Common adult orthopaedic injuries

• Most adult musculoskeletal injuries are managed by the same few rules: protect the limb, document nerves and vessels, image the right joint, reduce or immobilise early, and involve the patient in decisions about surgery.
• Shoulder dislocation is reduced with a technique you know (a biomechanical method is preferred first), then imaged again and supported in a sling as needed for about a week; young men have the highest recurrence risk. ^[2]
• Rotator cuff tears are a major cause of shoulder pain; about 1% of adults seek primary care for a new shoulder pain episode each year, and roughly half of full-thickness tears are symptom-free. ^[3]
• Scaphoid fractures follow a fall on an outstretched hand, hurt in the anatomical snuffbox, and can look normal on the first X-ray; MRI is first-line imaging in many guidelines. ^[6][10]
• Hip fractures should be operated on the day of, or the day after, admission; a displaced intracapsular fracture is best treated with cemented arthroplasty. ^[1]
• Ottawa ankle rules decide when an X-ray is truly needed after an ankle injury, and functional bracing and early movement beat prolonged casting for an uncomplicated sprain. ^[4][5]
• Pain control follows simple rules: paracetamol regularly, opioids added by severity, and NSAIDs avoided in frail or older adults with fractures. ^[10]

By the end of this page you should be able to:

1. Describe the mechanism and presentation of a primary traumatic anterior shoulder dislocation and its rotator cuff complications.
2. Classify adult shoulder pathology and outline investigation and management of rotator cuff tears.
3. Assess and manage clavicle, humerus, elbow and distal radius injuries, with timing of surgery. ^[7][10]
4. Diagnose and manage scaphoid fractures, including when to use MRI, CT and casting. ^[6][10]
5. Diagnose and treat de Quervain tenosynovitis. ^[9]
6. Apply Ottawa rules, manage ankle sprains functionally, and advise on recovery. ^[4][5]
7. Plan care for an adult with hip or femoral fracture, including surgery timing, anaesthesia and arthroplasty choice. ^[1]
8. Recognise complications and arrange follow-up.

Common adult orthopaedic injuries are acute injuries of bones, joints and soft tissues of the limbs that present in adult practice, from sports fields to emergency departments. They range from dislocations and fractures to sprains, ligament ruptures and tenosynovitis. This page covers shoulder dislocation and rotator cuff tears, clavicle and humeral injuries, elbow and wrist injuries, scaphoid fracture, de Quervain tenosynovitis, hip and femoral injuries, and ankle sprain with the Ottawa rules. It assumes the adult skeleton: growth plates are closed and remodelling is limited, so acceptable deformity thresholds are tighter than in children. Open fractures, compartment syndrome and polytrauma follow the major trauma pathway; see Plain text: Long-bone fractures, fat embolism and dislocations (emergency medicine). Hip fracture is detailed below and follows the NICE pathway. ^[1][10]

Musculoskeletal injuries are among the commonest reasons for adult attendance. Shoulder pain affects around 70% of people in their lifetime and presents at an estimated incidence of 14.7 cases per 1000 patients per year. ^[3] About 1% of adults consult primary care for a new shoulder pain episode each year. ^[3]

Shoulder dislocation is the commonest major joint dislocation: incidence 12 to 26 per 100 000 person-years, with young men dislocating during sport and women more often at home. ^[2] Recurrence is common in the young: men aged 10 to 19 have a 29% recurrence rate and women the same age 19%; men under 40 carry a 13-fold increase in risk and male sex a 3-fold increase. ^[2]

Hip fractures are the commonest major fragility fractures of older adults and require coordinated multidisciplinary care. Scaphoid fractures account for roughly 60% to 70% of all carpal fractures and usually result from a fall onto an outstretched, dorsiflexed hand. ^[6] An ankle sprain is the commonest acute soft-tissue injury of the lower limb; ankle injuries are among the most common presenting problems in urgent care. ^[5]

Trauma mechanism explains the pattern: falls on the outstretched hand produce shoulder anterior dislocation, Colles and scaphoid fractures; direct blows and falls produce clavicle and humeral shaft fractures; rotational and inversion injuries produce ankle sprains. Rotator cuff tears arise from both degeneration and trauma. Risk factors include advanced age, diabetes, smoking, body mass index and osteoporosis; tears are seen more often in females and in the dominant arm. ^[3] Repetitive hyperextension of the wrist in sports such as gymnastics, tennis and diving predisposes to scaphoid stress fracture. ^[6] Football and jumping sports predispose to ankle inversion injuries, and previous sprain or chronic ankle instability predisposes to recurrence. ^[5] Alcohol use, poor bone quality and frailty increase the risk of hip fracture in older adults.

Shoulder dislocation. Most acute dislocations are anterior. The capsule and labrum are stripped (Bankart lesion), the humeral head may carry a compression fracture (Hill-Sachs) and the anterior glenoid rim may fracture. Reducing the joint early limits neurovascular stretch. Rotator cuff tears on reduction occur in more than half of dislocated shoulders, and in 98% of symptomatic shoulders in adults over 40. ^[2]

Rotator cuff. Chronic tendinopathy alters collagen organisation; repeated internal and external overload leads to partial- then full-thickness tear. Pro-inflammatory cytokines (including TNF-alpha and IL-1beta) are present in the subacromial bursa and correlate with pain. ^[3] Fatty infiltration of the cuff muscles (Goutallier grades) worsens prognosis and is a reason to refer. ^[3]

Scaphoid. The blood supply is retrograde from distal to proximal. A displaced or untreated fracture, particularly of the proximal pole, is liable to non-union and avascular necrosis; an ununited scaphoid can lead to scaphoid non-union advanced collapse (SNAC). ^[6]

Hip. A hip fracture is both a local fracture and a medical event: pain, immobility and surgery add to the risk of delirium, malnutrition and functional loss. Undisplaced intracapsular fractures are at risk of avascular necrosis of the femoral head. ^[1]

Ankle. An inversion injury stretches the lateral ligament complex, beginning with the anterior talofibular and progressing to the calcaneofibular ligament. Swelling and haemarthrosis follow. Functional treatment promotes ligament healing in a loaded, proprioceptive environment. ^[5]

Figure 1HipdisX

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An X-ray showing a dislocated left hip after trauma, described on Commons as a superiorly dislocated hip.

Figure 2X-ray of scaphoid fracture

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A wrist radiograph showing a fracture across the waist of the scaphoid bone, indicated by an arrow.

Figure 3Colles fracture

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An X-ray image of a fractured radius showing the characteristic Colles' fracture with displacement and angulation of the distal end of the radius.

Figure 4Galeazzi-Fraktur Roentgen ap und seitlich - 002

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AP and lateral wrist/forearm radiographs of a Galeazzi fracture in which the lateral view clearly shows dorsal dislocation of the distal ulna.

Figure 5Monteggia LAT

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Lateral radiograph of the elbow of a 63-year-old woman showing a Monteggia fracture (fracture of the proximal ulna with dislocation of the radial head at the elbow).

Figure 6Shoulder dislocation, Y-projection before reduction

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A Y-projection radiograph of the left shoulder of a 25-year-old male before reduction that is described on Commons as showing an anterior shoulder dislocation.

Figure 7AnterDisAP

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An AP X-ray described on Wikimedia Commons as 'Anterior dislocation of the right shoulder.'

Look, feel and move. Inspect deformity, swelling, bruising and skin (open versus closed). Palpate bony tenderness and compare both sides. Test active and passive range of motion and strength. Record a neurovascular examination: motor and sensory function in the relevant nerve territories and pulses, colour, warmth, capillary refill and temperature. Repeat after every manipulation, splint or position change. A pulseless deformed limb is realigned and splinted before imaging. Red flags are open fracture, compartment syndrome, pulselessness and multi-level injury.

Anterior dislocation presents with the arm slightly abducted and externally rotated, a squared-off shoulder and a palpable humeral head anteriorly. Elderly patients may present late with a "frozen" or painful shoulder; always consider rotator cuff tear and fracture. After reduction, test axillary nerve function (deltoid and lateral arm sensation) and check for cuff strength.

Rotator cuff tears present with pain, often at night and on overhead use; traumatic tears may follow a pop with weakness. Strength tests include Jobe (empty can) for supraspinatus, external rotation lag / lift-off (Gerber) for subscapularis, and drop arm. ^[3] Pseudoparalysis is an inability to hold the arm at 90 degrees of abduction or flexion. ^[3] Fatty infiltration, atrophy and deltoid bulk are noted. ^[3]

Clavicle fractures present with pain, deformity and a palpable step after a fall onto the shoulder or an outstretched hand. Most are mid-shaft. Neurovascular status and skin are checked. Proximal humerus fractures occur in older patients after a low-energy fall: pain, swelling and loss of shoulder movement. The greater tuberosity, surgical neck and four-part patterns matter because they change treatment. Humeral shaft fractures often allow the patient to cradle the arm; radial nerve function must be documented. ^[10]

Posterior dislocation follows a fall on the outstretched hand: shortened forearm and prominent olecranon, with gross valgus/varus instability. The terrible triad combines dislocation with radial head and coronoid fractures and is unstable. Olecranon fractures present with loss of active extension. Radial head fractures follow a fall on the hand with valgus load. ^[10] (See also Long-bone fractures, fat embolism and dislocations.)

Distal radius fractures (Colles, Smith, Barton) present with deformity, including the "dinner-fork" of a displaced Colles fracture. The wrist and distal radioulnar joint are assessed. Scaphoid fracture presents with radial wrist pain, tenderness in the anatomical snuffbox and reduced grip strength. ^[6] Focal snuffbox tenderness and pain on axial thumb compression raise suspicion. ^[6]

Hip fracture presents with a shortened, externally rotated leg and inability to bear weight after a fall, often with groin pain. Log-roll and careful skin and pressure-area checks are needed. Delirium, anaemia, volume depletion, electrolyte and diabetic problems are corrected pre-operatively. ^[1]

An ankle sprain presents with lateral ankle pain, swelling and bruising after an inversion injury. Examine the malleoli, the talar dome and the Achilles tendon. Test weight-bearing ability and record neurovascular findings. Ottawa rules decide imaging.

The table lists first-line and confirmatory tests. The exact cut-off for deciding imaging after ankle injury is the Ottawa ankle rule result; the cut-off for scaphoid first-line MRI is clinician suspicion after a careful examination. ^[6][10]

A painful swollen limb after trauma raises a wide differential. The separating features are mechanism, distribution, joint involvement and imaging. ^[6]

Management follows the simple order: life before limb, limb before bone. Resuscitate, examine, image, temporise, then decide. The table in the diagnosis section summarises mechanism and investigation; this section adds management by injury.

Align the patient, give analgesia and image. Choose a reduction technique you know well; a biomechanical (scapular) method is advised first. ^[2] If the first attempt fails, image for complications, attempt again under procedural sedation and analgesia, and resort to open reduction rarely. ^[2] After reduction, a sling as needed for one week; then early restoration of rotator cuff function, coordination and proprioception. ^[2] Consider surgery by shared decision for age under 40, contact athletes, or significant bone loss; a meta-analysis of early Bankart repair versus non-operative care reported 8.9% versus 49% recurrence and 90% versus 62% return to sport at two years. ^[2] Concomitant rotator cuff tears and iatrogenic fractures are common, particularly in women over 40, so re-examine carefully. ^[2]

Diagnose with ultrasound or MRI; MR arthrography is the most sensitive and specific method, while ultrasound and MRI have comparable accuracy. ^[3] Initial treatment is structured physiotherapy targeting the deltoid and cuff, analgesia and activity modification. ^[3] Oral paracetamol and NSAIDs give short-term relief; corticosteroid injection can help short-term pain but carries a signal of tendon harm with repeated use (steroid-injected patients developed tears more often, with mean follow-up 39 months). ^[3] Hyaluronic acid and platelet-rich plasma are alternatives with some short-term benefit. ^[3] Refer promptly for traumatic or massive tears, pseudoparalysis, significant functional loss, tendon retraction, delamination, fatty infiltration or failure after a conservative trial. ^[3]

Most mid-shaft fractures are managed conservatively in a sling, with analgesia and early pendular movement. A systematic review and meta-analysis of displaced mid-shaft fractures treated non-surgically reported a pooled DASH score of 16.1 at three months, 9.9 at six months and 6.3 at one year, non-union in about 14% and secondary surgery in about 13% at one year. ^[8] Operative fixation (plating) is considered for markedly displaced or shortened fractures, open injuries, skin tenting, neurovascular compromise or floating shoulder. A CT may be needed for medial or comminuted patterns. ^[7][8]

Proximal humerus: undisplaced and most low-energy displaced fractures are managed non-operatively; consider surgery for open injury, skin tenting, vascular injury, fracture-dislocation or head split. ^[10] Humeral shaft: most isolated fractures unite in a functional brace; displaced, open, pathological and failed conservative cases are fixed (plate preferred, nail selected). Radial nerve function must be documented before and after any manipulation. ^[10]

Posterior dislocation is reduced under analgesia or sedation (traction in line with the forearm) and tested for stability through range; a terrible triad needs surgical fixation and ligament repair. Olecranon fractures needing anatomic reduction are fixed. Radial head fractures are mostly managed according to displacement and articular step; excision or arthroplasty is reserved for complex or old cases.

Reduce under Bier's block if dorsally displaced; do not use nitrous oxide alone. ^[10] Manipulation and a cast is acceptable in many adults. ^[10] K-wire fixation is offered when the articular surface is not fractured or can be reduced closed; open reduction and internal fixation is considered if closed reduction of the joint surface fails. ^[10] Timing: intra-articular fractures within 72 hours, extra-articular within 7 days; re-displacement within 72 hours of the decision to operate. ^[10] Geriatric fractures are mostly non-operative. ^[7] Emergency priorities follow the Long-bone fractures pathway (open fractures, compartment syndrome).

Suspect with snuffbox tenderness after a fall on an outstretched hand. ^[6] Initial X-rays are often negative, so MRI is recommended as first-line imaging after a thorough examination; CT helps union assessment. ^[6][10] For undisplaced waist fractures, cast immobilisation is the primary treatment; surgical fixation (percutaneous screw) for displaced, proximal pole, delayed or non-union. ^[6] Prolonged immobilisation (thumb spica) is typical and clinical follow-up is needed because non-union and avascular necrosis may develop months later. ^[6]

Diagnose by pain over the first dorsal compartment, painful gripping and a positive Finkelstein test. Initial management is rest, splinting (thumb spica) and NSAIDs. Corticosteroid injection into the tendon sheath gives good benefit and ultrasound guidance increases efficacy. ^[9] Persistent symptoms after injection, or recurrent triggering, is an indication for surgical release. ^[9]

Hip fracture: operate on the day of, or the day after, admission after correcting reversible medical issues (anaemia, anticoagulation, volume depletion, electrolytes, diabetes, heart failure, arrhythmia or ischaemia, infection). ^[1] Give paracetamol 6-hourly and additional opioids as needed; NSAIDs are not recommended. ^[1] Aim to allow unrestricted weight-bearing immediately after surgery. ^[1] Displaced intracapsular fractures are treated with cemented arthroplasty (total hip replacement or hemiarthroplasty), with total replacement preferred where the patient walked independently outdoors with no more than a stick, is expected to live and function beyond two years, and is fit. ^[1] Subtrochanteric fractures are nailed; trochanteric fractures above and including the lesser trochanter are treated preferentially with extramedullary implants such as a sliding hip screw. ^[1] Use MRI or CT if radiographs are normal but clinical suspicion persists (MRI first; CT if MRI unavailable within 24 hours or contraindicated). ^[1] Mobilise from the day after surgery with orthogeriatric multidisciplinary care, falls and bone health assessment. ^[1]

Apply Ottawa rules to decide radiographs. ^[4][10] Functional treatment (early movement, bracing or taping, physiotherapy) consistently produces faster recovery and lower recurrence than prolonged immobilisation. ^[5] RICE in the acute phase; consider NSAIDs (avoid in frail or older adults). ^[10] Advise immediate unrestricted weight-bearing as tolerated for stable unimalleolar ankle fractures and orthopaedic review within two weeks if stability is uncertain. ^[10]

• Shoulder dislocation: iatrogenic fracture (women over 40, greater tuberosity fracture), axillary nerve injury, rotator cuff tear, recurrence. ^[2]
• Rotator cuff: progression of tear, fatty infiltration, sleep disturbance, recurrent shoulder pain; surgery carries re-tear risk. ^[3]
• Clavicle: non-union (~14%) and secondary surgery (~13%) at one year after non-operative treatment of displaced mid-shaft fractures; malunion and hardware failure after fixation. ^[8]
• Scaphoid: non-union, avascular necrosis of the proximal pole and SNAC wrist. ^[6]
• Hip: delirium, infection, venous thrombosis, pneumonia, pressure ulcers, failure of fixation or arthroplasty; falls and further fragility fractures.
• Ankle: chronic ankle instability, recurrent sprain, missed fracture, stiffness.

Most soft-tissue injuries recover well with functional rehabilitation. Displaced mid-shaft clavicle treated non-operatively shows substantial recovery by three months with further improvement to one year. ^[8] Rotator cuff repair relieves pain but re-tear is possible; recovery depends on tear size and fatty infiltration. Hip fracture carries significant mortality and dependence in older adults despite good surgery. Scaphoid fractures unite with adequate immobilisation, but delay worsens outcome. Ankle sprains rarely need surgery; the risk is recurrence and chronic instability. ^[5]

• Fall-prevention and bone health programs in older adults, including osteoporosis assessment after hip fracture. ^[1]
• Sports technique and conditioning, especially wrist and ankle proprioception.
• Early reduction and appropriate immobilisation to prevent recurrence and complications.
• Safeguarding awareness for injuries inconsistent with the history.

• Older adults: avoid NSAIDs for pain in fractures; cognitive and functional status guide management; comorbidities must be optimised before hip surgery. ^[1][10]
• Pregnancy: trauma principles as standard; minimise radiation; individual surgical and drug decisions with obstetric input.
• Children: different pathways apply (remodelling, growth plate injury); see Plain text: Common paediatric orthopaedic injuries.

• Document neurovascular status, realign, splint and transfer; a pulseless limb must not wait for imaging.
• Use clinical rules (Ottawa) to avoid unnecessary radiographs. ^[4][10]
• A thumb spica cast for scaphoid and a functional brace for ankle sprain are low-cost effective options. ^[6][5]
• Hip fracture care needs surgery and orthogeriatric support; arrange transfer where unavailable.

Common adult orthopaedic injuries (this page); long-bone fractures, fat embolism and dislocations (emergency medicine); common paediatric orthopaedic injuries; pelvic and hip fractures; neck and shoulder (rotator cuff) rehabilitation; hand and wrist trauma; ankle sprain and instability.