Orthopaedics & Traumatology

Orthopaedics and traumatology is a broad speciality encompassing many sub-disciplines. Each sub-area operates with its own techniques, accumulated expertise and equipment. At Nis Clinic's Orthopaedics & Traumatology department, diagnosis and treatment planning are provided across the following areas:

• Arthroscopy and sports injuries (knee, shoulder): Meniscus tears, cruciate ligament injuries, shoulder rotator cuff pathologies.
• Spine surgery (spinal surgery): Disc herniation, spinal stenosis, vertebral fractures, spinal deformities.
• Paediatric orthopaedics and traumatology: Developmental dysplasia of the hip, childhood fractures, foot deformities, posture and gait problems.
• Foot and ankle surgery: Hallux valgus, Achilles tendon injuries, chronic ankle instability.
• Orthopaedic oncology: Advanced diagnosis of bone and soft-tissue tumours, treatment planning in collaboration with oncology.
• Shoulder and elbow surgery: Frozen shoulder, rotator cuff repair, tennis elbow and golfer's elbow, elbow instability.
• Osteoarthritis management: Knee and hip osteoarthritis; conservative treatment, intra-articular injection, joint replacement planning.
• Upper and lower limb surgery: Long-bone fractures, extra-articular trauma, soft-tissue repairs.
• Hip fractures: Particularly critical in elderly patients, with an early-surgery protocol.
• Hand and upper limb surgery: Tendon lacerations, nerve entrapment syndromes (carpal tunnel, cubital tunnel), Dupuytren's contracture.

Each sub-area demands its own depth of expertise; patient referrals are therefore made with the most appropriate team and imaging plan for each clinical picture.

Trauma patients generate the most demanding clinical pathways in orthopaedics. A fall, sports injury, workplace accident, motorcycle collision or road traffic accident — the mechanism varies, but the spectrum of injury is wide. At one end sits simple soft-tissue bruising; at the other, comminuted fractures across multiple sites. The equipment, organisation and discipline of the team assessing and planning care directly influence outcome.

Delay in initial management of a trauma patient prolongs both morbidity and rehabilitation time. At Nis Clinic we are committed to the following principles:

• Specialist first contact: The initial assessment of a trauma patient is carried out by an orthopaedic specialist; triage decisions, imaging requests and surgical planning are concentrated in a single pair of hands.
• Imaging access: Plain radiograph, with CT and MRI planning in the same session when needed — reducing diagnostic time from hours to minutes.
• Anaesthesia and operative coordination: When a surgical decision is made for a fracture, anaesthetic consultation and operative preparation proceed simultaneously.
• Conservative vs surgical balance: Not every fracture requires surgery. Greenstick fractures in children, undisplaced clavicle fractures, and certain hand and foot fractures heal with conservative management. A tendency towards surgery is not our standard — correct indication is.
• Fracture treatment philosophy: Techniques continue to evolve — locking plate systems, intramedullary nails, external fixators, minimally invasive osteosynthesis. The aim is to return patients to daily life as quickly and smoothly as possible; the most appropriate technique is selected in pursuit of this goal.

In cases with medicolegal implications — such as road traffic accidents or workplace injuries — discharge summaries and imaging reports are retained in the patient record; official documentation requests for insurance and legal proceedings are fulfilled.

Arthroscopy is a minimally invasive surgical technique in which a small camera (arthroscope) and fine surgical instruments are introduced into a joint. Compared with open surgery, the skin incision is smaller, intra-articular structures are visualised directly, and repairs are carried out with precision. Recovery time is substantially shorter.

The two regions most frequently treated with arthroscopy are the knee and the shoulder.

Knee arthroscopy:

• Meniscus repair or partial meniscectomy: The type of tear, its location and the patient's age guide the decision. Repair is preferred in younger patients; selective excision is chosen for degenerative tears in older patients.
• Anterior cruciate ligament (ACL) reconstruction: One of the most common sports injuries. Graft selection (hamstring tendon or bone–patellar tendon–bone) is determined by the patient's profile.
• Cartilage lesions: Microfracture, mosaicplasty, cell-based therapies — chosen according to lesion size and the patient's activity level.

Shoulder arthroscopy:

• Rotator cuff repair: The majority of rotator cuff tears are repaired arthroscopically; open surgery is reserved for large, chronic tears.
• Subacromial decompression: Bone shaving and bursa clearance in impingement syndrome.
• Bankart repair: Labral repair for recurrent shoulder dislocation.
• Frozen shoulder (adhesive capsulitis): Capsular release in cases that have not responded to conservative treatment.

One point we emphasise particularly in sports injuries: an early, accurate diagnosis is more valuable than unnecessarily prolonged rest. In a professional or amateur athlete with suspected meniscus lesion, cruciate ligament tear or cuff damage, weeks of conservative management without MRI can sometimes delay recovery. We establish a clear diagnosis, then make a decision on that basis — that is our approach.

Osteoarthritis — commonly known as wear-and-tear arthritis — is a chronic condition that develops as articular cartilage gradually deteriorates over time. The most frequently affected sites are the knee, hip, spine and small joints of the hand. In populations with an ageing demographic, such as Northern Cyprus (TRNC), the clinical burden increases each year. Our approach is stepwise; immediate joint replacement or immediate surgery is not the clinical standard.

1. Conservative treatment (mild to moderate osteoarthritis):

• Weight management: losing 5 kg reduces the load moment on the knee by approximately 20% — and can postpone the need for joint replacement by years.
• Exercise programme: quadriceps and gluteal strengthening. An individualised programme with physiotherapy input.
• Lifestyle modification: transition from high-impact sports to swimming, cycling and walking.
• Medical treatment: NSAIDs, paracetamol, assessment of chondroitin/glucosamine where appropriate.

2. Intra-articular injections (moderate osteoarthritis):

• Hyaluronic acid: Supports the viscoelastic properties of synovial fluid. Beneficial in patients who can wait 3–6 months for effect.
• Platelet-rich plasma (PRP): For inflammation modulation in selected patients. The level of evidence varies by disease stage; we do not recommend it for every case of osteoarthritis.
• Corticosteroid: Short-term pain control; used sparingly, as repeated injections may damage cartilage.

3. Surgery (advanced osteoarthritis):

• Knee replacement (total or unicompartmental): Considered when conservative treatment has failed, the patient has night pain, their walking distance is markedly reduced, and functional loss is evident. The decision is taken together with the patient, accounting for age, weight, activity expectations and general health.
• Hip replacement: In selected cases of severe hip osteoarthritis, avascular necrosis or following a hip fracture. The recovery process and long-term implant longevity are discussed with the patient from the outset.

Joint replacement is a major decision for a patient; we do not rush it. It is considered when conservative options have been exhausted and quality of life has been significantly compromised.

Spine and limb surgery are two distinct but frequently overlapping sub-areas within orthopaedics. A patient with a disc herniation may simultaneously have hip osteoarthritis; a patient recovering from hand surgery may develop an elbow entrapment syndrome. When multiple sites are affected, the clinical picture is therefore addressed within a single, integrated treatment plan.

Spine (spinal) surgery:

• Lumbar and cervical disc herniation: Microsurgical discectomy in patients who have not responded to conservative management (physiotherapy, NSAIDs, muscle relaxants, epidural injection) and who have progressive neurological deficit (motor loss, loss of bladder or bowel control).
• Spinal stenosis (narrow canal): Decompression is considered when walking distance is markedly reduced in older patients.
• Vertebral fractures: Conservative management in osteoporotic compression fractures, or vertebroplasty/kyphoplasty in selected cases.
• Spinal deformities: Monitoring of adolescent idiopathic scoliosis; surgical referral for progressive cases that have not responded to conservative measures.

Hand and upper limb surgery:

• Carpal tunnel syndrome: Open or endoscopic decompression when conservative management of median nerve compression is insufficient.
• Cubital tunnel syndrome: Ulnar nerve entrapment at the elbow; nerve transposition.
• Trigger finger (tenosynovitis): Release of the tendon sheath.
• Dupuytren's contracture: Palmar fasciectomy when conservative treatment fails.
• Hand trauma: Tendon lacerations, phalangeal fractures, extensor and flexor tendon repairs.

Hip fractures:

In patients aged 65 and over in particular, a femoral neck or intertrochanteric fracture is a critical emergency. Early surgery (within 48 hours where possible) significantly changes outcomes: bed-related complications (pneumonia, deep vein thrombosis, pressure sores) and the morbidity arising from prolonged immobilisation are prevented. A hip fracture in an elderly patient is therefore a clinical urgency; co-existing conditions (cardiac assessment, diabetes, anticoagulant use) are optimised rapidly and surgery is planned promptly.

A child's skeleton is not simply a smaller version of an adult's. Growth plates (epiphyseal lines) are open; fracture patterns are different, healing is markedly faster, and the risk profile for deformity follows a different course to that in adults. Paediatric orthopaedics therefore requires a distinct perspective.

Common orthopaedic presentations in children:

• Developmental dysplasia of the hip (DDH): Screening in the newborn period is important. Cases identified early can often be managed conservatively with a Pavlik harness; late diagnosis may require closed or open reduction. Do not neglect the screening protocol.
• Flat foot (pes planus): In the vast majority of children, flat feet are physiological and resolve spontaneously. Assessment is indicated when there is pain, a gait abnormality, or a rigid flat foot. Routine insoles at an early age are not needed for every child — avoiding unnecessary medicalisation is equally our responsibility.
• Childhood fractures: The most common sites in children are the forearm, elbow and clavicle. The great majority heal with conservative plaster treatment; closed reduction is used in displaced cases, and intramedullary nailing in selected situations. Plate-and-screw fixation in children is rarely the first choice.
• Posture and gait problems: In-toeing, out-toeing, genu varum (bow legs), genu valgum (knock knees). Most are age-related normal variants. Parental concern is high; the primary approach in these cases is not treatment but accurate information for the family.
• Adolescent scoliosis: Cobb angle measurement and a monitoring plan for spinal curves identified at school screening or by a family member. Observation below 25 degrees, bracing between 25 and 45 degrees, surgical assessment above 45 degrees.
• Osgood–Schlatter disease and growing pains: Infrapatellar pain in an active young athlete is usually apophysitis; it resolves with rest and activity modification.

Decisions in paediatric patients are always made together with the family. Rather than rushing to surgery or recommending unnecessary treatment, a conservative approach that harnesses the child's growth potential takes priority.