Orthopaedics — Dislocations, Fracture Healing and Back Pain, NMC MBBS licence examination syllabus (Nepal Medical Council).
Whether you documented the nerve before reducing the joint decides whether a deficit afterwards is a complication or an accusation.
The first orthopaedics chapter covered describing fractures and the emergencies that accompany them. This one covers the joint that has come out, why bone sometimes fails to heal, and the back pain that is not mechanical.
A dislocated joint is not something to see on the next list. Time out of joint matters for three reasons: vessels and nerves are stretched while it remains displaced, cartilage is under abnormal pressure, and muscle spasm increases — so the longer you wait, the harder the reduction becomes and the more force it takes.
The single most important habit: document the neurovascular examination before you touch it, and repeat it afterwards. Pulse, sensation and movement, written down. Without that record, a nerve deficit found after reduction cannot be distinguished from one caused by it — which matters clinically for the patient and, as the forensic chapter sets out, medicolegally for you.X-ray before reduction where it does not delay care. A dislocation with an associated fracture is a different problem, and traction applied without knowing can displace the fracture further.
Reduce with adequate analgesia and muscle relaxation. Reduction should be achieved by overcoming spasm, not by overpowering it — force applied to a resisting joint causes fractures and nerve injury.
Three joints matter most, and each carries its own characteristic risk.
Shoulder — the commonest major dislocation, usually anterior. The axillary nerve is at risk, so test sensation over the deltoid before and after. The patient holds the arm slightly away from the body and resists any attempt to move it.
Hip — usually posterior, and classically a dashboard injury in a road crash, so look for other injuries. Two things are at risk: the sciatic nerve, and the blood supply to the femoral head. That second point is why hip dislocation is reduced urgently — delay increases the risk of avascular necrosis, which can destroy the joint in a young person.
Knee — rare, and a genuine limb-threatening emergency because of popliteal artery injury.
Fracture healing needs three things, and every treatment decision is about supplying one of them:
So non-union is not mysterious — one of those was missing. Excessive movement, a gap between the ends, soft tissue caught between them, dead bone, or infection. And smoking, which impairs the blood supply and is one of the strongest modifiable risk factors for a fracture failing to unite.
Some bones have a precarious blood supply as a matter of anatomy, and these are the classic sites of avascular necrosis: the scaphoid, the femoral head, and the talus. In each, the blood supply enters in a way that a fracture can interrupt — which is why a scaphoid fracture is treated seriously despite often looking trivial on the initial film.Children are different in two useful ways. They heal considerably faster than adults, and they remodel — a degree of angulation that would be unacceptable in an adult may correct itself with growth. That is why acceptable reduction differs by age, and why no angulation limits are given in this chapter.
A cast is a rigid container placed around a limb that is about to swell. That combination is why cast complications exist.
Increasing pain under a cast is never normal and is never treated with more analgesia alone. It is compartment syndrome until proven otherwise, and the immediate action is to split or remove the cast — the full clinical picture is covered in the first orthopaedics chapter. Giving stronger painkillers to a patient developing compartment syndrome removes the only warning sign while the limb is being lost.Every patient leaving with a cast needs specific instructions, and the examination expects you to know them: return immediately for increasing pain, numbness, tingling, colour change, or inability to move the fingers or toes. Elevate the limb. Do not push objects inside the cast to scratch, which causes wounds that cannot be seen and become infected.
Most back pain is mechanical, self-limiting and needs no imaging. The clinical task is identifying the small number with a serious cause.
Cauda equina syndrome is the one that must not be missed, because delay causes permanent loss of bladder, bowel and sexual function. The features are:
You have to ask. Patients do not volunteer bladder or perineal symptoms — they are embarrassing, and the patient does not connect them to their back. A back pain assessment that does not include those questions has not excluded cauda equina.
Other red flags: age at either extreme, fever, weight loss, a history of cancer, night pain that wakes the patient, significant trauma, and long-term steroid use.
Without red flags, early imaging does not help and can harm. Age-related degenerative changes are present in large numbers of people with no pain at all, so a scan frequently finds something — which then worries the patient, invites intervention, and correlates poorly with their symptoms.
And the advice is the opposite of instinct: keep moving, and stay at work if at all possible. Bed rest was standard advice for decades and makes outcomes worse.
No healing times, immobilisation durations, angulation limits or doses appear here: they vary with bone, age and pattern, and in children with remaining growth. Use your local protocol.
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