy for up to three months may be required to help aid the ability to walk again.

Leg Injuries

Femur

The femur (or thighbone) is the longest and strongest in the human body and therefore it usually takes a great deal of force to fracture. Road traffic accidents, particularly those involving pedestrians, bicycles and motorcycles are the major cause of femur fractures.

The long, straight part of the femur running from the hip to the knee is known as the femoral shaft, and a break anywhere along this is called a femoral shaft fracture.

The femoral shaft is divided into three regions:

  • Proximal – this is the upper region of the femur, containing the head, neck and trochanters

  • Middle – this is also known as the body of the femur or the shaft

  • Distal – this is the lower region of the femur by the knee, consisting of two prominences called condyles

Therefore, a femur fracture is classified by where the site of injury occurs, for example a ‘proximal femur fracture’ and so on. In addition to the site of injury, there are many further types of femur fracture that may occur, including: 

  • Compound fractures – where the bone breaks through the skin

  • Comminuted fractures – where the bone is broken into three or more pieces

  • Oblique fractures – where the break is at an angle across the bone

  • Spiral fracture – where the break line circles the entire shaft

  • Transverse fracture – where the fracture is a straight horizontal line going across the femur

Requiring urgent medical attention, the injured femur will be X-rayed to determine whether the bone has been broken and if so, the type and location of the fracture sustained. In some cases, a computed tomography (CT) scan may also be required because occasionally, fracture lines are too thin to be observed by an X-ray.

Fractures to the femur invariably require surgery to aid the healing process. The surgery may involve external fixation, which requires metal pins or screws to be positioned into the bone above and below the fracture. An external fixator provides good stability and is a temporary solution until further surgery can be carried out.

The most common surgery used for fixing a fractured femur is through the use of an intramedullary nail. This procedure involves inserting a titanium rod into the bone marrow canal in the central shaft of the femur to hold the fracture in position. An intramedullary nail is then screwed into the bone to secure the titanium rod.

Alternatively, an intramedullary nail procedure may not be possible for some femur fractures. This may be if there has been a deformity of the bone-marrow filled “medullary canal” (where the rod would normally be inserted), perhaps caused either by trauma or by birth defects. In such cases, plates and screws may instead be used to align the bone.

After surgery, a period of rehabilitation will be required to return the leg to as close to pre-injury levels as possible. Weight bearing is an immediate issue so clinicians may recommend only minimal leg movement during the early period of recovery, and as time progresses, crutches or a walking frame will be introduced to aid mobility. Due to the loss of muscle strength in the leg, rehabilitation involving physical therapy such as leg-strengthening exercises will be necessary to promote increased joint movement and flexibility.

Femur fractures usually take approximately four to six months to heal. However, in a minority of cases, the reunion of the bone may not be completely successful, or potentially there may be further secondary medical complications that cause the recovery period to take much longer.

Such serious complications may include: 

  • Compartment syndrome, which is an extremely painful condition resulting from built-up pressure within the muscles. This pressure can reduce the flow of blood to the nerve and muscle cells and may cause permanent disability if not immediately relieved

  • Infections that may become life-threatening if not treated quickly (most common in compound fractures)

  • Potentially fatal blood clots (also known as thrombus), which are fixed fibrous blockages that prevent blood flow

  • Embolisms (also potentially fatal), where there is a blood clot that becomes free and travels to the heart, lungs or brain

  • Broken bones cutting through surrounding blood vessels or nerves

Knee injuries

The knee is an intricate joint with many constituents. The bones include the femur (thighbone), the tibia (the shinbone) and the patella (kneecap), and it also encompasses ligaments to control movement and connect the bones, as well as shock-absorbing cartilage between the femur and tibia called the meniscus.

There are two main types of ligament in the knee, collateral ligaments (on the sides of the knee) and cruciate ligaments (which cross over each other inside the knee). The collateral ligaments control the sideways movement of the knee whilst the cruciate ligaments control forwards and backwards movements

As it is such a complex joint and bears a large amount of bodyweight, the knee is susceptible to an assortment of injuries. Most can be dealt with without the need for medical procedures, and the recommended initial treatment for a mild knee injury is known by the simple acronym “R.I.C.E.”:

  • Rest – avoid further action on the injured knee

  • Ice – apply ice to minimise swelling

  • Compression – this will later reduce any swelling

  • Elevation – lying down and keeping the injured knee above heart-level minimises further swelling

Meanwhile, serious knee injuries require greater medical attention and often surgery. Treatment should be sought immediately if there is severe pain felt, or if the knee gives way, or there is an audible popping sound.

Many serious knee injuries involve damage to at least one of four main components of the knee. Primarily, these are injuries to the ligaments, and include:

  • Anterior cruciate ligament (ACL) – this joins the thighbone to the shin, and if injured will require reconstructive surgery. It is the most commonly injured knee ligament in the UK.

  • Posterior cruciate ligament (PCL) – this is the ligament at the back of the knee, connecting the thighbone to the shin.

  • Medial collateral ligament (MCL) – this is the ligament on the inner side of the knee, connecting the thighbone to the shin.

  • Cartilage or meniscus – torn cartilage situated at the top of the shin may require surgical repair.

Multiple injuries to the ligaments of the knee can have serious complications such as diminishing the flow of blood and nerve supplies to the legs. In such cases, medical intervention through leg amputation is a likely eventuality.

Kneecap

The kneecap (also known as the patella) connects the muscles in the front of the thigh (femur) to the shinbone (or tibia). It fits into a V-shaped notch in the femur and is pulled up or down as the leg is bent or straightened.

However, if the notch in the femur is uneven or too shallow for the kneecap to fit into, it could slide out of position resulting in a partial or complete dislocation. The kneecap is particularly susceptible to this if it receives a sharp blow, such as through trauma from a fall.

After a potentially serious knee injury, X-rays may establish whether the kneecap is still in position. Should it be dislocated, it will need to be returned to its proper position (known as reduction). Dislocation can often cause further painful damage to the kneecap and femur, sometimes leading to arthritis. If this is the case, a type of keyhole surgery (known as an arthroscopy) may be carried out to diagnose and treat the arthritic joint.

If only a partial dislocation has occurred, non-surgical remedies may be prescribed such as exercises to promote the strengthening of the thigh muscles and the maintaining of the kneecap’s alignment. However, surgery to realign the knee and tighten the tendons may be required should the condition later become chronic.