Trauma surgery

Dr Cox has subspecialty fellowship training in major trauma surgery including

  • Pelvic and acetabular fractures
  • Periprosthetic fractures
  • Hip fractures and dislocations
  • Proximal hamstring avulsions
  • General Orthopaedic trauma

Pelvis and acetabular fractures

The pelvis is a complex 3D structure composed of the fused ilium, ischium and pubis bones on each side and supporting ligaments. It is connected to the spine via the sacrum bones and the legs via the hip joints. It forms a ring which can be broken as the result of high energy trauma in younger patients, or low energy falls in older patients with osteoporosis.  Management of these injuries is complex and may require input from other specialities due to associated bowel, bladder or genital injuries.

Periprosthetic fractures

Fractures around prostheses (hip or knee replacements) can pose many challenges.  If the prostheses were well functioning and remain well fixed, then often the fractures can be fixed in isolation with specific fixation techniques. Conversely, fractures around loose or failing prosthesis usually require revision of the joint replacement along with fixation of the fracture.

Hip fractures

Hip fractures usually occur in older patients following a fall from standing height.  The fracture can occur through the neck of femur (“nof”) or the trochanteric region (intertrochanteric).  In most cases, intertrochanteric fractures are managed with surgical fixation (commonly a short femoral nail) whilst displaced fractures through the neck are managed with hip replacement. This can be either total or hemiarthroplasty.  Hemi (“half”) relates to replacing the femoral head (“ball”) component whilst leaving the patient’s acetabulum (“socket”) alone.  Many patients do well with total hip arthroplasty, but the lower complexity and favourable risk profile of hemiarthroplasty justifies its use in the particularly elderly or low demand patients.

Because of the unplanned nature of hip fracture surgery and the significant medical comorbidities common in this patient group, other specialists from Internal Medicine, Geriatrics and Rehabilitation are often actively involved in the acute and ongoing care of these patients.

Hip dislocations

The hip is a very stable joint, so dislocations are usually the result of high energy trauma (such as motor vehicle or motorbike accidents).  The reduction is usually done in the Emergency department under anaesthetic.  After reduction, detailed scans are required to the confirm the hip is perfectly reduced and to exclude associated fractures (eg acetabular wall or femoral head fractures).  The dislocation often damages the femoral head cartilage and blood supply, so close follow-up is required to check for the development of avascular necrosis (AVN) or osteoarthritis.

Proximal hamstring avulsions

The hamstrings are a group of muscles in the back of the thigh (biceps femoris, semimembranosus and semitendinosus). They attach proximally to the ischial tuberosity (the part of the pelvis bone you sit on) and split to attach distally on both sides of the leg just below the knee joint.  Mid-substance (muscle belly or musculotendinous junction) injuries are a very common sporting injury and respond very well to non-operative therapy with light activity until pain settles.  Proximal hamstring avulsions however, involve the tendon ripping off the ischial tuberosity attachment on the pelvis, sometimes with a small flake of bone torn off too. These injuries have less healing capacity and so are often fixed surgically in high demand patients.  This involves reattaching the tendons with suture anchors into the bone and protecting the repair whilst it heals.  The risks include re-rupture and injury to the sciatic nerve. Complications are rare in acute repairs (within 3 weeks) but increase with delayed repairs because scar tissue makes the surgery more difficult.

Hamstring avulsion repair rehab protocol

General Orthopaedic trauma

The human skeleton has a remarkable capacity to heal itself and many fractures will heal if adequately immobilised in a cast or brace. However, surgical management can be indicated to prevent:

  • mal-union (healing in a displaced position)
  • stiffness (following extended immobilisation of joints)
  • non-union (not healing) especially if immobilisation is not possible

Surgical treatment usually involves open reduction and internal fixation (ORIF) using metal plates, screws or rods.  This holds the fracture in the correct position, whilst allowing early mobilisation.

Tendon ruptures can be treated without surgery in some cases, as long as careful protocols are followed. Advances in these rehab protocols allow us to manage most Achilles tendon ruptures without surgery. It provides good functional outcomes without the inherent risks of surgery; which include infection, wound breakdown and anaesthetic risks.

Achilles tendon rupture rehab protocol

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