MRCS Applied Basic Science and Clinical Topics

Applied basic sciences 337

potential the membrane depolarises and is a break in electrical transmission. Action
after the peak it repolarises. For a short time, potentials can not cross a synapse. Information
the cell membrane potential becomes more is carried across a synapse by chemical
negative than the resting potential before transmitters. Chemical transmission is slower
it returns to normal. Action potentials are then electrical transmission. This results in a
initiated by many different types of stimuli. delay in transmission. Transmission is in one
Sensory nerves respond to chemicals, light, direction. A synapse consists of a:
pressure, touch and stretch. In the central
nervous system most nerves are stimulated • Presynaptic neurone
by neurotransmitters at synapses. Stimuli • Synaptic gap
must be above a threshold level to initiate an • Postsynaptic neurone
action potential. After a nerve has fired there
is a period of time during which it cannot Chemical transmitters are made and stored
be stimulated again. This is known as the in the presynaptic terminal. Transmitters are
refractory period. stored in cytoplasmic vesicles.

Biochemical changes Function of synapses

The sodium pump produces gradients of both Neurotransmitters are released by an action
sodium and potassium ions across the cell potential and require the presence of calcium
membrane. Both ions are used to produce ions. The action potential arriving in the
the action potential. Sodium concentration terminal axon opens calcium channels.
is high on the outside of the neurone and Intracellular calcium is increased. Calcium
low on the inside. Neurones have sodium causes vesicles to fuse to the membrane and
and potassium channels with gates that the transmitter to be released. Transmitters
open and close in response to the membrane diffuse across the synaptic gap and binds to
voltage. Opening of sodium channels allows post-synaptic receptors. The synaptic gap is
sodium to rush into the cell. The spike of short and the transmitter travels across it by
the action potential is caused by opening of simple diffusion.
sodium channels. The membrane recovers by
closing the sodium channels and opening the When a transmitter binds to a receptor
potassium channels. it produce a change in membrane
potential. Depolarisation is known as an
Myelin sheath excitatory postsynaptic potential (EPSP).
Hyperpolarisation is know as an inhibitory
The conduction velocity of an action potential postsynaptic potential (IPSP). Most
along an axon is increased by a myelin sheath transmitters produce EPSPs – acetylcholine,
produced by Schwann cells in the peripheral adrenaline and noradrenaline. The major
nervous system and oligodendrogliocytes in transmitters producing IPSPs are glycine
the central nervous system. Multiple layers and GABA. There are both excitatory and
of lipid membranes are wrapped around the inhibitory nerves coming into most synapses.
nerve. Gaps are left every few millimetres and If there are enough EPSPs, the postsynaptic
are called nodes of Ranvier. In a myelinated membrane will be depolarised to the
nerve the impulse jumps from node to node. threshold level. An action potential will be
Conduction velocities for un-myelinated produced and a signal will be transmitted
neurones are about 1 m/sec. Conduction along the postsynaptic nerve. Once the
velocities for myelinated neurones are about signal has been delivered, the transmitter is
100 m/sec. removed. In some cases the transmitter is
broken down by an enzyme in the synapse. In
Synapses and neuromuscular other cases, the transmitter is taken back up
junctions into the presynaptic neurone.

Synapses Neurotransmitters
Acetylcholine
The junction between two nerves is called a
synapse (Figure 22.3). At the synapse there Acetylcholine (ACh) is a simple molecule
synthesised from choline and acetyl-CoA.

338 Chapter 22  Trauma and orthopaedic surgery Figure 22.3  Structure and
Structure and function of a synapse function of a synapse

Axon

Presynaptic Synaptic
neurone vesicles

Autoreceptor Reuptake
transporter

Synaptic cleft

Receptors Postsynaptic
neurone

This occurs through the action of the enzyme phenylalanine and tyrosine. Tyrosine is
choline acetyltransferase. Neurones that produced in the liver from phenylalanine
synthesise and release ACh are termed through the action of phenylalanine
cholinergic neurones. ACh receptors are hydroxylase. Tyrosine is then transported
ligand-gated cation channels. Two main to catecholamine-secreting neurones. A
classes of ACh receptors have been identified series of reactions convert it to dopamine,
and are known as muscarinic and nicotinic to noradrenaline and finally to adrenaline.
receptors. Both receptor classes are abundant Catecholamines exhibit peripheral nervous
in the human brain. Nicotinic receptors system excitatory and inhibitory effects. They
are further divided into those found at bind to two different classes of receptors
neuromuscular junctions and those found at termed the α- and β-adrenergic receptors.
neuronal synapses. Numerous compounds The adrenergic receptors are coupled to
have been identified that act as either agonists intracellular G-proteins. Noradrenaline
or antagonists of cholinergic neurones. The released from presynaptic noradrenergic
principal action of cholinergic agonists is the neurones is recycled in the presynaptic
excitation or inhibition of autonomic effector neurone by a reuptake mechanism.
cells. ACh is destroyed by hydrolysis using the
enzyme acetylcholinesterase. The responses of Serotonin
cholinergic neurones can also be enhanced by
administration of cholinesterase inhibitors. Serotonin (5-hydroxytryptamine, 5HT)
is formed by the hydroxylation and
Catecholamines decarboxylation of tryptophan. The greatest
concentration of 5HT (90%) is found in the
The principal catecholamines are enterochromaffin cells of the gastrointestinal
noradrenaline, adrenaline and dopamine. tract. Most of the remainder of the body’s
These compounds are formed from 5HT is found in platelets and the central

Applied basic sciences 339

nervous system. Neurones that secrete 5HT Skeletal muscle
are termed serotonergic. The function of
serotonin is exerted by its interaction with Skeletal muscle is striated muscle under
specific receptors. Several serotonin receptors voluntary control. Muscle fibres are organised
have been identified and they are classified as into motor units. When a single nerve enters
5HT1 to 5HT7. Some of these receptor types a muscle it splits and activates several muscle
have subgroups. Most of these receptors are cells. When the nerve fires, the whole motor
coupled to G-proteins that affect the activities unit is stimulated and the muscle cells
of either adenylate cyclase or phospholipase contract together. Muscles with large motor
C. Some serotonin receptors are presynaptic units have coarse movements. Muscles with
and others postsynaptic: small motor units produce fine and graded
movements. Muscle cells have a short
• 5HT2A receptors mediate platelet refractory period.
aggregation
Neuromuscular junction
• 5HT2C receptors are important in control Each muscle fibre is innervated by one
of food intake motor neurone. Each muscle fibre has
one neuromuscular junction. Each motor
• 5HT3 receptors are present in the neurone can innervate multiple muscle
gastrointestinal tract and are related to fibres.
vomiting
Excitation-contraction coupling
• 5HT6 and 5HT7 receptors are distributed An end-plate potential is generated by a
throughout the limbic system single motor neurone action potential. This
is enough to depolarise the muscle and
• 5HT6 receptors have high affinity for initiate a muscle action potential. This is
antidepressant drugs propagated in both directions along the
sarcolemma and T tubule system. The T
Following the release of 5HT, some is taken tubular system communicates with the
back up by the presynaptic serotonergic sarcoplasmic reticulum. Voltage-gated
neurones. calcium channels open and releases calcium
into the sarcoplasm, around the myofibrils.
γ-Aminobutyric acid Interaction of calcium with troponin C results
in muscle contraction. Muscle relaxation
Several amino acids have distinct excitatory occurs when calcium is pumped back into the
or inhibitory effects upon the nervous sarcoplasmic reticulum.

system. γ-aminobutyric acid (GABA) is an Muscle contraction
inhibitor of presynaptic transmission in the There are two types of muscle contraction
central nervous system. GABA is formed by – isotonic and isometric. In an isotonic
the decarboxylation of glutamate catalyzed contraction the muscle shortens, keeping a
by glutamate decarboxylase. GABA exerts its constant tension. In an isometric contraction
effects by binding to two distinct receptors, the muscle does not shorten and tension
GABA-A and GABA-B. The GABA-A receptors builds up. Most muscle actions are a
form a chloride channel. The binding combination of both types of contraction.
of GABA to GABA-A receptors increases
the chloride conductance of presynaptic Physiology of contraction
neurones. The GABA-B receptors are coupled A single nerve impulse produces a muscle
to an intracellular G-protein and act by twitch. A single stimulus usually releases
increasing conductance of an associated enough acetylcholine to produce an action
potassium channel. potential in the muscle cell membranes.
This will cause the muscle to contract after
Muscle and skeletal
contraction

There are three basic types of muscle

• Skeletal muscle
• Cardiac muscle
• Smooth muscle

340 Chapter 22  Trauma and orthopaedic surgery

a short delay. A simple twitch usually only appearance of skeletal muscle is due to the
generates about 20–30% of the maximum alignment of molecules in bands and lines.
tension and the muscle starts to relax before The most prominent are the A and I bands
the maximum tension is reached. Muscle and the Z line. The unit between two Z lines is
contractions can be added together to called the sarcomere. When muscle contracts
produce more force. If a second stimulus is the sarcomere shortens and the Z lines move
given before a muscle relaxes, the muscle closer together.
will shorten further. This process is known
as summation. If many stimuli are given Actin and myosin
very close together the muscle will go into
continuous contraction called tetanus which When muscle contracts, the protein filaments
gives a maximum tension several times slide together. Muscle is composed of two
higher than a simple twitch. Another way to contractile proteins:
increase the force of contraction is to recruit
more motor units. Muscle produces the • Thin filaments – actin, is found in both A
greatest isometric tension at intermediate and I bands
lengths. At rest, many of the body’s muscles
are close to their optimum lengths. • Thick filaments – myosin, is found in the
A band
Fibre types
Actin and myosin connect through
Within skeletal muscles, there are different crossbridges. The more crossbridges there
types of muscle fibres. The relative are, the higher the tension. ATP is required
proportions of the different types varies for both contraction and relaxation of muscle.
between muscles and individuals. Type It is required for the sliding of the filaments,
1 or red fibres have many mitochondria, accomplished by a bending movement of the
contain myoglobin, contract slowly but resist myosin heads. ATP is also required for the
fatigue. Type 2 or white fibres contain few separation of actin and myosin which relaxes
mitochondria, rely on glycolysis to supply the muscle. A sudden inflow of calcium is the
energy, contract rapidly but fatigue quickly. trigger for muscle contraction. In the resting
state, the protein tropomyosin winds around
The sarcomere actin and covers the myosin binding sites. The
calcium binds to a second protein, troponin.
The basic unit of muscle contraction is This causes the tropomyosin to be pulled to
the sarcomere (Figure 22.4). The striated deform, exposing the myosin binding sites.
With the sites exposed, the muscle contracts.

Structure of the sarcomere Figure 22.4  Structure of the
sarcomere

l band Sarcomere
Z line A band
H zone
M line

Applied basic sciences 341

Joints of the upper limb The superior radioulnar joint

The shoulder The superior radioulnar joint is a synovial
pivot joint. Articulation occurs between the
The shoulder girdle is made up of a complex head of the radius and annular ligament
of five joints: and radial notch of the ulna. The annular
ligament is attached to the anterior and
• Sternoclavicular joint posterior margins of the radial notch of the
• Acromioclavicular joint ulna and this forms a collar around the head
• Subacromial space of the radius. The synovial membrane and
• Glenohumeral joint capsule is continuous with that of the elbow.
• Scapulothoracic joint The nerve supply is from the median, ulnar,
musculocutaneous and radial nerves. The
The glenohumeral joint is a synovial ball and movements are pronation and supination.
socket joint. Articulation occurs between
the head of the humerus and the glenoid Nerves of the upper limb
cavity. The articular surfaces are covered
with hyaline cartilage. The surface area of Brachial plexus
the glenoid cavity is deepened by a rim of
fibrocartilage – the glenoid labrum. The The brachial plexus has the following parts:
capsule is thin, allows a large range of
movement and is strengthened by ligaments, • Roots – which are from the anterior rami of
as follows: the C5 to 8 and T1 nerves

• Glenohumeral ligaments • Trunks – upper, middle and lower from the
• Transverse humeral ligament joining of the roots
• Coracohumeral ligament
• Coracoacromial ligament • Divisions – from splitting of the trunks
• Cords – from the union of the division.
The nerve supply is from the axillary and
suprascapular nerves. The stability of the joint The cords are lateral to the first part of the
if provided by the muscles that cross it. The axillary artery and are mediolateral and
movements are flexion, extension, abduction, posterior to the second part of the axillary
adduction lateral and medial rotation. artery (Figure 22.5).

The rotator cuff is made up of: Axillary nerve

• Supraspinatus The axillary nerve arises from the posterior
• Infraspinatus cord of the brachial plexus (C5, C6). It passes
• Teres minor through the quadrangular space and winds
• Subscapularis around the neck of humerus. The muscles
supplied are the deltoid and teres minor.
The elbow An axillary nerve palsy may occur as a result
of anterior dislocation of the shoulder joint.
The elbow is a synovial hinge joint. The result is:
Articulation occurs between the trochlea and
capitulum of the humerus and the notch of • Motor impairment – abduction of the arm
the ulna and the radial head. The articular • Sensory impairment – sensation reduced
surfaces are covered with hyaline cartilage.
The capsule is strengthened by medial and over the deltoid muscle
lateral ligaments. The synovial membrane
is continuous with that of the superior Radial nerve
radioulnar joint. The nerve supply is from
median, ulnar, musculocutaneous and radial The radial nerve arises from the posterior cord
nerves. The long axis of the extended arm is of the brachial plexus (C5–T1). It passes along
at an angle to the long axis of the arm. This is with the profunda brachial artery and travels
known as the carrying angle. The movements through the radial groove on the posterior
are flexion and extension. aspect of the humerus. The muscles supplied
are triceps and all the muscles of the extensor
compartment of the forearm. The radial nerve
may be damaged in fractures of the shaft of

342 Chapter 22  Trauma and orthopaedic surgery

Roots, trunks, division, cord and branches of the brachial plexus Figure 22.5  Roots, trunks,
division, cord and branches of
Roots the brachial plexus. (Reproduced
from Goodfellow JA. Pocket
Trunks C5 Tutor Neurological Examination.
Divisions London: JP Medical Ltd, 2012.)
Cords C6
Nerve C7
C8
Lateral cord
T1
Posterior cord Medial
Musculoskeletal cord

nerve
Axillary nerve

Radial nerve
Median nerve

Ulnar nerve

the humerus as it passes through the spiral Ulnar nerve
groove. The results is:
The ulnar nerve arises from the medial cord
• A wrist drop of the brachial plexus (C8, T1). It passes
• Motor impairment – inability to extend the behind the medial epicondyle of humerus
and in front of the flexor retinaculum at the
elbow, wrists and fingers wrist. The muscles supplied in the forearm
• Sensory impairment – sensation reduced are the flexor carpi ulnaris and the medial
half of flexor digitorum profundus and
over the lower posterior part of the arm, in the hand, the hypothenar muscles, all
forearm and the anatomical ‘snuff box’ the interossei, the 3rd and 4th lumbricals,
adductor policis, and palmaris brevis. An
Median nerve ulnar nerve palsy results in:

The median nerve has two roots – medial • Hypothenar wasting and claw-hand
and lateral (C5–T1). The medial root arises deformity
from the medial cord of the brachial plexus.
The lateral root arises from the lateral cord • Motor impairment – wrist flexion and
of the brachial plexus. It passes through the ring and little finger flexion at the distal
carpal tunnel. The muscles supplied are all the interphalangeal joints. Adduction and
muscles of the forearm except for flexor carpi abduction of of the fingers and adduction
ulnaris and the medial half of flexor digitorum of the thumb
profundus and in the hand, the muscles of
the thenar eminence and the lateral two • Sensory impairment – sensation reduced
lumbricals. A median nerve palsy results in: over the medial half of the palm and the
medial one and half fingers
• Thenar eminence wasting with an ape-like
thumb Bones of the hands

• Motor impairment – wrist flexion and The eight carpal bones (Figure 22.6) are made
finger flexion at the interphalangeal joints up of two rows of four.
(except the 4th and 5th DIP joints). Flexion
of the index and middle fingers at the The proximal row contains the:
metacarpophalangeal joints and inability
to abduct and oppose the thumb • Scaphoid
• Lunate
• Sensory impairment – sensation reduced • Triquetral
over the lateral half of the palm and the • Pisiform
lateral three and half fingers

Applied basic sciences 343

Bones of the wrist and hand Figure 22.6  Bones of the wrist and
hand. (Reproduced from Tunstall R
Distal and Shah N. Pocket Tutor Surface
phalange Anatomy. London: JP Medical Ltd,
2012, and courtesy of Sam Scott-
Middle Hunter, London.)
phalange
Proximal 2nd
phalange metacarpal
1st
3rd metacarpal
metacarpal Capitate
Trapezoid
4th Trapezium
metacarpal Scaphoid
Radius
5th
metacarpal

Hamate
Pisiform
Triquetrum

Lunate

Ulna

The distal row contains the: are flexion, extension, abduction, adduction,
medial and lateral rotation.
• Trapezium
• Trapezoid The knee
• Capitate
• Hamate The knee is a synovial joint but it is not a
simple hinge. It has two component which
Joints of the lower limb are articulations between the femoral and
tibial condyles and the patellofemoral joint. It
The hip is stabilised by the knee ligaments as follows:

The hip is a synovial ball and socket joint. • Anterior cruciate ligament prevents
Articulation occurs between the head of the anterior translation of the tibia
femur and the acetabulum of the hip bone.
The articular surface is horseshoe-shaped • Posterior cruciate ligament prevents
and deficient at the acetabular notch. The posterior translation of the tibia
cavity is deepened by a rim of fibrocartilage
knows as the acetabular labrum. The articular • Medial collateral ligament provides valgus
surfaces are covered with hyaline cartilage. stability
The capsule is strengthened by ligaments as
follows: • Lateral collateral ligament provides varus
stability
• Iliofemoral ligament
• Pubofemoral ligament • Posteromedial capsule resists external
• Ischiofemoral ligament rotation
• Transverse acetabular ligament
• Posterolateral capsule resists internal
The nerve supply is from the femoral, rotation
obturator and sciatic nerves. The movements
The menisci are semi-lunar shaped
fibrocartilages. They increase the joint
congruence and distribute the load across
the joint. They are avascular and heal poorly

344 Chapter 22  Trauma and orthopaedic surgery

beyond the peripheries. Knee movements are Skeletal fractures
complex; the knee has dynamic stability.
Pathophysiology
The ankle
Dislocation is total loss of congruity between
The ankle joint is a synovial hinge joint. two articular surfaces. Subluxation is partial
Articulation occurs between the lower end loss of congruity between two articular
of tibia, the two malleoli and the body of the surfaces. A fracture is a break in continuity of
talus. The articular surfaces are covered with a bone. Fractures heal by restoration of bone
hyaline cartilage. The capsule is thin and continuity. The rate of healing varies with
allows a large range of movement. The capsule age and is quicker in children. Cancellous
is strengthened by ligaments as follows: bone heals more quickly than cortical bone.
Some movement at fractures site is required
• Medial or deltoid ligament for healing to occur. It also requires an
• Anterior talofibular ligament uninterrupted blood supply. Bone healing
• Calcaneofibular ligament can arbitrarily be divided in to five stages
• Posterior talofibular ligament (Table 22.1).

The nerve supply is from the deep peroneal Principles of management
and tibial nerves. The movements are
dorsiflexion and plantar flexion. Important Some general principles can be applied to
anatomical relations to the ankle include: fracture management. For every fracture it is
necessary to consider:
Structures that pass superficial to the extensor
retinacula: • Reduction of the fracture
• Immobilisation of the fracture
• Saphenous nerve • Rehabilitation
• Long saphenous vein
• Superficial peroneal nerve Stages of bone healing

Structures that pass deep to the extensor Stage Features
retinaculum:
Stage 1 Haematoma formation
• Tibialis anterior tendon Bone ends bleed
• Extensor hallucis longus tendon Stage 2 Periosteum is stripped for
• Anterior tibial artery Stage 3 variable length
• Deep peroneal nerve Stage 4 Surrounding soft tissues may be
• Extensor digitorum longus Stage 5 damaged
• Peroneus tertius
Acute inflammation
Structures that pass behind the medial Cell division begins within 8 hours
malleolus deep to the flexor retinaculum: Cell proliferation seen within
periosteum
• Tibialis posterior tendon
• Flexor digitorum longus Callus formation
• Posterior tibial artery Dead bone is resorbed
• Tibial nerve Immature woven bone is laid
• Flexor hallucis longus down

Structures that pass behind the lateral Woven bone is replaced by
malleolus superficial to the superior peroneal lamellar bone
retinaculum: Fracture becomes united

• Sural nerve Phase of remodelling
• Short saphenous vein Medullary cavity is restored
Bone returns to normal shape
Structures that pass behind the lateral
malleolus deep to the superior peroneal Table 22.1  Stages of bone healing
retinaculum:

• Peroneus longus tendon
• Peroneus brevis tendon

Skeletal fractures 345

The need for accurate reduction varies Union and consolidation
from fracture to fracture. There is usually a
need to correct rotational or valgus or varus Fracture repair is a continuous process. The
deformity. Intra-articular fractures need stages into which it is divided are somewhat
accurate anatomical reduction. Reduction arbitrary. Union should be regarded as an
can be performed as either an open or closed incomplete repair and is present when an
procedure. Immobilisation is required until ensheathing callus is formed. The fracture
fracture union occurs and can be performed site is still tender. Minimal movement at
by external or internal methods. the fracture site is present. Consolidation
should be regarded as a complete repair.
External methods of immobilisation Radiologically the fracture line is obliterated.
include: The fracture site is non-tender and no
movement is possible. The time to union
• Plaster casts and consolidation depends on many factors
• Traction including:
• External fixation
• Age
Internal methods of immobilisation include: • Fracture type
• Blood supply
• Plates
• Intramedullary nails Fractures heal quicker in children. Upper
• K-wires limb fractures heal quicker than lower limb
fractures. Spiral fractures heal quicker than
Indications for internal fixation include: transverse fractures.

• Intra-articular fractures – to stabilise an Complications
anatomical reduction
The majority of fractures heal according to
• Repair of blood vessels and nerves – to expectations. In some cases, the healing
protect vascular and nerve repairs process is delayed by complications. The
possible early and late complications of
• Multiple injuries fractures are shown in Table 22.2. Early
• Elderly patients – to allow early complications are often related to damage to

mobilisation Early and late complications of fractures
• Long bone fractures – tibia, femur and
Early Late
humerus
• Failure of conservative management Infection Delayed union
• Pathological fractures Fat embolism Non-union
• Fractures that require open reduction Muscle and Malunion
• Unstable fractures tendon injuries Avascular necrosis
Nerve injuries Myositis ossificans
Complications of internal fixation include: Vascular injuries Volkmann’s contracture
Visceral injuries Stiffness and instability
• Infection Algodystrophy
• Non-union Reflex sympathetic
• Implant failure dystrophy
• Refracture
Table 22.2  Early and late complications of fractures
Indications for external fixation include:

• Acute trauma – open and unstable
fractures

• Non-union of fractures
• Arthrodesis
• Correction of joint contracture
• Filling of segmental limb defects – trauma,

tumour and osteomyelitis
• Limb lengthening

Complications of external fixation include:

• Overdistraction
• Pin-tract infection

346 Chapter 22  Trauma and orthopaedic surgery

adjacent structures. Late complications are rupture. It also occurs without injury in
often related to local bone problems. unconscious or paraplegic patients. Pain
is an early symptom. Joint stiffness and a
Delayed union reduced range of movement are late features.
In the late stage of the process, a bony
Delayed union is prolongation of the time to lump is often palpable. Early x-rays shows
fracture union. No definite timetable to define fluffy calcification. Late x-rays shows bone
delayed union exists. Delayed union is due to: formation. Management involves joint rest
in the position of function. Once pain settles,
• Inadequate blood supply mobilisation can be begun. After several
• Infection months, consideration should be given to
• Incorrect splintage excision of the bony mass.
• Intact fellow bone
Avascular necrosis
In delayed union, the fracture site remains
tender. The bones may still move when Avascular necrosis occurs when a fracture
stressed. On x-ray the fracture remains visible interrupts the blood supply to adjacent bone.
and little callus formation or periosteal Certain regions are prone to bone ischaemia
reaction is seen. Management usually and necrosis including the head of the femur,
involves continuation of the previous fracture the proximal scaphoid and the body of the
management. It may be necessary to replace talus. Pain is the main symptom due to fracture
casts or reduce traction. Functional bracing non-union. X-ray shows an increase in bone
may promote bone union. If union is delayed density. Surgical intervention is required if
more than 6 months, then it may be necessary there is a reduction in function. This may
to consider internal fixation or bone grafting. require an arthrodesis or arthroplasty.

Non-union Compound fractures

Non-union is failure of the fracture site to All open fractures must be assumed to be
unite. It has many causes including: contaminated. The aim of treatment is to
prevent them from becoming infected. First
• Bone or soft tissue loss aid treatment is the same as for a closed
• Soft tissue interposition fracture. Peripheral neurovascular status
• Poor blood supply should be assessed. In addition, the wound
• Infection should be covered with a sterile dressing.
• Pathological fracture Wounds should be photographed so that
• Poor splintage or fixation repeated uncovering is avoided. Antibiotic
• Fracture distraction prophylaxis should be given and the tetanus
immunisation status should be evaluated.
Clinical assessment shows remaining
movement at the fracture site. Movement is Open fractures require early operation and
often relatively painless. Radiologically, the ideally this should be within 6 hours of injury.
fracture is still visible and the bone ends on The aims of surgery are to:
either side of the fracture are sclerosed. Non-
union can be either hypertrophic or atrophic • Clean the wound
depending on the presence or absence of • Remove devitalised tissue
bone loss. Asymptomatic non-union may not • Stabilise the fracture
require active treatment except splintage. For
hypertrophic non-union, internal or external Small clean wounds can be sutured. Large
fixation may be necessary to achieve union. dirty wounds should be debrided and left
For atrophic non-union bone grafting is open. Debrided wounds can be closed by
invariably required. delayed primary suture at about 5 days.

Myositis ossificans Pathological fractures

Myositis ossificans is due to heterotopic A pathologic fracture is one caused by a
ossification with a muscle. The elbow is the disease leading to a weakness of the bone
commonest joint involved. It is occasionally (Table 22.3). This process is most commonly
seen following a joint dislocation or muscle

Skeletal fractures 347

Causes of pathological fractures

Generalised Localised Malignant

Osteoporosis Chronic infection Osteosarcoma
Metabolic bone disease Solitary bone cyst Chondrosarcoma
Paget’s disease Fibrous cortical defect Ewing’s tumour
Myelomatosis Chondroma

Table 22.3  Causes of pathological fractures

due to osteoporosis, but may also be due to used to provide structural support. Both
other pathologies such malignancy, infection, form a scaffold into which osteoblasts and
inherited bone disorders or a bone cyst. osteoclasts can grow. The graft stimulates
The commonest cancers that metastasise to local bone growth by the process of
bone and result in pathological fractures are osteoinduction. Osteoblast differentiation
breast, prostate, kidney, lung and thyroid. A leads to graft resorption. Remodelling occurs
pathological fracture usually occurs during as load is applied to the graft.
normal activities when the underlying disease
process weakens the bone to the point where Bone grafts can be harvested from the
it is unable to perform its normal function. iliac crest, proximal tibia and distal radius.
The iliac crest is the most common donor
The aims of surgery for a pathological site but its use is associated with significant
fracture are to provide pain relief and a stable morbidity. Cortico-cancellous grafts are
bone or joint that will allow the patient to harvested as strips. Cancellous bone can
mobilise shortly after surgery and will last be taken from the inner or outer table.
for the remaining life of the patient. Given Segments of bone can be transplanted as free
the frequent large amount of bone loss, the vascularised grafts. Local rotational bone
degree of osteoporosis in the elderly, and the grafts may also be used. The blood supply to
decreased ability of bone to heal at a tumour the graft is maintained. They are technically
site, this is often difficult to achieve. The difficult to perform and the results are
techniques used in these patients differ from unpredictable.
those used in young trauma patients.
Allografts
Principles of bone grafting
Allograft bone is more plentiful and can be
Loss of bone can occur in several situations harvested from living donors or cadavers.
including trauma, tumours or following the Donor site morbidity is eliminated. Cadaveric
use of prostheses. The use of bone grafts may bone and femoral heads are stored in tissue
be necessary to fill the resulting defect. Bone banks. Bone is frozen at –20 to –86˚C. Freeze
grafts can be classified as: drying and storage at room temperature
is occasionally used. Allografts are used in
• Autograft – Bone from the same individual reconstruction after tumour resection or
• Allograft – Bone from another individual of revision hip surgery. Infection is the major
concern with the used of allografts. Bacterial
the same species contamination may occur, especially
• Xenograft – Bone from another species with cadaveric grafts but this risk can be
eliminated with irradiation of the graft.
Autografts Viral contamination with hepatitis or HIV is
possible. Bone should be kept in quarantine
Autogenous bone is the ideal graft material and living donors tested 90 days after the
but it may only be available in limited
amounts. Cancellous bone can be used
to fill cavity defects. Cortical bone can be

348 Chapter 22  Trauma and orthopaedic surgery

bone is harvested. Allograft bone is available • Stage 4 – complete fracture with significant
as morsellised bone for impaction grafting, displacement
strut grafts to cover cortical bone and massive
allografts to replace significant proportions of Intracapsular fractures reduce the blood
native bone. supply to the femoral head. They are at
high-risk of delayed union, non-union or
Bone substitutes avascular necrosis. If the femoral head is to be
preserved they need anatomical reduction.
Interest exists in developing artificial bone Extracapsular fractures do not interfere with
substitutes that would eliminate the supply femoral head blood supply and do not require
and infection problems associated with auto anatomical reduction.
and allografts. Possible bone substitutes
include calcium triphosphate, hydroxyapatite, Management
calcium carbonate and glass-based cements.
Unfortunately, most bone substitutes are All patients should be considered for
brittle and are unable to withstand significant surgery if fit enough for an operation. Early
load bearing. mobilisation is associated with improved
long-term prognosis. Ideally surgery
Hip fractures should be performed within 24 hours and
postoperative rehabilitation should be by a
In the UK, approximately 60,000 proximal multidisciplinary team. Multidisciplinary
femoral fractures occur each year. The mean rehabilitation should involve mobilisation
age of patient is 80 years. The incidence strategies, early supported discharge and
increases exponentially above the age of 65 intermediate care.
years and the main risk factors are female
sex and osteoporosis. About 40% of patients Intracapsular fractures
with a hip fracture die within a year and 50%
of survivors are less independent than before The three treatment options for
the injury. Most morbidity and mortality is intracapsular fractures are reduction and
related to coexisting medical conditions. The internal fixation, femoral head replacement
cost of managing all hip fractures in the UK is or total joint replacement. Internal fixation
about £2 billion per year. is indicated in undisplaced fractures or
displaced fractures in patients less than
Clinical features 70 years of age. Internal fixation is usually
achieved with the use of three cancellous
Proximal femoral fractures usually occur screws. Complications include non-union
following a fall. Patients often have other and avascular necrosis. Femoral head
significant co-morbidity. The main symptom replacement is indicated in displaced and
is hip pain and an inability to weight bear. The pathological fractures. The options available
leg may be shortened and externally rotated. include:

Investigation • Cemented Thompson prosthesis
• Uncemented Austin Moore prosthesis
The diagnosis confirmed by a anterior- • Bipolar prosthesis
posterior and lateral x-ray. However,
impacted undisplaced fractures may Total hip replacements should be
present diagnostic difficulty. Fractures considered in those with a displaced
are best separated into intracapsular intracapsular fracture who were able to walk
and extracapsular fractures. The Garden independently, are not cognitively impaired
classification of hip fractures is as follows: and are medically fit for anaesthesia and the
operation. Complications of femoral head
• Stage 1 – incomplete or impacted fracture and joint replacement include:
• Stage 2 – complete fracture with no
• Dislocation
displacement • Loosening
• Stage 3 – complete fracture with partial • Peri-prosthetic femoral fracture

displacement

Skeletal fractures 349

Extracapsular fractures confined to the lateral part of the ankle are
Extracapsular fractures are usually repaired also stable. Type C injuries often appear
with a dynamic hip screw. This allows undisplaced but there is often a significant
impaction and stabilisation of fracture. The ligament injury. Consideration should be
prognosis is related to the number of bone given to examination under anaesthesia and
fragments but about 90% of fractures proceed fixation. The majority of displaced fractures
to uncomplicated fracture union. require open reduction and fixation. The
medial and posterior malleoli are fixed with
Ankle fractures lag screws. The fibular fracture is stabilised
with a plate.
Ankle fractures are the commonest lower
limb fractures. They occur following high- Other common fractures
energy impacts or low-energy twists. Low-
energy twists cause rotation of the talus Scaphoid fracture
within the joint and occur if the foot is either
internally or externally rotated. Scaphoid fractures account for 75% of all
carpal bone injuries and are usually caused
Classification by a fall on the outstretched hand. They
The Weber classification is based on the level usually occur in young and middle-aged
of any associated fibular fracture in relation to adults. About 10% are associated with other
the syndesmosis: fractures. Most scaphoid fractures are stable.
If recognised and treated appropriately, then
• Type A – below the syndesmosis over 90% heal without complication. The
• Type B – at the level (often spiral or symptoms of a scaphoid fracture include
pain on the radial side of the wrist, swelling
oblique) of the syndesmosis in that area, and difficulty gripping objects.
• Type C – above the syndesmosis The classical sign is tenderness in the
‘anatomical snuff-box’. The commonest site
This classification does not take account of fracture is through the waist of the bone.
of other injuries (e.g. medial malleolus). The initial x-ray may be normal. If there is
The Lauge–Hansen classification is based clinical suspicion of a fracture then the wrist
on the position of the foot and direction of should be splinted and the x-ray repeated. CT
deforming force: scanning is useful if their remains diagnostic
doubt. Treatment of undisplaced fractures
• Supination–adduction is by splinting for 6 weeks. The blood supply
• Supination–external rotation of the scaphoid enters the bone distally and
• Pronation–abduction diminishes proximally. As a result, fractures
• Pronation–eversion through the proximal pole are at greatest risk
• Pronation–dorsiflexion of complications including avascular necrosis
and non-union. Internal fixation should be
Investigation considered for displaced fractures.
A plain anterior-posterior and lateral ankle
x-ray will show the fracture/dislocation. Colles fracture
A motrice view (10–20°) in line with the
intermalleolar line my show any diastasis – A Colles fracture is a fracture of the distal
widening of the gap between the tibia and radius with dorsal displacement and
fibula. angulation of the distal fragment. It was first
described by the Irish surgeon and anatomist,
Management Abraham Colles, in 1814. It is most commonly
Suspected ankle fractures should be promptly seen in post-menopausal women and usually
assessed. Fracture-dislocations should be occurs after a fall on the outstretched hand.
reduced and stabilised. This is required It results in a classic ‘dinner fork’ deformity
to prevent overlying skin necrosis. Future of the wrist. There are five components to the
management depends on the fracture type deformity:
and stability. Type A injuries are stable and
require minimal splintage. Type B injuries

350 Chapter 22  Trauma and orthopaedic surgery

• Dorsal angulation of the distal fragment occur through the growth plate and therefore
• Dorsal displacement of the distal fragment they are unique to children. They are classified
• Radial deviation of the hand according to the degree of involvement of
• Supination physis, metaphysis and epiphysis:
• Proximal impaction
• Type I – Epiphyseal slip – no fracture
In severe cases, there may be dislocation of • Type II – Fracture through the epiphyeal
the distal radio-ulnar joint or fracture of the
styloid process of the ulna. Management plate with proximal fragment
depends on the severity of the fracture and • Type III – Fracture through the epiphysis
the age of the patient. A minimally displaced
fracture may be treated with a cast alone. The extending into the epiphyseal plate
cast is applied with the distal fragment in • Type IV – Fracture through both the
palmar flexion and ulnar deviation. A fracture
with mild angulation and displacement epiphysis and shaft crossing the epiphyseal
may require closed reduction. Significant plate
angulation and deformity may require an • Type V – Crush injury causing obliteration
open reduction and internal fixation or of the growth plate
external fixation.
Classification is important as it determines
Paediatric fractures both the treatment and prognosis. Overall,
physeal fractures are responsible for about
About 50% of boys and 25% of girls will 30% of all long bone fractures in children. In
sustain a fracture during childhood. Children general, the following statements hold true
tend to develop a specific pattern of fractures. for Slater and Harris fractures:
The commonest location of fractures is the
upper extremities. The distal radius and • Type I involve the growth plate but growth
humerus are the commonest sites of fracture. is rarely disturbed

Paediatric fractures are fundamentally • Type II fractures are the most common
different from those seen in adults. • Type III fractures involve the joint and can
The decreased bone mineral density,
proportionally stronger ligaments and result in chronic morbidity
tendons, increased bone flexibility and • Type III fractures often require surgical
developing growth plates lead to unique
fracture patterns. Greenstick fractures occur treatment
when the bone bends and partially breaks • Type IV fractures can also result in chronic
but does not extend through the width of the
bone. Salter and Harris fractures (Figure 22.7) morbidity
• Type V fractures are difficult to diagnose

and can result in limb shortening

Management

Bones in children have a tremendous power
for remodelling and in their management,
more angulation or displacement can be

Salter and Harris classification of epiphyseal injuries

I ll lll lV V
Figure 22.7  Salter and Harris classification of epiphyseal injuries

Degenerative and rheumatoid arthritis 351

accepted than in adults. Unfortunately, Rheumatoid arthritis
rotational malalignment does not remodel.
Rheumatoid arthritis is an autoimmune
Degenerative and inflammatory synovial disease of unknown
rheumatoid arthritis aetiology. The worldwide prevalence is
Osteoarthritis approximately 1% and the female to male
ratio is about 3:1. The onset of symptoms is
Osteoarthritis is the commonest condition usually between 20 and 40 years of age. As
affecting synovial joints. It is no longer well as the synovium of joints, it can also
considered as simple ‘wear and tear’. involve the tendon sheaths. It is seem more
A change in the cartilaginous matrix is commonly in those with human leukocyte
probably an important aetiological factor. antigens DR4 and DW4. Pathologically, it is
Primary osteoarthritis is of unknown characterised by:
aetiology. Secondary osteoarthritis is
the result of congenital or infective joint • An inflammatory process within the
disorders or trauma. The pathology is synovium
characterised by:
• Joint destruction and pannus formation
• Loss of hyaline cartilage • Periarticular erosions
• Subchondral bone sclerosis
• Subchondral cyst formation Clinical features
• Osteophyte formation
Rheumatoid arthritis, usually affects multiple
Several patterns of joint involvement are joints. The commonest joints involved are the
recognised including generalised nodular hands, elbows, knees and cervical spine. There
osteoarthritis and large joint osteoarthritis. is often prolonged early morning stiffness and
stiffness after rest. The joint pain associated
Clinical features with rheumatoid arthritis is invariably
The joint pain associated with osteoarthritis relieved by movement. Soft tissue swelling
is worse after exercise or at the end of the and erythema is often marked and systemic
day and is relieved by rest. Early morning features may be present. Extra-articular
stiffness or stiffness after rest is limited. There manifestations occur in approximately about
may be bony joint swelling. Systemic features 20% of patients (Table 22.4). Rheumatoid
are few. arthritis is seen as part of several well defined
syndromes (Table 22.5).
Management
The aims of treatment of osteoarthritis In the early stages of the disease in the
are to reduce joint pain and improve joint hands, synovitis of the metacarpophalangeal
function. In the early stages, pain can often (MCP) and proximal interphalangeal (PIP)
be improved with simple analgesia. Life joints is often the main clinical feature. Both
style modification is also important. Anti- hands are usually affected in a symmetrical
inflammatory drugs can often help and pattern. The tendon sheaths may also be
intra-articular steroid injections can reduce inflamed. This early stage often progresses to
symptoms. If symptoms fail to improve joint and tendon erosions which prepare the
with conservative measures, surgery ground for later mechanical derangement.
may be required. The surgical options for Joint instability and tendon rupture results in
degenerative joints are: progressive deformity and functional loss. In
the late stage of the disease, the hands typically
• Arthroscopic lavage and debridement show subluxation of the MCP joints, radial
• Osteotomy – alteration of joint alignment deviation of the wrist joint and ulnar deviation
• Arthroplasty – replacement of diseased of the fingers (Figure 22.8). Swan neck
(hyperextension of the PIP joint with flexion
joint of the DIP joint) and boutonniere deformities
• Arthrodesis – fusion of disease joint (flexion of the PIP joint and extension of the
DIP joint) of the fingers may occur.

352 Chapter 22  Trauma and orthopaedic surgery

Extra-articular manifestations of Syndromes associated with rheumatoid
rheumatoid arthritis arthritis

System Manifestation Syndrome Clinical features
Felty’s syndrome
Ocular Keratoconjunctivitis sicca Rheumatoid arthritis
Pulmonary Episcleritis Still’s disease Neutropenia
Cardiac Scleritis Lymphadenopathy
Cutaneous Pulmonary nodules Sjögren’s
Pleural effusion syndrome Splenomegaly
Neurological Fibrosing alveolitis Rheumatoid arthritis in
Pericarditis/pericardial childhood
effusion Rash
Valvular heart disease Fever
Conduction defects Splenomegaly
Palmar erythema Rheumatoid arthritis
Rheumatoid nodules Reduced lacrimal and
Pyoderma gangrenosum salivary secretion
Vasculitic rashes and leg
ulceration Table 22.5  Syndromes associated with rheumatoid
Nerve entrapment arthritis
Cervical myelopathy
Peripheral neuropathy Rheumatoid hands
Mononeuritis multiplex

Table 22.4  Extra-articular manifestations of
rheumatoid arthritis

Management Figure 22.8  Rheumatoid hands

Management of rheumatoid arthritis requires The timing of surgery is a complex decision
a multidisciplinary approach. Disease and depends on:
modifying drugs include: • Patient’s age
• Stage of disease
• Non-steroidal anti-inflammatory drugs • Level of disability
• Methotrexate, sulphasalazine, • Site of the involved joints
Early surgical intervention may be helpful
penicillamine, gold in maintaining a patient’s functional level.
• Corticosteroids Deformities of the hand or wrist lead to
• Cytotoxic drugs loss of the ability to grip, grasp and pinch,
often leaving the patient unable to perform
Surgical intervention in patients with
rheumatoid arthritis can achieve pain
relief, deformity correction and functional
improvement. A number of surgical
procedures are available including:

• Myofascial techniques
• Excisions
• Reconstructions
• Joint fusions
• Joint replacements

Degenerative and rheumatoid arthritis 353

the activities of daily living. The surgical Indications for hip replacement surgery
treatments for rheumatoid arthritis of the include:
hand and wrist include:
• Osteoarthritis
• Synovectomy • Rheumatoid arthritis
• Tenosynovectomy • Still’s disease
• Tendon realignment • Ankylosing spondylitis
• Arthroplasty • Congenital dysplastic or dislocated hips
• Arthrodesis • Paget’s disease
• Trauma or avascular necrosis
Hip replacement surgery • Septic arthritis

Hip replacement surgery was developed by Contraindications for hip replacement
Sir John Charnley in the 1960s. More than surgery:
50,000 hip replacements are performed each
year in the UK and over 2 million hips have • Uncontrolled medical problems
been replaced worldwide. Over 100 different • Skeletal immaturity
types of prosthesis have been used. The • Active infection
‘gold standard’ is the Charnley cemented • Neuropathic joint
prosthesis. • Progressive neurological disease
• Muscle weakness
Principle components
Surgery
The acetabular component is usually
made of high density polyethylene. This To justify surgery, patients should have
is biocompatible, has a low coefficient of significant pain, functional disturbance and
friction and a low rate of wear. Ceramic failed conservative therapy. The principle
acetabular components have improved aims of surgery are to reduce joint pain
surface properties but are expensive and have and improve joint function. The operative
a tendency to brittle failure. Metal cups are technique requires thorough skin preparation
obsolete due to high friction, loosening and with sterile adhesive plastic drapes. Operating
wear. The femoral component is usually made teams should wear two pairs of gloves and
of stainless steel, titanium or cobalt-chrome body exhaust suites may be worn. Laminar air
alloy. It is resistant to corrosion with high flow should be provided in the operative field
endurance. Improved longevity is seen with a and antibiotic prophylaxis should be given.
small femoral head. Specific complications include:

Polymethylmethacrylate cement • Neurovascular injuries
• Leg length discrepancy
Polymethylmethacrylate cement acts as a • Dislocation
filling agent without adhesive properties. • Infection
Macrolocking occurs with cement in drilled • Aseptic loosening
holes. Microlocking occurs with cement • Implant wear and failure
in the interstices of cancellous bone. It • Heterotopic ossification
produces an exothermic reaction during • Femoral fractures
preparation. Addition of barium weakens • Trochanteric non-union
the cement. Antibiotic impregnation • Abductor mechanism weakness
may increase the resistance to infection.
Recently uncemented prostheses have The outcome of hip replacement surgery is
been developed. These require a more affected by many factors including the:
exacting insertion technique. They are
anchored by an interference fit achieved by • Type of implant used
a porous surface or hydroxyapatite coating. • Underlying diagnosis
Uncemented prostheses have a tendency to • Sex of patient
early failure. • Cement type
• Cementing technique
• Surgical approach

354 Chapter 22  Trauma and orthopaedic surgery

Joint resurfacing presents more insidiously and pain is often
the prominent symptom. The diagnosis of
The outcome of hip replacement surgery of chronic infection can be difficult.
joint replacement surgery is less predictable
in younger patients and those with an active Investigation
life style. Metal-on-metal hip resurfacing has The following investigations should be
been developed for use in younger patients. considered:
The head of the femur is preserved and is
developed into chamfered cylinder. A metal • Microbial culture
head is cemented in place and a metal cup • Inflammatory markers
is placed in the acetabulum. Compared to • Plain radiography
total hip replacement, joint resurfacing has • Bone scan
a lower risk of complications, lower risk of • Histology
dislocation, less bone loss and a reduced risk • Molecular methods
of component loosing. The short-term results
are very encouraging but the long-term The diagnosis depends on identification of
outcome remains unclear. bacteria from fluid around the joint.

Infected joint replacements Management
Antibiotics should be started once the
Most joint replacements are carried out diagnosis is considered but alone they are
with few complications. When it occurs, rarely able to eradicate established infection.
infection is a devastating outcome. It is The antibiotic of choice should be based
uncommon and occurs in approximately 1% on culture results. In acute infection joint,
of cases. It results in major morbidity and debridement and washout of the joint may
considerable cost. The risk can be reduced by, be appropriate. In chronic infection with a
excluding patients who have active infection, loose joint, the implant should be removed.
antibiotic prophylaxis and meticulous theatre Revision surgery can be performed as a one-
technique. stage or two-stage procedure. If insertion of
new prosthesis is considered inappropriate,
Microbiology then excision arthroplasty or joint fusion
may be required. Complications following
The commonest organisms identified in revision joint surgery include massive bone
infected joint replacements are: loss, periprosthetic fracture and recurrence of
infection.
• Coagulase-negative staphylococcus (45%)
• Staphylococcus aureus (35%) Infections of bones
• Streptococcal species (10%) and joints
• Gram-negative bacteria (<5%) Acute osteomyelitis

Early infection is usually a result of Acute osteomyelitis usually occurs in
intraoperative contamination. Late infection children. It is invariably a haematogenous
usually results from haematogenous spread. infection from a distant focus of sepsis.
Bacteria adhere to prosthetic materials Organisms responsible for acute
and produce a biofilm which isolates the osteomyelitis include:
bacteria from host defences and antibiotics.
Significant infection can result from a • Staphylococcus aureus
small bacterial inoculum. A low-grade • Streptococcus pyogenes
inflammatory process then occurs and this • Haemophilus influenzae
leads to bone erosion and loss of bone stock. • Gram-negative organisms

Clinical features Salmonella infections are often seen in those
with sickle-cell anaemia.
Acute joint infection presents with sign of a
wound infection. A purulent discharge from
the wound is often present. Chronic infection

Infections of bones and joints 355

Pathology Investigation
Plain x-rays are usually normal during the
Infection usually occurs in the metaphysis first 3 to 5 days of the infection. In the second
of long bones. Acute inflammation results week, radiological signs include periosteal
in raised intraosseous pressure and new bone formation, patchy rarefaction
intravascular thrombosis. Suppuration of the metaphysis and metaphyseal bone
produces a subperiosteal abscess that may destruction. In cases of diagnostic doubt,
discharge into the soft tissues. Spread of the bone scanning or MRI can be helpful. The
infection into the epiphysis can result in joint diagnosis can be confirmed by aspiration of
infection. Within days of infection, bone pus from an abscess or the metaphysis. About
death can occur. Fragments of dead bone 50% of patients have positive blood cultures.
become separated in the medullary canal
(sequestrum). New bone forms deep to the Management
stripped periosteum (involucrum). If the General supportive measures should include
infection is rapidly controlled, resolution can intravenous fluids and analgesia. The painful
occur. If the infection is poorly controlled, limb often requires a splint or skin traction
chronic osteomyelitis may develop. to relieve symptoms. Aggressive antibiotic
therapy should be instituted. If the patient
Clinical features fails to respond to conservative treatment,
surgery may be required. A subperiosteal
The patient usually presents with pain, malaise abscess should be drained. Drilling of the
and fever and is often unable to weight bear. metaphysis is occasionally required. Overall,
Early signs of inflammation are often few. The about 50% of children require surgery.
bone is often exquisitely tender with reduced
joint movement. Late infection presents with Septic arthritis
soft-tissue swellings or discharging sinus. The
differential diagnosis includes: Septic arthritis is an acute inflammatory
condition of a joint, usually resulting from
• Cellulitis bacterial infection. Untreated, it will lead to
• Acute suppurative arthritis destruction of the articular cartilage. About
• Rheumatic fever 50% cases occur in children less than 3 years
• Sickle-cell crisis of age. In infants less than 1 year old, the hip
is the commonest joint involved. In older
Metastatic infection can occur at distant children the knee is the commonest joint
sites (e.g. brain, lung). Spread into the affected. About 10% of patients have multiple
adjacent joint can result in a septic joint involvement.
arthritis. This complication occurs in
young children in whom the growth plate is Pathology
permeable, bones in which the metaphysis The infecting organism depends on age
is intracapsular or when the epiphysis of (Table 22.6). Organisms can enter the joint
the bone is involved by metastatic infection.
Involvement of the physis can result in
altered bone growth.

Infecting organisms seen in septic arthritis

<3 years old Children <50 years old Adults
H. influenzae S. aureus
S. aureus >3 years old N. gonorrhoea >50 years old
Coliforms S. aureus S. aureus
H. influenzae Gram-negative bacteria
Streptococci

Table 22.6  Infecting organisms seen in septic arthritis

356 Chapter 22  Trauma and orthopaedic surgery

via a number of routes including penetrating or arthroscopic procedure. Early joint
wounds, from the epiphysis or metaphysis mobilisation should be encouraged.
or via haematogenous spread. This provokes
an acute inflammatory response and a large Pott’s disease
number of neutrophils accumulate in the
joint. They release proteolytic enzymes that Pott’s disease is tuberculous spondylitis. It is
break down the articular cartilage resulting well recognised in Egyptian mummies and
in an effusion and reduced synovial blood was described by Sir Percival Pott in 1779. It
supply. is now rare in Western countries but is still
prevalent in the developing world.
Clinical features
Pathology
The exact presentation depends on the age of Pott’s disease usually occurs secondary
the patient. Children are usually systemically to infection elsewhere and is due to a
unwell and present with pain in the affected combination of osteomyelitis and arthritis.
joint. All movements of the joint are painful. It often occurs at more than one vertebral
They are reluctant to stand on weight-bearing level and usually affects the anterior part of
joints. The affected joint is usually swollen, the vertebral body. It is more common in
red and warm. Hip involvement results the thoracic spine. Bone destruction leads to
in flexion and external rotation. In adults, vertebral collapse and kyphosis. The spinal
septic arthritis is usually associated with canal can be narrowed resulting in cord
immunosuppression. Complications of septic compression and neurological deficit.
arthritis include:
Clinical features
• Avascular necrosis of the epiphysis Back pain is the commonest presenting
• Joint subluxation or dislocation symptom and may be present for several
• Growth disturbance months before the diagnosis is made. The
• Secondary osteoarthritis pain can be both spinal and radicular. About
• Persistent or recurrent infection 50% of patients have neurological signs at
presentation. Most patients have some degree
The differential diagnosis includes: of kyphosis. A cold abscess may point in the
groin.
• Irritable hip
• Pethe’s disease Investigation
• Osteomyelitis The serum ESR is often massively raised
• Gout and a tuberculin skin test is usually positive.
• Pseudogout A plain x-ray may show lytic destruction
of the anterior vertebral body, anterior
Investigation vertebral collapse, reactive sclerosis and
an enlarged psoas shadow. A CT or MRI
The most important investigation is culture provides information on the disc space
of a joint aspirate. This should be performed and neurological involvement. A CT also
prior to the administration of antibiotics. allows a guided biopsy to be obtained
Other appropriate investigations should for microbiological and pathological
include inflammatory markers and a plain assessment.
x-ray.
Management
Management Treatment involves both tuberculous
chemotherapy and possible surgery. Nine
Antibiotics should be started after joint months of combination chemotherapy
aspiration and empirical therapy should should be used involving up to four drugs.
be based on the likely organisms, adjusted Isoniazid and rifampicin should be given
depending on antibiotic sensitivity. for the full 9 months. Pyrazinamide,
Antibiotics should be continued for
6 weeks. The surgical management
involves joint drainage and lavage. This
may be performed as either an open

Disorders of the upper limb 357

ethambutol or streptomycin should be give Investigations
for the first 2 months. Surgery is indicated if
there is: The results of investigations are often normal.
A chest x-ray may show a cervical rib. Nerve
• Neurological deficit conduction studies may be needed to exclude
• Spinal deformity with instability a distal nerve compression. An arch aortogram
• No response to medical treatment may show a subclavian artery aneurysm.
• Non-diagnostic percutaneous biopsy Duplex scanning may show arterial or venous
compression and the effect of position.
The surgical approach depends on the
extent of the disease and the level of spinal Management
involvement. It usually involves radical
debridement and posterior stabilisation. Symptoms may improve with physiotherapy.
If symptoms are disabling, then it
Disorders of the upper limb may be necessary to consider surgical
decompression. This involves resection of
Thoracic outlet most of the first rib and can be achieved
compression syndrome through either a supraclavicular or
transaxillary approach. About 10% of
Thoracic outlet compression syndrome patients undergoing surgery will develop
describes a collection of upper limb a pneumothorax. Following surgery, 80%
neurological and vascular symptoms arising report a symptomatic improvement and
as a result of proximal compression of the more than 50% of patients are symptom free.
neurovascular structures in the region of Failure to improve is often due to a double
the first rib. It usually affects middle-aged crush compression syndrome or incomplete
women and the male:female ratio is about division of the compressing structure.
1:3. Approximately 10% of patients have
bilateral symptoms. Compression can result Dislocation of the shoulder
from a bone, muscle or fibromuscular band.
The compressing lesion is usually congenital. The shoulder is one of the commonest
Approximately 30% of cases are precipitated joints to dislocate due to the shallowness of
by trauma (e.g. whiplash injury). glenohumeral joint, the range of movement,
ligamentous laxity, possible glenoid dysplasia
Clinical features and the vulnerability of the joint. External
rotation in abduction levers the head of the
Neurological features are more common humerus out of the glenoid socket. The joint
than vascular. Subclavian artery aneurysms capsule is often torn and the glenoid labrum
and axillary vein thrombosis are uncommon. may be avulsed (Bankart lesion).
Symptoms are often worsened by carrying
weights or lifting arms above the head. Clinical features
Differential diagnosis includes:
Dislocation is usually caused by fall on
• Cervical spondylosis the outstretched hand. It has a bimodal
• Distal nerve compression age distribution. The first peak occurs in
• Pancoast’s tumour young adult men after significant trauma.
• Connective tissue disorders The second peak occurs in elderly women
• Vascular and venous embolic disease after minimal violence. Pain is often severe.
The arm is usually held in abduction and
Diagnosis often depends mainly on the externally rotated. All movement is restricted.
history. Signs are few but the diagnosis may be The lateral outline of shoulder is flattened. A
confirmed with the reproduction of symptoms bulge may be felt below the clavicle.
with arms flexed and abducted (Roos test) or
loss of the radial pulse with head turned to the Investigation
opposite side and the neck extended (Adson
manoeuvre). An anterio-posterior x-ray of the shoulder
shows overlapping of the humeral head and

358 Chapter 22  Trauma and orthopaedic surgery

glenoid fossa (Figure 22.9). The head of the Posterior dislocation
humerus is seen below and medial to the Posterior dislocation of the shoulder is rare
joint. An x-ray is mandatory to exclude a and accounts for less than 2% of shoulder
humeral fracture. dislocations. It is usually due to indirect forces
Management resulting in internal rotation and adduction.
Numerous methods of reduction have been It is occasionally seen following convulsions
described. It may be reduced by simple or electric shocks. An anterio-posterior
traction and countertraction in slight x-ray may appear ‘normal’ and the injury is
abduction. Kocher method requires the easily missed. If there is any doubt regarding
elbow to be flexed to 90˚; the arm to be slowly diagnosis then a CT scan is useful.
rotated laterally to 75˚ and the elbow lifted
forward and arm rotated medially. An x-ray Painful shoulder
should be taken to confirm reduction and
exclude a fracture. The arm should be rested Causes of shoulder pain include:
in a sling for 2 to 3 weeks. Complications of an
anterior dislocation include: • Impingement syndromes
• Axillary nerve injury • Rotator cuff tears
• Vascular injury • Frozen shoulder
• Fracture-dislocation • Calcific tendonitis
• Shoulder stiffness
• Unreduced dislocation Rotator cuff impingement
• Recurrent dislocation Rotator cuff impingement is due to
abrasion of the rotator cuff muscles on the
An AP x-ray of the shoulder showing coracoacromial arch. Impingement is usually
anterior dislocation reversible. Untreated it may lead to rotator
cuff tears or degenerative changes in the
Figure 22.9  An AP x-ray of the shoulder showing glenohumeral joint. It causes a ‘painful arc’
anterior dislocation between 60 and 120° of abduction. A full
range of passive movement is possible. Plain
radiographs may be normal. Management
is by subacromial steroid injection or
subacromial decompression.

Rotator cuff tears
Rotator cuff tears usually occur in the middle
aged and elderly. They result from either
chronic impingement or acute injury and
usually present with pain and weakness.
Supraspinatus and infraspinatus are usually
involved resulting in weakness in abduction
and resisted external rotation. An MRI should
be obtained to confirm the clinical diagnosis
and assess the size of the tear and the extent
of retraction. Treatment options include
conservative management and either open or
arthroscopic repair.

Frozen shoulder
A frozen shoulder is due to chronic
inflammation and fibrosis of subsynovial
layer. It often occurs after minor trauma or a
period of immobility. It reduces the range of
active and passive movement, particularly

Disorders of the upper limb 359

loss of external rotation. It is associated with characterised by pain over the medial aspect
severe pain and recovery may be prolonged. of the elbow. Pain is exacerbated by wrist
Treatment options include physiotherapy and flexion. Tenderness is distal to the medial
manipulation under anaesthetic. epicondyle. Management is similar to lateral
epicondylitis.
Calcific tendonitis
Calcific tendonitis is due to deposition of Ulnar nerve entrapment
calcium salts in the supraspinatus tendon. It at the elbow
produces severe pain over the anterolateral
aspect of the shoulder. There is usually a The ulnar nerve runs behind the medial
full range of passive movement. Pain is epicondyle at the elbow. It runs in a tunnel
aggravated by shoulder movement. Calcium formed by the aponeurosis between the two
deposits on x-ray are diagnostic. Treatment heads of flexor carpi ulnaris. The aponeurosis
options include anti-inflammatory drugs, is slack in elbow extension but becomes tight in
physiotherapy, subacromial injection or elbow flexion. Disorders of the elbow joint can
subacromial decompression and removal of result in nerve compression and symptoms are
calcium deposits. often worse when elbow is flexed.

Lateral epicondylitis Clinical features
The main symptoms are pain and
Lateral epicondylitis is often referred to as paraesthesia in the ring and little finger.
tennis elbow. It is due to inflammation at the This may be associated with weakness of
origin of the wrist and finger extensors. It is an grasp and grip and loss of manual dexterity.
enthesopathy of the lateral epicondyle. Wasting of the intrinsic muscles of the hand
can occur.
Clinical features
Lateral epicondylitis usually occurs between Management
30 and 50 years of age. Men and women Night splints to reduce elbow flexion may
are equally affected and 75% experience improve symptoms. Surgical options include:
symptoms in their dominant arm. It causes
pain over the lateral epicondyle radiating to • Ulnar nerve decompression
the forearm. Tenderness is usually maximum • Medial epicondylectomy
5 mm distal to the insertion of the tendon. • Anterior transposition
Resisted wrist extension increases the pain.
Plain x-ray may show calcification in the soft Olecranon bursitis
tissues.
Olecranon bursitis is inflammation of the
Management bursa overlying the olecranon process at the
Non-surgical management involves anti- elbow (Figure 22.10). Inflammation may
inflammatory drugs, rest and steroid be caused by a variety of mechanisms. It is
injection. Surgical treatment should be often the result of repetitive trauma but may
considered if there is no improvement occasionally occur as a result of infection.
with 6 months of conservative treatment. It The patient notices a painful lump over the
involves division and reattachment of the olecranon process with painful movement
tendon. About 85% patients notice a dramatic of the elbow joint. Examination will confirm
improvement in symptoms. a swollen bursa. Treatment is with anti-
inflammatory drugs and aspiration if the
Medial epicondylitis swelling fails to settle.

Medial epicondylitis is often referred to as Disorders of the hand
golfer’s elbow. It is less common than lateral
epicondylitis but occurs in the same age Carpal tunnel syndrome
group. It is an enthesopathy of the pronator
teres and flexor carpi radialis tendon. It is The carpal tunnel is formed by the flexor
retinaculum stretching across the carpus.

360 Chapter 22  Trauma and orthopaedic surgery Figure 22.10  An olecranon bursa
An olecranon bursa

It forms a tight tunnel through which passes of the flexor retinaculum. This may be
the long flexors to the fingers and thumb and performed endoscopically. About 70%
the median nerve (Figure 22.11). Swelling patients are symptom-free following surgery.
within the tunnel causes nerve compression
and ischaemia. Carpal tunnel syndrome de Quervain’s disease
affects 3% of women and 2% of men. About
30% cases are due to an underlying medical de Quervain’s disease is also known
condition including: as stenosing tenovaginitis. It is due to
inflammation and thickening of the tendon
• Hormonal – pregnancy/menopause sheaths of extensor pollicis brevis and
• Rheumatoid arthritis abductor pollicis longus. It occurs where both
• Hypothyroidism tendons cross the distal radius.
• Diabetes
Clinical features
Clinical features It usually presents in middle age. Pain is
noted over the radial aspect of the wrist and
Carpal tunnel syndrome usually presents often occurs after repetitive activity. The pain
in middle age. The female:male ratio is is often worsened by abduction of the thumb
approximately 8:1. Pain and parasthesia is against resistance. Passive abduction across
noted in the distribution of the median nerve. the palm often causes the pain (Finkelstein
Symptoms are often worse at night and signs test). The tendon sheath is thickened and
are few. Tapping over the carpal tunnel can tender over the radial styloid.
reproduce symptoms (Tinel sign). Flexion
of the wrist for 60 seconds may precipitate Management
symptoms (Phalen sign). Thenar wasting Symptoms can often be improved with steroid
and loss of 2-point discrimination in the injections into the tendon sheath. Persistent
distribution of the median nerve are late symptoms require surgery. The tendon sheath
features. The diagnosis is confirmed by nerve should be split avoiding the dorsal sensory
conduction studies which show slowed nerve branch of radial nerve.
conduction across the wrist.
Dupuytren’s contracture
Management
Dupuytren’s contracture is a fibroproliferative
Nocturnal symptoms can often be controlled disease of the palmar fascia. It was first
with night splints. Steroid injections may described in 1614 and a detailed anatomical
produce temporary symptomatic relief. study presented by Dupuytren in 1831.
Troublesome symptoms require division

Disorders of the hand 361

Anatomy of the carpal tunnel Figure 22.11  Anatomy of the
carpal tunnel. (Reproduced
Flexor tendons courtesy of The Radiology
Department, St George’s Hospital,
Ulnar artery London.)

Trapezium Flexor
retinaculum

Median nerve

Trapezoid

Capitate Hamate

The aetiology is unclear but it is possibly Clinical features
inherited as an autosomal dominant The most noticeable clinical feature is
condition with limited penetrance. It is thickening of the palmar fascia with nodule
occasionally associated with plantar fasciitis formation (Figure 22.12). Flexion contracture
and Peyronie’s disease. It is more common in occurs at the metacarpophalangeal and
northern Europe. The male to female ratio is proximal interphalangeal joints, usually
4:1. It affects 5% men over the age of 50 years. affecting the ring and little finger. In the late
Risk factors include: stage of the disease cords develop proximal to
the nodules. About 65% cases are bilateral.
• Diabetes mellitus
• Alcohol excess Management
• HIV infection Surgical treatment involves excision or
• Epilepsy incision of the palmar fascia. The options
• Trauma include fasciotomy, fasciectomy or
• Manual labour

Dupuytren’s contracture Figure 22.12  Dupuytren’s
contracture

362 Chapter 22  Trauma and orthopaedic surgery

dermofasciectomy. Surgery should be • Anterior and posterior draw test
considered if the metacarpophalangeal • Lachman’s test
contracture is greater than 30˚ and there is • Pivot shift test
functional disability. Patients need intensive • McMurray’s test
postoperative physiotherapy. Approximately
20% of patients develop complications. The Investigation
recurrence rate is approximately 50%. Plain radiographs may show avulsion
fractures and exclude fractures around
Ganglions the knee. MRI is the most useful imaging
modality for assessing the integrity of the
Ganglions are the commonest cause of ligaments. It will show the extent of soft tissue
swellings around the hand and wrist. They injuries. Arthroscopy as an investigative
are cystic lesions arising from either the joint procedure is now almost obsolete.
capsule or a tendon sheath. The aetiology is
unknown. They are more common in women. Management
They usually occur between 20 and 40 years
of age. Meniscal injuries
Mensical injuries may be traumatic or
Clinical features degenerative. They are classified by their
Most ganglia present as smooth swellings position and shape. Acute peripheral injuries
2–4 cm in diameter. Most are painless. Pain can be repaired. Chronic central injuries often
can occur due to compression of adjacent require arthroscopic partial meniscectomy.
neurovascular structures. Total meniscectomy risks later degenerative
changes and should be avoided.
Management
If a ganglion is asymptomatic, no specific Anterior cruciate injuries
treatment is required. The old treatment Acute anterior cruciate injuries result in
of ‘hitting with the family bible’ should be a haemarthrosis which results in variable
condemned. Aspiration can be attempted amounts of pain and instability. They are
but the outcome is poor and recurrence often associated with a medial meniscal tear.
is common. Excision is the treatment of Treatment options depend on the expectation
choice. The lesion should be explored and the life-style of the patient. Options
down to the joint capsule or tendon sheath. include physiotherapy and rarely or later
Inadequate surgery results in a high cruciate ligament reconstruction. The most
recurrence rate. popular grafts are hamstring and bone-patella
tendon-bone grafts.
Knee injuries
Posterior cruciate injuries
Clinical features Posterior cruciate injuries usually occur
The history of any knee injury will suggest following dashboard injuries. They result in
which structures may be damaged. Direct varus knee instability. Treatment is controversial
or valgus forces injure the collateral ligaments. due to less reliable surgical results. Surgical
Indirect forces injure the cruciate ligaments reconstruction is reserved for multiple
and menisci. Twisting in flexion can damage ligament injuries.
the menisci. Immediate swelling suggests a
haemarthrosis. An audible ‘pop’ can occur Collateral ligament injuries
with a cruciate ligament injury. Mechanical Medial collateral ligament injuries are
locking is characteristic of a meniscal injury. common. Clinical evaluation allows injuries
Examination should look at joint alignment, to be graded as follows:
wasting, swelling and bruising. Localised
tenderness should be elicited and the range • Grade 1 – Local ligament tenderness – no
of passive and active movement should be instability
assessed. Provocation tests include:
• Grade 2 – Unstable at 20° of flexion – stable
in extension

Disorders of the foot 363

• Grade 3 – Unstable in flexion and especially on rough ground. There is no
extension valgus deviation of the hallux. The MTPJ is
swollen and enlarged and dorsiflexion of the
MRI is useful in evaluating the extent MTPJ is reduced. A rocker-soled shoe may
of injury. The management of collateral improve symptoms. If significant symptoms
ligament injuries should be as follows: occur, then surgery may be required. The
surgical options include:
• Grade 1 injuries require analgesia and
early mobilisation • Extension osteotomy
• Cheilectomy
• Grade 2 injuries require a hinged knee • Arthroplasty
brace • Arthrodesis

• Grade 3 injuries require surgical repair Claw toes

Disorders of the foot Claw toes result from flexion of the
interphalangeal joints and hyperextension
Hallux valgus of the metatarsophalangeal joints. They
are often idiopathic but can be associated
Hallux valgus is the commonest deformity with rheumatoid arthritis, poliomyelitis and
of the foot. It results in excessive valgus peroneal muscular atrophy.
angulation of the big toe. It is only seen in
populations that wear shoes. Splaying of the Clinical features
forefoot with varus angulation of the first Claw toes result in pain in the forefoot.
metatarsal predisposes to the condition. The Symptoms are usually bilateral. Walking
anatomical deformity consists of increased may be restricted. They also cause painful
forefoot width, lateral deviation of the hallux callosities on the dorsum of the toes or under
and prominence of the first metatarsal head. the metatarsal heads.
As the deformity increases, the long tendons
of the hallux are shifted laterally. Management
If the toes can be passively straightened then
Clinical features a ‘metatarsal bar’ may help. Special footwear
Hallux valgus is more common in women may reduce symptoms. If non-operative
and is often bilateral. Symptoms result from a management fails, then surgical options
bursa over the metatarsal head (often known include:
as a bunion) hammer toes, metatarsalgia and
osteoarthritis of the first metatarsophalangeal • Interphalangeal arthrodesis
joint (MTPJ). The diagnosis can be confirmed • Joint excision
by x-ray. The intermetatarsal angle should be • Metatarsal osteotomy
less than 20° and the hallux angle should be • Digital amputation
less than 15°.
Plantar fasciitis
Management
Surgical management should be considered Plantar fasciitis is a self-limiting condition
if the patient is symptomatic. The surgical that occurs in middle age. It presents with
options include: intermittent heel pain. It is usually unilateral
but 15% cases are bilateral. Pain is often
• First metatarsal osteotomy worse early in the morning. Examination
• Exostectomy and capsulorrhaphy shows tenderness over the medial plantar
• Excision of the proximal one-third of the aspect of the calcaneal tuberosity. About 50%
of patients have a heel spur on plain x-ray.
proximal phalanx (Keller operation) The differential diagnosis includes Reiter’s
• Arthrodesis syndrome, an entrapment neuropathy or a
calcaneal stress fracture. Management should
Hallux rigidus involve the use of supportive heel pads and

Hallux rigidus is due to osteoarthritis of
the first MTPJ. It affects men more often
than women. It results in pain on walking,

364 Chapter 22  Trauma and orthopaedic surgery

other orthotic devices and anti-inflammatory • Inactivity
drugs. Surgery is rarely indicated. • Cigarette smoking
• Poor diet
Morton’s neuroma • Family history
• Early menopause
Morton’s neuroma is a painful forefoot • Endocrine disease – Cushing’s syndrome,
disorder. It is caused by thickening and
fibrosis of the interdigital nerves. The diabetes, hyperthyroidism
aetiology is unknown. It usually affects • Drugs – steroids, thyroxine, diuretics
the second or third web space and causes
plantar pain at the level of metatarsal heads. Clinical features
It may be associated with distal sensory Clinical features of osteoporosis include
loss. The differential diagnosis includes pain, decreased mobility, deformity, loss
metatarsalgia, metatarsophalangeal synovitis, of independence and osteoporosis-related
a stress fracture and Freiberg’s infarction fractures.
(osteochondrosis of the 2nd metatarsal
head). Initial management is non-operative. Investigation
Surgical excision of the neuroma should be Useful investigations to detect the presence of
considered if symptoms fail to settle. osteoporosis include:

Osteoporosis • Dual-energy x-ray absorptionometry
• Quantitative CT scanning
Osteoporosis is a systemic skeletal disease • Bone biopsy
characterised by low bone mass and • Biochemical markers of bone turnover
micro-architectural deterioration. It is
associated with increased bone fragility and Prevention
susceptibility to fractures. It is defined as a Optimisation of peak bone mass can be
bone mineral density less than 2.5 standard achieved by exercise and supplementary
deviations below the mean. Established dietary calcium. A reduced rate of bone loss
osteoporosis is a low bone mineral density is seen with use of hormonal replacement
associated with an osteoporosis-related therapy in post-menopausal women ,
fracture. moderation of alcohol intake and stopping
smoking.
Pathophysiology
Bone undergoes continuous resorption and Metabolic bone disease
formation. About 10% of the adult skeleton Osteomalacia and rickets
is remodeled each year. Bone loss results
from an imbalance between resorption and Both osteomalacia and rickets result from
formation. The human skeleton comprises Vitamin D deficiency. The outcome is
approximately 80% cortical bone and 20% incomplete osteoid mineralisation. In
trabecular bone. childhood, prior to epiphyseal closure,
this causes rickets. In adults, it causes
Osteoporotic fractures occur at sites with osteomalacia. Causes of osteomalacia include:
more than 50% trabecular bone such as
the vertebral bodies, proximal femur and • Vitamin D deficiency
distal forearm. Bone loss leads to thinning • Malabsorption
of the trabecular plates. This causes a • Renal disease – familial
disproportionate loss of bone strength. Peak
bone mass is achieved by the age of 30 years. hypophosphataemic rickets
After skeletal maturity bone is lost at about • Anticonvulsant therapy
1% per year. Women experience accelerated • Tumours
bone loss after the menopause. Factors
associated with increased bone loss include: Clinical features
Osteomalacia is usually due to dietary
deficiency in the elderly or Asian population.

Metabolic bone disease 365

Rickets is usually due to familial signs include characteristic skull and long
hypophosphataemic rickets. Rickets usually bone deformities. Complications causing
presents in early childhood with: symptoms include:

• Failure to thrive • Pathological fractures – complete or
• Valgus or varus long bone deformities incomplete
• Skull deformities – craniotabes
• Enlarged costochondral junctions – • Neurological effects
• Osteoarthritis
Rickety rosary • Sarcomas
• Lateral indentation of the chest wall – • Cardiac failure

Harrison’s sulcus Investigation
• X-ray shows a widened epiphyses and Skeletal x-rays in the osteolytic phase may
show osteoporosis circumscripta. Bone
cupped distal metaphysis softening can produce bowing, platybasia,
protrusion of the acetabuli or greenstick
Osteomalacia presents in adults with: fractures. In the mixed phase, radiological
investigations shows generalised bone
• Bone pain and tenderness enlargement. In the sclerotic phase they show
• Proximal myopathy increased bone density with trabecula and
• True pathological or pseudo-fractures cortical thickening. The serum calcium and
phosphate are usually normal. The serum
Investigation alkaline phosphatase is often increased.
In osteomalacia, the serum calcium and Serum uric acid levels are increased in about
phosphate are low and alkaline phosphatase 30% of patients.
is increased. Skeletal x-rays may show
translucent bands in the medial femoral Management
cortex, pubic ramus or scapula (Looser’s Anti-inflammatory drugs can be used
zones). In familial hypophosphataemic to control bone pain. Biphosphonates
rickets, the serum calcium is normal and will reduce bone turnover. Neurological
phosphate is low. A bone biopsy is rarely complications and fractures may require
required but, if performed, would show surgical intervention.
increased unmineralised osteoid.
Paget’s sarcomas
Management
Treatment is with Vitamin D replacement Most osteosarcomas that develop late in life
therapy and phosphate supplements in those are associated with Paget’s disease. Malignant
with familial hypophosphataemic rickets. change occurs in less than 1% of patients
with Paget’s disease. The commonest site is
Paget’s disease of bone the femur. The prognosis of Paget’s sarcomas
is poor with a median survival of 1 year and
Paget’s disease of bone is named after Sir only 5% of patients are alive at 5 years.
James Paget who first described osteitis
deformans in 1877. The aetiology is unknown Locomotor pain
but it is possibly due to a viral infection. Low back pain
Histological features include enlarged
osteoclasts. Increased bone turnover Lumbar back pain is one of the commonest
produces a mosaic pattern of lamellar bone. causes of chronic disability. It is usually due
The disease has three phases – osteolytic, to abnormality of the intervertebral discs at
mixed and sclerotic. the L4/5 or L5/S1 level. It can occur at any age
but is most common in previously fit adults
Clinical features between 20–45 years.
Paget’s disease is often identified as
an incidental finding on an x-ray in an
asymptomatic patient. If symptomatic,
it usually causes bone pain. The clinical

366 Chapter 22  Trauma and orthopaedic surgery

Pathology with an acute disc rupture depends on the
nerve root compressed (Table 22.7).
With age, the nucleus pulposus of the
intervertebral disc dries out. The annulus Investigation
fibrosus also develops fissures. Nuclear
material may then herniate through A lumbar spine x-ray will exclude other bone
annulus fibrosus. It may also perforate lesions. CT scanning is an effective diagnostic
the vertebral end-plate to produce a study when the spinal and neurological
Schmorl node. Flattening of the disc with levels are clear and bony pathology is
marginal osteophyte formation is known as suspected. MRI is now the investigation
spondylosis. Osteoarthritis may develop in of choice. It is most useful when the exact
the facet joints. Osteophyte formation may spinal and neurological levels are unclear,
narrow the lateral recesses of spinal canal. when a pathological condition of the spinal
These can encroach on the spinal canal and cord or soft tissues is suspected or when an
result in spinal stenosis. Acute herniation underlying infective or neoplastic cause is
of disc contents can also occur. This usually possible.
happens to one side of the posterior
longitudinal ligament. Posterolateral rupture Management
can compress nerve roots. Central posterior
rupture can compress the cauda equina. Bed rest is of unproven benefit and recovery is
not hastened by traction. Anti-inflammatory
Clinical features drugs provide symptomatic relief. The role
of epidural steroid injection is unclear.
Acute disc rupture usually presents with Chemonucleolysis is less effective than
sudden onset of low back pain on stooping or surgical discectomy. Surgery is required if
lifting. The pain often radiates to buttock or there is:
leg and may be associated with parasthesia
or numbness in the leg. Cauda equina • Cauda equina compression –
compression can cause urinary retention. neurosurgical emergency
Examination may show a ‘sciatic’ scoliosis.
Lumbar tenderness and paravertebral spasm • Neurological deterioration with
maybe be present and all back movements conservative management
are usually restricted. Straight leg raising is
often reduced. Neurological examination is • Persistent symptoms and neurological
essential. The neurological signs associated signs

The surgical options are laminectomy and
microdiscectomy. Postoperative rehabilitation
and physiotherapy are essential.

Neurological signs associated with acute disc rupture

Neurological level Signs
L5 root
Weakness of hallux extension
S1 root Loss of knee reflex
Sensory loss over the lateral aspect of the leg and dorsum of the foot
Cauda equina Weakness of foot plantar flexion
Loss of ankle reflex
Sensory loss over the lateral aspect of the foot
Urinary retention
Loss or perianal sensation

Table 22.7  Neurological signs associated with acute disc rupture

Locomotor pain 367

Facet joint dysfunction presents with back pain and neurological
symptoms. Patients have a characteristic
Facet joint dysfunction usually presents stance and the ‘step’ in the lumbar spine may
with recurrent low back pain. The pain is be palpable. The diagnosis can be confirmed
often related to physical activity and may be on a lumbar spine x-ray. Most patients
referred to the buttock. It is often relieved by improve with conservative management.
lying down and rest. Lumbar spine movement Surgery may be required if:
is often good and neurological signs are rare.
Lumbar spine x-rays show narrowing of the • Disabling symptoms
disc space and oblique views may show facet • Progressive displacement more than 50%
joint malalignment. Treatment includes • Significant neurological compromise
physiotherapy, analgesia and facet joint
injections. Surgery is rarely necessary but Anterior or posterior fusion may be required.
spinal fusion may need to be considered.
Spinal cord compression
Spinal stenosis
The clinical features of a spinal cord lesion
Spinal stenosis is narrowing of the spinal depends on its rate of development.
canal due to hypertrophy of the posterior Trauma produces acute compression with
disc margin. It may be compounded by facet rapidly developing neurological effects.
joint osteophyte formation. Spinal stenosis Benign neoplasms can cause substantial
may also be associated with achondroplasia, compression with little neurological deficit.
spondylolisthesis and Paget’s disease. It The causes of spinal cord compression can
usually presents with either unilateral or be:
bilateral leg pain, initiated by standing or
walking and relieved by sitting or leaning • Trauma – vertebral body fracture or facet
forward – ‘spinal claudication’. The patient joint dislocation
prefers to walk uphill rather than downhill.
Lumbar spine x-rays often show degenerative • Neoplasia – benign or malignant
spondylolisthesis. The diagnosis can be • Degenerative – prolapsed intervertebral
confirmed by MRI. It can often be treated
conservatively. Surgery involves laminectomy disc, osteophyte formation
and decompression. • Vascular – epidural or subdural

Spondylolisthesis haematoma
• Inflammatory – rheumatoid arthritis
Spondylolisthesis means forward shift of • Infection – tuberculosis or pyogenic
the spine. It usually occurs at L4/L5 or L5/
S1 level. It can only occur if the facet joint infections
locking mechanism has failed. It is classified
as: Anatomy

• Dysplastic – 20% The spinal cord is shorter than spinal canal.
• Lytic – 50% The spinal cord ends at the interspace
• Degenerative – 25% between the L1 and L2 vertebrae. Below the
• Post-traumatic termination of the cord the nerve roots form
• Pathological the cauda equina (Figure 22.13). Within the
• Postoperative cervical spine, segmental levels of the cord
correspond to the bony landmarks. Below this
In lytic spondylolisthesis the pars level there is increasing disparity between
interarticularis is in two pieces levels. Spinal pathology below L1 presents
(spondylolysis). The vertebral body and with only root signs.
superior facet joints subluxate and dislocate
forward. The degree of overlap is usually Clinical features
expressed as a percentage. The cauda equina
or nerve roots may be compressed. It usually The clinical features of spinal cord
compression can be variable and a high index
of suspicion is required. Motor symptoms
include easy fatigue and gait disturbance.
Sensory symptoms include sensory loss and
parasthesia. Light touch, proprioception

368 Chapter 22  Trauma and orthopaedic surgery

Vertebral Anatomy of the cauda equina Figure 22.13  Anatomy of the
canal cauda equina. (Reproduced from
T12 Tunstall R and Shah N. Pocket
Pelvic Tutor Surface Anatomy. London:
brim Conus JP Medical Ltd, 2012, and courtesy
L2 medullaris of Sam Scott-Hunter, London.)
L5 root
S2 root Cauda equina

L5

S2

Sacral hiatus

and joint position sense may be reduced. pedicle. The integrity of the disc may indicate
Tendon reflexes are often increased below the diagnosis. ‘Good disc = bad news’ often
the level of compression, absent at the level indicates malignancy. ‘Bad disc = good news’
of compression and normal above. Reflex and may indicate infection. MRI is now the
changes may not coincide with sensory level. investigation of choice to define the extent
of any soft tissue disease. A bone scan may
Cervical spine disease produces indicate the pattern and extent of bone
quadriplegia. Thoracic spine disease pathology.
produces paraplegia. Lumbar spine disease
affects L4, L5 and sacral nerve roots. Management
Sphincter disturbances are late features of Acute spinal cord compression is a ‘surgical’
cervical and thoracic cord compression. emergency. In those with malignant disease,
Cauda equina compression due to central radiotherapy may be the treatment of choice.
disc prolapse produces: In general, tumour, infection and disc
disease produces anterior compression and
• Loss of perianal sensation surgical decompression should be achieved
• ‘Root pain’ in both legs through an anterior approach. The cervical
• Painless urinary retention spine can be approached between the larynx
medially and the carotid sheath laterally. The
Most patients with surgically treatable causes thoracic spine can be approached through
of spinal compression have spinal pain. the chest by a posterior thoracotomy or
Movement-induced pain suggests vertebral costotransversectomy.
fracture or collapse. Exquisite tenderness
suggests an epidural abscess. Low-grade Bone tumours and
background pain may suggest tumour amputations
infiltration or osteomyelitis. Primary bone tumours

Investigation Bone and connective tissue cancers account
for less than 1% of all new cancers diagnosed
Spinal x-rays may show bone or paravertebral
soft tissue disease. Other features which may
be seen on a plain x-ray include vertebral
collapse, lytic lesions and loss of the vertebral

Bone tumours and amputations 369

in the UK each year. Primary bone tumours surrounded by dense bone. Local excision is
are rare. Secondary tumours are more curative.
common, especially in the elderly. The
classification of benign and malignant bone Osteochondroma
tumours is shown in Table 22.8.
Osteochondromas are the commonest of
Clinical features and investigation the bone tumours. Lesions can be single or
multiple. They usually appear in adolescence
Most primary bone tumours present with as cartilaginous overgrowth at the epiphyseal
bone pain, a limb swelling and localised plate. The tumour grows with the underlying
tenderness. Pain is usually worse following bone. The metaphyses of long bones are the
activity. Pain in an extremity may result commonest sites. They usually present as
in a limp. Rapid growth and associated a painless lump or occasionally joint pain.
erythema are suggestive of malignancy. The Excision should be considered if they cause
tumour may present with a pathological debilitating symptoms.
fracture, but this uncommon. Systemic
symptoms, such as fever and night sweats, Chondroma
are rare. Tumours that spread to the lungs
only rarely results in respiratory symptoms Chondromas are benign tumours of cartilage.
and this usually indicates extensive lung The lesions may be single or multiple (Ollier’s
involvement. The diagnosis of a bone or disease). They usually appear in the tubular
connective tissue tumour can be confirmed bones of the hands and feet. A plain x-ray will
by plain x-ray, CT scan, MRI and a carefully show a well-defined osteopenic area in the
planned biopsy. medulla. The lesion can often be excised and
bone grafted.
Osteoid osteoma
Giant-cell tumour (osteoclastoma)
Osteoid osteomas are benign bone tumours.
When they clinically present, they are usually Giant-cell tumours are benign, locally invasive
less than 1 cm in diameter . They are more and metastatic in equal proportions. They are
common in young adults. The tibia and found in the sub-articular cancellous regions
femur are the commonest sites. Severe pain, of long bones and only occurs after closure of
relieved by anti-inflammatory drugs, is often the epiphyses. Patients are usually between
the presenting complaint. A plain x-ray has 20 and 40 years. A plain x-ray shows an
characteristic appearance of a radiolucency asymmetric rarefied area at the end of a long
bone. The cortex is thinned or even perforated.

Classification of primary bone tumours

Cell type Benign Malignant
Bone Osteoid osteoma
Cartilage Chondroma Osteosarcoma
Osteochondroma Chondrosarcoma
Fibrous tissue Fibroma j
Bone marrow Eosinophilic granuloma Fibrosarcoma
Ewing’s sarcoma
Vascular Haemangioma Myeloma
Uncertain Giant-cell tumour Angiosarcoma
Malignant giant cell tumour

Table 22.8  Classification of primary bone tumours

370 Chapter 22  Trauma and orthopaedic surgery

Treatment by local excision and grafting • Kidney (5%)
often leads to recurrence. Wide excision and • Thyroid (2%)
joint replacement is the treatment of choice.
Amputation is required for malignant or Clinical features
recurrent tumours. The clinical features of bone metastases
include:
Osteosarcoma
• Pain or localised bone lump
Osteosarcomas occur in the metaphyses of • Pathological fracture
long bones. The commonest sites are around • Hypercalcaemia
the knee or proximal humerus. They destroy • Cord compression
bone and spread into the surrounding
tissue. Untreated, they rapidly metastasise Investigation
to the lung. They usually occur between 10 Plain x-rays can be normal even in those
and 20 years but later in life they are seen patients with extensive bone metastases.
in association with Paget’s disease of bone. If an x-ray is abnormal, it will show either
A plain x-ray shows a combination of bone an osteolytic or sclerotic lesion. Osteolytic
destruction and formation. The periosteum metastases are encountered most frequently,
may be lifted (Codman’s triangle). Soft especially in breast and lung carcinomas.
tissue calcification produces a ‘sunburst’ Sclerotic metastases are typically seen in
appearance. Treatment usually involves prostate cancer. Metastases usually appear
amputation and chemotherapy. Amputation in the medullary cavity, spread to destroy the
may be combined with prosthetic medullary bone and then involve the cortex.
replacement. The 5-year survival is about The differential diagnosis of bone metastases
50%. The worst prognosis is seen in those with on a plain x-ray includes:
proximal and axial skeletal lesions.
• Calcified enchondroma
Chondrosarcoma • Hyperparathyroidism
• Chronic sclerosing osteomyelitis
Chondrosarcoma occurs in two forms • Bone infarct
as either ‘central’ tumours in the pelvis • Myeloma deposit
or proximal long bones or ‘peripheral’
tumours in the cartilaginous cap of an Isotope bone scanning has a higher
osteochondroma. They tend to metastasise sensitivity than x-rays and may identify other
late. Wide local excision is often possible. asymptomatic lesions. MRI is more sensitive
than bone scanning and plain x-rays in the
Metastatic bone tumours detection of bone metastases.

About 30% of patients with malignant disease Management
will develop bone metastases and 10% of The aims of treatment are to relieve pain and
these patients will develop a pathological preserve mobility. If a pathological fracture
fracture. About 90% of skeletal metastases are occurs, consideration should be given to
multiple. Tumours spread to bone by: internal fixation for early mobilisation and
pain relief. Prophylactic internal fixation
• Direct invasion to prevent a pathological fracture may be
• Haematogenous spread required if there is:
• Lymphatic spread
• Spread via the paravertebral venous plexus • Greater than 50% erosion of a long bone
cortex
The commonest sites for bone metastases
are the lumbar vertebrae, pelvis and ribs. • A metastasis of more than 2.5 cm in
The primary tumours which most commonly diameter
spread to bone are:
• Metastasis in high-risk area (e.g.
• Breast (35%) subtrochanteric femur)
• Prostate (30%)
• Bronchus (10%) • Metastasis with persistent pain

Bone tumours and amputations 371

Radiotherapy is useful for the rapid relief Clinical features
of back pain. Spinal decompression may The clinical features of multiple myeloma
be needed if cord compression occurs. include:
Percutaneous vertebroplasty involves the
injection of acrylic bone cement into the • Bone pain – especially back pain
vertebral body in order to relieve pain and • Pathological fracture
stabilise the vertebral column. Vertebroplasty • Spinal cord compression
should be considered for patients who have • Hypercalcaemia
vertebral metastases and no evidence of cord • Renal failure
compression or spinal instability, if they have • Anaemia
either mechanical pain resistant to analgesia • Immunosuppression
or if they have vertebral body collapse. • Amyloidosis

Multiple myeloma Investigation
The diagnosis can be confirmed by finding:
Multiple myeloma is a malignant disease of
plasma cells in the bone marrow. It accounts • Paraprotein in the serum or urine on
for 1% of all cancers. There are about 2500 new electrophoresis
cases each year in UK. Most patients are over
60 years of age. The disease is characterised by • Lytic lesions on plain x-rays
production of monoclonal immunoglobulins • Bone marrow aspirate with more than 10%
which can be detected in serum, urine or both.
plasma cells
Pathogenesis
Management
The disease occurs due to the monoclonal Overall, about 70% of patients respond to
overgrowth of one clone of plasma cells treatment, but complete remission is rare. The
which produces either a monoclonal median survival is 3 years. Treatment options
immunoglobulin or paraprotein. In 80% include:
of patients, an IgG or IgA is detectable in
serum. In 20% of patients, no paraprotein is • Melphalan chemotherapy
detectable in the serum. Free light chains may • Interferon-a
cross the glomerulus and appear in the urine. • Bone marrow transplantation
These are known as Bence–Jones proteins. • Dialysis for renal failure
• Bisphosphonates for hypercalcaemia
• Radiotherapy for localised bone pain



Chapter 23 Urology

Applied basic sciences take the shape of about 15 cone-shaped
Anatomy of the renal lobes, each containing renal cortex
upper renal tract surrounding a portion of the medulla called
a renal pyramid. Between the renal pyramids
The kidneys are projections of cortex called renal
columns. Nephrons, the urine-producing
The kidneys are retroperitoneal structures on functional structures of the kidney, span
the posterior abdominal wall, largely covered the cortex and medulla. The initial filtering
the by the costal margins. The right kidney portion of a nephron is the renal corpuscle,
is slightly lower than left. The hilum lies on located in the cortex. This is followed by a
medial border of each kidney and transmits renal tubule that passes from the cortex deep
the ureter, renal vein and branches of the into the medullary pyramids. Part of the renal
renal artery. The kidneys are surrounded by cortex, a medullary ray, is a collection of renal
a fibrous capsule and beyond that is found tubules that drain into a single collecting
perinephric fat and fascia. The upper end of duct. The components of the renal tubule are
each ureter expands in to the renal pelvis. The the proximal tubule, the Loop of Henle and
renal pelvis divides into two or three major the distal convoluted tubule and collecting
calyces. Each major calyx divides into two or duct.
three minor calyces. The arterial supply is by
the renal artery arising directly from the aorta. The ureters
The venous drainage is via the renal vein into
the inferior vena cava. The relations of the Each ureter is about 25 cm long and is
right and left kidney are shown in Table 23.1. lined by transitional epithelium. They are
retroperitoneal structures and run down
Structure of kidney over the psoas muscle. They lie in the line
of the tips of the transverse processes of the
The substance, or parenchyma, of the lumbar vertebrae. They cross the bifurcation
kidney is divided into two major structures. of the common iliac artery and run down on
Superficial is the renal cortex and deep is the the lateral wall of the pelvis to the region of
renal medulla (Figure 23.1). These structures ischial spine. The anatomical relations of the

Anatomical relations of the kidney

Right kidney Left kidney

Anterior Suprarenal gland Suprarenal gland
Posterior Liver Spleen
Second part of duodenum Stomach
Hepatic flexure of colon Pancreas
Splenic flexure of colon
Diaphragm
Costodiaphragmatic recess of pleura Diaphragm
Twelfth rib Costodiaphragmatic recess of pleura
Psoas muscle Twelfth rib
Psoas muscle

Table 23.1  Anatomical relations of the kidney

374 Chapter 23 Urology

Anatomy of the kidney Figure 23.1  Anatomy of the
kidney
Renal papilla
Renal artery Renal cortex
Renal medulla
Renal vein
Renal pelvis Renal capsule
Major calyx Minor calyx

Ureter Renal column
Renal pyramid

left and right ureters are shown in Table 23.2. with the prostate and the base is related
Three natural constrictions are found along to the rectum, vas deferens and seminal
their course where the: vesicles. In women, the uterus lies against its
posterosuperior surface. The base is related
• Renal pelvis joins the ureter to the vagina and cervix. The ureters join the
• Ureter crosses the pelvic brim bladder at the upper lateral angles. On the
• Ureter enters the bladder interior of the bladder, the ureteric orifices
are joined by the interureteric ridge. With
Anatomy of the lower the urethral orifice this forms a triangular
renal tract area known as the trigone. As the bladder
distends it strips the peritoneum off the
The bladder anterior abdominal wall. The wall is made of
smooth muscle and is lined by transitional
The bladder is pyramidal in shape and, when epithelium.
empty, it is an extraperitoneal structure. Its
superior surface is covered by the pelvic The bladder has two sphincters. The
peritoneum. Anteriorly, it lies behind the internal sphincter is smooth muscle and
pubis bone. The apex is attached to the is found at the bladder neck. The external
umbilicus by the median umbilical ligament. sphincter is voluntary muscle distal to the
This represents the remnant of the fetal internal sphincter. The blood supply is from
urachus. The inferolateral surfaces are related the superior and inferior vesical branches
to the levator ani and obturator internus of the internal iliac arteries. Lymphatic
muscles. In men, the bladder neck fuses

Anatomical relations of the ureter

Anterior Right ureter Left ureter
Posterior
Duodenum Pelvic colon
Terminal ileum Left colic vessels
Right colic and ileocolic vessels Left testicular/ovarian vessels
Right testicular/ovarian vessels
Psoas muscle
Psoas muscle Bifurcation of left common iliac artery
Bifurcation of right common iliac artery

Table 23.2  Anatomical relations of the ureter

Applied basic sciences 375

drainage is to the iliac and para-aortic composition of blood. The secondary
nodes. The bladder has both a motor and functions are the metabolism of vitamin
sensory nerve supply. The motor supply is D and the production of renin and
autonomic. A sympathetic supply arises from erythropoietin.
L1/L2 and is inhibitory. A parasympathetic
supply arises from S2–S4 and is motor to The nephron
the detrusor muscle. The sensory supply is
parasympathetic. Each kidney contains about one million
nephrons (Figure 23.2). There are two types
The prostate of nephron. Cortical nephrons are important
in regulating the chemical composition
The prostate is a fibromuscular and glandular of urine. Juxtamedullary nephrons are
organ surrounding the proximal urethra. It important in concentrating urine. Each
has five lobes – anterior, posterior, middle nephron is made up of a:
and two lateral lobes. Above it is continuous
with the base of the bladder. The apex sits on • Glomerulus
the sphincter urethrae in the deep perineal • Bowman’s capsule
pouch. Posteriorly, it is separated from the • Proximal convoluted tubule
rectum by Denonvillier’s fascia. Anteriorly, it • Loop of Henle
is separated from the pubis by extraperitoneal • Distal convoluted tubule
fat. It is surrounded by the prostatic venous
plexus. Ejaculatory ducts, formed by the Several tubules enter one collecting duct. A
fusion of the vas deferens and seminal number of ducts run through the medullary
vesicles enter the upper posterior part of the pyramids and enter the calyceal system.
prostate and open into the urethra. The blood Blood is filtered within the nephron. The
supply is from the inferior vesical artery. glomerular endothelium is fenestrated.
Solute-rich but protein-free fluid passes into
The male urethra Bowman’s capsule. The composition of the
filtrate is modified as it passes through the
The male urethra is about 20 cm in length renal tubule. The composition is altered by
and is divided into three parts. The prostatic absorption and secretion from the peritubular
urethra is about 4 cm in length. The posterior capillaries. This mainly occurs in the proximal
wall has a longitudinal elevation known as convoluted tubule. The loop of Henle has an
the urethral crest. Along each side of the important role in water balance.
urethral crest is the prostatic sinus. In the
middle of the crest is an elevation known Blood supply of nephron
as the verumontanum. The prostatic utricle
opens into the verumontanum. On each side The glomerular capillaries receive blood
of the utricle opens the ejaculatory ducts. The from afferent arterioles. The capillaries
membranous urethra is about 2 cm in length then drain into efferent arterioles. High
and is the narrowest part of the urethra. It glomerular capillary pressure facilitates
traverses the external urethral sphincter in filtration. Peritubular capillaries receive
deep perineal pouch. The spongy urethra blood from the efferent arterioles. This is the
is about 15 cm in length. It traverses the site of resorption and secretion. Resorption
corpus spongiosum of the penis. The external is assisted by a low capillary pressure. Over
urethral orifice is the narrowest part of the 99% of the fluid filtered in the glomerulus is
urethra. Immediately within the meatus the resorbed in the peritubular capillaries.
urethra dilates into a terminal fossa.
Juxtaglomerular apparatus
Renal physiology
The juxtaglomerular apparatus abuts the
Functions of the kidney afferent arteriole and distal convoluted
tubule. It is important in regulating the
The primary functions of the kidneys are to content of the filtrate. Cells of the distal
regulate blood volume and the chemical convoluted tubule at this point are called
the macula densa. They monitor the sodium

376 Chapter 23 Urology

The structure of a nephron

Bowman’s Proximal Distal Key
capsule convoluted convolufed H2O
tubute Solutes
Glomerulus tubule Filtrate
Ascending
Cortex Descending limb Collecting tubule
limb
Outer
medulla

Inner
medulla

Loop of Henle

To ureter

Figure 23.2  The structure of a nephron

content of the filtrate. Juxtaglomerular Resorption
cells are specialised smooth muscle cells in
the arteriole that act as baroreceptors and Most resorption occurs in the proximal
contain large amounts of renin. convoluted tubule. The primary chemical that
drives resorption is sodium. Sodium passively
Control of renal function diffuses out of the proximal convoluted
tubule and is actively transported in to the
Filtration peritubular capillaries. Movement of sodium
has three important effects:
About 20% of the blood that enters the
glomerulus is filtered. High pressure • Creates an osmotic gradient for water
within the glomerular capillaries favours resorption
filtration. The rate of filtration is known as
the glomerular filtration rate (GFR) and • Creates an electrical gradient for
is controlled by intrinsic and extrinsic negatively charged ions
mechanisms. Intrinsic mechanisms
includes myogenic regulation – changes • Allows secondary active transport in the
in arteriolar smooth muscle constriction the proximal convoluted tubule
and tubuloglomerular feedback – changes
in response to sodium concentration in Regulation of urine concentration
the distal convoluted tubule. Extrinsic and volume
mechanisms include sympathetic neural
stimulation and the renin–angiotensin Maintaining the concentration of body fluids
system. is integral to homeostasis. Concentration
is measured in osmolarity. A concentrated
solution will have a high osmolarity. A dilute
solution will have a low osmolarity. If blood

Urological trauma 377

osmolarity rises, the response will be for Investigation
water reabsorption to increase and urine
volume to decrease. If blood osmolarity falls, The aims of imaging in the assessment of
the response will the opposite. renal trauma are to assess both the extent of
injury and to determine the function of the
Antidiuretic hormone contralateral kidney. Plain radiograph may
Blood osmolarity is measured by specialised show rib fractures, loss of the psoas shadow
neurones in the hypothalamus called and the renal outline. A contrast-enhanced
osmoreceptors. They determine how much abdominal CT scan will detect extravasation
antidiuretic hormone (ADH) is secreted by of urine, distortion of the caliceal system
the posterior pituitary gland. ADH increases and provide a crude index of renal function.
water reabsorption in the collecting duct Failure of radiological contrast excretion
and decreases urine volume. When blood suggests a renal pedicle injury and, if the
osmolarity rises, ADH release is increased. patient is cardiovascularly stable, the
When blood osmolarity falls, ADH release need for renal angiography. Ultrasound
is decreased. ADH works by increasing the will identify haematomas and perirenal
permeability of the collecting ducts to water. collections. Renal injuries are classified as
follows:
Aldosterone
Aldosterone is produced in the renal • Class 1 – Renal contusion or contained
cortex. It increases sodium resorption and subcapsular haematoma
potassium excretion in the distal convoluted
tubule. Release of aldosterone is stimulated • Class 2 – Cortical laceration without
by: urinary extravasation

• Low plasma sodium • Class 3 – Parenchymal lesion extending
• High plasma potassium more than 1 cm into renal substance
• Low blood volume and pressure
• Class 4 – Laceration extending across
Urological trauma cortico-medullary junction
Renal trauma
• Class 5 – Renal fragmentation or reno-
In the UK, 90% of renal injuries result from vascular pedicle injury
blunt abdominal trauma. Isolated renal
trauma is uncommon and approximately Management
40% of patients have other associated
intra-abdominal injuries. Direct trauma Approximately 80% of renal injuries are
crushes the kidney against the ribs. Indirect minor. Class 1 and 2 injuries can be managed
trauma can result in vascular or pelviureteric conservatively. Early surgical intervention
disruption. is required for reno-vascular pedicle
injuries, pelviureteric junction disruption
Clinical features and shock with signs of intraperitoneal or
The clinical features of a renal injury include: retroperitoneal bleeding. Surgery should be
performed through a midline incision and
• Loin or abdominal abrasions or bruising a transperitoneal approach. Control of the
• Loin tenderness renal pedicle should be obtained before the
• Loss of loin contour retroperitoneal haematoma is opened. The
• Loin mass surgical priorities are to save life, remove
• Macroscopic haematuria and possible clot devascularised tissue, preserve renal function
and repair and drain the collecting system.
colic Late complications of renal trauma are:

A renal pedicle injury is possible in the • Hypertension
absence of haematuria. • Arteriovenous fistula
• Hydronephrosis
• Pseudocyst or calculi formation
• Chronic pyelonephritis
• Loss of renal function

378 Chapter 23 Urology

Lower urinary tract trauma Bulbar urethral injury

The management of lower urinary tract Bulbar urethral injury is the commonest type
trauma is controversial and often confusing. of urethral injury. It is usually the result of
In multiply injured patients, there are direct trauma caused by falling astride an
the conflicting priorities of monitoring object. Clinical features include blood from
urine output with a urethral catheter and the urethral meatus and perineal bruising.
preventing exacerbation of any possible If the patient is unable to pass urine then
urethral injury. Lower urinary tract injury a urethral catheter should not be passed
should be suspected if the following are seen: as the procedure can convert a partial tear
into a complete urethral injury. If a catheter
• Blood from urethral meatus is required, it should be inserted via the
• Perineal bruising suprapubic route. The diagnosis can be
• High riding prostate on rectal examination confirmed by an ascending urethrogram.
Prophylactic antibiotics should be given. Late
Potentially useful investigations include CT, complications include a urethral stricture.
ascending urethrogram or cystogram.
Membranous urethral injury
Bladder injury
Membranous urethral injuries often occur in
Bladder injury is often associated with pelvic multiply injured patient and unless suspected
fractures. It is also seen following direct can easily be missed. About 10% of men
blow to the abdomen with a full bladder. with pelvic fracture have a membranous
Rupture can be either intraperitoneal or urethral injury and the tear can be either
extraperitoneal. Clinical features include partial or complete. Partial injuries present
lower abdominal peritonism and the inability with urethral bleeding and perineal bruising.
to pass urine. An abdominal CT may show Complete injuries present with the inability
urine extravasation. The diagnosis can be to pass urine. On rectal examination, the
confirmed by cystography. Intraperitoneal bladder and prostate is displaced upwards. If
rupture of the bladder requires laparotomy, a membranous urethral injury is suspected,
bladder repair, urethral and suprapubic a urethral catheter should not be passed. The
drainage. Extraperitoneal rupture of the diagnosis can be confirmed by ascending
bladder can be treated conservatively with urethrogram (Figure 23.3). Treatment is with
urethral drainage. Prophylactic antibiotics a suprapubic catheter. Urethroplasty may be
should be given.

An ascending urethrogram showing rupture Figure 23.3  An ascending
of the bulbar urethra urethrogram showing rupture of
the bulbar urethra

Urinary tract infections and calculi 379

required. Late complications include urethral Dimercaptosuccinic acid (DMSA) scanning
stricture, impotence and incontinence. to assess renal damage and micturating
cystogram to evaluate vesico-ureteric reflux.
Urinary tract infections
and calculi Lower urinary tract infection
Urinary tract infection
Lower urinary tract infections are more
Bacteriuria is the presence of bacteria in the common in women. Symptoms include
urine. Significant bacteriuria is present when suprapubic pain, frequency and dysuria and
more than 105 colony forming units are found can be treated with increased fluid intake and
per mL of urine. The commonest organisms antibiotics. Symptoms can be improved by
causing urinary tract infections (UTIs) are: alkalisation of the urine. An MSU should be
repeated at 7 days to check that the infection
• Escherichia coli has been cleared.
• Proteus mirabilis
• Pseudomonas aeruginosa Acute pyelonephritis

Pathogenesis Acute pyelonephritis presents with pyrexia,
frequency, dysuria and loin pain. An MSU
Urine proximal to the distal urethra will invariably be positive for the infecting
is normally sterile. Most UTIs are due organism. Imaging in the acute situation
organisms arising from the faecal flora and is not required. Treatment is by parenteral
they are invariably the result of ascending antibiotics. Complications included
infection. Rarely, UTIs can arise secondary to pyonephrosis which can occur if there is
a bacteraemia. Host defences against urinary coexisting upper urinary tract obstruction.
infection include the voiding of urine, urinary Pyonephrosis requires urgent decompression
antibodies, desquamation of epithelial usually by percutaneous nephrostomy. If
surfaces, and antibacterial enzymes. UTIs inadequately treated, pyonephrosis it can
can be uncomplicated or complicated. result in a perinephric abscess.
Uncomplicated UTIs have no underlying
structural abnormality. Complicated UTIs Urinary tract infection in children
arise secondary to a structural lesion and can
result in renal damage. About 1% of boys and 3% of girls will develop
a UTI. Risk factors include posterior urethral
Investigation valves, neuropathic bladder and stones. UTIs
in children are often associated with vesico-
All upper UTIs require investigation. ureteric reflux (VUR). Reflux of infected
Lower UTIs in children and in adult men urine can result in scarring, hypertension
should also be investigated. The aims of and renal failure. Scarring in the presence
investigation are to establish the diagnosis of sterile reflux is uncommon. About 50%
of a UTI, identify the organism involved of children with UTIs and VUR have renal
and its antibiotic sensitivity and exclude a scarring. Most renal scarring occurs in the
structural or pathological abnormality of the first 2 years of life. The aims of treatment in
urinary tract. The diagnosis of a UTI can be children are to:
suggested by dip-stick testing of urine. The
presence in the urine of nitrites or leukocyte • Relieve symptoms
esterase is very suggestive of a Gram- • Prevent recurrence
negative infection. The diagnosis should be • Identify predisposing factors
confirmed by microscopy and culture of a • Prevent renal damage
urine. Investigation of UTIs in adults should
involve renal ultrasound and cystoscopy, All neonates and boys require investigation
supplemented by other modalities guided by after one infection. Prophylactic antibiotics
the clinical presentation. Investigation of UTIs may be required for recurrent infections.
in children should be by renal ultrasound, Spontaneous resolution of vesico-ureteric
reflux occurs in 80% of children. Indications
for surgical reimplantation of the ureters are:

380 Chapter 23 Urology

• Recurrent UTIs resulting from poor Differential diagnosis of ureteric colic
compliance with antibiotic prophylaxis
Non-renal causes Renal causes
• Breakthrough infections despite
prophylaxis Appendicitis Tumour (clot colic)
Diverticulitis Pyelonephritis
• Gross VUR with atonic ureters Ectopic pregnancy Retroperitoneal fibrosis
Salpingitis Stricture
Alternatives to surgery includes Torted ovarian cyst Papillary necrosis
subendothelial injection of collagen or Teflon Abdominal aortic
at the vesico-ureteric junction. aneurysm

Urinary tract calculi Table 23.3  Differential diagnosis of ureteric colic

Pathogenesis identification of other causes of loin pain.
Serum electrolytes and calcium should
Urinary tract calculi form from crystalline be checked. An MSU should be obtained
aggregates of organic molecules. Factors for microbiological evaluation. Metabolic
favouring stone formation include increased evaluation should be considered if there is:
urinary concentration of constituents, the
presence of promoter substances and a • Family history of urolithiasis
reduction in concentration of inhibitors. The • Bilateral stone disease
life time risk of developing a ureteric calculus • Presence of inflammatory bowel
is about 5% and recurrence rates are close
to 50%. They occur most commonly in men disease, chronic diarrhoea or
aged between 30–60 years. About 90% are malabsorption
idiopathic but about 10% are due to metabolic • History of bariatric surgery
derangement including hyperparathyroidism, • Medical conditions associated with
vitamin D excess and primary hyperoxaluria urolithiasis
The chemical composition of stones is as • Nephrocalcinosis
follows: • Osteoporosis or pathological fracture
• Stones formed from cystine, uric acid or
• Calcium oxalate (40%) calcium phosphate
• Calcium phosphate (15%) • The patient is a child
• Mixed oxalate/phosphate (20%)
• Struvite (15%) Management
• Uric acid (10%)
Most cases of ureteric colic can be managed
Clinical features conservatively with the use of adequate
hydration, opiate and anti-inflammatory
Ureteric calculi usually present with pain due analgesia until resolution of symptoms when
to obstruction of urinary flow. Ureteric colic the stone is passed. Indications for urgent
typically is severe, colicky loin to groin pain. intervention in a patients with ureteric calculi
The pain may radiate into the scrotum in men include:
and labia in women. It may be associated with
urinary frequency, urgency and dysuria. The • Presence of infection with urinary tract
pain may settle with the passage of the stone obstruction
or if stone fails to migrate further. Abdominal
examination is usually unremarkable. The • Urosepsis
different diagnosis of ureteric colic is shown • Intractable pain or vomiting
in Table 23.3. Complications of ureteric • Impending acute renal failure
calculi include obstruction, ureteric strictures • Obstruction in a solitary or transplanted
and infection.
kidney
Investigation • Bilateral obstruction stones

Microscopic haematuria is often present. CT
KUB has replaced the IVU as the investigation
of choice. It has a higher sensitivity for the
detection of stones and may also allow

Urinary tract infections and calculi 381

Most ureteric calculi less than 5 mm in lead to a deterioration in renal function.
diameter will pass spontaneously. If the Acute infection in an obstructed kidney is a
calculus is greater 5–10 mm in diameter and urological emergency. The patient is usually
fails to pass spontaneously consideration will unwell with loin pain, swinging pyrexia
need to be given to intervention dependent of and dysuria. Without drainage, rapid renal
the position of the calculus: destruction may occur. It requires emergency
percutaneous nephrostomy. Overall, less than
• Upper third of ureter – Extracorporeal 1% patients with stones require open surgery.
shock wave lithotripsy (ESWL)
Bladder calculi
• Lower third of ureter – Ureteroscopy
(USC) + lithotripsy Bladder calculi are uncommon in the Western
world. They are well-described in ancient
• Middle third of ureter – Either ESWL or medical literature. Hippocrates wrote about
USC the management of bladder stones and
operations to remove stones via the perineum
Lithotripsy is the use of shock waves to break were described in the centuries before Christ.
up stones. It requires an energy source – Suprapubic lithotomy was described in the
spark-gap electrode or piezoceramic array, 15th century and transurethral lithotomy
a coupling device between patient and became popular in the 18th century.
electrode – water bath or cushion and a Lithotripsy was first described in 1822.
method of stone localisation – fluoroscopy or Early surgical attempts at treating bladder
ultrasound. calculi was often associated with significant
morbidity and mortality.
If large stones are present in the renal
pelvis or upper ureter, consideration should Pathophysiology
be given to percutaneous nephrolithotomy,
particularly if the stone is more than 3 cm Bladder calculi are usually associated with
in diameter or a ‘staghorn calculus’ is urinary stasis. Infection increases the risk of
present (Figure 23.4). Chronic infection stone formation. Foreign bodies (e.g. suture
with urease-producing organisms (e.g. material) can also act as a nidus for stone
Proteus) precipitates stone formation. formation. However, bladder calculi can form
Magnesium ammonium phosphate or in a normal bladder. There is no recognised
staghorn calculi result. Large staghorn
calculi may be asymptomatic but they can

Staghorn calculus Figure 23.4  A Staghorn calculus

382 Chapter 23 Urology

association with ureteric calculi and most kidney more often than right and 10% cases
bladder calculi form in the bladder per se. are bilateral. The aetiology is often unknown
They vary in size and can be multiple. They but important factors may be aberrant lower
are more common in elderly men. Most pole vessels or persistence of a fetal urothelial
stones in adults are formed of uric acid. fold.
Long-standing untreated bladder stones
are associated with the development of Clinical features
squamous cell carcinoma of the bladder. PUJ obstruction usually presents in
adolescence or early adult life and presents
Clinical features with loin pain, worse after alcohol intake.
Many bladder calculi are asymptomatic. If they In late cases, a renal mass may be palpable.
do cause symptoms they include suprapubic Haematuria is an uncommon feature. About
pain, dysuria and haematuria. Abdominal 10% of patients develop UTIs and 3% have
examination may be normal. Patients may renal colic.
present in acute urinary retention.
Investigation
Investigation The diagnosis can be confirmed by
Historically stones were diagnosed by the ultrasound or abdominal CT scanning.
passage of urethral ‘sounds’. Today they Isotope renography allows assessment of the
can be identified on plain abdominal x-ray, percentage of renal function.
ultrasound, abdominal CT and cystoscopy.
Uric acid stones are radiolucent but may have Management
an opaque calcified layer. Any underlying The aims of treatment are to relieve symptoms
bladder abnormality should be sought. and preserve renal function. This can be
achieved by a pyeloplasty. The Anderson–
Management Hynes pyeloplasty is the commonest
Indications for surgery for bladder calculi procedure performed (Figure 23.5). If there
include: is severe renal impairment (<20% function)
then nephrectomy may be required.
• Recurrent urinary tract infections
• Acute urinary retention Haematuria
• Frank haematuria
Both microscopic and macroscopic
Historically the surgical approach involved haematuria are abnormal and invariably
‘cutting for a stone’. This was via either a require investigation. Microscopic
perineal or suprapubic approach. The three haematuria is defined as the presence of
common approaches today are: five or more RBCs per high-power field
on urine microscopy. The prevalence of
• Transurethral cystolitholapaxy macroscopic and microscopic haematuria
• Percutaneous cystolitholapaxy are approximately 1% and 5% respectively.
• Open suprapubic cystostomy About 50% of patients with haematuria will
have an underlying abnormality. Overall, 10%
Complications of cystolitholapaxy include: and 35% of adult patients with microscopic
and macroscopic haematuria respectively will
• Infection have a urological malignancy. The causes of
• Haemorrhage haematuria are shown in Table 23.4.
• Bladder perforation
• Hyponatraemia Investigation
All patients with haematuria should
Extracorporeal shockwave lithotripsy is undergo investigation aimed at excluding a
relatively ineffective for bladder calculi. surgical cause. They should undergo urine
microscopy and culture, urine cytology,
Pelviureteric junction
obstruction

Pelviureteric junction (PUJ) obstruction
is more common in men. It affects the left

The Anderson–Hynes pyeloplasty Haematuria 383

Figure 23.5  The Anderson–Hynes
pyeloplasty

Causes of haematuria

Surgical Glomerular Non-glomerular

Transitional cell carcinoma IgA nephropathy Urinary tract infections
Stone disease Glomerulonephritis Tuberculosis
Renal cell carcinoma Systemic lupus erythematosis Schistosomiasis
Trauma Bacterial endocarditis Drugs
Benign prostatic hyperplasia Blood dyscrasias
Urethral stricture Exercise-induced haematuria

Table 23.4  Causes of haematuria

ultrasound and cystoscopy. If the results of vein and inferior vena cava. Blood-borne
these investigations are normal, then the spread can result in ‘cannon ball’ pulmonary
patient should be referred for a nephrological metastases.
opinion.
Clinical features
Renal cell carcinoma About 10% of patients present with the
classic triad of haematuria, loin pain and a
Benign tumours of the kidney are rare and mass. Other presentations include a pyrexia
all renal neoplasms should be regarded as of unknown origin and hypertension.
potentially malignant. Renal cell cancer Polycythaemia can occur due to
accounts for approximately 3% of all new erythropoietin production. Hypercalcaemia
cases of cancer diagnosed in men and around can occur due to production of a PTH-like
2% of all cancers in women. There are about hormone.
8000 new cases per year in the UK. It arises
from proximal tubule cells. Alternative names Investigation
include hypernephroma, clear cell carcinoma The diagnosis can often be confirmed by renal
and Grawitz tumour. The male:female ratio is ultrasound. An abdominal CT scan allows
approximately 2:1 and an increased incidence assessment of renal vein and caval spread.
is seen in von Hippel–Lindau syndrome. Echocardiogram should be considered if
Pathologically they may extend into the renal

384 Chapter 23 Urology

tumour in the inferior vena cava extends Schistosoma haematobium infection
above diaphragm. The Robson staging of is associated with an increased risk of
renal cell carcinoma is as follows: squamous carcinoma.

• Stage 1 – Confined to the kidney Clinical features
• Stage 2 – Involvement of perinephric fat
About 80% of patients present with painless
but Gerota fascia intact haematuria. Bladder tumours can also
• Stage 3 – Spread into renal vein present with treatment-resistant urinary
• Stage 4 – Spread into adjacent or distant infection, bladder irritability and sterile
pyuria. Pathological staging requires bladder
organs muscle to be included in specimen. Tumours
are then staged according to depth of tumour
Management invasion:

Unless extensive metastatic disease is • Tis – In situ disease
present, treatment invariably involves • Ta – Epithelium only
surgery. The surgical option usually involves • T1 – Lamina propria invasion
a radical nephrectomy. The kidney is • T2 – Superficial muscle invasion
approached through either a transabdominal • T3a – Deep muscle invasion
or loin incision. Laparoscopic surgery may • T3b – Perivesical fat invasion
be considered. The renal vein is ligated early • T4 – Prostate or contiguous muscle
to reduce tumour propagation. The kidney The grade of tumour is also important:
and adjacent tissue (adrenal, perinephric fat)
is excised. Lymph node dissection is of no • G1 – Well differentiated
proven benefit. Solitary (e.g. lung) metastases • G2 – Moderately well differentiated
can occasionally be resected. Radiotherapy • G3 – Poorly differentiated
and chemotherapy have little role.
Management
Bladder carcinoma
Superficial TCC requires transurethral
Bladder cancer is a common cancer with resection and regular cystoscopic follow-up.
10,500 new cases diagnosed each year in Consideration should be give to prophylactic
the UK. It is the most frequently occurring chemotherapy if there are risk factors for
tumour of the urinary system and accounts recurrence or invasion. Immunotherapy may
for around 1 in every 30 new cancers. The also be required. Bacillus Calmette–Guerin is
male:female ratio is 3:1. Most bladder an attenuated strain of Mycobacterium bovis. It
carcinomas are transitional cell tumours reduces the risk of recurrence and progression
(TCCs). Superficial tumours are usually low and about a 50% response rate is seen. It is
grade and associated with a good prognosis. occasionally associated with development of
Muscle invasive tumours are of higher grade systemic mycobacterial infection.
and have a poorer prognosis.
Carcinoma in situ is an aggressive disease
Pathology and is often associated with positive cytology.
About 50% patients progress to muscle
Of all bladder carcinomas, 90% are TCCs, 5% invasion. Consideration should be given to
are squamous cell carcinomas and 2% are immunotherapy. If this fails patient may need
adenocarcinomas. TCCs should be regarded radical cystectomy.
as a ‘field change’ disease with a spectrum of
aggression. About 80% of TCCs are superficial For patients with invasive TCC the options
and well differentiated and only 20% progress are radical cystectomy or radiotherapy.
to muscle invasion. Aetiological factors include: Radical cystectomy has an operative mortality
of about 5%. Urinary diversion can be
• Occupational exposure – analine dyes, achieved by:
chlorinated hydrocarbons
• Valve rectal pouch – modified
• Cigarette smoking ureterosigmoidostomy
• Analgesic abuse – phenacitin
• Pelvic irradiation

Urinary tract obstruction 385

• Ileal conduit The management can be with dilatation (gum-
• Neo-bladder elastic bougie, metal sounds), urethrotomy
(internal or external) or urethroplasty.
Complications of urinary diversions include:
Benign prostatic hyperplasia
• Renal and intestinal reservoir stones
• Urinary tract infections Benign prostatic hyperplasia affects 50% men
• Metabolic derangements – older than 60 years and 90% of men older
than 90 years. It results from hyperplasia of
hyperchloraemic acidosis the prostatic stromal and epithelial cells,
• Reservoir rupture resulting in the formation of large, fairly
• Neoplasia discrete nodules in the periurethral region
of the prostate. The nodules compress the
Local recurrence after surgery and urethra to cause partial, or sometimes
radiotherapy occurs in about 15% and virtually complete, obstruction interfering
50% of patients respectively. Preoperative with normal urine flow.
radiotherapy is no better than surgery alone.
The role of systemic adjuvant chemotherapy Clinical features
remains to be defined. Ureteric TCCs are Benign prostatic hyperplasia presents
usually managed by nephrouretectomy. with obstructive and irritative symptoms.
Obstruction causes poor urinary stream,
Urinary tract obstruction hesitancy, dribbling and retention. Irritation
causes frequency, nocturia, urgency and urge
Over 70% of men with lower urinary tract incontinence.
symptoms have proven bladder outflow
obstruction. The causes of bladder outflow Investigation
obstruction can be structural or functional Diagnosis of bladder outflow obstruction can
and are shown in Table 23.5. be confirmed by uroflowmetry (Figure 23.6).
Other investigations should include urea
Urethral strictures and electrolytes to check renal function, an
ultrasound to excluded hydronephrosis and
Causes of urethral stricture include: the measurement of post-micturition urine
volume. A serum PSA should be measured to
• Congenital excluded malignancy.
• Trauma – instrumentation, urethral
Management
rupture The aims of treatment of benign prostatic
• Infection – gonocococcal, non-specific hyperplasia are to relieve symptoms

urethritis, syphilis, TB
• Inflammatory – balanitis xerotica

obliterans
• Neoplasia – squamous, transitional cell or

adenocarcinoma

Causes of bladder outflow obstruction

Structural Functional
Urethral valves
Urethral strictures Bladder neck dyssynergia
Neurological disease – spinal cord lesions, multiple sclerosis,
Benign prostatic hyperplasia diabetes
Carcinoma of the prostate Drugs – anticholinergics, antidepressants
Bladder neck stenosis

Table 23.5  Causes of bladder outflow obstruction

386 Chapter 23 Urology
    
Characteristic uroflowmetry results Figure 23.6 Characteristic
uroflowmetry results. 1 = Normal;
Flow rate (mL/s) 2 = Benign prostatic hyperplasia;
30 3 = Urethral stricture.

1

2

3

.ir/0 60
Time (s)
ssand improve quality of life, relieve
nbladder outflow obstruction and to treat prostatic hyperplasia. The bulk of the prostate
is reduced endoscopically. The prostate is
complications resulting from bladder outflow excided using a wire loop. The bladder is
irrigated with glycine. The chips of prostatic
iaobstruction. Treatment options can be either tissue are washed from the bladder and an
irrigation catheter is inserted. Obstruction is
pharmacological or surgical. Drugs include reduced and urinary symptoms considerably
improved in over 90% of patients. Absorption
rsa-adrenergic antagonists, 5a-reductase of the irrigation fluid can result in acute
hyponatraemia – the TUR syndrome. The
inhibitors and LHRH antagonists. Surgical possible complications of TURP are shown in
options include: Table 23.6. Postoperative retention occurs in
about 5% of patients. Retrograde ejaculation
e• Transurethral prostatectomy (TURP) occurs in about 80% of patients. Post-
.p• Transurethral or interstitial thermotherapy prostatectomy incontinence is a transient
phenomenon in many men but becomes a
• Interstitial laser prostatectomy

ip• Urethral stents

• Open prostatectomy

://vTURP is the ‘gold standard’ treatment for

bladder outflow obstruction due to benign
httpEarly
Complications of TURP Late
Intermediate

Primary haemorrhage Secondary haemorrhage Bladder neck stenosis
Extravasation Retrograde ejaculation Urethral stricture
Fluid absorption (TUR syndrome) Erectile dysfunction
Infection
Clot retention
Epididymo-orchitis
Incontinence

Table 23.6 Complications of transurethral prostatectomy (TURP)