Orthopaedic

ORTHOPEDICS
Dr. H. von Schroeder Paul Kuzyk, Mark Shekhman and Adam Sidky, chapter editors Anna Kulidjian, associate editor
AN APPROACH TO ORTHOPEDICS History Physical Examination Investigations
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FEMUR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Femoral Diaphysis Fractures Supracondylar Femoral Fracture KNEE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Common Knee Symptoms Evaluation of Knee Complaints Ligamentous Injuries of the Knee Anterior Cruciate Ligament (ACL) Tear Posterior Cruciate Ligament (PCL) Tear Medial Collateral Ligament (MCL) Tear Lateral Collateral Ligament Tear Meniscal Tear Patella/Quadriceps Tendon Rupture Dislocated Knee PATELLA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Patella Dislocation Chondromalacia Patellae Patellar Fracture TIBIA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Tibial Plateau Fracture Tibial Diaphysis Fracture
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FRACTURES - GENERAL PRINCIPLES Clinical Features of Fractures Initial Management Radiographic Description of Fractures Definitive Management Open Fractures Fracture Healing Complications of Fractures Compartment Syndrome
Avascular Necrosis (AVN)
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SHOULDER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . General Principles Acromioclavicular Joint Sprain Clavicular Fracture Anterior Shoulder Dislocation Posterior Shoulder Dislocation Rotator Cuff Lesions Impingement Syndrome Frozen Shoulder HUMERUS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Humeral Shaft Fracture Proximal Humeral Fracture ELBOW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Supracondylar Fracture Radial Head Fracture Olecranon Fracture Elbow Dislocation FOREARM FRACTURES . . . . . . . . . . . . . . . . . . . . General Principles Nightstick Fracture Galeazzi Fracture Monteggia Fracture Complications of Forearm Fractures WRIST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Scaphoid Fracture Colles Fracture Smiths Fracture Bartons Fracture Complications of Wrist Fractures SPINE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Differential Diagnosis of Back Pain Degenerative Back Pain Cauda Equina Syndrome Trauma Thoracic and Lumbar Spine
................................... HIP Differential Diagnosis of Hip Pain Pelvic Fractures Hip Dislocation Hip Fracture Arthritis of the Hip Avascular Necrosis (AVN) of the Femoral Head
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ANKLE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Evalution of Ankle Complaints Ankle Fractures Ligamentous Injuries Recurrent Ankle Subluxation FOOT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Evaluation of Foot Complaints Talar Fracture Calcaneal Fracture Achilles Tendonitis Achilles Tendon Rupture Plantar Fasciitis Bunions Metatarsal Fracture ORTHOPEDIC INFECTIONS . . . . . . . . . . . . . . . Osteomyelitis Septic Arthritis PEDIATRIC ORTHOPEDICS . . . . . . . . . . . . . . . . Fractures in Children Evaluation of the Limping Child Epiphyseal Injury Pulled Elbow Developmental Dysplasia of the Hip Legg-Calve-Perthes Disease Slipped Capital Femoral Epiphysis Congenital Talipes Equinovarus (CTEV) Scoliosis BONE TUMOURS . . . . . . . . . . . . . . . . . . . . . . . . . . Benign Bone Tumours Benign Aggressive Bone Tumours Malignant Bone Tumours SURGICAL PROCEDURES . . . . . . . . . . . . . . . . . . REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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MCCQE 2006 Review Notes
Orthopedics OR1
AN APPROACH TO ORTHOPEDICS
HISTORY
Identification identifying data include: occupation, hobbies, hand dominance chief complaint past orthopedic history injuries, past non-surgical treatment, past surgery investigations: Xray, CT scan, MRI, etc. other medical history past surgery, medical illnesses, allergies, medications History of Present Illness important to obtain details regarding onset and progression of symptoms pain OPQRST (Onset, P rovoking / Alleviating factors,Quality, Radiation, Site, Timing) muscular, bony, or joint pain ? number of joints involved and symmetry of involvement inflammatory symptoms morning stiffness (> 30 min), tenderness, swelling, redness, warmth mechanical/degenerative symptoms increased with activity, decreased with rest locking, giving way, instability weakness, deformity, stiffness, crepitus neoplastic and infectious symptoms constant pain, night pain fever, night sweats anorexia, fatigue, weakness, weight loss mets from ( PT B arnum Loves Kids): P rostate, Thyroid, Breast, Lungs, Kidney activities of daily living getting up, sitting down, using bathroom, combing hair, transferring referred symptoms shoulder pain from the heart or diaphragm arm pain from the neck leg pain from back back pain from the kidney, aortic aneurysm, duodenal ulcer, pancreatitis
PHYSICAL EXAMINATION
Look, Feel, Move always examine the joint above and below look - skin, shape, position - compare sides SEADS: S welling, Erythema, Atrophy, Deformity, Skin changes feel - palpate soft tissue, bone, joint line assess: tenderness, temperature, effusion, deformity move the affected joint(s) active and passive range of motion (ROM), crepitus present?, instability? passive ROM > active ROM suggests soft tissue inflammation or muscle weakness neurovascular tests pulse, reflexes, power (grade with MRC scale), sensation (most accurate method of eliciting sensory deficits is by two-point discrimination) special tests depend on joint observe gait: walking, heel-to-toe, on heels, on toes
INVESTIGATIONS
Diagnostic Imaging plain X-rays: 2 views taken at 90 to each other CT/myelography, MRI, EMG (electromyelography) / NCS (nerve conduction study) 99Tc (Technetium) bone scan reflects osteoblastic activity or inflammatory reaction positive with fractures, tumours, local reaction gallium scan positive when uptake on gallium is greater than on 99Tc reflects hypervascularity, taken up by leukocytes positive with infection Blood Tests for Painful, Swollen Joint
CBC, ESR, Rheumatoid Factor (RF), ANA, C-reactive protein (CRP)
OR2 Orthopedics
FRACTURES - GENERAL PRINCIPLES

mechanism: remember the process leading to the fracture traumatic pathologic - tumour, metabolic bone disease, infection, osteopenia stress - repetitive mechanical loading
CLINICAL FEATURES OF FRACTURES

pain and tenderness loss of function deformity abnormal mobility and crepitus (avoid) altered neurovascular status (important to document)
ABCDEs
INITIAL MANAGEMENT
limb - attend to neurovascular status (above and below) rule out other fractures/injuries (especially joint above and below) rule out open fracture take an AMPLE history - Allergies, Medications, Past medical history, Last meal, Events surrounding injury analgesia splint fracture - makes patient more comfortable, decreases progression of soft tissue injury, decreases blood loss Imaging
RADIOGRAPHIC DESCRIPTION OF FRACTURES
rule of 2s 2 sides: bilateral 2 views: AP and lateral 2 joints: above and below the site of injury 2 times: before and after reduction patient identification identify views open or closed (gas in soft tissue = open) site which bone if diaphyseal decribe by thirds : proximal/middle/distal extra-articular: diaphysis/metaphysis intra-articular type spiral - rotational force, low energy (# line > 2x bone width) oblique - angular and rotational force transverse - direct force, high energy comminuted (> 2 pieces) - direct force, high energy soft tissue calcification, gas, foreign bodies displacement (position of distal fragment with respect to proximal) apposition/translation - describes what percentage of surfaces remain in contact angulation - describes which way the apex is facing rotation - distal fragment compared to proximal fragment shortened - due to overlap or impaction goals Obtain and Maintain Reduction reduce stabilize rehabilitate
attempt closed reduction
DEFINITIVE MANAGEMENT
successful stabilization cast external fixation traction rehabilitate
unsuccessful open reduction stabilization internal fixation
Figure 1. Fracture Management MCCQE 2006 Review Notes Orthopedics OR3
FRACTURES - GENERAL PRINCIPLES. . . CONT.

Reduction is reduction necessary? may not be for clavicle, fibula, vertebral compression fractures reduce when amount of displacement is unacceptable imperfect apposition may be acceptable while imperfect alignment is rarely acceptable closed when possible indications for open reduction - remember NO CAST N - Non-union O - Open fracture C - neurovascular Compromise A - intra-Articular fractures (require anatomic reduction) S - S alter-Harris III, IV, V and/or special situations depending on site T - polyT rauma others failure to reduce closed cannot cast or apply traction due to site (e.g. hip fracture) pathologic fractures fractures in paraplegics for nursing access potential for improved function with open reduction with internal fixation (ORIF) complicatoins infection non-union new fracture through screw holes implant failure Stabilization stabilize the fracture site but do not completely immobilize the limb if possible external stabilization 1. splints/tape 2. casts 3. traction 4. external fixator internal fixation 1. percutaneous pinning 2. extramedullary fixation (screws, plates, wires) 3. intramedullary fixation (rods) - biomechanically advantageous Rehabilitation to avoid joint stiffness isometric exercises to avoid muscle atrophy range of motion (ROM) for adjacent joints CPM following rigid fixation of fracture allows joint motion to prevent stiffness for intra-articular fractures after cast/splint removed and fracture healed > resistive muscle strengthening evaluate bone healing (clinical, x-ray)
OPEN FRACTURES
EMERGENCY!
fracture communicates with skin surface examine fracture carefully to classify (Table 1) Table 1. Classification of Open Fractures
Size Type 1 < 1 cm Type 2 >1cm Type 3 >1cm Soft Tissue Injury Minimal Moderate; no dead soft tissue Extensive muscle damage; includes gunshot wounds, major vascular injury barnyard injury Antibiotics Ancef Ancef Ancef, Gentamycin, Flagyl
initial management 1. do not reduce open fractures unless there is neurovascular compromise from position of fracture 2. remove gross debris i.e. turf, rocks 3. all open fractures are contaminated, therefore obtain culture and cover wound with sterile dressing 4. administer tetanus vaccine/booster (Table 2) 5 start antibiotics 6. splint 7. NPO and prepare for O.R. 8. irrigation and debridement, 9. reduction and stabilization after I&D OR4 Orthopedics
ONCE IN O.R.:

must get to O.R. within 6 hours, since risk of infection increases after this time wound usually left open to drain re-examine, with possible repeat I&D in 48 hours and closure if appropriate Table 2. Indications for Tetanus Vaccination
Tetanus History unknown or <3 Td doses >3 Td doses Clean Wound Td Y N* TIG N N Dirty Wound Td Y N** TIG Y N
* Y if >10 years since last dose ** Y if >5 years since last dose Td=0.5 mL adsorbed tetanus toxoid TIG=250 units tetanus immune globulin
Complications of Open Fractures osteomyelitis soft tissue damage neurovascular injury blood loss nonunion
FRACTURE HEALING
Normal Healing weeks 0-3 weeks 3-6 weeks 6-12 months 6-12 years 1-2 hematoma, macrophages surround fracture site osteoclasts remove sharp edges, callus forms within hematoma bone forms within the callus, bridging fragments cortical gap is bridged by bone normal architecture is achieved through remodelling
Figure 2. Stages of Bone Healing Evaluation of Healing - Tests of Union clinical - no longer tender to palpation or angulation stress x-ray - trabeculae cross fracture site, visible callus bridging site
COMPLICATIONS OF FRACTURES
Table 3. Complications of Fractures
Early Local Neurovascular injury Infection Compartment syndrome Implant failure Fracture blisters Late Malunion Nonunion Osteonecrosis Osteomyelitis Heterotopic ossification Post-traumatic arthritis Reflex sympathetic dystrophy (RSD)
Systemic
Sepsis Deep vein thrombosis (DVT) / pulmonary embolus (PE) Fat embolus Acute respiratory distress syndrome (ARDS) Hemorrhagic shock
Orthopedics OR5

COMPARTMENT SYNDROME(see Figure 3)
in anatomical "compartments" where muscle and tissue bounded by fascia and bone (fibro-osseous compartment) with little room for expansion (i.e. forearm, calf) increased interstitial pressure in compartment exceeds capillary perfusion pressure which leads to muscle necrosis and eventually nerve necrosis intracompartmental pressures over 30 mm Hg usually require intervention
Etiology fracture, dislocation soft tissue damage and muscle swelling crush injury arterial compromise muscle anoxia venous obstruction increased venous pressure constrictive dressing, cast, splint Diagnosis classically the tibial compartments also in forearm flexor compartment may lead to Volkmanns ischemic Figure 3. Pathogenesis of Compartment Syndrome contracture clinical signs and symptoms early pain greater than expected for injury not relieved by analgesics increase with passive stretch of compartment muscles pallor palpable tense, swollen copmparment late paralysis (inability to move limb - late) pulses are usually still present paresthesias NOT pulslessness most important feature found on physical exam is PAIN out of proportion to injury (the other signs are late signs) compartment pressure monitoring in unresponsive or unreliable patients normal tissue pressure is about 0 mm Hg pressure increases markedly in compartment syndromes. when intra-compartmental pressure rises to within 10 to 30 mm Hg of patient's diastolic blood pressure inadequate perfusion and/or ischemia results fasciotomy usually is indicated when the tissue pressure rises to 40-45 mm Hg in a patient who has any signs or symptoms of a compartment syndrome-even if distal pulses still present Table 4. Signs of Compartment Syndrome in Anterior Leg and Forearm
Anterior leg Fracture Type Weakness Pain Sensory Tibial fracture Toe, foot extension Toe, foot flexion 1st dorsal web space Volar forearm Supracondylar (humerus) Finger, wrist flexion Finger, wrist extension Volar aspect of fingers
Treatment remove constrictive dressings bivalve casts down to skin and spread open place limb at level of heart emergency fasciotomy to release compartments if difference between diastolic blood pressure and compartment pressure is less than 30 mmHg (treat within 4-6 hours of onset symptoms)
OR6 Orthopedics

AVASCULAR NECROSIS (AVN)
Causes steroid use (inflammatory arthritis, inflammatory bowel disease (IBD), allergies, renal disease, asthma); NOT dose related - idiosyncratic alcohol post-traumatic fracture/dislocation septic arthritis sickle cell disease Gauchers disease Caissons disease - deep sea diving/the bends idiopathic Table 5. AVN Classification
Stage 1 2 Clinical Features Preclinical phase of ischemia and necrosis; no pain Painful X-ray Features No plain x-ray abnormality; may be detectable on MRI Early radiographic changes i.e. fragment appears dense, normal bone contour Radiographic changes obvious, abnormal bone contour Collapse of articular surface and signs of arthritis on both sides of the joint
3 4
Painful Very painful
Mechanism occurs following disruption of blood supply to bone occurs especially in those bones extensively covered in cartilage which rely on intra-osseous blood supply and distal to proximal blood supply, e.g. head of femur, proximal pole of scaphoid, body of talus results in ischemia pathologic changes include resorption, subchondral fractures and loss of cartilage
SHOULDER
GENERAL PRINCIPLES
shoulder is a complex 4 part joint glenohumeral joint acromioclavicular (AC) joint scapulothoracic joint sternoclavicular joint examination should involve each of the joints in isolation the joint is highly mobile therefore decreased stability dislocations and subluxations following trauma are common rotator cuff and tendon degeneration are more common than osteoarthritis (OA) may be referred pain from C-spine
Physical Examination of the Shoulder LOOK - inspect both shoulders anteriorly and posteriorly, clavicle, deltoids, scapula (SEADS) FEEL - for tenderness, swelling, temperature changes, muscle characteristics (include all joints and bones)
MOVE - Active/Passive
Active ROM forward flexion and abduction external rotation (elbows at side and flexed 90 degrees, move arms away from midline) internal rotation (hand behind the back, measure wrt. level of the spine) Passive ROM abduction 180 degrees adduction 45 degrees flexion 180 degrees extension 45 degrees internal rotation level of T4 external rotation 40 - 45 degrees MCCQE 2006 Review Notes Orthopedics OR7
SHOULDER . . . CONT.
X-Ray radiographic views of the shoulder should include AP, trans-scapular, and axillary views (at least) stress views of the acromioclavicular joint where indicated look for the Mercedes Benz sign (see Figure 4) in the trans-scapular radiograph to look for dislocation humeral head should occupy the circle and be overlapping glenoid
Figure 4. Mercedes Benz Sign

Adapted with permission from McRae, Clinical Orthopedic Examination, 3rd ed. Churchill Livingstone, New York, 1994.
ACROMIOCLAVICULAR (AC) JOINT SPRAIN
AC joint is usually injured after fall onto shoulder with adducted arm 2 main ligaments which attach clavicle to scapula acromioclavicular (AC) ligament coracoclavicular (CC) ligament acromioclavicular sprains Type I: partial injury, no instability, no displacement (sprain of AC ligament) CC-intact Type II: disrupted AC ligament, sprain of CC ligament Type III: disrupted AC and CC ligaments with superior clavicle displacement (shoulder displaced inferiorly) Type IV: clavicle displaces superiorly and posteriorly through trapezius Type V: clavicle displaced inferior to acromion or coracoid (beware brachial plexus injury!) physical examination palpable step between distal clavicle and acromion pain with adduction (touch opposite shoulder) radiographically apparent on stress view (hold weights in hand) treat type I or II with ice, immobilization, early ROM and strengthening treat type III the same or repair if skin compromise imminent operative repair of type IV and V excision of lateral clavicle with reconstruction of CC and AC ligament
CLAVICULAR FRACTURE
fall on shoulder or onto outstretched hand presents as pain and tenting of skin cosmetically poor but not disabling brachial plexus and arterial injuries in 10% classified by proximal, middle (most common), or distal third of clavicle treatment of proximal and middle third clavicular fractures closed reduction with figure-of-eight brace or sling x 1-2 weeks early ROM and strengthening distal third clavicular fractures are unstable and may require ORIF
ANTERIOR SHOULDER DISLOCATION
over 90% of all shoulder dislocations, usually traumatic may be of two general types: involuntary: traumatic, unidirectional, Bankart lesion, responds to surgery voluntary: atraumatic, multidirectional, bilateral, rehab, surgery is last resort occurs when abducted arm is externally rotated or hyperextended recurrence rate depends on age of first dislocation associated with Hill-Sachs lesion indentation of humeral head after impaction on glenoid rim
at age 20: 80%; at age 21-40: 60-70%; at age 40-60: 40-60%; at age > 60: < 10%
OR8 Orthopedics
also associated with Bankart lesion avulsion of capsule when shoulder dislocates associated bony avulsion called "Bony Bankart Lesion" occurs in 85% of all anterior dislocations axillary nerve and musculocutaneous nerve at risk some associated injuries more common in elderly vascular injury and fracture of greater tuberosity Physical Examination squared off shoulder humeral head can be palpated anteriorly arm held in slight abduction and external rotation loss of internal rotation with anterioinferior humeral head axillary nerve may be damaged, therefore check sensation and contraction over lateral deltoid; for musculocutaneous nerve check sensation of lateral forearm and contraction of biceps apprehension test: for recurrent shoulder instability with patient supine, gently abduct and externally rotate patients arm to a position where it may easily dislocate; if shoulder is dislocatable, patient will have a look of apprehension on face X-Rays humeral head anterior (to Mercedes Benz sign) in trans-scapular view axillary view is diagnostic AP view may show Hill-Sachs lesion if recurrent rule out associated humeral neck fracture Treatment intravenous sedation and muscle relaxation gentle longitudinal traction and countertraction +/ alternating internal and external rotation Hippocratic Method - foot used in axilla for countertraction (not recommended - risk of nerve damage) Stimsonss method - patient prone with arm hanging over edge of table, weight hung on wrist (typically 5 lbs for 15-20 mins) X-Ray to verify reduction and check neurologic status sling x 3 weeks with movement of elbow, wrist, fingers rehabilitation aimed at strengthening dynamic stabilizers and avoiding the unstable position (i.e. external rotation and abduction) recurrent instability and dislocations may require surgery
POSTERIOR SHOULDER DISLOCATION
5% of all shoulder dislocations caused by force applied along the axis of the arm shoulder is adducted, internally rotated and flexed the four Es which cause posterior dislocation are: Epileptic seizure Ethanol intoxication Electricity (ECT, Electrocution) Encephalitis often missed due to poor physical exam and radiographs if caused by seizure, often bilateral shoulder dislocations
Physical Examination anterior shoulder flattening, prominent coracoid blocked external rotation, limited abduction X-Rays humeral head posterior in trans-scapular view Treatment inferior traction on flexed elbow + pressure on back of humeral head may require reduction under general anesthetic splint for 3 weeks following reduction
ROTATOR CUFF LESIONS
the rotator cuff is a sheet of conjoined tendons SITS : S upraspinatus, Infraspinatus, Teres minor, Subscapularis stabilizes the head of the humerus in the glenoid, when arm extended or abducted about 80% of 80 year olds have rotator cuff lesions Orthopedics OR9
supraspinatus infraspinatus subscapularis joint capsule
teres minor
Figure 5. Muscles of the Rotator Cuff and Position at the Glenoid

Illustration by Kevin Millar
IMPINGEMENT SYNDROME
also called "Painful Arc Syndrome" describes impingement of supraspinatus tendon between humeral head/greater tuberosity and anatomic arch between anterior edge and undersurface of acromion, AC joint and CA ligament
Physical Examination painful arc between 90-130 degrees of abduction pain on palpation of rotator cuff impingement test place patients hand on opposite shoulder and lift elbow off chest - reproduces pain may have associated osteophytes under acromion or AC joint Types of Impingement Syndrome mild (wear) inflamed rotator cuff aching, reversible, +/ weakness treatment is non-operative (physiotherapy, NSAIDs) moderate ("tear") tendon is thick and fibrotic, microtears night pain and shoulder weakness prominent non-operative treatment +/ steroid injection severe ("repair") tear of rotator cuff, cannot start abduction may require surgical repair
FROZEN SHOULDER
process which involves adhesive capsulitis
Primary Adhesive Capsulitis idiopathic, usually associated with diabetes mellitus may resolve spontaneously in 9-18 months Secondary Adhesive Capsulitis due to prolonged immobilization "Shoulder-Hand Syndrome" - hand in cast, immobilized shoulder following myocardial infarction, stroke, shoulder trauma Treatment active and passive ROM (physiotherapy) NSAIDs and steroid injections if limited by pain MUA (manipulation under anesthesia) or arthroscopy for debridement/decompression diabetics usually have poor outcomes
OR10 Orthopedics
HUMERUS
HUMERAL SHAFT FRACTURE
from falls on outstretched hand, MVAs or direct load applied to arm generally treated non-surgically complications include radial nerve injury and nonunion
Treatment undisplaced fracture +/ radial nerve palsy collar and cuff x 4-6 weeks, then active exercises for shoulder, wrist and hand if fracture united radial nerve palsy usually improves spontaneously over 3-6 months; if no improvement at 3 months then EMG displaced fracture apply collar and cuff or sugar-tong plaster splint cast and reassess radial nerve immobilize 2-3 weeks then go to frontal brace and begin active upper limb exercises ORIF indicated if: 1) poor closed reduction, 2) polytrauma, 3) segmental fracture, 4) pathologic fracture, 5) neurovascular compromise, 6) associated fracture of proximal ulna floating elbow
PROXIMAL HUMERAL FRACTURE
especially common fracture in osteoporotic person fall on o uts tretched h and ( FOOSH) pain, swelling and tenderness around the shoulder (especially around greater tuberosity) fracture involves proximal humeral diaphysis (surgical neck) +/ greater tuberosity +/ lesser tuberosity classify into 2, 3, and 4 part fractures
Treatment if needed, treat for osteoporosis undisplaced stable/impacted, use Velpeau sling x 1 week then active ROM unstable (unusual), use Velpeau sling x 3 weeks then gentle ROM displaced > 1 cm or angulated > 45 attempt closed reduction, Velpeau sling x 2 weeks, gentle ROM ORIF if unsatisfactory reduction fracture with dislocation of glenohumeral joint high incidence of neurovascular injury and osteonecrosis ORIF; hemiarthroplasty may be necessary
Fractures in this region may involve the anatomical neck (rare) (1), the surgical neck (2), the greater tuberosity(3), or the lesser tuberosity (4) Combinations of these injuries are common and may involve two-part (5), three-part (6), and four-part fractures (7)
Figure 6. Fractures of the Proximal Humerus

Reproduced with permission from McRae, Practical Fracture Treatment, 2nd ed. Churchill Livingstone, New York, 1989.
Orthopedics OR11
ELBOW
Figure 7. Anatomy of the Elbow
Figure 8. Displaced Supracondylar Fracture of Humerus
SUPRACONDYLAR FRACTURE
usually in children fall on outstretched hand Treatment children closed reduction +/ percutaneous pinning in O.R. with fluoroscopy cast in flexion x 3 weeks adult undisplaced fracture, may be treated in cast displaced fracture, ORIF since closed reduction usually inadequate Complications stiffnes most common see Complications of Fractures section
RADIAL HEAD FRACTURE
mechanism: fall on out s tretched h and ( FOOSH) clinically: progressive pain due to hemarthrosis with loss of ROM and pain on lateral side of elbow aggravated by forearm pronation or supination careful, may not be seen radiographically look for sail sign of anterior fat pad or the prescence of a posterior fat pad on x-ray to detect occult radial head fractures
Mason Classification Type 1: undisplaced segmental fracture, usually normal ROM Type 2: displaced segmental fracture, ROM compromised Type 3: comminuted fracture Type 4: Type 3 with posterior dislocation Treatment Type 1: elbow slab, sling 3-5 days, early ROM Type 2: ORIF radial head Type 3/4: excision of radial head +/ prosthesis
OLECRANON FRACTURE
fall on point of elbow with avulsion by triceps or fall on outstretched arm active extension absent gross displacement can not be reduced closed because of pull of triceps
Treatment undisplaced: above elbow cast 2 weeks, early ROM displaced: ORIF, above elbow slab x 1 week, early ROM
ELBOW DISLOCATION
usually young people in sporting events or high speed MVA > 90% are posterior or posterior-lateral fall on outstretched hand rule out concurrent radial head or coracoid process fractures
Treatment of Posterior Dislocation closed reduction: traction then flexion above elbow backslab with elbow 90 degrees and wrist pronated open reduction if unstable or loose body (unusual) Complications stiffness intra-articular loose body usually from joint surface cartilage not obvious on x-ray occasionally medial epicondyle is pulled into joint, especially in children heterotopic ossification (bone formation) prevented by indomethacin immediately following surgery recurrent dislocation is extremely rare OR12 Orthopedics
FOREARM FRACTURES
GENERAL PRINCIPLES OF FOREARM FRACTURES
more commonly fracture of both bones, usually displaced if only one bone fractured look for dislocation of other displaced fractures of radius or ulna mostly treated by ORIF, as non-surgical methods often result in limitation of pronation/supination forearm fractures in children are usually of the greenstick type, in which only one cortex is involved cross union - radius malunites to ulna loss of pronation/supination loss of extension of elbow difficult to reduce and maintain closed accurate reduction is essential, usually requires ORIF shoulder-hand syndrome (frozen shoulder)
COMPLICATIONS SPECIFIC TO FOREARM FRACTURES
NIGHTSTICK FRACTURE(see Figure 9)
isolated fracture of ulna, with minimal displacement mechanism: from holding arm up to protect face from blow rule out fracture clinically and radiographically treatment: below elbow cast 6 weeks for distal 1/3 fractures if angulation of proximal 2/3 severe; consider ORIF fracture of distal radius dislocation of distal radio-ulnar joint (DRUJ) at wrist treatment: immobilize in supination to reduce DRUJ, ORIF
(see GALEAZZI FRACTURE Figure 10)
Figure 9. Nightstick Fracture

Illustration by Chesley Sheppard
Figure 10. Galeazzi Fracture

Reproduced with permission from McRae, Practical Fracture Treatment,
2nd ed. Churchill Livingstone, New York, 1989.
MONTEGGIA FRACTURE(see Figure 11)
fracture of ulna with associated dislocation of radial head treatment: ORIF is recommended- open reduction of the ulna is usually followed by indirect reduction of the radius
Figure 11. Monteggia Fracture Showing Anterior and Posterior Dislocation of Radial Head
Adapted with permission from McRae, Practical Fracture Treatment, 2nd ed. Churchill Livingstone, New York, 1989.
Orthopedics OR13
WRIST
SCAPHOID FRACTURE (see Figure 12)
Etiology second most common carpal fracture, common in young adults maintain a high index of suspicion with falls o n outs tretched h and (FOOSH ) blood supply is from distal to proximal poles of scaphoid
- risk of avascular necrosis (AVN)
Diagnosis clinical pain on wrist movement i.e positive scaphoid test tenderness elicited in anatomical snuff box and over scaphoid tubercle x-ray AP/lateral/scaphoid views required x-ray alone may not reveal scaphoid fracture +/ bone scan and/or CT scan Treatment
Suspected Scaphoid Fracture undisplaced ve x-ray +ve cast 8 weeks (check weekly x 3) displaced ORIF
Figure 12. Scaphoid Fracture

Reproduced with permission from McRae, Practical
Fracture Treatment, 2nd ed. Churchill Livingstone,
New York, 1989.
cast 2 weeks (thumb spica) repeat x-ray ve +ve
cast off fracture healed yes no
clinical exam ve STOP +ve bone scan
STOP
cast +/ OR
Figure 13. Scaphoid Fracture Algorithm Complications nonunion +/ AVN highest incidence of AVN (30%) is with fracture of proximal 1/3 high incidence of nonunion and AVN with significant displacement
COLLES' FRACTURE(see Figure 14)
Figure 14. Colles' Fracture and Associated Bony Deformity

OR14 Orthopedics
WRIST . . . CONT.
Etiology most common wrist fracture fall on o uts tretched h and ( FOOSH) most common in osteoporotic bone Diagnosis clinical swelling, ecchymosis, tenderness dinner fork deformity (Figure 14) assess neurovascular status (carpal tunnel syndrome) X-ray: distal fragment is 1. dorsally displaced with dorsal comminution 2. dorsally tilted fragment with apex of fracture volar 3. supinated 4. radially deviated 5. shortened (radial styloid normally 1cm distal to ulna) +/ fracture of ulnar styloid Treatment nondisplaced short arm cast applied to wrist under gentle traction neutral wrist position displaced 1. anesthesia - hematoma block commonly used 2. disimpaction - axial traction with increasing force over 2 minutes (pull on thumb and ring finger, with countertraction at the elbow) 3. reduce by pulling hand into slight flexion full pronation full ulnar deviation 4. maintain reduction with direct pressure to fracture site, apply well moulded dorsal-radial slab (splint) 5. post-reduction x-ray (AP/lateral), goal to correct dorsal angulation and regain radial length 6. check arm after 24 hours for swelling, neurovascular status 7. circular cast after 1-2 weeks; check cast at 1, 2, 6 weeks; cast off after 6 weeks, physiotherapy (ROM, grip strength) if inadequate reduction at any time try closed reduction under GA ORIF
SMITHS FRACTURE(see Figure 15)
Type a Figure 15. Smiths Fracture

Illustration by Marc Dryer
Type b
Type c
Diagnosis clinical presentation and radiographic evidence fracture similar to Colles but volar displacement of distal radius Treatment hematoma block closed reduction in supination and slight flexion splint ORIF if unstable reduction
BARTONS FRACTURE(see Figure 16)

Diagnosis clinical presentation and radiographic evidence intra-articular fracture of distal radius resulting from shearing force classified as dorsal or volar depending upon location of fragment MCCQE 2006 Review Notes
Dorsal Figure 16. Bartons Fracture

Illustration by Marc Dryer
Ventral
Orthopedics OR15
WRIST . . . CONT.
Treatment attempt closed reduction although rarely adequate dorsal: slight extension, pronation, splint volar: slight flexion, supination, splint usually requires ORIF if unstable reduction
COMPLICATIONS OF WRIST FRACTURES
most common complications are poor grip strength, stiffness, and radial shortening 80% have normal function in 6-12 months early difficult reduction +/ loss of reduction compartment syndrome extensor pollicis longus (EPL) tendon rupture acute carpal tunnel syndrome finger swelling with venous or lymphatic block late malunion, radial shortening painful wrist secondary to ulnar prominence frozen shoulder ("shoulder hand syndrome") post-traumatic arthritis carpal tunnel syndrome reflex sympathetic dystrophy (RSD)
SPINE
DIFFERENTIAL DIAGNOSIS OF BACK PAIN
degenerative (90% of all back pain) mechanical (degenerative, facet) spinal stenosis (congenital, osteophyte, central disc) peripheral nerve compression (disc herniation) cauda equina syndrome neoplastic primary, metastatic trauma fracture (compression, distraction, translation, rotation) spondyloarthropathies e.g. ankylosing spondylitis referred aorta, renal, ureter, pancreas
Epidemiology common problem L4-5 and L5-S1 most common sites 10% nerve root compression less than 2% results from tumour, trauma, other diseases
DEGENERATIVE BACK PAIN

Pathogenesis loss of vertebral disc height with age results in bulging and tears of annulus fibrosus change in alignment of facet joints osteophyte formation pain sensation is transmitted by branches of adjacent nerve root, which innervates disc and facet joints results in both localized pain and referred pain down adjacent spinal nerve radiating pain typically occurs in buttocks and down legs pain may originate from disc +/ facet joints disc herniations are most commonly posterolateral or lateral (see Colour Atlas NS20) posterolateral herniations (most common) affect the nerve root below the disc (i.e. the L4-L5 disc compresses L5 root) natural history: 90% improve with non-operative treatment within 3 months non-operative modified activity back strengthening NSAIDs surgical decompression +/ fusion no difference in outcome between non-operative and surgical management in 2 years OR16 Orthopedics MCCQE 2006 Review Notes
SPINE
. . . CONT.
Table 6. Types of Low Back Pain

Mechanical Back Pain Disc Origin Pain Dominance Aggravation Onset Duration Treatment Back Flexion Gradual Long (wks, months) Relief of strain, exercise Facet Origin Back Extension standing, walking More sudden Shorter (days, wks) Relief of strain, exercise Direct Nerve Root Compression Spinal Stenosis Leg Exercise, extension walking, standing Congenital or acquired Acute or chronic history (weeks to months) Relief of strain, exercise Root Compression Leg Flexion Acute leg back pain Short episode attacks (minutes) Relief of strain, exercise + surgical decompression if progressive or severe deficit
spinal stenosis acquired stenosis best thought of as a progression or end stage degenerative disc disease, in which osteophytic growth results in a narrowed spinal canal Table 7. Differentiating Claudication
Neurogenic Aggravation Alleviation Time Character With standing or extension walking distance variable Change in position (usually flexion, sitting, lying down) Relief in 10 minutes Neurogenic neurological deficit Vascular Walking set distance Stopping walking Relief in 2 minutes Muscular cramping
X-Rays AP, lateral, obliques indicated for new onset back pain (i.e. r/o tumour, congenital deformities) look for "Winking Owl sign > signifies tumour invasion of pedicle CT scan/myelography, MRI for spinal stenosis, cauda equina syndrome, disc herniation x-rays not very helpful for chronic degenerative back pain radiographic degeneration does not correlate well with back pain
CAUDA EQUINA SYNDROME
most frequent cause is large central disc herniation progressive neurological deficit presenting with saddle anesthesia decreased anal tone and reflex fecal incontinence urinary retention SURGICAL EMERGENCY! will cause permanent urinary/bowel incontinence if untreated
Table 8. Lumbar Radiculopathy/Neuropathy

Root motor sensory reflex test L4 quadriceps tibialis anterior posteromedial knee reflex limitation of femoral stretch L5 ankle dorsiflexion great toe extensor hip abductor lateral calf or 1st web space hamstring reflex limitation of straight leg raise S1 ankle plantar flexion lateral aspect of foot ankle reflex limitation bowstring
Orthopedics OR17
SPINE
. . . CONT.
Figure 17. Dermatomes of the Upper and Lower Limbs
Figure 18. Alignment of Cervical Spine

Adapted with permission from McRae, Clinical Orthopedic
Examination, 3rd ed. Churchill Livingstone, New York, 1994.
TRAUMA
C-Spine X-rays can you see C1 to superior portion of T1? - if not, film is INADEQUATE should have Swimmers view (one arm above head and one arm below head) for adequate visualization of C7-T1 open mouth odontoid view for adequate visualization of atlanto-axial joint identify 1) alignment (on lateral films - see Figure 18) anterior body (1) posterior body (2) should curve to anterior foramen magnum facet joints (3) laminar fusion line (4) should curve proximally and point to posterior base of foramen magnum 2) vertebral bodies height and width 3) cartilage 4) soft tissues prevertebral soft tissue: C3=3-5 mm, C7=7-10 mm Clearing C-spine X-rays
x-ray (AP/lat/odontoid) abN N uncons cons neck pain yes CT abN flex/ext x-ray N cleared no
Figure 19. Algorithm for Clearing C-spine X-rays
OR18 Orthopedics
SPINE
Root Motor
. . . CONT.
Table 9. Cervical Radiculopathy/Neuropathy

C5 Deltoid supraspinatus Biceps Axillary nerve (middle deltoid) Biceps Middle deltoid C6 Biceps Brachioradialis Thumb and index finger Brachioradialis reflex C7 C8 Triceps Digital flexors intrinsic Middle finger Ring and little finger
Sensory Reflex
Triceps Finger jerk reflex
THORACIC AND LUMBAR SPINE

Table 10. Elements of 3 Column Spine
Anterior Column Anterior longitudinal ligament Anterior annulus fibrosis Anterior 1/2 of vertebral body Middle Column Posterior longitudinal ligament Posterior annulus fibrosis Posterior 1/2 of vertebral body Posterior Column Posterior body elements Supraspinous, intraspinous ligaments acet joints ligamentum flavum
Table 11. Basic Types of Spine Fractures and their Mechanisms

Type 1. Compression Anterior Lateral 2. Burst 3. Distraction 4. Fracture dislocation Mechanism Flexion Anterior flexion Lateral flexion Axial load +/- flexion/rotation Flexion, distraction, common in lap-belted MVC (Chance) Flexion-Rotation, Shear, Flexion Distraction
Chance Fracture of the Spine failure of anterior, middle, and posterior columns caused by high tensile force; most commonly seen in MVC lap-belted passenger CT scan to assist with diagnosis X-Ray (see Figure 20) oblique views show "Scottie Dog" look for disruption of "Scottie Dog" to identify spondylolysis
S N P I superior facet transverse process pars interarticularis inferior facet
Adapted with permission from McRae, Clinical
Figure 20. Scottie Dog
Orthopedic Examination, 3rd ed. Churchill Livingstone, New York, 1994.
Treatment compression wedge: conservative if < 50% compression burst: may push material into spinal canal therefore surgical correction (distraction and IF for stabilization) distraction Chance: if part-bony, part-soft tissue, conservative management with hyperextension orthosis surgical stabilization required with extensive soft tissue, ligamentous injury rotation burst type: inherently unstable therefore internal stabilization MCCQE 2006 Review Notes Orthopedics OR19
HIP
DIFFERENTIAL DIAGNOSIS OF HIP PAIN IN THE ADULT
traumatic fracture (femur or pelvis), dislocation, labral tear arthritic septic, osteoarthritis, inflammatory (see Rheumatology Chapter) vascular AVN of femoral head trochanteric bursitis and gluteal tendonitis neoplastic referred hip pain is felt in the groin area and anterior thigh spine usually involves buttock and posterior thigh knee, abdominal viscera, vascular (intermittent claudication)
X-Ray Diagnosis views: AP, lateral, Judet (oblique) views Table 12. Radiological Diagnosis of Hip Pathology
Finding Loss of joint space Subchondral Sclerosis Osteophytes Erosions Leg shortening Osteoarthritis (OA) Localized +++ Acetabulum and head +++ None +/ AVN None ++ Head only None None None Hip Fracture None None None None +++ if displaced
Note: AVN becomes same as OA later in disease process, and hip fracture may have preexisting OA
PELVIC FRACTURES
most common fracture involves pubic rami, followed by ilial, ischial, acetabular, coccygeal and sacral bones
Tile Classification (see Figure 21) Type A: stable, minimally displaced, includes avulsion fractures and fractures not involving pelvic ring, e.g. rami fracture Type B: partially unstable, rotationally unstable, but vertically stable, e.g. open book fracture from external rotational force to pelvis Type C: unstable, rotationally and vertically unstable, associated with rupture of ipsilateral ligaments, e.g. vertical shear fracture
Type A Type B Type C Unstable Vertical Fracture Stable Avulsion Fracture Open Book Figure 21. Illustration of the Tile Classification of Pelvis Fractures
Illustration by Seline McNamee
Diagnosis history of injury, high energy trauma examination reveals local swelling, tenderness; if unstable, may have deformity of the hips and instability of pelvis with palpation x-rays (i.e. AP, inlet, and outlet views) Treatment ABCs assess genitourinary injury (rectal exam/vaginal exam mandatory) Type A - bedrest and mobilization with walking aids Type B/C - external or internal fixation OR20 Orthopedics MCCQE 2006 Review Notes
HIP
. . . CONT.
Complications hemorrhage - life threatening bladder/bowel injuries neurological damage obstetrical difficulties persistent sacro-iliac (SI) joint pain post-traumatic arthritis of the hip with acetabular fractures
HIP DISLOCATION
mainly seen with artificial hips
1. Anterior (rare) blow to knee with hip widely abducted clinically: limb fixed, externally rotated and abducted femoral head tends to migrate superiorly attempt closed reduction under GA then CT of hip to assess joint congruity 2. Posterior severe forces to knee with hip flexed and adducted (e.g. knee into dashboard in MVA) clinically: limb shortened, internally rotated and adducted femoral head tends to migrate inferiorly/medially +/ fracture of posterior lip of acetabulum or intra-articular fracture sciatic nerve injury common especially with associated acetabular fracture assess knee, femoral shaft for other injuries/fractures +/ fracture of posterior lip of acetabulum or intra-articular fracture attempt closed reduction under GA +/ image intensifier then CT to assess congruity and acetabular integrity traction x 6 weeks, then ROM ORIF if unstable, intra-articular fragments, or posterior wall fractures 3. Central associated with acetabular fracture 4. After Total Hip Arthroplasty (THA) occurs in 1-4% of primary THA and 16% in revision cases about 74% of THA dislocations are posterior, 16% anterior and 8% central THA are unstable in the position of flexion and internal rotation Treatment complete muscle relaxation is key conscious sedation (IV fentanyl and versed) or spinal or GA assistant applies downward pressure to pelvis reduction for posterior dislocation fully flex hip, abduct and externally rotate hip, apply upward traction on femur reduction for anterior dislocation fully flex hip , adduct and internally rotate hip, apply downward pressure on femur Complications post-traumatic arthritis due to cartilage injury or intra-articular loose body femoral head injury including osteonecrosis + fracture; 100% if nothing12 hours before reduction sciatic nerve palsy in 25% (10% permanent) fracture of femoral shaft or neck heterotopic ossification coxa magna (occurs in up to 50% of children after a hip dislocation) sciatic nerve palsy in 25% (10% permanent) fracture of femoral shaft or neck knee injury (posterior cruciate ligament (PCL) tear with dashboard injury)
HIP FRACTURE
Epidemiology common fracture in elderly female > male in osteopenic individual, fracture may precede simple fall (muscle stronger than bone) in younger individual, fracture related to high energy injury markedly displaced associated with other injuries Diagnosis characteristic history, unable to bear weight on affected limb limb shortened, externally rotated, painful ROM, antalgic gait obtain AP of pelvis and lateral of involved hip if findings equivocal - bone scan and tomograms MCCQE 2006 Review Notes Orthopedics OR21
HIP
. . . CONT.
Subcapital (Intracapsular)
Intertrochanteric (Extracapsular)
Subtrochanteric (Extracapsular)
Basicervical (Intracapsular)
Figure 22. Blood Supply to Femoral Head and Fracture Classification

1. Subcapital Fractures fracture between femoral head and intertrochanteric line main vascular supply to femoral head from distal arterial ring to proximal head through femoral neck fracture interrupts blood supply articular surface restricts blood supply to femoral head AVN risk depends on degree of displacement Table 13. Garden Classification of Subcapital Fractures
Type I 2 3 4 Extent Incomplete Complete Complete Complete Displacement Impacted None Some Marked Alignment Valgus Neutral Varus Varus Trabeculae Malaligned Aligned Malaligned Aligned
Treatment if needed, treat osteoporosis restore anatomy, attempt to save head type of treatment depends on displacement and patient age undisplaced (Garden 1,2) internal fixation to prevent displacement displaced (Garden 3,4) - depends on patient age and function older patient, low function > unipolar hemiarthroplasty (Moores Prosthesis) older patient, high function > bipolar hemiarthroplasty young patient, high function > reduction with internal fixation within 12 hrs of fracture Complications avascular necrosis (AVN), non-union, deep vein thrombosis (DVT) 2. Intertrochanteric Fracture extra-capsular fracture, therefore good femoral head viability fracture stability determined by number of fragments, integrity of calcar and direction of fracture line greater and lesser trochanters may be separate fragments posterior fragment may be avascular, therefore possible delayed union Classification classification based on number of parts and stability 2 part - stable, trochanter intact 3 part - one trochanter separated, unstable if large calcar fragment 4 part - unstable, both trochanters separated reverse obliquity about 15% of intertrochanteric fractures; fracture line runs inferiolaterally from lesser trochanter Treatment obtain a good closed reduction under fluoroscopy on the fracture table after reduction obtained, internal fixation with dynamic hip screw and plate reverse obliquity fractures are highly unstable and require fixation with dynamic condylar screw and plate OR22 Orthopedics MCCQE 2006 Review Notes
HIP
. . . CONT.
3. Subtrochanteric Fracture least common hip fracture highly unstable transverse, spiral or oblique fracture passes below lesser trochanter younger population with high energy injuries x-rays show flexed and abducted proximal fragment, from pull of iliopsoas on lesser trochanter, gluteus medius and minimus on greater trochanter Treatment obtain a good closed reduction under fluoroscopy on the fracture table internal fixation with intramedullary nail
ARTHRITIS OF THE HIP
many causes (osteoarthritis, post-traumatic, developmental dysplasia of the hip, RA, etc.)
Diagnosis usually in an older individual gradual onset of groin/medial thigh pain, increasing with activity limb shortening decreased internal rotation/abduction of hip fixed flexion deformity positive Trendelenburg sign x-ray - joint space narrowing, sclerosis, subchondral cysts, osteophytes Treatment non-operative weight loss, walking aids, physiotherapy, analgesia (acetaminophen), NSAIDs surgery realign - osteotomy replace - arthroplasty ablate - arthrodesis, excision Trendelenberg Test (see Figure 23) patient stands on affected leg, normally gluteus medius muscle on ipsilateral side contracts to keep pelvis level a positive test is if the contralateral side drops or if patient compensates by leaning way over supported leg may occur anywhere along line "ab" e.g. weak abductors, avulsion of gluteus medius, trochanteric fracture/removal may occur anywhere along line bc e.g. painful hip due to osteoarthritis, femoral neck in varus, acetabular instability may occur anywhere along line ac e.g. fractured pelvic side wall
Figure 23. Causes of a Positive Trendelenberg Sign
AVN OF THE FEMORAL HEAD (see Avasular Necrosis section)

Clinical sudden onset of severe pain, related to weight-bearing worse at night rapid progression (compared to osteoarthritis) Diagnosis x-ray - r/o hip fracture bone scan - see healing fracture MRI (best) Treatment early: vascularized fibular graft to preserve femoral head, rotational osteotomy in young patient with moderate disease late: hip replacement
FEMORAL DIAPHYSIS FRACTURES
high energy (MVA, fall from height, gunshot wounds) low energy (spiral fracture in children) high morbidity/mortality (hemorrhage, fat embolism, ARDS, MODS) blood replacement often required frequently comminuted soft tissue trauma Orthopedics OR23
FEMUR
Clinical leg is shortened, externally rotated unable to weight bear assess neurovascular status r/o: open fracture, soft tissue compromise r/o: child abuse with spiral fractures in children Treatment ABCs of trauma are essential immobilize leg with Thomas Splint adequate analgesia surgical fixation (intramedullary nail) within 24 hours high rate of surgical union after 6 to 12 weeks early mobilization of hip and knee
SUPRACONDYLAR FEMORAL FRACTURE

high energy, multiple trauma knee joint is disrupted severely with bicondylar fracture poor prognosis with comminuted fractures high incidence of post-traumatic arthritis
Treatment internal fixation and early knee ROM quadriceps strengthening
KNEE
Figure 24. Diagram of Right Tibial Plateau

Adapted with permission from McRae, Clinical Orthopedic Examination, 3rd ed. Churchill Livingstone, New York, 1994.
COMMON KNEE SYMPTOMS
locking = spontaneous block to extension torn meniscus, loose body pseudo-locking = restricted ROM without mechanical block arthritis (effusion, pain), muscle spasm following injury instability = giving out torn arterior cruciate ligament (ACL), patellar subluxation, torn meniscus, loose body traumatic knee swelling effusion, usually represents hemarthrosis ligamentous injury with hemarthrosis meniscal injury traumatic synovitis non-traumatic knee swelling without trauma septic or crystal-induced arthritis seronegative arthritis (AS, Reiter's, Psoriatic, IBD) seropositive arthritis (RA, SLE) avascular necrosis sickle cell disease
EVALUATION OF KNEE COMPLAINTS

History ligament injuries require high energy force meniscal injury in young person requires moderate force, while in older person only requires mild force OR24 Orthopedics MCCQE 2006 Review Notes
KNEE . . . CONT.
Physical Examination LOOK:SEADS, alignment FEEL: effusion, crepitus MOVE: gait, strength, ROM Special Tests of the Knee Anterior and Posterior Draw Tests demonstrate torn ACL and PCL, respectively knee flexed at 90 degrees, foot immobilized, hamstrings released if able to sublux tibia anteriorly then ACL may be torn if able to sublux tibia posteriorly then PCL torn Lachmann Test demonstrates torn ACL hold knee in 10-20 degrees flexion, stabilizing the femur try to sublux tibia anteriorly on femur similar to anterior drawer test, more reliable due to less muscular stabilization Posterior Sag Sign demonstrates torn PCL may give a false positive anterior draw sign flex knees and hips to 90 degrees, hold ankles and knees view from the lateral aspect if one tibia sags posterior than the other, its PCL is torn; loss of prominence of tibial tuberosity Pivot Shift Sign demonstrates torn ACL start with the knee in extension internally rotate foot, apply valgus force to knee look and feel for anterior subluxation of lateral tibial condyle slowly flex while palpating knee and feel for pivot which is the tibiofemoral reduction reverse pivot shift (start in flexion, externally rotate, apply valgus and extend knee) suggests torn PCL Collateral Ligament Stress Test palpate ligament for "opening" of joint space while testing with knee in full extension apply valgus force to test MCL, apply varus force to test LCL repeat tests with knee in 20 degrees flexion to relax joint capsule opening only in 20 degrees flexion due to MCL damage only opening in 20 degrees of flexion and full extension is due to MCL, cruciate, and joint capsule damage test for Meniscal tear Crouch Compression test is the most sensitive test joint line pain when squatting McMurrays test useful collaborative information with knee in flexion palpate joint line for painful pop internally rotate foot, varus stress, and extend knee to test lateral meniscus externally rotate foot, valgus stress, and extend knee to test medial meniscus X-Rays of the Knee AP standing, lateral skyline view with knees in flexion, beam is aimed from anterior tibia to anterior femur allows for view of patellofemoral joint obliques for intra-articular fractures 3 foot standing view radiograph from hip to foot with patient in standing position useful in evaluating leg length and genu varus / valgus
LIGAMENTOUS INJURIES OF THE KNEE
may have hemarthrosis and/or effusion in acute phase deceleration or pivoting injury must check for effusion and tenderness on physical exam
ANTERIOR CRUCIATE LIGAMENT (ACL) TEAR

History indirect varus blow to knee hyperextended knee + internal rotation audible pop, knee instability, giving way immediate swelling inability to continue activity Physical posterolateral joint line tenderness positive Lachmann, pivot shift, anterior draw effusion, +/ hemarthrosis +/ associated medial meniscus tear, MCL injury (O'Donahue's Unhappy Triad) associated with Segond fractures - lateral tibial avulsion fractures MCCQE 2006 Review Notes Orthopedics OR25
KNEE . . . CONT.
Treatment based on activity and functional impairment stable with minimal functional impairment early mobilization physiotherapy and quadriceps strengthening instability with functional impairment / high demand lifestyle ACL reconstruction
POSTERIOR CRUCIATE LIGAMENT (PCL) TEAR

much less common than ACL injury History fall onto flexed knee with plantar flexed foot hit anterior tibia on dashboard in motor vehicle accident hyperflexion or hyperextension with anterior tibial force Physical positive posterior sag sign false positive anterior draw true positive posterior draw reverse pivot shift sign Treatment non-operative vs. surgical PCL reconstruction
MEDIAL COLLATERAL LIGAMENT (MCL) TEAR

History valgus force to knee +/ "pop" heard severe pain with partial tears complete tear may be painless Physical swelling tender above and below medial joint line assess joint space opening with valgus force pain MCL laxity with end point - partial tear absence of end point - complete tear rule out ACL and medial meniscus tear Treatment minor immobilize briefly, early ROM and strengthening moderate knee immobilizer or cast early physiotherapy with ROM and strengthening severe or combined surgical repair of associated injuries surgical repair of isolated MCL tear is controversial
LATERAL COLLATERAL LIGAMENT TEAR
varus force to knee similar history, physical to MCL rule out common peroneal nerve injury (difficult dorsiflexion and decreased sensation at the top of the foot) treatment as for MCL medial meniscus torn 8x more than lateral 1/2 are traumatic, 1/2 are degenerative usually associated with other ligamentous injuries if traumatic
MENISCAL TEAR
History twisting force when the knee is partly or completely flexed e.g. squatting and then rotating rapidly, skiing, football, tennis acute immediate pain, difficulty weight bearing, +/ locking chronic pain, swelling, instability OR26 Orthopedics MCCQE 2006 Review Notes
KNEE . . . CONT.
Physical effusion lack of full extension (locking) pinpoint joint line tenderness McMurray's test Diagnosis and Treatment MRI is diagnostic only non-operative (unless locked) ROM and strengthening exercises NSAIDs failed non-operative arthroscopy (diagnostic and therapeutic)
PATELLAR/QUADRICEPS TENDON RUPTURE
low energy injury, sudden forceful contraction during attempt to stop fall partial or complete more common in patients with diabetes, SLE, RA, steroid use
History fall onto flexed knee inability to extend knee Physical palpable gap between patella and quadriceps may have hemarthrosis / effusion of knee Investigations knee radiographs to rule out patellar fracture joint aspirate may show hemarthrosis Treatment surgical repair of tendon
DISLOCATED KNEE
bad high energy injury associated injuries popliteal artery intimal tear or disruption 35-50% capsular, ligamentous and common peroneal nerve injury
Investigations angiogram Treatment closed reduction, above knee cylinder cast x 4 weeks alternately, external fixation especially if vascular repair surgical repair of all ligaments if high demand patient
PATELLA
PATELLA DISLOCATION
Etiology commonly seen in young adults patella dislocates laterally over flexed knee predisposition - weak vastus medialis muscle and tight lateral retinaculum, valgus knees can be acute, chronic or recurrent acute occurs with direct blow, excessive muscular forces recurrent type is associated with shallow intercondylar groove or patella alta (high riding patella) may have associated osteochondral fracture of anterior lateral femoral condyle or avulsion of medial patella Diagnosis severe pain difficulty extending knee positive patellar apprehension sign sublux patella laterally over extended knee pain if subluxation is reproduced, patient apprehensive chronic patient reports catching, giving way with walking or turning MCCQE 2006 Review Notes Orthopedics OR27
PATELLA . . . CONT.
Treatment acute - non-operative reduce patella gentle ROM strengthen quadriceps, especially vastus medialis support during sports activities chronic / recurrent often non-operative treatment unsuccessful lateral retinacular release (surgical) plus medial plication tibial tubercle transfer corrects line of force by reinserting patella medially and distally
CHONDROMALACIA PATELLAE
also known as patellofemoral syndrome commonly seen in young adults, especially females softening of articular cartilage, usually medial aspect of patella etiologies: malalignment, trauma, congenital abnormal shape of patella or femoral groove, recurrent patellar subluxation or dislocation, excessive knee strain (athletes)
History deep aching anterior knee pain exacerbated by prolonged sitting, strenuous athletic activities, stair climbing Physical pathognomonic: pain with firm compression of patella into medial femoral groove tenderness to palpation of underside of medially displaced patella increased Q-angle - angle formed between thigh and patellar tendon pain with extension against resistance through terminal 30-40 degrees X-Rays AP, lateral, skyline Treatment non-operative treatment physio (isometric quads strengthening) NSAIDs surgical treatment with refractory patients tibial tubercle elevation arthroscopic shaving and debridement and lateral release
PATELLAR FRACTURE
History direct - blow to patella indirect - sudden muscular contraction immediate pain Physical marked tenderness, pain patellar deformity inability to extend knee proximal displacement of patella unable to straight leg raise because disruption of extensor mechanism X-Ray AP, lateral (need to exclude bipartite patella - common congenital fragmentation of the patella) Treatment isolated vertical fractures - non-operative treatment - plaster cast 6 weeks, early ROM transverse displaced fracture - ORIF comminuted fracture - ORIF; may require complete or partial patellectomy
OR28 Orthopedics
TIBIA
TIBIAL PLATEAU FRACTURE
result from femoral condyle(s) being driven into the proximal tibia often due to a valgus or varus force lateral > medial Treatment if depression is < 3 mm long leg cast-brace, NWB x 2 months if depression > 3 mm, displaced or comminuted ORIF +/ bone graft to elevate fragment
TIBIAL DIAPHYSIS FRACTURE
high intensity injury associated with crush injuries and MVAs soft tissue, nerve and vessel injury common assess neurovascular status rule out open fracture displacement is difficult to control good reduction is required minimal shortening and angulation healing time: 16 weeks on average
Treatment ABCs closed injuries = closed reduction long leg cast x 4-6 weeks followed by BK cast until healed open injuries ORIF with external fixator wounds on anterior surface heal poorly and may necrose unstable injuries or failed closed reduction require IM nail high risk of compartment syndrome closed reduction and cast; admit and observe for compartment syndrome surgery; prophylactic fasciotomy if operating on tibia fracutre
ANKLE
EVALUATION OF ANKLE COMPLAINTS
history ask about pain, swelling, mechanism of injury, effect on standing/walking physical examination neurovascular status look, feel, move (dorsiflexion, plantarflexion) assess for tenderness at knee (Maisonneuve), lateral and medial malleoli special test: anterior draw (for ankle), talar tilt, squeeze test, Thompson test
X-ray views AP, Lateral and Mortise (15 degrees internal rotation) Mortise gives true view of talus in tibiotalar joint space between talus > tibia and talus > fibula space should be symmetric and < 4 mm with no talar tilt disrupted space signifies ligamentous or bony injury when to x-ray - Ottawa ankle rules ankle x-ray is only required with pain in malleolar zone AND bony tenderness over posterior aspect of the distal 6 cm of medial or lateral malleolus OR inability to weight bear both immediately and in E.R. foot x-ray series is only required with pain in midfoot zone AND bony tenderness over navicular or base of fifth metatarsal OR inability to weight bear both immediately and in E.R.
Orthopedics OR29
ANKLE . . . CONT.
ANKLE FRACTURES
Figure 25. Ring Principle of Ankle Fractures and Danis-Weber Classification
Adapted with permission from Dandy, Essential
Orthopedics and Trauma, 2nd ed. Churchill Livingstone,
New York, 1993.
Ring Principle of the Ankle the ankle can be thought of as a ring (see Figure 25) a: lateral malleolus b: medial malleolus c: posterior malleolus (posterior medial malleolus) d: deltoid ligament e: syndesmotic ligament (syndesmosis) f: calcaneofibular ligament fractures of the ankle involve ipsilateral ligamentous tears or bony avulsion contralateral shear fractures pattern of fracture determined by mechanism of injury avulsion fractures are transverse shear fractures are oblique if pure inversion / eversion shear fractures are spiral if rotational force Danis-Weber Classification based on level of fibular fracture relative to syndesmosis Type A (infra-syndesmotic) pure inversion injury avulsion of lateral malleolus below plafond or torn calcaneofibular ligament +/ shear fracture of medial malleolus Type B (trans-syndesmotic) external rotation and eversion avulsion of medial malleolus or rupture of deltoid ligament spiral fracture of lateral malleolus starting at plafond Type C (supra-syndesmotic) pure external rotation avulsion of medial malleolus or torn deltoid ligament fibular fracture is above plafond frequently tears syndesmosis Maisonneuve fracture if at proximal fibula posterior malleolus avulsed with posterior tibio-fibular ligament Lauge Hansen Classification based on mechanism of injury; first word= position of foot, second word = direction of movement of the talus in relation to the leg Supination-External Rotation most common (45-65%) supination and external rotation, resulting in oblique fracture at the level of the sydesmosis equivalent to Weber Type B Pronation-Abduction sequence of injury: 1) avulsion fracture of medial malleolus or rupture of deltoid ligament; 2) abduction force then either ruptures the syndesmosis or avulses its bony attachment sites; 3) lateral force from talus impacts and fractures fibula at or above level of syndesmosis and ruptures interosseous membrane Pronation-External Rotation sequence of injury: 1) transverse fracture of the medial malleolus or disruption of deltoid ligament; 2) external rotation then results in rupture of the anterior tibiofibular ligament or its bony insertion; 3) oblique or spiral fracture of fibula above the level of the joint; 4) posterior injury with tibiofibular ligament rupture or avulsion of posterior malleolus fibular fracture may be proximal (i.e., Maisonneuve fracture) equivalent to Weber Type C Supination-Adduction sequence of injury: 1) supination force may rupture portions of lateral collateral ligaments or may avulse distal fibula, resulting in transverse fracture below the level of intact syndesmosis; 2) adduction forces talus against the medial side of the joint, resulting in vertical fracture of the medial malleolus Equivalent to Weber Type A OR30 Orthopedics MCCQE 2006 Review Notes
ANKLE . . . CONT.
Treatment undisplaced fractures: NWB BK cast displaced fractures: reduction ASAP indications for ORlF all fracture-dislocations all type C fractures trimalleolar (lateral, medial, posterior) fractures talar shift or tilt failure to achieve or maintain closed reduction prognosis dependent upon anatomic reduction high incidence of post-traumatic arthritis
LIGAMENTOUS INJURIES
Medial Ligament Complex (deltoid ligament) responsible for medial stability usually avulses medial or posterior malleolus posterior malleolus = posterior part of medial malleolus usually associated with syndesmotic or lateral ankle sprain
Figure 26. Lateral View of Ligaments of Left Ankle Lateral Ligament Complex (ATFL, CFL, PTFL) responsible for lateral stability clinical: swelling and discoloration, pop sound, giving way diagnosis: stress x-rays and mortise view talar inversion produces joint separation exceeding the unaffected side by six degrees (talar tilt test)
frequncy of injury: ATFL > CFL > PTFL
Anterior Talofibular Ligament (ATFL) most common ligamentous ankle injury sprained by inversion and while ankle is in plantar flexion swelling and tenderness anterior to lateral malleolus, ++ ecchymoses anterior draw test for ankle positive with Grade III ATFL injury attempt to sublux talus anteriorly if positive then stress other lateral ligaments talar tilt test for integrity of other ligaments Grading and Treatment of Ligamentous Ankle Injuries Grade I (microscopic stretch or tear) pain RICE (Rest, Ice, Compression, Elevation) Grade II (macroscopic tear) pain on motion strap ankle in dorsiflexion and eversion no more than 6 weeks, physio for proprioceptive re-training Grade III (complete tear) unstable ankle talar tilt apparent on mortise view BK walking cast x 3 weeks, physiotherapy for proprioceptive re-training surgical intervention may be required etiology ligamentous laxity joint (loss of normal proprioception) internal derangement of anatomy intra-articular loose body treatment depends on cause strengthening and balance training for neuropathic joint ligament reconstruction for lateral laxity and talar tilt arthroscopy / arthrotomy for internal derangement MCCQE 2006 Review Notes
RECURRENT ANKLE SUBLUXATION
Orthopedics OR31
FOOT
EVALUATION OF FOOT COMPAINTS
history pain, swelling, loss of function, sensory changes, deformity, mechanism of injury, activity level of patient physical inspection, palpation, active and passive ROM, weight bearing status neurovascular status x-rays AP, lateral, oblique (as a minimum) 60% of talus covered by articular surface decreased surface area for vascular perforation blood supply to talus: distal to proximal fractures of the neck at risk of AVN mechanism: MVA or fall from height axial loading or hyper-plantar flexion injury talar neck driven into tibial margin rule out potential associated injuries spinal injuries, femoral neck fractures, tibial plateau fractures
TALAR FRACTURE
X-Rays AP/lateral films with CT scan or tomograms of talus Treatment BK cast, NWB x 6 months ORIF: to reduce displacement and prevent AVN or non-union Complications undisplaced: 0-10% risk of AVN displaced: 100% risk of AVN
CALCANEAL FRACTURE
mechanism is axial loading (eg. fall from a height onto the heels) rule out potential associated injuries spinal injuries (10%) femoral neck fractures tibial plateau fractures
Physical heel viewed from behind is wider, shorter, flatter, varus tilt may be swollen, with bruising on soles X-Rays (see Figure 27) Brodens views (oblique views of subtalar joint) Bohler's Angle decreased (normal: 20 - 40 degrees) Treatment goal is to prevent widened heel and maintain subtalar joint congruency
NWB, early ROM
ORIF if depressed centrally or tongue-type fracture closed vs. open treatment is controversial
ACHILLES TENDONITIS
Figure 27. Bohler's Angle
chronic inflammation from running and shoe-wear Illustration by Marc Dryer (high heels) may develop heel bumps (inflammation of superficial bursa overlying lateral insertion of Achilles tendon into calcaneus)
Diagnosis pain, aggravated by passive stretching tenderness, swelling crepitus on plantar flexion Treatment rest, gentle stretching, NSAIDs proper footwear +/ orthotics do NOT inject steroids (prone to rupture) usually an audible pop or a sensation of being kicked at site mid tendon or musculotendinous junction (2-6 cm from insertion on calcaneus) spontaneously ruptures during loading activity (e.g. squash, tennis) secondary to steroid injection OR32 Orthopedics
ACHILLES TENDON RUPTURE
FOOT
. . . CONT.
Diagnosis history of pain and inability to walk tenderness, palpable gap, weak plantar flexion apprehensive to toe-off when walking Thompson Test (patient lying prone) squeezing calf does not passively plantar flex foot Treatment low demand or elderly patient cast with foot in plantar flexion to relax tendon high demand or young surgical repair vs. cast (controversial)
PLANTAR FASCIITIS
repetitive strain injury of plantar fascia common in runners, jumpers, ballet dancers, obesity chronic inflammation due to microtears of plantar fascia
History intense pain on waking or after rest subsides as patient walks may be associated with systemic diseases diabetes mellitus enthesopathies including seronegative and seropositive arthritis Physical swelling, local tenderness over plantar fascia mostly at medial calcaneal tubercle pain with toe dorsiflexion (stretches plantar fascia) X-Ray sometimes show heel spur at insertion of fascia into medial calcaneal tubercle Note: spur is reactive, not the cause of pain Treatment non-operative (90% resolve) rest and NSAIDs x 4-6 months steroid injection ultrasound and stretching exercises supportive shoes with heel cup surgical in refractory cases (must r/o nerve entrapment as cause of pain first) release of plantar fascia 50% effective at pain relief spur removal not required can now be done endoscopically
BUNIONS
two primary causes: heriditary, shoewear, 10x more frequent in women Hallux Valgus may be associated with metatarsus primus varus valgus alignment of MTP joint is aggrevated by eccentric pull of EHL and intrinsics secondary exostosis forms with bursa and thick skin creating the bunion
Treatment treatment is cosmetic and for pain with shoes non-operative first properly fitted shoes and toe spacer surgical removal of bunion with realignment of 1st MTP joint
METATARSAL FRACTURE
as with the hand, 1st, 4th, 5th metatarsals (MT) are relatively mobile, while the 2nd and 3rd are fixed (see Table 14)
Orthopedics OR33
FOOT
. . . CONT.
Table 14. Types of Metatarsal Fractures

Fracture Avulsion of Base of 5th MT Jones Fracture midshaft 5th MT March Fracture shaft 2nd, 3rd MT 1st MT Fracture Mechanism Sudden inversion followed by contraction of peroneus brevis Stress injury Stress injury Trauma Clinical Tender base of 5th MT x-ray foot Painful shaft of 5th MT Painful shaft of 2nd or 3rd MT Painful 1st MT Treatment Requires ORIF if displaced
NWB BK cast x 6 weeks ORIF if athlete Symptomatic ORIF if displaced otherwise NWB BK cast x 3 weeks then walking cast x 2 weeks ORIF
Lisfranc Fracture dislocation
Tarso-MT fracture-
Fall onto plantar flexed foot or direct crush injury
Shortened forefoot prominent base
ORTHOPEDIC INFECTIONS
OSTEOMYELITIS
bacterial, viral or fungal infection of bone OR bone marrow infants, young children, patients with sickle cell anemia, septic arthritis, open fractures, diabetes and immuncompromised more susceptible than healthy adults infection can be due to direct (trauma, surgery) or hematogenous route S. aureus (most common cause of hematogenous route) mixed infection i.e. Staph, Enterobacteriaceae, Pseudomonas (trauma, post-op, diabetic or IV drug use) Salmonella(Sickle Cell Disease) H. influenzae(young children) M. tuberculosis (affects both sides of joint)
History asymptomatic (chronic) history of infection at another site, direct trauma to the area acute sepsis fever, chills, dehydration, lethargy presentation is typically less acute in adults Physical febrile local tenderness, swelling, heat at metaphysis, decreased joint motion neonates pseudoparalysis associated with septic arthritis often few signs and symptoms in the adult; usually tender, inflammation Diagnostic Tests bloodwork elevated ESR, serial WBC, C-reactive protein blood cultures before antibiotics started (often negative in adults) cultures and gram stain from wound or bone biopsy X-rays acute: often normal, lucencies appear after 2-4 weeks chronic: onion-skin appearance
CT/MRI MEDICAL EMERGENCY
reveal medullary edema and destruction, periosteal reaction, cortical destruction, articular damage, and soft-tissue involvement bone scan Indium, Gallium and Technetium show locally increased uptake; Gallium more specific for infection Treatment IV antibiotics x 4-6 weeks irrigation and debridement +/- amputation of extremity antibiotic bead insertion at site of wound: tobramycin, gentamycin, or vancomycin-impregnated bone cement beads removal or replacement of prosthesis OR34 Orthopedics MCCQE 2006 Review Notes
ORTHOPEDIC INFECTIONS. . . CONT.

SEPTIC ARTHRITIS
routes of spread hematogenous (most common) direct spread from adjacent infection inoculation
Table 15. Organisms in Septic Arthritis

Age 0-6 months 6-36 months >36 months Adults Organisms S. aureus E. coli S. aureus H. influenzae S. aureus streptococci S. aureus N. gonorrhoeae (especially adults < 30 years) Antibiotic Choice Cloxacillin Tobramycin / Gentamycin Cloxacillin +/ Ampicillin Cloxacillin +/ Penicillin G Cloxacillin (S.aureus) Ceftriaxone (N. gonorrhoeae)
N. gonorrhoeae - most common cause of septic arthritis; can affect multiple joints; if disseminated can have tenosynovitis, skin lesions, young adult males S. aureus - most common cause of non-gonococcal adults M. tuberculosis - often accompanies bone lesions (direct spread), also commonly via hematongenous spread others B. burgdorferi (Lyme disease) S. schenckii (most common fungal cause) Salmonella(Sickle Cell disease) Pseudomonas (IV drug use) History severe pain acute sepsis fever, chills, dehydration, lethargy
MEDICAL EMERGENCY!
Physical local joint tenderness, swelling, heat neonates get pseudoparalysis joint held in slight flexion to reduce intra-articular pressure unable or unwilling to move joint Diagnostic Tests blood and throat swab cultures joint aspirate for cultures, crystals, WBC, Gram stain, ESR, C-reative protein (CRP), glucose bone scan (hip only) not used to make diagnosis assesses viability of femoral head Treatment medical: IV fluids and antibiotics, analgesia surgical: aspiration or open surgical debridement Complications early septic dislocation AVN femoral head (increased intra-articular pressure due to pus) late cartilage and epiphyseal destruction osteomyelitis Other Joint Infections Reactive Arthritis post infectious most common cause streptococci do not need antibiotics (culture is sterile) Viral Arthritis hepatitis B, rubella, mumps, parvovirus B19
Orthopedics OR35
PEDIATRIC ORTHOPEDICS
FRACTURES IN CHILDREN
different from fractures in adults periosteum is thicker and stronger in children type of fracture usually greenstick or buckle because periosteum is intact on one or both sides adults fracture through both cortices epiphyseal growth plate plate often mistaken for fracture and vice versa x-ray opposite limb for comparison ligamentous injury rarely occur in children mechanism which causes ligamentous injury in adults causes growth plate injury in children anatomic reduction gold standard with adults may cause limb length discrepancy in children (overgrowth) accept greater angular deformity in children (remodelling) intra-articular fractures have worse consequences in children because they usually involve the growth plate time to heal shorter in children always be aware of the possibility of child abuse make sure injury mechanism compatible with injury high index of suspicion, look for other signs, including x-ray evidence of healing fractures at other sites
EVALUATION OF THE LIMPING CHILD(see Pediatrics Chapter) EPIPHYSEAL INJURY
Figure 28. Salter-Harris Classification of Epiphyseal Injury

Adapted with permission from Dandy, Essential Orthopedics and Trauma, 2nd ed. Churchill Livingstone, New York, 1993.
Salter-Harris Classification
SALT(E)R
(see Figure 28)
Stable (Type I) transverse through growth plate Above (Type II, most common) through metaphysis and along growth plate Low (Type III - involves articular surface) through epiphysis to plate and along growth plate Through (Type IV - involves articular surface) through epiphysis and metaphysis Ram (Type V) crush injury of growth plate Treatment of Epiphyseal Injury Type I and II closed reduction and cast immobilization heals well, 95% do not affect growth Type III and IV anatomic reduction by ORIF since intra-articular, and also to prevent growth arrest Type V high incidence of growth arrest no specific treatment annular ligament slips between radial head and capitellum follows pull on child's forearm rule out child abuse 2-6 years old, due to underdeveloped radial head forearm is pronated, painful and will not move point tenderness over radial head pseudoparalysis of arm radiographs not for diagnosis, but to rule out fracture treatment gentle supination while moving from extension to flexion pain relieved and function returns immediately may immobilize x 1 day in sling for comfort OR36 Orthopedics
PULLED ELBOW
PEDIATRIC ORTHOPEDICS. . . CONT.

DEVELOPMENTAL DYSPLASIA OF THE HIP (DDH)
formerly called congenital dysplasia of the hip (CDH) due to ligamentous laxity and abnormal slope of acetabular roof predisposing factors (6 Fs) Family history, F emales (> males), Frank breech, First born, le Ft side spectrum of conditions dislocated femoral head completely out of acetabulum dislocatable head in socket head subluxes out of joint when provoked dysplastic acetabulum, more shallow and more vertical than normal if painful suspect septic dislocation
Physical diagnosis is clinical limited abduction of the flexed hip (< 50-60 degrees) affected leg shortening results in asymmetry in skin folds and gluteal muscles, wide perineum Barlow's test (unstable but located hip) flex hips and knees to 90 degrees and grasp thigh fully adduct hips, push posteriorly Ortolani's test (for dislocated hip) initial position as above but try to reduce hip with fingertips during abduction palpable clunk if reduction is a positive test Galleazzi's Sign difficult test if child < 1 year knees at unequal heights when hips and knees flexed dislocated hip on side of lower knee Trendelenburg test and gait useful if older (> 2 years) Imaging can U/S in first few months to view cartilage follow up radiograph after 3 months CT scan (rarely done) Treatment and Complications 0-6 months: Reduce hip using Pavlik harness to maintain abduction and flexion 6-18 months: reduction under GA, hip spica cast x 2-3 months (if Pavlik harness fails) > 18 months: open reduction; pelvic and/or femoral osteotomy complications redislocation, inadequate reduction, stiffness AVN of femoral head
LEGG-CALVE-PERTHES DISEASE
self-limited AVN of femoral head etiology unknown, 20% bilateral, males more common increased incidence with family history, low birth weight, and abnormal pregnancy/delivery male:female = 4:1 key features: AVN of proximal femoral epiphysis, abnormal growth of the physis, and eventual remodeling of regenerated bone clinical picture limping child usually 4-10 years old tender over anterior thigh flexion contracture; decreased internal rotation, abduction x-ray may be negative early eventually, characteristic collapse of femoral head (diagnostic) subchondral fracture metaphyseal cyst treat to preserve ROM and preserve femoral head in acetabulum physiotherapy for ROM brace in flexion and abduction x 2-3 years femoral or pelvic osteotomy prognosis better in males < 5 years old, < 1/2 head involved, abduction > 30 50% of involved hips do well with conservative treatment complicated by early onset osteoarthritis and decreased ROM
Type I Salter-Harris epiphyseal injury most common adolescent hip disorder, peak at 12-15 years risk: male, obese, hypothyroid acute (sudden displacement) and chronic (insidious displacement) forms Etiology is Multifactorial genetic (autosomal dominant, Blacks > Caucasians) cartilaginous physis thickens rapidly under growth hormone (GH) effects sex hormone secretion, which stabilizes physis, has not yet begun overweight - mechanical stress History acute - sudden, severe pain with limp chronic - limp with medial knee or anterior thigh pain MCCQE 2006 Review Notes
SLIPPED CAPITAL FEMORAL EPIPHYSIS
Orthopedics OR37
PEDIATRIC ORTHOPEDICS. . . CONT.

Physical Whitmans sign: with flexion there is an obligate external rotation of the hip restricted internal rotation, abduction, flexion pain at extremes of ROM tender over joint capsule X-Rays need AP and frog-leg lateral views posterior and medial slip if mild slip, AP view may be normal or slightly widened growth plate compared with opposite side Treatment and Complications acute - gentle reduction, possible ORIF chronic- ORIF of slip to fix in current position and prevent progression complications - AVN (most common), chondrolysis, pin penetration, premature OA, chronic loss of ROM
CONGENITAL TALIPES EQUINOVARUS (CTEV)
also known as club foot 3 parts to deformity Talipes: talus is inverted and internally rotated Equinus: ankle is plantarflexed Varus: heel and forefoot are in varus (supination) may be idiopathic, neurogenic, or syndrome-associated examine hips for associated DDH examine knees for deformity examine back for dysraphism (unfused vertebral bodies) 1/1,000 newborns, 50% bilateral, occurrence M > F, severity F > M treat by changing cast q 2-3 weeks correct deformities in order forefoot adduction, ankle inversion, equinus surgical release in refractory case (50%) delayed until 3-4 months of age 3 year recurrence 5-10% mild recurrence common; affected foot is permanently smaller/stiffer that normal foot, with decreased calf circumference
SCOLIOSIS
Table 16. Etiology of Scoliosis
Type Idiopathic Congenital Secondary Neuromuscular Other Cause Most common (90%) Vertebrae fail to form or segment Leg length discrepancy, muscle spasm UMN or LMN lesion, myopathy Osteochondrodystrophies, neoplastic, traumatic
age: 10-14 years appears to be multifactorial with evidence of idiopathic scoliosis being a single gene disorder following Mendelian patterns with variable penetrance and heterogeneity more frequent and more severe in females Physical asymmetric shoulder height when bent forward Adams Test: rib hump when bent forward scapulae prominent, flank creased, pelvis asymmetric associated posterior midline skin lesions cafe-au-lait spots, dimples, neurofibromas axillary freckling hemangiomas, hair patches pelvic obliquity associated pes cavus or leg atrophy apparent leg length discrepancy X-Rays 3 foot standing films use Cobb's method to measure curvature may have associated kyphosis Treatment Based on Degree of Curvature < 20 degrees: observe for changes > 20 degrees or progressive: bracing (many types) > 40 degrees, cosmetically unacceptable or respiratory problems require surgical correction OR38 Orthopedics MCCQE 2006 Review Notes
BONE TUMOURS
primary bone tumours are rare after 3rd decade metastases to bone are relatively common after 3rd decade Diagnosis pain, swelling, tenderness routine x-ray - describe by: location (which bone, diaphysis, metaphysis, epiphysis) size involvement (cortex, medulla, soft tissue) radiolucent, radiodense or calcified reaction of surrounding bone (sclerosis, borders) margin any pathological fracture malignancy is suggested by rapid growth, warmth, tenderness, lack of sharp definition staging should include bloodwork CT chest liver function tests bone scan as much information as possible on anatomic extent of tumour (including plain films, tomography, bone scanning, angiography,CT, +/ MRI if necessary) should be obtained prior to biopsy should be referred to specialized centre prior to biopsy if you are not going to resect it dont biopsy it classified into benign, benign aggressive, and malignant
BENIGN BONE TUMOURS

1. Osteoid Osteoma age 10-25 years small, round radiolucent nidus (< 1 cm) surrounded by dense bone tibia and femur; diaphyseal produces severe intermittent pain, mostly at night characteristically relieved by ASA 2. Osteochondroma metaphysis of long bone cartilage-capped bony spur on surface of bone (mushroom on x-ray) may be multiple (hereditary form) - higher risk of malignant change generally not painful unless impinging on neurovascular structure malignant degeneration occurs in 1-2 % 3. Enchondroma age 20-40 years 50% occur in the small tubular bones of the hand and foot; others in femur, humerus, ribs benign cartilage growth, develops in medullary cavity single/multiple enlarged rarefied areas in tubular bones lytic lesion with specks of calcification on x-ray 4. Cystic Lesions includes unicameral bone cyst, aneurysmal bone cyst, fibrous cortical defect children and young adults local pain, pathological fracture or accidental detection translucent area on metaphyseal side of growth plate cortex thinned/expanded; well defined lesion treatment of unicameral bone cyst with steroid injections +/ bone graft Treatment in general, curettage +/ bone graft
BENIGN AGGRESSIVE BONE TUMOURS

1. Giant Cell Tumours 80% occur > 20 years, average 35 years distal femur, proximal tibia, distal radius pain and swelling cortex appears thinned, expanded; well demarcated sclerotic margin 1/3 benign, 1/3 invasive, 1/3 metastasize 30% reccur within 2 years of surgery 2. Osteoblastoma aggressive tumour forming osteoid lesions > 2 cm in size and grow rapidly painful most frequent in spine and long bones (humerus, femur, tibia) Treatment controversial, should do metastatic work up wide local excision +/ bone graft MCCQE 2006 Review Notes
Orthopedics OR39
BONE TUMOURS. . . CONT.

MALIGNANT BONE TUMOURS
Table 17. Most Common Malignant Tumour Types For Age
Age 1 1 - 10 10 - 30 30 40 >40 Tumour Neuroblasotma Ewings of tubular bones Osteosarcoma, Ewings of flat bones Reticulum cell sarcoma, fibrosarcoma, parosteal osteosarcoma, malignant giant cell tumour, lymphoma Metastatic carcinoma, multiple myeloma, chondrosarcoma
1. Osteosarcoma bimodal age distribution ages 10-20 (60%) > 50 with history of Paget's disease invasive, variable histology; frequent metastases predilection for distal femur (45%), tibia (20%) and proximal humerus (15%) history of trauma common painful, tender, poorly defined swelling x-ray shows Codman's Triangle: characteristic periosteal elevation and spicule formation representing tumour extension into periosteum with calcification treatment with complete resection (limb salvage, rarely amputation) adjuvant chemo, radiotherapy 2. Chondrosarcoma primary: previous normal bone, patient over 40; expands into cortex to give pain, pathological fracture, flecks of calcification secondary: malignant degeneration of preexisting cartilage tumour such as enchondroma or osteochondroma occurs in pelvis, femur, ribs, shoulder x-ray shows large exostosis with calcification in cap highly resistant to chemotherapy, treat with aggressive surgical resection 3. Ewing's Sarcoma thought to be undifferentiated member of a family of neural tumours distinct form neuroblastoma most occur between 5 - 20 years old florid periosteal reaction in diaphysis of long bone; ages 10-20 present with mild fever, anemia, leukocytosis and elevated ESR moth-eaten appearance with periosteal "onion-skinning" metastases frequent treatment: chemotherapy, resection, radiation 4. Multiple Myeloma most common primary malignant tumour of bone in adults 90% occur in people > 40 years old anemia, anorexia, renal failure, nephritis, ESR elevated osteoporosis, punched out lesions, compression fracture weakness, bone pain diagnosis serum/urine protein electrophoresis bone marrow aspirate treatment: resection, chemotherapy, radiation 5. Bone Metastases see bonezine ring (see Figure 29) PT B arnum Loves Kids 2/3 from Breast or P rostate also consider T hyroid, Lung, Kidney usually osteolytic; prostate occasionally osteoblastic bone scan may be helpful stabilization of impending fractures internal fixation IM rods bone cement
Figure 29. Bonezine Ring
OR40 Orthopedics
SURGICAL PROCEDURES
SLIDING HIP SCREW INSERTION
Objective to reduce and stabilize a hip fracture. Indications intertrochanteric fractures Landmarks palpate the greater trochanter and the shaft of the femur. Procedure fracture reduction the patient is positioned supine on an orthopaedic fracture table traction is placed on the fractured leg and the distal portion of the leg is abducted and internally rotated to obtain an anatomical reduction of the fracture an image intensifier (fluoroscope) is used to ensure the fracture is properly reduced obtaining a good closed reduction prior to the surgery is crucial incision an Incision is made over the middle of the greater trochanter and extended distally down the lateral side of the thigh the length of the incision depends on the length of the plate approach the fascia lata is incised in line with the skin incision the fascial covering of the vastus lateralis muscle is incised this exposes the vastus lateralis muscle this muscle is divided by blunt dissection in line with its fibers finally, the periosteum is incised and divided to expose the lateral aspect of the femoral shaft Note: care must be taken to coagulate the perforating branches of the profunda femoris arteries that are divided during this approach screw insertion a guide wire is inserted just distal to the greater trochancter (distal to the fracture site) and angled at 135 into the femoral neck and head the guide wire should run into the femoral neck just superior to the calcar Note: the guide wire must not enter the hip joint the image intensifier is used to ensure the position of the guide wire is correct ext a reamer is used to drill a hole over the guide wire finally, the lag screw is advanced into the femoral head over the guide wire the guide wire is removed and the lag screw remains in place plate insertion the proximal end of the plate articulates with the end of the lag screw this allows for dynamic compression across the fracture site the plate is fixed to the lateral aspect of the femoral shaft using bicortical screws closure the plate is buried under the vastus lateralis muscle the fascia of the vastus lateralis and the fascia lata are sutured closed finally the skin is closed Complications varus collapse with lag screw cut out (migration of the lag screw into the hip joint) avascular necrosis of the femoral head deep vein thrombosis and pulmonary embolism
Orthopedics OR41
REFERENCES
Miller, MD. Review of orthopedics. 3rd ed. 2000. WB Saunders Co.
OR42 Orthopedics
TMCCQE 2006 Review Notes
1. Systemic disease of the skeleton a)achondroplasia ( chondrodystrophia foetalis ) - AD, enchondral ossification disorder, short body ( 90-120cms ), perichondral ossif.normal, mainly in long bones, more in proximal part of limb (femur relatively shorter than tibia), body normal, high forehead and supraciliary arcs, varosity of shin, lumbar hyperlordosis, intellect normal - On X ray: deformities, arched diaphysis, irregular pelvis, small vertebrae - Therapy: osteotomy prolongation( Ilizars technique= bone cut and leave to heal via making callus, secondary healing ) possible 1mm per day b)dysostosis cleidocranialis - AD, enchondral and perichondral ossification disorder; clavicle aplasia, dwarfism, intellect affected, hypermobility of upper limb girdle, muscle defects, scoliosis, funnel chest, brachycephalia, late closing of fontanellas (skull growth failure), teeth disorders Therapy: active exercise and bandage for stabilization of shoulder c) nail-patella sy : nail disorder, patella or radius luxation, abnormal pigmentation of iris, spondylolistesis d) osteogenesis imperfecta = dysfunction of osteoblasts (failed production of osteoid and its mineralization), cortical bone very thin, spongios bone not well formed, which leads to bone weakness, - early form : AR, many fxs in intrauterine period, newborns often already dead, or live for 2yrs max - late form : AD, multiple fx without big trauma, also spontaneous, traction of muscles causing deformities, in teenage years decreasing or vanishing, typical blue sclerae (not always), on X ray : deformities, thin corticalis, poor spongiosa, Loosers zones=transverse condense lines in metaphysis), coxa and crura vara antecurvata; therapy: Calcium, Fluouride only small effect, prevention of trauma, correction osteotomy e) M. Albers-Schoenberg = osteopetrosis, osteosclerosis : dysfunction of osteoclasts, bone bigger but more fragile, medullar canal obliterated, leads to haematopoetic disorders, haematopoesis moved in liver, spleen; anemia, immunodeficiency, septic conditions; cranial nerves compressed in bone canals, when fractured longer fixation required f)arthrogryposis multiplex congenita : connective tissue disease, paraarticular soft tissue affection causing joint dysfunction, no progression, symmetrical, extremities elongation, typical skin folds, ends as joint ancylosis; ther: rhb, exercise, bandages, osteotomy, arthrolysis g)Marfans sy : mesenchymal disorder, long thin body, long spider fingers and toes, muscle hypotonic, soft ligaments causing deformities, scoliosis; hypermobile joints, wing scapula, plane feet; contractures of PIP joints; lens subluxation, aortic aneurysm; hydroxyproline in urine; - on X ray typical widening of medullar cavity; ther: exercise h) mucopolysaccharidosis : gargoylismus, Hurlers disease, Morquio disease ( intellect normal ) i) Rickets: vit D deficiency (malnutrition, resorption disorder, no sun light), mineralization failure, leading to deformities such as caput quadratum with brain compression, widening of bone cartilage junction of ribs (rosary beads), vertebral deformities, hunch (gibbus), crura vara, pelvis deformity - increased ALP, decreased Ca and phosphate in blood - X ray : I grade irregular metaphysis shape, II gr irregular epiphysis, metaphysis wider (calyx like), compacta curved; III dense mataphysis, Loosers zones, IV repair, new calcification -ther: high doses of vit D, sun light j)M. Recklinghausen = osteodystrophia fibrosa cystica generalisata : parathyroid ca, increased PTH, cystic destruction of all bones, increased osteoid production, bone tissue fibrosis, osteoporosis; multiple fractures, intraoseal bleeding leading to brown tumors, also nephrolithiasis, nephrocalcinosis, typical skull deformities, spontaneous fx - ther: adenoma extirpation, bone prolongation, deformities reconstruction
2. Osteoarthritis of the hip joint - generally = degeneration of hyaline cartilage; - primary : cartilage metabolism disorder, cartilage softening, fissures, erosions synovitis, synovial hyperproduction, worse nutrition and lubrication subchondral sclerosis, minifx causing bone pseudocysts cartilage and subchondral bone destruction!! - secondary : same principle but caused by trauma, axial deviation, congenital dysplasia, aseptic necrosis, corticosteroids therapy, diabetes, gout, rheumatoid arthritis, psoriasis, chronic infections - Symptoms: pain, morning stiffness, on small joints typical deformities ( Heberdens nodes ), also DIP joints affected ( not in rheumatoid arthritis !!), joint dysfunction - Kellgren Lawrence classification.: (very important to know!!!) x ray classification - I grade: narrowing of joint line, minimal osteophytes - II grade: obvious narrowing, bigger osteophytes, slight subchondral sclerosis -III grade : multiple osteophytes, sclerosis, pseudocysts, small deformities - IV grade: no joint line, big osteophytes, sclerosis, pseudocysts, big deformities - hip joint : primary, secondary(usually after trauma, congenital dysplasia ) - pain first only in exertion, then also in rest, movement limited mainly medial rotation, -e.g. of examination of rotation range, used in papers, patient with hip arthritis : S sagital (also flexion) : 0 0 90 : from extension(0) over zero position (0) to flexion(90) F frontal (adduction) : 5 0 15 : from abduction(5) over zero to adduction (5) T transversal (rotation) : 15- 15 0 : from lateral rotation(15) cant go to zero position, nor in medial rotation contracture in adduction, antalgic claudicating ( move fast when step on affected side ) - X ray: see above - ther: conservative : weight reduction, walking sticks, rehab, analgesics(paracetamol, tramadol), Non Steroidal antirheumatics(ibuprofenum,diclofenac, COX2 inhibitors-celecoxib, rofecoxib, meloxicam), SYSADOA=symptomatic slowly acting drugs of ostearthrosis): chondroitinsulphat, hyaluronic acid (not big effect!!), steroid antirheumatics intraarticular application only, risk of infection!!! surgery : osteotomy = less damaged part of cartilage moved into more exposed parts ( valgus or varus osteotomy, using stable angle plates to fix new position of femoral head and neck ) alloplastic = replacement of head and fossa ( most used, most successful!! ) resection plastic = damaged head resection, femoral traction for 8wks to make fibrous tissue between femoral part and pelvis angular osteotomy = changed position of proximal femoral part, analgesic effect arthrodesis = definitive firming of joint in 15deg flexion, 0-5deg abduction, neutral rotation, leg stable but no movement in joint ( problems with sitting, hygiene etc.) 3. Rheumatoid diseases and their surgical treatment = inflammation of locomotor system which affects also soft tissues - slowly progression ending as total loss of mobility - usual in small joints, but not in DIP, typical deformities ( ulnar drift, button hole, swan neck) - predisposition( HLA system) + biologic, metabolic or endocrine disorder - typical morning stiffness, doesnt depend on exertion - investigations :blood: increased CRP, positive rheumatoid factor; in synovial fluid increased proteins(>35g/dl) X ray : narrowing of joint line, demineralization, subchondral erosions, ankylosis (typical minuschanges, in osteoarthrosis are pluschanges); Larsen classif.0-5 - ther: prevention, early diagnosis + treatment, avoid deformities, tendon ruptures, immobility NS antirheumatics, analgesics, steroids, immunomodulants(memothrexat) radiotherapy : external, yttrium into joint surgery : a)preventive : tendosynovectomy (taking off reactive synovial membrane of tendons, wrist,
talocrural joint, flexors of fingers) synovectomy ( to prevent joint destruction, must be done early; classical- stratum synoviale and stratum fibrosum; arthroscopic only stratum synoviale ) b)reconstructions: osteotomy for axis repair ( for plane foot, hallux valgus, growth deformities in juvenile rheum.arthritis) c)therapeutic : arthrodesis gives no pain and stability but no movement in joint spondylodesis in instabilities of C spine, myelopathy due to compression plastics: most common, reconstruction of soft tissue : mainly in hand for fingers deformities, release on side of contracture, firm on opposite side resection of joint, traction followed by scarification, typical in basis of hallux proximal phalanx ( Keller arthroplastic ) due to hallux valgus interposition today only foreign material ( alloplastic) mostly hip or knee, less shoulder and elbow, then MCP and PIP joints - !!be aware of!! : vasculitis associated with rheumatoid diseases, difficult intubation when TemproMandibular joint affected, destruction and pseudoarthrosis of dens axis, pulmonary disorders, adrenal crisis, immunosuppression, cardiomyopathy, renal insufficiency - rheumatoid arthritis = disorder of synovia ( NOT of cartilage!!), polyarticular, Not in DIP joints - dg according to: morning stiffness, swelling, rheumatoid nodules, progressive! - ethio: autoantibodies forming immunocomplexes, activate complement, PANUS formation, which spreads in synovialis causing instability and destruction or causes cartilage destruction (enzyme metalloproteinase) - other signs : vasculitis, rheumatoid nodules(on extensors side), kidney and heart affection ulnar deviation of fingers, swan neck deformities - SLE : antiDNA antibodies, antinuclear antibodies, decreased complement(C3,C4) - typical butterfly erythema, joint and kidney affection - antibodies against fetus gravidity very risky and complicated - Sjoegren sy autoantibodies, salivary and lacrimal gland affected, dry eye, dry mouth - sclerodermia antibodies against vessel wall vessel changes, board skin - M. Bechterew mainly SI and intervertebral joints, HLA B27, 20-30 yrs old men, begin as a pain of heels, ossification of spinal disci and ligaments, spine in kyhpotic position, also called bamboo spine, in accidents Th spine usually broken ( normally is not thanks to ribs fixation) - Reiters sy : caused by Chlamydia, Salmonella, Shigella, Mycoplasma; associated with ceratoconjunctivitis, urethritis - psoriatic arthritis : seronegative, asymmetrical, also DIP joints, panus growing also into the joint - lymes borreliosis : erythema migrans, pain, swelling, reactive arthritis, ATB necessary - gout : crystals arthropathy, mainly in men, in postmenopausal women - MTP joint of hallux is affected 1st, usually after eating or alcohol excess or exertion, all typical signs of inflammation, toffi in soft tissues, white stuff found in aspiration, ther: NSantirheumatics, colchicin, also small amount of steroids put in joint 4. Lower limb deformities a) congenital : critical period for limbs development is in 4th-7th intrauterine week - poisons(thalidomide), hypoxia, malnutrition, radiation, infections(rubella), stress, alcohol etc. - Swansons classification .: false development, false differentiation and separation, duplication, gigantism, hypoplasia, congenital constrictions(amniotic stripes sy), generalized skeletal defects - transversal similar to surgical amputation, partial or whole part of limb missing - longitudinal eg. one bone from forearm missing, then typical deviation to the side of missing bone - types: focomelia = complete longitudinal defect, mainly in upper but can be both limbs, hand or foot connected straight to girdle, thalidomide!!! talipomanus = radius longitudinal defect, results as a varus deformity in wrists, thumb aplasia, also heart and renal defects and thrombocytopenia (TAR=thrombocytopenia absent radius) sy FFU = femur-fibula-ulna congenital pseudoarthrosis of crus: usually in distal part of tibia,often in neurofibromatosis, typical angular deformity, Boyds classif. I-VI in according to place when
pseudoarthrosis occurs and Ti condition; tx: difficult due to worse healing ability in pathological bone tissue, using transplant of bone graft from mother, intramedular fixation, plate OS, resection, amputation
congenital femoral pseudoarthrosis: usually proximal femur, Pappas classif. I-IX, describing defects from hypoplasia to total aplasia - ther: reposition, retention, rotation osteotomy(leg rotated 180deg, then talocrural joint used instead of knee for external prosthesis attachment, distraction, prolongation but in distal part of femur (normally done in proximal femur!!) b) acquired : post traumatic in epiphyseal fx ( S-H III,IV,V) most risky when fx of distal Fe or Ti, causes angular deformities, control X ray after 1yr required also in rickets, M. Blount ( aseptic necrosis of Ti condylus), osteoarthritis, RA, inflammations - coxa valga subluxans as a part of congenital hip dysplasia - coxa vara adolescentium : proximal femoral growth plate disorder, head moving dorsally and down, which means varus and retroversion position, usually boys 12-15yrs old, endocrine disorders, hip joint trauma, associated with Froehlich sy ( decreased gonadotrophin, obesity, small genitals) or in thin fast growing children; - pain (in medial part of thigh and knee!!), reduced medial rotation and abduction due to adductor muscles contracture, when examined there is a spontaneous lateral rotation (Drehmanns sign) - X ray in AP and Lauensteins position (thighs wide open) - ther: Ki wires fixation through the neck; correcting osteotomy ( valgus, derotation) - complic: early arthrosis, cartilage necrosis when multiple repositions - genua valga : due to lateral femoral condylus hypoplasia, OI, rickets, trauma, syphilis, polio - knees inside, Xshape, associated with plane feet, dx: in accord.to intermalleolar distance, angle femur and shin ( normal<8deg) - ther: supracondylar osteotomy, epiphyseodesis(small rivet into growth plate on one side, bone growing only on one side, can be temporary or permanent), epiphyseodistraction - genua vara : due to medial femoral condylus hypoplasia, knees outside, O shape, dg in accord.to intercondylar distance, Fe- Ti angle - ther : high tibial osteotomy, form valgus position, epi-desis, epi-distraction, prolongation - genua recurvata : rare, rickets, epiphysis cartilage damage, leads to hyperextension of knee - ther: supracondylar osteotomy, soft tissue reconstruction - genua flecta = contracture as a terminal stadium of osteoarthritis, RA, after polio, in haemophilia(recurrent bleeding into joint), knee in flexion, extension impossible - ther: in children tendons prolongation, other wise total replacement necessary! 5. The pathologic posture and scoliosis - scoliosis : = spinal deformity in frontal plane genetically predisposed (apart from deformities due to eg shorter leg ) - spine divided into 2 columns, ventral and dorsal(which is important for stability), spine constructed for walking on all 4, in humans too much loaded, reason for deformities - dg in according to X ray measurement of angles, so-called Cobbs angle a) congenital s.: asymmetrical vertebral malformations, progressive; - ther: osteotomy, spondylodesis in early age (2-4yrs) b) idiopathic : most common, more in girls, usually decreased Th kyphosis (gibbus not that often), rotation and torsion of vertebrae, curve more than 60deg can lead to breathing problems due to thorax deformity - infantile : in children under 3yrs, usually spontaneous healing, ther: curves under 20deg only observe, >20deg use corset (event.spondylodesis when 10yrs old), >50deg always surgery juvenile : between 3yrs and teenage, usually <40deg, progressive in maturing, ther: surgery need when curve >40deg, and when fast progress adolescent : since teenage to the end of growing, usually stops progress when bones matured, curve>40deg needs surgery c) other causes : neurofibromatosis, motoric lesions, tb, trauma, operation, OI, Marfans sy, different legs length ( called postural scoliosis )
- examination: measurement of sagital deviation on X ray, let down thread from vertex and measure distance from intergluteal fissure, measure rib prominence when patient bends forward, describe flexibility of spinal curve(is it changing when moving?), assess bone age for telling prognosis, assess laxity of joints - ther: <10deg no scoliosis; <20deg observe if there is any progress; <40deg use corset stop progress, only in flexible curve, Milwaukee, Boston >40deg need surgery!! = curve correction and fixation ( spondylodesis ) + corset for 6mths, segmental transpedicular or pedicular fixation ( no need of corset afterwards) 6. Benign tumors of the locomotion apparatus 1 osteoma : from bone tissue, most common in skull, can be associated with polyposis coli (so-called Gardners sy), indicate endoscopy!! 2 osteoid osteoma(osteoblastoma) : forming nidus with capillaries in centre ( <1cm called osteoma, >1cm called osteoblastoma), reaction of corticalis sclerosis, osteolysis of spongiosa; typical night pain due to venostasis ( analgetics dont help, ASA helps, aspirin test used for dg.), on spine causing algesic pseudoscoliosis; ther: partial resection 3 enchondroma : in long bones, in short bones of hand, can convert to malignant, Olliers disease- when multiple unilatelar occurrence, enchondromatosis (AD, many of them) high chance of malignant change 4 osteochondroma ( osteocartilage exostosis ) : most common, in 1st-2nd decade, typical in metaphysis, sessile or pedunculated with cartilaginous cap on top, ther: excision 5 chondroblastoma : from cartilaginous tissue, aggressive growth, typical in epiphysis, can irritate, in 2nd-3rd decade, ther: intralesional excision, in aggressive ones marginal excision - semimalignant tumors 1 giant cell tumor ( osteoclastoma ) : locally aggressive, in meta- and epiphysis, in 3rd-4th decade, painful, pathologic fx may occur, histology same as a brown tumor (M.Recklinghausen). ther: extirpation and cement filling ( after 2yrs filling changed to bone graft) 2 haemagioma : mainly in vertebrae and skull, typical striping on X ray or dots on CT scan 3 glomus tumor : on the ends of fingers, very painful ( espec.when temperature changes) 4 chordom remnant of notochord, at sacrum or C0/C1, very slow and long growing without any problems, can be massive, when reaches S2 segment urinating problems 5 adamantinom : in diaphysis, very rare - tumors from any soft tissue around may occur 7. Malignant tumors - 60% of malignant tumors occur in knee - most common are secondary tumors ( metastasis ) 1 osteosarcoma : production of carcinomatous osteoid, more in men, 15-30yrs old, in knee, femur, humerus; no borders, reaction of periosteum ( Codmans triangle on X ray), can be also associated with M.Paget ( osteitis deformans) or post radiation; survival 60-80% a) low grade : typical in planum popliteum, no need of chemotherapy ( ChT) b) high grade (95%) : neoadjuvant ChT + wide resection + adjuvant ChT - when metastasis in lungs still good prognosis,when metastasis in bones poor prognosis Ewing sarcoma : children, Fe, Ti, Hu, from diaphysis marrow, typical onion reaction of periost, genetic translocation t(11,22); in tests: high sedimentation, CRP and leucocytes ( can resemble osteomyelitis or histiocytosis), survival 60%, most important is ChT malignant fibrous histiocytosis : 20-35 yrs old, similar to osteosarcoma, also same therapy, often + extraskeletal part chondrosarcoma : >50yrs old, pelvis, fingers, Fe, Hu; can occur from enchondroma, exostosis; ther: only wide resection, very poor prognosis when transcortical growth multiple myeloma ( plasmocytoma, Kahler disease ): in axial skeleton, old people, men, demineralization leading vertebral damages, paraprotein in urine metastasis into skeleton : most common in spine, pelvis, ribs, sternum, skull a) in children : Wilms tu, retinoblastoma, neuroblastoma, leukemia b) adults: clear cell ca of kidney, ca of lungs, ca of thyroid gland ( bleeds a lot), ca of prostate(osteoplastic),
2 3 4 5
ca of mamma, melanoblastoma - ther: extirpation and cement filling, plate OS, palliative OS, replacements of joint, radiotherapy to prevent reoccurrence 8. The common characteristics of the tumors ( classification, diagnostic, clinical features, laboratory and X ray examinations, the principals of the therapy - 1st signs: pain, oedema, reduced movement, random finding on X ray, be aware of haematoma lasting more than 6wks after injury!!, pathologic fx!! - classif.in according to tissue and differentiation : I from bone V from vessels IX tumorous affections II from cartilage VI from connective tissue III giant cell VII others IV from bone marrow VIII not classified - surgical Enneking classif.: BENIGN : GRADE TUMOR METASTASIS 1 not active 0 0 0 2 active 3 aggressive T 0 own capsule T 1 pseudocapsule 0 0 0 0 or 1 0 0 or 1
MALIGNANT : GRADE I low malignancy II high malignancy III transcortical spreading 1 2 1 or 2 TUMOR 1 or 2 1 or 2 1 or 2 METASTASIS 0 0 1
- satellite focuses : in reactive zone ( in pseudocapsule), in low grade sa, resection out of reactive zone necessary, on MRI seen as a big oedema around the bone - skip focuses : in same compartment, healthy tissue in between tumor and skip focus, spreading along vessels, in high grade sa, dont change prognosis of cancer ( metastasis occurrence does change prognosis), MRI of whole bone necessary - laboratory typical findings : - osteosarcoma : increased LDH, bone ALP; - Ewing sa : high temperature, increased sedimentation, CRP and leukocytes, anemia - myeloma : very high sedimentation, anemia, hypercalcaemia - investigation: 1 scintigraphy using radioisotopes describes metabolic activity, high sensitivity but low specifity 2 X ray : localization, size, borders, periosteal reaction ( Codman triangle in osteosarcoma), type (osteoplastic, ostelytic ) 3 angiography : vascularization, relation to vessels 4 DSA ( digital subtraction angiography ) : also selective embolisation possible 5 CT : esp.for metastasis in lungs or brain diagnostic 6 MRI : esp.for soft tissue affection, dg skip focuses, bone marrow inlfiltration 7 histology : FNAB, peroperative biopsy, explorative excision
- ther: chemotherapy, radiotherapy, surgery - ChT : neoadjuvant ( NAChT) before surgery- encapsulation, decreased blood supply, decreased oedema, act on micrometastasis, skip focuses, min 2-3wks between ChT and surgery adjuvant ( AChT) during or after surgery ( bone cement into cavity causing toxic and thermal destruction of cells; phenol, cryotherapy - to assess ChT effect : decreased size, necrosis(more than 90% necrotic=good prognosis) - can be combined with radiotherapy and embolization of tumor vessels - surgery : - types of resections : a) intralesional = opening of pseudocapsule and extirpation b) marginal = go over capsule, remnants causing reoccurrence!!! c) block = out of capsule, into healthy tissue d) radical = whole compartment + also in next compartment ( eg exarticulation ) - ablative = amputation, exarticulation; sparing ( with or without replacement ) - in according to Enneking classif.: 1 no surgery I wide 2 intralesional or marginal II radical 3 marginal(T0), wide (T1) III individual in according to prognosis ( when good radical, when poor just palliative ther)
9. Congenital foot deformities - pes equinovarus congenitus : common, more in boys, multifactor cause, signs: tip toe falls down (equinus=horse foot like), heels turned inside(varus position), foot in inversion( stand on lateral edge of foot), typical skin folds on heel, atrophy of calf muscles, short Ach.tendon - types: positional=passive correction possible; rigid=correction impossible - on X ray: watch and compare angles between calcaneus and talus long axes, in AP and lateral plane, in max plantar and dorsal flexion - ther: exercise, correction plaster bandage(whole leg, knee in 90 flexion), if not successful surgery required(around 6th-8thmonth): Achilles tendon prolongation+dorsal capsulotomy, or complete relaxation(Ach.tendon, muscles tendons, ligg., capsule) then calcaneus in right position, reposition of naviculare bone onto talus head and fixation(Ki wires+PF for 2months) - pes calcaneovalgus (hook foot) : more in girls, signs: calcaneus in valgus position, max dorsal flexion(the foot dorsum can touch the shin) - ther: only exercise, prognosis very good - congenital steep talus: rare, etiology unknown, signs: the Ach.tendon shorter, whole foot in valgus position, talus in vertical position, talus head in medial and plantar side of the foot, tip of the foot in dorsal flexion, rigidity - ther: always surgical: after soft tissue release bones reposition and Ki wires fixation - metatarsus varus(pes adductus) : congenital or as a remnant of pes equinovarus, signs: the foot is rotated inside, walking with tip toes in - ther: exercise, correction plaster, surgery for not corrected equinovarus - digitus V. supraductus : 5th toe in medial deviation, crossed over other toes - ther: taping reposition, skin or tendon plastic 10. Acquired deformities of the foot and fingers - pes equinus : usually in palsies ( CP, poliomyelitis, peripheral ), signs: the foot fixed in plantar flexion, toes in max dorsal flexion, step on the heel impossible, whole weight on metatarsal heads, transverse foot arch damaged, atrophy of calf muscles - ther: exercise, correction bandages, surgical prolongation of the Ach.tendon - pes excavatus : usually in myelodysplasia, muscular dystrophy, Friedreichs disease(dorsal spinal
cord fascicles degeneration), signs: high foot arch, contracture of plantar fascia and soft tissue, typical claw position of toes - ther: release of plantar structures, event. wedge osteotomy(cutting out wedge shaped piece of bone and reposition) - pes planovalgus (longitudinal flat foot ) : weak ligg., M.Down, Ehlers-Danlos sy, Marfan sy, poliomyelitis, JRA, Littles disease(spastic diplegia of infants); signs: lower or no longitudinal arch, the heel in valgus position, talus moved down and medial, leading to eversion position of the foot - types: 1st grade : only when standing on it; 2nd gr.: also when foot lifted but can be passively repositioned; 3rd gr.: fixed, reposition impossible; necessary to distinguish talus verticalis!! - on X ray: Boehlers angle is <25, talus, navicular and MT not in one line, can be seen os tibiale externum(variety in post.tibial muscle insufficiency) - ther: good prevention(dont force children to walk too early, good shoes, bare foot walking; arch supporters; surgery when painful and children older 13yrs: ant.tibial muscle tendon led through navicular bone or prolongation of calcaneus - in adults: as a remnant from childhood, in occupations where long standing, tarsus fx; pain, pressure, seizures; ther: supporters, wedge resection of tarsus or subtalar arthrodesis - pes transversoplanus(transversal flat foot): the most common, high heels!!, exertion on MT heads; pain, med.plantar nerve compression, wider tip of the foot causing pressure sores -ther: heart shaped supports(behind MT heads!!), resection of 2nd-5th MT head(Hoffmanns), or Hellals MT osteotomy (cut out bone wedge from dorsal part of MT , reposition and fixation) - hallux valgus : weak muscles or ligg., bad shoes; signs: big toe deviated to 2nd toe, protuberance on medial part of 1st MT head and painful bursa above, arthrotic changes in MTP joint, for dg measure metatarso-phalangeal and intermetatarsal angles - on X ray : big toe in valgus position, 1st MT in varus position, protuberance on medial side, arthritic changes on MTP joint - ther: supports, correctors; surgery: - Kellers arthroplastic (resection of 1/3 of proximal Ph basis and arthrodesis) - Austins operation(MT head resection+lateral drift) - also wedge osteotomy of proximal Ph, soft tissue reconstruction(adductor mm.cut, joint capsule shortening - hallux varus : rare, after some scarification, in sclerodermia; ther: surgical correction - hallux rigidus : in ostearthrosis of MTP joint of big toe, after inflammation, after surgery; slowly gets stiff, osteophytes occur, extension very painful, ther: Kellers arthroplastic+ excision of osteophytes - digitus malleus (hammertoe) : associated with transversal flat foot and hallux valgus, MTP joints in extension, PIP joints in flexion hammer like position, painful bursae, pressure sores,mainly in 2nd toe, ther: resection of proximal Ph head - digitus hamatus ( drum stick toe) : PIP joints in extension, DIP joints in flexion, ther: phalangectomy - Haglunds exostosis : bone protuberance on tuber calcanei; painful, bursitis behind Ach.tendon, oedema; ther: supporters, never inject steroids (damage of tendon, easy to break), resection - calcar calcanei : due to calcification and ossification of inflammatory changes on plantar side of tuber calcanei, painful, walking almost impossible, ther: soft supporter 11. Tumorous affections of the locomotion apparatus - juvenile bone cyst : in 1st-2nd decade, osteolytic, with sclerotic margins, one or more chambers, in metaphysis, high chance of pathological fx (need to differentiate malignant tumor), inside is straw yellow colored liquid, active till teenage and then disappears spontaneously - ther: corticosteroids stop production of liquid - metaphysis fibrous cortical defect: fibrous tissue around the knee and tibia, dif.dg: giant cell tumor! - aneurysmatic bone cyst : very aggressive!!, decreases bone stability, well bordered, pathologic fx may occur, when open blood is coming out - ther: interruption of blood supply (periost taken off, a. nutritiva damaged) - fibrous dysplasia : genetic site mutation, typ. associated with Albright sy (pubertas praecox, caf au lait spots), typical milk opacification, bone is bending to form club shape, stress fx, malignant change possible (never use radiotherapy!!) -ther: extirpation, spongioplastic, observation, deformities reconstruction
- histiocytosis X : M.Letterer-Siwe, M.Hand-Schuller-Christian, eosinophile granuloma - when in bone typical onion skin reaction of periost, in blood increased sedimentation, CRP, - in vertebra causing its damage(vertebra plana Calve) - myositis ossificans : progressive or circimscripta(after trauma), typical ossification from periphery - brown tumor in M.Recklinghausen(hyperparathyreoidism) : dif.dg giant cell tumor - Pagets disease : loss of bone architecture, fibrous remodeling, mineralization failure, high chance of malignity!! 12. The common features of the endoprosthetics, the types of joint replacement - main indications : osteoarthrosis, fx, resection of bone due to tumor, - can be total or partial replacement - is decided in according to age of patient and to his activity a) cemented : fixed inside the bone cavity by methylmetacrylate cement, must be done in exact position b) non cemented : inserted into preformed socket, prosthesis with special surface porous coating + layer of hydroxyapatit, intimate contact of new bone tissue and prosthesis surface=bond osteogenesis - primary stabilization = press fit insertion of prosthesis into the bone - secondary stabilization = osteoblasts growing into macroporous surface of the prosthesis - materials used: ceramic, steel, Cr-Co-Mo alloy, titan, polyethylene for socket, methylmetacrylate as a cement - cemented prosthesis can be loaded from 2nd post op day, non cemented usually after 3months - complications: luxation(bad exercise, wrong position of implant), thrombosis, infection can also cause release of prosthesis from its socket 13. The artificial replacements of the knee joint - hemiarthroplastic : when only one compartment damaged, also called unicompartmental or unicondylar; doesnt solve femoropatellar joint problems, quite quickly destroyed - total replacement : high stability- one piece prosthesis, not used very often, problem with rotation movement of the knee low stability- 2pieces prosthesis, more often used, possible only when ligaments are ok (esp. collateral ligg ), also PCL is saved when replacement done - also patella can be replaced - complic.: release of prosthesis mostly due to infection (any infection in body is contraindication for joint replacement!!!) - when replacement failed arthrodesis required (knee flexion impossible) 14. The artificial replacement of the hip joint a)partial = CCEP ( cervico-capital endoprosthesis) : in femoral neck fx esp. in older people with lower activity; only head of joint is replaced, surgery is shorter, faster verticalization of patient b)total =TEP (total endoprosthesis) : mainly in osteoarthritis, both head and socket replaced; - cemented : socket only from polyethylene with thin wire around for check of exact insertion; after destroyed cartilage and osteophytes excised, fixed with cement; prosthesis body with head inserted into proximal femur, head must be fully smooth to minimalize abrasions (which are always there) causing aggressive granuloma - non cemented : socket has got articular ( titanium) and acetabular (polyethylene)part; inserted into preformed socket in the bone, types: spherical, conical; with self cutting thread, press fit, spacing; usually with special macroporous surface with hydroxyapatite; prosthesis body with special made surface inserted into proximal femur - cemented can be loaded after 2nd post op week, non cemented fully loaded after 3months - complic.: luxation, release due to infection or wrong position, thrombosis 15. The preosteoarthritic state of secondary osteoarthritis - when cause is not in cartilage a) mechanical overexertion ( axial deviation, obesity, chronic overexertion in occupation, sport) b)joint deformities ( congenital hip dysplasia, coax vara adolescentium, intraarticular fx) c)aseptic necrosis of joint(hip joint in alcoholics, blood supply damage, steroids therapy) d)metabolic systemic diseases(diabetes, gout)
e)chronic joint inflammations(RA, psoriasis) - pathogenesis exactly the same as in primary osteoarthritis, leads to irreversible cartilage damage 16. Primary osteoarthrosis - generally = degeneration of hyaline cartilage; - primary : cartilage metabolism disorder, cartilage softening, fissures, erosions, synovialitis, synovial hyperproduction, poor nutrition and lubrication, subchondral sclerosis, mini fx causing bone pseudocysts lead to: irreversible cartilage and subchondral bone destruction!! - pain, morning stiffness, in small joints typical deformities ( Heberdens nodes ), also DIP joints affected ( not in rheumatoid arthritis !!), joint dysfunction - Kellgren Lawrence classification : (very important to know!!!) - I grade: narrowing of joint line, minimal osteophytes - II grade: obvious narrowing, bigger osteophytes, slight subchondral sclerosis -III grade : multiple osteophytes, sclerosis, pseudocysts, small deformities - IV grade: no joint line, big osteophytes, sclerosis, pseudocysts, big deformities - therapy: conservative : weight reduction, walking sticks, rhb, analgetics(paracetamol, tramadol), NSantirheumatics(ibuprofenum,diclofenac, COX2 inhibitors-celecoxib, rofecoxib, meloxicam), SYSADOA=symptomatic slowly acting drugs of ostearthrosis): chondroitinsulphat, hyaluronic acid (not big effect!!), steroid antirheumatics intraarticular application only, risk of infection!!! surgery : cheilotomy = extirpation of osteophytes, only short lasting help osteotomy = less damaged part of cartilage moved into more exposed parts ( valgus or varus osteotomy, using stable angle plates to fix new position of femoral head and neck ) alloplastic = replacement of head and fossa ( most used, most successful!! ) resection plastic = damaged head resection, femoral traction for 8wks to make fibrous tissue between femoral part and pelvis triple osteotomy (hip) = cut of all pelvic bones (pubis, ischium, ilium ) and reposition angular osteotomy = changed position of proximal femoral part, analgesic effect arthrodesis = definitive firming of joint in 15deg flexion, 0-5deg abduction, neutral rotation, leg stable but no movement in joint ( problems with sitting, hygiene etc.) 17. The Sheurmanns disease = kyphosis dorsalis juvenilis - etiology: unknown, probably enchondral ossification failure in growing period, mainly in boys between 12-18yrs, ussualy in lower Th spine - affection of intervertebral disci, Schmorls nodules (hernia of discus into vertebra) - wedge shape deformities of vertebrae and narrowing of intervertebral spaces - increased Th kyphosis, smooth, no gibbus, decreased mobility, elasticity - measurement of angles in lateral X ray (Cobbs angle) - ther: when <40 only reduce sport activities, >40 needs corset, rarely dorsal surgical correction and spondylodesis 18. Amputations of the limbs - to take off ill part of body, used to decrease impairment or to save life - indic: vessels disorders ( diabetic angiopathy, arterial insufficiency) limb saving surgery(to save as much as possible); trauma ( irreversible ischaemia, infection, gangrene); tumors = radical resection, usually in malignant, generalized; infection (untreatable); congenital abnormalities (when inhibit exoprosthesis using); neuropathies (leading to ulcers, infections) - types : open ( guillotine) circular incisions of each layer, left open, closed afterwards with end reconstruction; mainly used in wars flap each tissue flaps planned in advance to form end good for exoprosthesis - using myodesis ( new muscles attachment, typical in thigh adductors); myoplastic(muscles cut cca 10cms more distally than bone and antagonist muscles attached together to cover limb end,!!not in fingers which would lose their function) - in according to MESS ( mangled extremity severity score) - height of amputation : according to skin cover potential, muscle, nerves and vessels vitality
- in some cases better to do amputation, so patient can get used to it and have adequate life, rather than try to save his limb and have them stay in hospitals for ages with eventual amputation after non satisfactory treatment anyway - in surgery: use tourniquet to stop bleeding, very important is the quality of closing of the end, myoplastic to save minimal function, treat vessels and nerves, good reconstruction of bone end, Redon drainage after operation - complic: haematoma(can be infected), necrosis, oedema, releasing of suture, gangrene, contracture, phantom feeling(physiologic), phantom pain is serious, caused by amputation neuroma, may need revision, corona sequester of bone when unsatisfactory blood supply - in children : mostly exarticulation for saving of distal epiphysis so bone can grow - types: upper limb: interthoracohumeroscapular amputation, exarticulation of shoulder, humerus amputation, elbow exarticulation, Krukenbergs operation(excision between ulna and radius and forearm is transformed as a pincer so it can be used to hold something), kineplastic(aim is to use forearm muscles to operate prosthesis), wrist exarticulation, fingers amputation(better to take off whole stripe-Ph+MC, for better cosmetic image; save as much soft tissue as possible for better reconstruction; finger apex missing V-Y plastic=V incision and reposition of soft tissue, Y suture) lower limb: hemicorporectomy (half body excised, very rare, all stomata necessary); hemipelvectomy, hip joint exarticulation(extirpate also acetabular cartilage); amputation of femur( problems with exoprosthesis when end too short, or too long), knee exarticulation, crus amputation(Fi must be cut shorter than Ti), foot(most common; types: Scharp: transmetatarsal amp. (cut them to keep their proportions) Lisfrank joint exarticulation ( divide MT and Ph) Chopart joint exart. ( Tal-Nav; Cal-Cub joints) Pirogov:all bones and of calcaneus which then rotated in Ti axe,forms put down end Syme : whole foot, right above talocrural joint Boyd : foot bones amputation and tibiocalcanear arthrodesis) 19.Osteoarthritis of the knee joint, therapy - one or more compartments (Ti-Fem joint or Fem-Patellar joint or both) - signs: pain first after exertion then also in rest; crepitus when moving, roughness of joint, typical varus deformity, contracture, movement reduced, can lead to semi- or total ancylosis - dg in according to Kellgren-Lawrence classif.(I-IV) -ther: conservative : weight reduction, walking sticks, rhb, analgetics(paracetamol, tramadol), NSantirheumatics(ibuprofenum,diclofenac, COX2 inhibitors-celecoxib, rofecoxib, meloxicam), SYSADOA=symptomatic slowly acting drugs of ostearthrosis): chondroitinsulphat, hyaluronic acid (not big effect!!), steroid antirheumatics intraarticular application only, risk of infection!!! surgery: cheilotomy,correction osteotomy ( to rebuilt limb axe and reduce exertion just on one side); hemiarthroplastic ( unicondylar replacement), total replacement ( prosthesis with high or low stability) 20. The orthopaedic prosthetics a)prosthetic measurement = taking of measurable data for making any prosthesis - measurement, drawing, prints, plaster models - must be taken in position which prosthesis will be used in b)prosthetics = substitution of lost parts of body or substitution of lost function or treatment with using technical tools - types of exoprosthesis for lower limb: wooden, exoskeletal(shell like, works only thanks to active movement of limb), endoskeletal(works thanks to internal modules, can have cosmetic covering) - primary equipment = right after amputation, when the end of the limb is not stabilized yet; then followed by definitive equipment - prosthesis must have perfect shape and function(static and dynamic) - biomechanic rule must be made exactly in according to patients need (he must not be conformed to his artificial leg!!) - parts of prosthesis : socket (crown, walls, bottom; strictly individual ),substitution and auxiliary parts - limit for weight is 125kg ( obesity is contraindication, obese people can not coordinate well their prosthesis and are too heavy - very important is a localization of scar after amputation ( can be irritated in prosthesis, painful ) - for upper limb : cosmetic(no function), pneumatic, myoelectrical
c)orthotics = supports for treatment, partially compensating lost function - compensating(permanent), therapeutic, preventive - passive only for stabilization and fixation; active = dynamic or correction - support must be in contact with body at least in 3 places - limbs divided into segments: upper(H,W,E,S), lower (F,A,K,H) - orthoprosthesis= for substitution of lost part, but only due to congenital abnormalities d)calceotics = special orthopedic shoes e)epithetics = cosmetic substitution of lost part, without function f)adjuvatics = things which helps disabled people to be independent (wheelchairs, special tools for bathroom, kitchen etc.) 21. Compressive syndromes of the upper extremity = compression of nerves in anatomical spaces - symptoms: 1st stage: paraesthesia, EMG negative 2nd stage : par- + hypaesthesia, slower nerve conducting on EMG 3rd stage : total nerve damage, anaesthesia, no movement, no action on EMG - dg in according to clinical features and EMG - ther: steroids applied into place of compression, only short lasting effect more efficient is surgery to release of compressed nerve a)carpal tunnel syndrome ( n.medianus) : due to chronic overexertion, swelling of flexors tendons, ganglion, haemangioma, lipoma - pain mainly in rest, in the night, paraesthesia - ther: incision of carpal transversal ligament b)pronator syndrome (n.medianus) : same symptoms, localization seen on EMG - ther: incision of pronator ulnar attachment and proximal part of superficial flexor of fingers c)cubital syndrome (n.ulnaris in sulcus nervi ulnaris) : pareaesthesia, pain along ulnar part of forearm to 5th finger, worse in flexion when nerve stretched - ther: incision of m.flexor carpi ulnaris tendon, event. tendon transposition over ulnae sulcus d)Guyons canal syndrome (n.ulnaris in between hamulus ossis hamati and os pisiforme) : rare - ther: incision of carpal transversal ligament e)supinator syndrome (n.radialis, deep branch in supinator m.) - pain mainly in pronation and palmar flexion, paresis mainly of extensors of fingers, extension of wrist possible - ther: incision of Frohses arcade 22. Diseases of muscles, tendons and aponeurosis - also called entezopathy, tenzopathy - usual after overexertion, recurrent microtraumas, hit, chronic pressure, vibrations, overstretching - dystrophic changes, blood supply disorders, micro fissures, necrosis, haematoma remnants - typical is oedema which even more reduces nutrition - signs: pain, dysfunction, oedema, synovialitis, rupture of tendon may occur - in children usually associated with aseptic necrosis of bones - ther: relief, activity reduction, event. immobilization ( plaster, support ); antioedematics, NSAID, steroids applied in affected place(must be very carefully injected, overdose may cause tendon atrophy or tendon rupture, never into tendon, only into surrounding tissues!!) a)entezopathy of shoulder joint : rotator cuff - mostly supraspinate m. tendon affected, compressed between acromion and greater tuber of humerus = so-called impingement syndrome ( dystrophic changes, calcifications, bursitis); pain, typical painful arch sign( pain occur when abduction to 60 then disapears when abducted to cca 110 and more), when chronic leads to frozen shoulder(fibrosis of joint capsule), abduction impossible b)tendovaginitis of m.biceps long head tendon, rupture of biceps tendon quite common c)radial epicondylitis (so-called tennis elbow) d)ulnar epicondylitis (so-called spear elbow) e)entezopathy of wrist and hand : common is affection of m. flexor carpi ulnaris, can lead to tendovaginitis stenosans ( typical click phenomenon when moved), ther: incision of fibrous sheath - styloiditis radialis mainly m.extensor pollicis brevis, m.abductor pollicis longus (common sheath), called
de Quervain disease; pain when fist moved in ulnar abduction (Finkelstein sign), ther: local application of steroids ( NOT into tendon!!) - Dupuytrens contracture see quest. 30 f)bursitis trochanterica : under tractus iliotibialis, overexertion of glutei mm, more in women g)entezopathy of patellar ligament = jumpers knee, pain on apex, or Ti tuberosity - ther: reduce sport activity, NSAID, antioedematic, NO steroids into joint (high risk of rupture) h)Achilles tendon entezopathy : common, overexertion, pain when standing on tip toes, oedema - ther: maximal relief, event. plaster immobilization, never apply steroids (RUPTURE!!), surgical incision of tendon sheath or longitudinal cuts of tendon; complic.:rupture patient can not stand on tip toe, very painful, sunken relief of tendon, positive Thomas test ( when pressure on m. surae there is no plantar flexion of foot, ther: surgical suture or reconstruction(flap plastic), PF for 6-8wks 23. The aseptic bone necrosis - partial or total, transitory or irreversible - caused by damaged blood supply, caisson disease, diabetes, gout, HIV, sickle cell disease, forced reposition of hip joint, corticosteroids therapy, smoking, alcohol - symptoms not very specific - on X ray : in AP and Lauenstein position(legs in flexion and wide adduction) 1st stage=initial (demineralization, osteoporosis) 2nd stage=bone structure condensation, fragmentation 3rd stage=reparation ( possible only in children, not in adults!) 4th stage=definitive changes of bone structure - ther: reduced activity, avoid deformation of affected bone, Ca, NaF, vitamins, antioedematic, event.replacement a)Perthes disease : necrosis of proximal femoral epiphysis, more in boys, children usually complain on pain of the knee(can not localize pain yet), limp, rotation reduced; typical early sign on X ray widening of joint space(Waldenstroem sign), also subchondral fx, Herrings classif. - ther: surgical containment ( protection of soften femoral head by using own acetabulum ) using Salters osteotomy (distal pelvic fragment moved distally to cover femoral head), only Atlantas supports can be used when acetabulum is well formed and surgery not necessary b)aseptic necrosis of tuberositas tibiae : overexertion of patellar ligament c)Haglunds disease : necrosis of calcaneus apophysis (muscle attachment) d)Freibergs disease : necrosis of 2nd or 3rd MT head, usually associated with pes transversoplanus, walking almost impossible, typical calycinal shape of MT head, when head deformed resection necessary e)necrosis of navicular bone : often in children f)necrosis of lunate bone : mainly in manually working men, esp.due to vibrations, pain, reduced flexion, pseudocystic changes and deformation, results as a wrist osteoarthritis 24. Specific inflammations - cellular type of immune reaction which means CRP and sedimentation only little increased - producing of specific granulating tissue ( with no vascularisation )causing low drug penetrance - necrosis occurs indication for necrectomy - tb, leprosy, syphilis, also Chlamydia, toxoplasmosis, brucellosis and some viruses - tuberculosis : mainly atypical forms ( M.avium, M.bovis), in farmers typical hypertrophy of phalanges); mostly in Th spine as a spondylodiscitis forming paravertebral abscess called cold abscess because of not increased temperature, which when bursts runs down along spine to the pelvis - typical night sweat, loss of weight, sub febrile - for dg : take sputum, Mantoux test, PCR demonstration, do aspiration biopsy of joint liquid and also piece of synovialis!! - on X ray : non specific lesions as an osteolysis, destruction, failed structure - types: bone : typical miliary spread, osteolytic lesions without periosteal reaction, destruction=caries joint : spread on synovialis, hydrops, granular tissue = fungus spine : also called Morbus Potti, end plates of vertebrae affected first, then spread onto disci(which have no blood supply), when healing causing ancylosis - ther: anti TBC for 12months, supports, when operation need do it under cover of anti TBC drugs,
for damaged joints arthrodesis using special plate is the only possibility 25. Metastatic tumorous affection of the bones - very common compare to primary bone tumors - pain, oedema, palpable structure, pathologic fx (can be frist sign!!) - most common in spine, pelvis, ribs, sternum, skull - in children : Wilms tu, retinoblastoma, neuroblastoma, leukemia - adults: clear cell ca of kidney, ca of lungs, ca of thyroid gland ( bleeds a lot), ca of prostate(osteoplastic), ca of mamma, melanoblastoma - osteolytic, osteoplastic, combined (lack of typical periost reaction seen in osteosarcoma) - native chest X ray and scintigraphy of whole skeleton required, for dg of skip lesion use MRI - ther: extirpation and cement filling, plate OS, palliative OS, replacements of joint, radiotherapy to prevent reoccurrence 26. Nonspecific inflammations(osteomyelitis) - in children : very important because its acute or per acute process !!! - etiology : Staph, Strept, Haemofilus usually haematogenous infection - life threatening condition so always in-patient ATB i.v. when susp. (better give multiacting ATB for healing also Haem.inf. to prevent Haem.meningitis!!!) - punction and cultivation, event.joint lavage necessary - neonatal coxitis umbilical infection, severe condition, can result as a sepsis!!, very fast cartilage irreversible destruction; dg using USG ( event.MRI) - subperiostal abscess, no nutrition leading to form a sequester (piece of necrotic bone) - in adults : usually sub acute or chronic, mostly after surgery, also in diabetic gangrene - etiology : Staph.aureus, epidermidis, also Strept or Pseudomonas - punction and cultivation required but no need of hospitalization - pain, oedema, fever; also infected haematoma may occur after operation (typical sudden fever 3rd-7th post op day - ther: ATB for at least 6wks-3months!!; take out prosthesis and convert into external fixation, extirpation of sequester, necrectomy, debridement (clean out necrotic tissue remnants), rinse out lavage ( for better ATB penetrating, cleaning), compressive distraction, autospongioplastic to remodel blood supply, event.amputation or permanent fistula - also infected pseudoarthrosis may occur : instability and infection - external fixation, autospongioplastic, decortication for nutrition remodeling, event.amputation - infected total replacement must be removed, ATB and reimplantation - in severe cases remove, treat with ATB and new replacement only when infection healed
27. Vertebral algesic syndromes - causes of back pain: a)osteoarthrosis of intervertebral joints(spondyloarthrosis), spondylosis(discus affection) - cartilage destruction, subchobchondral bone damage, osteophytes causing spinal cord or nerve roots compression; leads to spinal canal stenosis causing radicular pain - slow degeneration leads to vertebral claudicating after exertion joint capsule or root compressed causing severe neuralgia, paroxysmal, lasting 5-6wks, there is no prevention - ther: releasing of compressed structures and spondylodesis(permanent vertebrae fixation) b)entezopathies of postural muscles c)synovitis, arachnoiditis(irregular shooting pain) d)so-called myofascial cycle m. multifidus(involuntary innervated) overexertion leading to spasm and hypoxia causing severe pain; when chronic leads to necrosis more seizures and hypoxia and vicious circle is closed e)cervico-cranial sy f)acute block of C spine g)hernia of discus (can be very serious due to compression of nervous structure )-mainly in L spine h) spondylolistesis(ventral slip of vertebra): isthmic(when vertebral isthmus damaged), congenital (in malrotated
vertebras, typical L5/S1, spondylodesis necessary); progressive olistesis in children always needs surgery, even without symptoms!! i)dont forget viscero-vertebral relations (same innervations for organs and for intervertebral joints) : eg. MI(C/Th junction), stomach ulcers (Th5/6), kidneys, menstruation pain j)other causes: pseudoradicular pain(sacroiliac block, hip joint osteoarthrosis), tb spondylodiscitis, M.Bechterev, cancer metastasis 28. Congenital dysplasia of the hip joint(DCC) - the most common malformation in children, more in girls, etiology(probably) hip socket displasia or congenital joint hypermobility - child must be examined the best in 3rd-5th day after birth (clinical and USG), then in 6th-9thwk, then in 12th-16th wk - in clinical exam. check for: -muscle tonus, limbs position (big flexion, abd or adduction is pathologic); mobility (reduced abduction is the most important sign of DCC!!); skin folds asymmetry; length of limbs(Galeazzi sign= one knee higher when in 90flexion ); Ortolani sign= when limb moved to abduction you can hear or feel click phenomenon when joint repositioned); Barlow sign = antero-posterior movement in hip possible; in older children or adults typical Trendelenburgs sign = tell patient to stand on one foot and bend other hip and knee to flexion, normally pelvis stays in horizontal line, in DCC other part of pelvis is falling down, due to luxation and weak glutei muscles - when USG not clear use X ray, there check for following lines and structures: a)shed = upper edge of hip socket b)Hilgenreiners line = horizontal line connecting centers of Y cartilage in acetabulum of R and L hip c)shape of the shed external edge not formed in DCC,shed very steep,sometimes neocotyle visible ( new formed socket in luxated joint) d)angle of the shed = line of shed connected to Hilgenreiners line, normal angle is 30 e)Ombredan-Perkinsons line = from the external edge of the shed down and perpendicular to Hilgenreiners line, dividing joint into 4 quadrants, ossification core of femoral head must be in medial inferior quadrant f)Shentons line = curve between medial part of femoral neck and superior branch of pubic bone, normally is fluent g)Kopitzs parallelogram = certain square formed by edge of shed and upper edge of femoral neck completed to tetragon, in DCC forms rhomboid - classif.: a)dysplasia : only steep shed, femoral head in medial inferior quadrant, angle of shed is bigger than 30 but smaller than 60, without symptoms b)subluxation : asymmetry, shed angle bigger than 30, no Shenton line, ossification core in lateral inferior quadrant, reduced abduction c)marginal luxation : shed angle bigger than 30, no Shenton line, core in lateral superior quadrant, shortening of the limb, reduced abduction, asymmetrical skin folds d)luxation : the same as above + head in lateral and proximal dislocation, Ortolani and Barlow sign positive - ther: conservative : the sooner the better!!, using Frejka pillow or Pavliks harness for dysplasia and subluxation, Hanausek biomechanical apparatus for hip luxation, to keep limbs in abduction to form right position of the femoral head and shape of shed; rule is : dont exceed 70 abduction (risk of vessels damage!!), when hip luxated use over head traction : first traction of limbs in extension then slowly put in flexion in hips and abduction( never more than 70deg!!)for 6wks, than Hanausek apparatus for another 6-8wks (child must not be removed, not even for bath!!), very important is to check blood supply and innervations of limbs; than followed by Pavlik harness for 4-6months surgery(when conservative failed) : 1st do arthroscopy to find some inhibitions as a stricture of joint capsule due to m.iliopsoas tendon, inverted limbus acetabuli, hypertrophy of any soft tissue; then capsulotomy, reposition from frontal or medial incision and Hanausek apparatus - complic: aseptic necrosis due to vessels damage - remnants after failed treatment : wrong shaped acetabulum, wrong shaped femoral head, coxa vara, coxa valga - ther: Bosworth operation (reconstruction of acetabulum), Salter pelvic osteotomy (inferior part of pelvis moved ventrally and distally);Steels triple pelvic osteotomy (all 3 pelvis bones cut and acetabulum rotated); Chiari pelvic osteotomy ( distal framgment moved medially); varus osteotomy (to make smaller colo-diaphyseal angle); valgus osteotomy(to make bigger c-d angle); combined op.
29. Entezopaties and tendovaginitis - also called entezopathy, tenzopathy - usual after overexertion, recurrent microtraumas, hit, chronic pressure, vibrations, overstretching - dystrophic changes, blood supply disorders, micro fissures, necrosis, haematoma remnants - typical is oedema which even more reduces nutrition - signs: pain (more in rest, in the night),dysfunction,oedema, synovialitis, rupture of tendon may occur - in children usually associated with aseptic necrosis of bones a)shoulder : rotator cuff (RC) mainly supraspinate m.affected, compressed between acromion and greater tuber of humerus so-called impingement syndrome, leading to destruction, calcification, bursitis subacromialis calcarea; typical painful arch sign (pain occur when abduction to 60 then disapears when abducted to cca 110 and more), chronic results as a frozen shoulder - Neers classif.of impingement sy: -1st stage : oedema, bleeding reversible - 2nd stage : degeneration of RC tendons, defibring, microtraumas -3rd stage : RC rupture; 2nd and 3rd are irreversible! - for dg : X ray (AP, Y for subacromial space, USG, arthrography), painful arch, Neers test ( injected Mesocain into subacromial space positive when pain disappears) - ther: rhb, steroids(not into tendons!!), event.RC reconstruction, acromioplastic (arthroscopic or open Neers surgery) - rupture of RC : traumatic (fall onto arm in extension ); non traumatic (degenerative changes of RC, impingement sy ), 1st supraspinate m.affectes, when all muscles = massive rupture ( typical sign of falling arm ), check abduction, lateral and medial rotation against resistance b)tendovaginitis or rupture of biceps tendon : when ruptured typical palpable defect, ther:tenodesis c)radial epicondylitis d)ulnar epicondylitis e)tendovaginitis of flexors in carpal tunnel due to chronic overexertion, causing medianus nerve compression f)tendovaginitis stenosans and crepitans, digitus saltans = damage of loops holding flexors of fingers tendons ( patient can do flexion of finger but then can not go back to extension, associated with click phenomenon) g)disorders of patellar ligament and Ach.tendon (which is also quite often ruptured) - ther see above 30. Dupuytrens contracture - caused by pathologic process of palmar aponeurosis (flexor tendons NOT affected!!!) - forming hard fibrous nodules and stripes - ??genetic disposition, metabolic disorders, immunity disorders?? - types : palmar, digital, digito-palmar - typical position : hard nodules in palm, skin inverted, mainly 4th and 5th finger in permanent flexion (hand like in an oath), positive table test(palm can not be put flat on table) - benign form ( matured, simple dissection, healing and no reoccurrence); malignant form(stripes fixing skin, dissection impossible, healing long, reoccurrence very likely) - ther: excision, releasing of contractures using Z incisions 31. The radial and ulnar epicondylitis of the humerus a)radial EC, so-called tennis elbow, or lateral epicondylitis, is one of the most common elbow problems seen by an orthopedic surgeon - tendinitis of the muscle called the extensor carpi radialis brevis which attaches to the lateral epicondyle of the humerus - caused by a sudden injury or by repetitive use of the arm - pain is usually worse with strong gripping with the elbow in an extended position, as in a tennis back hand stroke, typical painful 3rd finger extension and active wrist extension is impossible - ther: steroid injection can be beneficial but no more than three injections are recommended - surgery : simple excision of diseased tissue from within the tendon, shaving down the bone and re-attachment of the tendon b)ulnar EC, so-called golfers elbow or medial epicondylitis, common attachment of flexors affection, painful or
impossible flexion of fingers and wrist 32. The differential diagnosis of the shoulder pain - osteoarthrosis ( mainly in older people) - fx of proximal humerus (intra but also extraarticular), fx of diaphysis with dislocation and joint irritation - shoulder joint luxation - acromio-clavucilar joint disorders ( in clavicle fx, also arthrosis) - impingement sy or rupture of rotator cuff - glenoid labrum damage, SLAP (superior labrum antero-posterior lesion, at biceps origin) - rupture of m.biceps tendon - thoracic outlet sy - cervico-brachial sy - pain from myocardial infarction
TRAUMATOLOGY 33. Types of fractures + dislocations -1- AO classif. : 1, 2, 3 = a bone ( 1- humerus,2-radius/ulna, 3-femur) 1-3 = bone part ( 1 prox.epiph, 2 diaph, 3 dist.epiph ) A,B,C = fracture type ( severity ) 1,2,3,4 = fr.type ( spiral, diagonal, transversal ) - ex : 3 2 A 1 = spiral simple fr.of femur diaphysis -1- types of dislocations : -2- ad latus ( to the side ), ad axim ( to make an angle ), cum rotatione ( with rotation, always needs to be repositioned), ad longitudinem ( length, cum contractione = shorter, cum distractione = longer ) -2- AO classification : -3- Diaphysis : -4- A = simple ( 2pieces ) A1 spiral, A2 diagonal, A3transverse(the least stabile) -5- B = with fragment (3pcs) B1 spiral fragm., B2 wedge fragm., B3 destroyed fragm. -6- C = cominutive( more fragments ) C1 spiral C2 segmental C3 cominutive -7- Epiphysis : -8- A = extraarticular A1 2 pcs, A2 with fragm.,3pcs, A3 metaphysis damage -9- B = partic.intraarticular B1 simple B2 complicate, B3 frontal -10-C = complet.intraarticular = diacondylic ( limb is shorter ) C1 T,Y shape, C2 epiphys simple+metaphys cominutive C3 cominutive -11-open or closed ( Tscherne ) - closed : G 0 = no damage of soft tissue G 1 = contusion of skin, bone going inside out G 2 = cont.of skin, fascia and muscles bordered hematoma G 3 = severe cont. = decolement ( abruption ), big hematoma, compartment sy - open : O 1 = skin perforation, inside out, small contamination O 2 = direct violence ( car crash), open from outside, mild contamin. O 3 = wide open, damaged arteries, nerves O 4 = subtotal amputation, damage of main arteries, severe infecti
34. Distal forearm fractures -12-the most common, children and adults, Xray in 2 planes or more necessary -13-signs : deformity, oedema, crepitation, dysfunction of fingers(n.medianus) -14-therapy : reposition, fixation, surgery -15-complications : diffic.reposition, damage of n.medianus, carpal tunnel sy, compartment sy, rupture of tendon m.ext.poll.long., Suddeck algodystrophic sy( when repetitive repositions) -16-Colles fr. = fr.of distal radius with fragment moved dorsaly - mostly women, fall on forearm in mild pronation and dorsal flexion - ther: reposition in local anesth. ( hand more to dorsal flex., then to palmar flex and ulnar duction ) + plaster to whole arm, cut in middle for space for oedema, for 6weeks -17-Smith fr. = the same as above but hand is in palmar flexion and fragment
moved ventraly -18-same signs, reposition in contrary to above, less common -19-in both, when reposition difficult = indicated for osteosynthesis -20-Fr.of proc.styloideus radii direct mechanism, carpal luxation, reposition or osteosynthesis -21-Fr.of dorsal part of radius + possible rupture of m.ext.poll.long tendon, plaster or surgery -22-Fr.of ventral part of radius : similar to Smith, plaster for 5weeks -23-Fr.of proc.styloid.ulnae : rare, no stabile carpus(Hutchinson fr.), pseudoarthrosis common -24-Damage of radio-ulnar joint :luxation, discus lesion, fixation in maximal suppination, syndesmosis reconstruction
35. Children fractures and epiphyseolysis - growing bone, flexible, high potential for remodelation ( can leave some axial dislocation, but never leave rotation disloc.that will never heal!!!) - types: subperiostal = green stick fr. torus fr = similar + compression epiphyseolysis or epiphyseofractures Salter Haris classification : very important to know+draw pics!!! ( fractures in growth plate ) I epiphyseolysis ( broken just in GP) II the same, from epi to metaphysis III fr.from GP to epiphysis IV transmetaepiphyseal fr. V compressive fr = stops growing, deformities Ther : conservative = plaster Surgery = miniinvasive, ESIN(elastic synthesis intramedulary nailing), external fixation POZOR!! Dont damage growth plate!!! When nailing through GP necessary, use only thin Ki wires Clavicula : common, in newborns as a birth trauma, visible as a big swelling caused by calus, in older child.or adults(bike,skateboards,iceskateting) medial fragment moved up(m.SCM attachm)=typical deformity -ther: children nothing, adults fixation with Desault bandage for 1-7weeks, surgery when nerves in axial affected or big dislocation Proximal humerus : birth trauma, fall on backwards extended arms; signs: swelling, pain, decreased movement, when head abrupted then rotated cuz of muscles attachments -ther: no disloc.only Desault bandage, when disloc.surgery required ( miniinvasive osteosynthesis, Ki wires, TEN(titan elastic nails) for 6wks Diaphysis of humerus : middle 1/3 pozor!! N.radialis( exam.of extensors necessary) -ther: only very small children- Desault bandage or external plate with tape dislocations, n.radialis affection always operation ( transfixation with Ki wires, plates, TEN) Distal humerus : supracondylar fr., radial condyl fr., ulnar condyl fr., distal epiphysis fr. !!!Supracondylar fr : most common, in extension, can be open, POZOR!!!n.radialis+a.brachialis usually damaged, complication: Volkmanns ischaemic contracture(irreversible flexors contracture due to more than 6hrs lasting ischaemia when too tight plaster, hyperextension+pronation-claw hand) -types :I no dislocation;II dislocation but fragments in contact;III total dislocation -ther : children must stay in hospital, I+II reposition+plaster for 4wks, III surgery, transfixaion Ki wires - complic : cubitus varus (bad axis), limited movement, ossification Lateral condylus : AP+diagonal Xray, complic.psedoarthrosis, ulnar nerv affect. Medial condylus : epicondylus abruption ( traction of attached flexors) possibly moved into cubital joint, transfixation after reposition, watch out ulnar nerve
Epiphyseolysis of distal humerus ( Salter-Haris IV ) Epiphyseolysis of capitulum radii when elbow luxation capitulum dislocated by humerus head, classif.into 4groups(accord.to dislocation), urgent treatment, risk of avascular necrosis of capitulum -ther: plaster, or reposition and fixation, or surgery(watch annular ligament) Fr.of proc.coronoides ulnae rare Elbow luxation rare in children(more in older ones), same mechanism like supracondylar fr., damage of capsule, ligg., muscles; pain, deformity, swelling, try innervations! -types: a)dorsal luxation of both bones(most common) b)ventral lux.with abrupted olecranon c)medial or lateral d)only radius lux.(Monteggio fr) e)pronation dolorosa=capitulum radii out of annular ligament, usual in small babies, when lifted up by holding their one arm, ligament in between humerus and radius, very painful!! -ther: a)-c) reposition+PF; d)reposition possible when fresh injury e) very painful, no movement of arm-reposition of ann.lig., doc can hear typical click when lig is back, baby will move forearm immediately, no fixation!!, check only when problems Fr.of forearm-very common, fall on hand in extension, big deformities -ther: high PF(whole arm), rules: fr.of proximal 1/3=fixation in supination position Fr.of middle 1/3=fix.in middle position Fr.of distal 1/3=fix.in pronation not complete plaster(oedema and compartment sy!!!), can leave small dislocation(will remodel) rotatory dislocations must be repositioned!! transfixation with Ki wires or TEN -complic: compartment sy, refracture, deformity, pseudoarthrosis, synostosis Monteggio fr.=fr.of distal ulna+radius head luxation osteosynthesis Galeazzi fr.=fr.of distal radius+ulnar head luxation reposition, PF for 6wks Wrist trauma the most common, all types(compressive, green stick, epiphyseolysis),pain, oedema, deformity, haematoma, a)torus=compressive-mostly radius, PF for 4wks b)green stick fr.-reposition(finish breaking of corticalis), high PF c)dislocated fr. similar to Colles or Smith( no Colles fr in children!!!) reposition, high PF for 6-8wks d)epiphysis separation S-H II, radius, reposition, PF in strong volar flexion Hand injuries carpus: boys, os scaphoideum,, in centre, PF metacarpi : subcapital metaphyseal fr, S-H II, mostly 1st and 5th MC, 5th MC called boxers fr., reposition, PF phalanges : very often, can be open, reposition+PF Hip luxation frontal hit to leg in knee and hip flexion, dorsal or ventral, urgent reposition in anesthesia!!!, then immobilization(spica bandage, traction), complic: myositis ossificans, avascular necrosis of femoral head!! Proximal femur a)cervical ( I transepiphysal with head luxation, II transcervical, IIIbasicervical, IV pertrochanteric), -ther:dont destroy vessels(necrosis)!!!, transfixation with Ki wires, nailing, cannula nails ) b) trochanters separation : caused by muscles attachments, big dislocations need to be operated, small ones only to spica, immobilization c) subtrochanteric fr. Femur diaphysis strong violence, birth trauma, abused child, pathological; reduced movement of joints, severe pain, haematoma, oedema -ther: spica bandage, traction(old method, used in small babies), when dislocated-surgery: intramedular nailing, TEN, Enders bars, plate osteosynthesis, external fixation - complic: anaemia(severe bleeding!!!), ischaemia, fat embolism, different length,
deformities, compartment sy 36. Open fractures Tscherne classification : - closed : G 0 = no damage of soft tissue G 1 = contusion of skin, bone going inside out(no perforation) G 2 = cont.of skin, fascia and muscles bordered hematoma G 3 = severe cont. = decolement ( abruption ), big hematoma, compartment sy - open : O 1 = skin perforation, inside out, small contamination O 2 = direct violence ( car crash), open from outside, mild contamin. O 3 = wide open, damaged arteries, nerves O 4 = subtotal amputation, damage of main arteries, severe infection Therapy : Closed closed reposition + PF, event.open reposition when dislocated and fixation ( Ki wires, inramedular nailing, plates), fasciotomy when compartment sy Open always open reposition + fixation(osteosynthesis,external fixation),ATB, soft tissue reconstruction(Tyrs plastic = skin=fascia=muscle flap), spongioplastic 37. Types of traumatic lesions of joints, therapy 1st grade : capsule distension small oedema, pain, joint stable, ther: rest, ice 2nd grade : ligament distension bigger oedema, haematoma, joint stable, ther:short immobilization (PF or support) rd 3 grade : partial rupture of ligament=distortion Xray neg., haematoma, oedema, subluxation, slightly instable, ther: PF, support 4th grade : complete rupture if ligament big oedema, haematoma, ther: suture of ligg.and capsule, fixation, analgetics, rhb -25-subluxation : incomplete separation, some parts still in contact, rupture of capsule or -26- ligg., ther: reposition(closed, open, MIPO), fixation, immobilization, analgetics etc. -27-luxation : complete separation+function loss, ligg.always ruptured, ther: reposition, immobilization, rhb -28-fractures extraarticular x intraarticular - intraarticular : cartilage fr surface only, fragment not seen on Xray, can caused problems, need to be removed, can lead to arthrosis osteochondral fr fragment also with bone, remove or MIO -29-luxation fractures : = luxation+fracture, eg.hip luxation with fr of acetabulum, very serious, early onset of arthrosis, inadequate therapy leads to instability and recurrent luxation, mostly in shoulder, ther: ORIF (Open Reduction and Internal Fixation) Therapy generally : - reposition : closed ( nailing, screws, external fixation, transfixation, taxis of ligaments) miniinvasive (MIO=miniosteosynthesis, MIPO=MiniInvsive Percutane Osteosynthesis, MIPPO=Miniimvasive Percutane Plate OS) open (ORIF=Open Reduction Internal Fixation) - stability after diff.operation - absolute : OS with nails, ORIF-bone is healed without making a callus - relative : MIPO, transfixation with Kirschner wires, external fixation slight movement is possible, bone healed with making callus) -30-types of osteosynthesis : Kirschner wires, screws(cortical with whole length fine thread; spongious with wide thread on ending part; cannula nails for MIO, inserted along the Ki wire) plates(straight, angular-angle stable, compressive with oval holes, neutralizing with round holes, supporting, edge plate, for varosity, for valgosity, cobra plate for arthrodesis after inflammation, esp.TB)nails( solid, intramedular fixation, steel, titanium) bars ( intramedular, flexible, TEN=titanium elastic nailing) external fixations(clamp, frame) -31-DHS = dynamic hip screw ( for pertrochanteric fr of femur) -32-LCP = locked condylar plate ( screws locked in holes, very high stability, also in -33osteoporotic bones when prosthesis contraindicated)
-34-DCS = dynamic condylar screw -35-DCP = dynamic compressive plate, LC-DCP = low contact DCP -36-LISS = less invasive stabilization system -37-Nails: UFN = unreamed femoral nail, UTN, UHN, TEN=titan elastic nail, PFN=proximal femoral nail, ESIN=elastic synthesis intramedulary neiling(used in children, not rigid) -38-External fixation more types, indicated for open fr.O3 and more, fr with defect, soft tissue contusion, infected fr., pseudoarthrosis, polytrauma followed by OS 38. fractures healing disorders Types of healing : secondary(fastest, mainly in diaphysis) through making callus = haematoma, stem cells, stimulation of osteoblasts and osteocytes primary ( slow growth to connection, mainly in intraarticular fr) complications : infection ( open fr., exo-, iatrogene ), Staph.aureus, Clostridium tetani!!! POZOR sepsis!!!, ther: ATB, debridement, lavage, when chronic inf.pseudoarthrosis! late healing = signs of healing, takes long time but less than 2x for normal healing, bridging spongioplastic may help(bones fragments transplant) healing in bad position when inadequate therapy, bad reposition, leads to redislocation, ther: osteotomy, osteosynthesis avascular(aseptic)necrosis due to damaged nutrition arteries( also in operation!!), mostly in femur head, talus, scaphoideum stop of growth fr in growth plate, bone bridge, deformities, arthrosis shortening of bone GP, defects prolonging of bone biomechanism, bigger bloo supply when healing !!Suddecks algodystrophic syndrome = reflex sympathetic dystrophy often after Colles fr., signs: marble osteoporosis in distal parts(decalcification), oedema, marble skin, hyperemia, hypohidrosis (decrease sweating), skin atrophy, fragile nails, atrophies of muscles and bones - pain, parestesis, dysestesis; ther:NSA, alpha sympatholitics, calcitonin, rhb !!Volkmanns ischaemic contracture in children, after supracondylar forearm fr., Acute arterial ischaemia with venous obstruction, affection of flexors tendons and nerves, typical claw hand Paraarticular ossification repeated repositions, rhb, usual in elbow Pseudoarthrosis not healed fr., operation therapy necessary, classif.see next quest. Arthrosis - mainly in inraarticular fr. !!Compartment sy compressed arteries and nerves in osteofascial space, caused by too tight plaster, oedema, haematoma, postischaemic oedema, too tight suture -39-pain, oedema, dysestesis, higher intracompartmental pressure(more then 30mmHg) -40-most common in shank, ther: relax bandage, NSA, mild elevation of limb, FASCIOTOMY! Reduced range of movement fibrotisation of paraarticular tissue 39. Pseudoarthrosis and treatment = no healed bone fracture Cech, Weber classification : I aseptic (caused by instable OS, blood supply disorders) x septic (infection) II a) vital = good blood supply, trend to be healed ( due to inadequate immob.) 1)hypertrophic big callus, called elephant foot 2)normotrophic - good biologic potential, good blood supply 3)oligotrophic when reposition of fragment not satisfact. -ther: not easy but satisfactory, rigid OS, decortication(many incisions in corticalis to renew vascularisation )with spongioplastic b)avital = +bone defect, blood supply nonsatisfac., fibrotisation, healing very difficult 1)dystrophic necrotic fragment attached only to one part of fx bone event. amputation!! when infectious
40. The principle of osteosynthesis(OS) = internal stabilization and fixation with foreign material, mainly some metals -41-types of osteosynthesis : Kirschner wires, screws(cortical with whole length fine thread; spongious with wide thread on ending part; cannula nails for MIO, inserted along the Ki wire) plates(straight, angular-angle stable, compressive with oval holes, neutralizing with round holes, supporting, edge plate, for varosity, for valgosity, cobra plate for arthrodesis after inflammation, esp.TB)nails( solid, intramedular fixation, steel, titanium; static or dynamic, using screw for fixation and stabilization of nail) bars ( intramedular, flexible, TEN=titanium elastic nailing) external fixations(clamp, frame) -42-DHS = dynamic hip screw ( for pertrochanteric fr of femur) -43-LCP = locked condylar plate ( screws locked in holes, very high stability, also in -44osteoporotic bones when prosthesis contraindicated) -45-DCS = dynamic condylar screw -46-DCP = dynamic compressive plate, LC-DCP = low contact DCP -47-LISS = less invasive stabilization system -48-Nails: UFN = unreamed femoral nail, UTN, UHN, TEN=titan elastic nail, PFN=proximal femoral nail, ESIN=elastic synthesis intramedulary neiling(used in children, not rigid) -49-External fixation more types, indicated for open fr.O3 and more, fr with defect, soft tissue contusion, infected fr., pseudoarthrosis, polytrauma followed by OS -50-advantages of LCP stability also in osteoporotic bone, used in MIPO -51-disadvantages of LCP open surgery, loss of periost, devitalizatiom, necrosis, refractures 41. The algodystrophical syndrome of Suddeck - also called reflex sympathetic dystrophy; mainly after Colles fx - severe complication of bone fx healing, etiology unknown - symptoms: pain, dysaesthesia (tactile hullcination), paraesthesia (pins and needles in skin) - signs: oedema, hyperaemia, decalcification causing marble osteoporosis, atrophy causing typical marble skin, hypohidrosis (decreased sweating), fragile nails, can lead to muscle and bone atrophy -52-ther: NSA, alpha-sympatholytics, calcitonin (experimentally), rhb 42. Volkmanns ischaemic contracure(VIC) and compartment syndrome(CS) a)VIC in children, very urgent!!!, after supracondylar forearm fx = acute arterial ischaemia + venous obstruction, -53-affecting wrist flexors and nerves ( mainly n.medianus)and arteries caused by broken fragments, reposition of bone, insertion of Ki wire, circular plaster -54-no pulse, pain, pale and cold extremities -55-causing typical position of hand flexion in elbow, hyperextension in MCP joints, pronation = claw hand -56-child with supracondylar fx must stay in hospital!!, regular checks to dg possible contracture -57-can lead to loss of forearm!!! b)CS mainly after trauma of shank, in every age, when not treated can lead to amputation!! = blood supply failure due to compression of arteries and nerves in osteofascial space -58-caused by oedema, haematoma, postischaemic oedema, too tight bandage, too tight suture -59-pain, oedema, dysaesthesia, increased intracompartmental pressure(more than 30mmHg) - ther: release bandage or plaster, NSA, mild elevation of limb, FASCIOTOMY 43. Fractures of the hand and wrist 1)fx of distal forearm ( Colles, Smith ), fx of proc.styloideus radii et ulnae, fx of ventral or dorsal part of radius, trauma of radio-ulnar syndesmosis see above or next quest. 2)carpal bones injuries most common is fx of scaphoideum, luxation of lunatum, perilunate luxation - often leads to avascular necrosis causing dysfunction of wrist, think of muscle tendons damage!! a)os lunatum luxation: caused by strong dorsal flexion - completely rotated(180deg) different shape on Xray, hard to diagnose, irritation of n.medianus, loss of blood supply!!, big oedema - ther: urgent open reposition, release of incancerated soft tissues, PF for 10wks
- late complic: necrosis( need to be treated with carpal arthrodesis=permanent joint fixation) - de Quervain fx = lunatum luxation+scaphoideum fx b)perilunate luxation more often,lunatum in normal position,other carpal bones disloc.dorsaly - ther: urgent reposition= strong traction of fingers followed by PF in palmar flexion for 5wks then PF in normal hand position for 3wks c)scaphoideum fx mostly in sportsmen, signs: stiff position of wrist, pain in fossa tabatiere, percussion on extended thumb painful; Xray in diagonal plane(if not seen expect fx and put in PF and wait for decalcification, then fx lines visible) -60-mostly fx of corpus ( then tuberculum, proximal or distal part ) -61-ther: OS with Herbert screw, high PF for 6wks then lower PF for another 6wks -62-complic: pseudoarthrosis(very painful), aseptic(avascular) necrosis of devitalized fragment, when not successful carpal arthrodesis necessary 3)metacarpi mostly 1st and 5th MC, localization: in head, subcapital, in diaphysis, in basis a)1th MC fx of basis : Wintersteins fx extraarticular, ther: traction reposition, thumb in abduction, PF for 5wks Bennets fx diagonal fx line, MC dislocated proximaly(shortening) Rolands fx cominutive, Y fx, ther of B,R : transfixation with Ki wires, plates or using binding wire, PF for 6wks b)1st MC subcapital fx : called boxers fx, typical palmar dislocation of abrupted head; ther: reposition(finger into 90deg flexion and push up dorsaly), then PF in 90deg flexion(tendons are relaxed in extension and would be retracted after treatment) c)luxation of 1st MC joint : partial, complete, complex(dislocation+rotation, incancerated sesam bones); ther: reposition and PF d)other MC typical spiral fx with dislocation ad axim or ad peripheriam, malrotation e)skiers thumb when thumb stay in stick, hyperabduction, rupture of collateral ligament 4)phalanges proximal Ph: typical dislocation(proximal fragment in flexion, distal in hyperextension,traction of muscles); ther:reposition,PF together with next finger -63distal Ph: often cominutive and open, basketball players fx fx of dorsal part, finger in semiflexion, pain, oedema, ther: fixation(DIP joint in hyperextension, PIP joint in flexion)for 6wks 44. Fractures of the forearm - direct or indirect, Xray AP and side, with both joints, rule: if one bone dislocated, the other must be luxated or broken too!!, in accord.to AO classif.A)simple B)with fragment C)cominutive ( more than one fragment), often open(mainly ulna), dislocation usual due to traction of muscles - ther: when simple high PF for 6-8wks ( fx of proximal part fixated in supination, fx of distal part fixated in pronation muscles relaxed!!) when dislocated surgical OS, 2incisions( one for each bone!!), mostly used plates(LCP), in children intramedular fixation (TEN) -64-Galeazzi fx fx of distal radius and luxation of distal part of ulna - ther: open reposition and stabilization using plates, suture of ligaments -65-Monteggio fx fx of proximal 1/3 of ulna and luxation of radius head, POZOR deep branch of radial nerv!! - ther: reposition and plate reconstruction, event.prolongation of ulna 45. Fractures of the elbow, traumatic dislocations of the elbow 1)fx of olecranon fall onto elbow, haematoma, extra- or intraarticular(more common), extension impossible, can palpate fissure between fragments ( dislocated by traction of triceps) - ther: OS using soft wire drawn over Ki wires, PF in extension 2)fx of radius head types: scalpiform(like chisel), cominutive, subcapital; pain, rotation impossible - ther: stable without any fixation, instable-OS(nails or head resection and prosthesis) 3)Monteggio fx see above 4)elbow luxation fall onto extended arm - humero-ulnar : dorsal(most common), dorsolateral, dorsomedial, ventral, divergent(distal part of humerus stuck between R and U) - radio-ulnar = Monteggio fx
- radius head subluxation = pronation dolorosa, only in children, head gets out of annular ligament(when lifted up by parents when only one hand held) -66-ther: reposition in limb traction, PF in flexion for 3wks, when persistent instability surgery 46. Fractures of the humerus 1)prox. humerus common in old people(pathological fxs) - Neers classif.: (important!)1 no dislocation; 2 fx of collum anatomicum with small dislocation; 3fx of collum chirurgicum; 4 fx of greater tuber; 5 fx of lesser tuber;6 luxation=humerus head completely dislocated -67-ther: 80% only in Desault bandage others: closed reposition and transfixation(Ki wires) or open reposition + OS(cannula nails inserted along Ki wires, nails, plates-PHILOS=plate with fixed angle), CCEP=cervico-capital endoprosthesis in risk of head necrosis -68-complic: damage of nerves and/or vessels, head necrosis, frozen shoulder, growth disorders in children 2)diaphysis of humerus mostly direct mechanism, in fx of middle and distal 1/3 watch radial nerv!! - AO class, when radial nerve damaged swan neck sign(extensors dysfunction) - ther: conservative only in children and when surgery contraindicated dislocated, with nerve lesion must be operated plates, intramedular nailing, screws, special expansive nails (injected saline after insertion) 3)distal humerus direct: fall onto limb in flexion, indirect in extension - AO : A extraarticular, B partially intraarticular, C completely intraarticular - be aware of supracondylar fx in children( Volkmanns contracture!!!) - only dislocation smaller than 1mm- PF ( compartment sy!!!), OS plates, nails, screws - other complic: paraarticular ossification, release of implants in osteoporotic bone, ulnar nerve paresis 47. Shoulder dislocations - traumatic- types: ventral(most common), dorsal, inferior (also called luxatio erecta, arm is in high abduction) - atraumatic = habitual, recurrent luxation due to inherited increased flexibility of joints, usually spontaneous reposition; use apprehension test(move passively patient shoulder to position in which luxation happens and he would be scared and stop you) -69-ventral luxation (subcoracoidal) fall onto arm in abduction and outer rotation; severe pain, held by patients other hand, active movement impossible, springy resistance -70-damage of glenoidal labrum(Bankarts lesion) can lead to recurrent luxation; then anterior instability causes Hill-Sachs defect ( impression fx of posterolateral part of humerus head, because head is pressed against labrum edge when luxated) - ther: reposition 1st tried without anaesthetics then in short anaesthesia Kochrs move ( from outer rotation and abduction to inner rotation and adduction), Hippocrats move (push your foot into lying patients axilla and pull extended arm), Djanelidzes move (patients on bed, prone, arm down from the bed, pull arm down and push humerus head with your palm); then Desault bandage for 3wks; event.operations: Bankarts operation ( reinsertion of glenoid labrum ), reinsertion and stabilization of capsule=capsular shift, transposition of subscapular muscle tendon onto greater tuber, stopper joint implant(in dorsal luxations) 48. The pelvic fractures - stability of pelvis thanks to SacroIliac joint - trauma of pelvic circle principle of contra lateral force ( hit in one side must cause damage in the other side too ) AO classif.: A avulsion, fx of ala ossis illium B failure of pelvic circle stability : open book fx (open in symphysis, force from front) lateral compression(symphysolysis,ventral segments overlapped, damage of dorsal SI ligaments; lateral force) C total instability(inner hemipelvectomy=half of pelvis moved up,no connection to sacrum) - trauma of organs(urin,bladder perforation, shear failure of urethra), nerves(mainly peroneal part of
sciatic nerve, femoral or obturator nerve), vessels - severe blood loss into retroperitoneal space(can be whole blood volume) !!haemorhagic shock!! - investig.: Xray(AP, special Pennals projections=for pelvic entrance and exit), CT scan (3D reconstruction), MRI (never in acute phase) - ther: stable fx rest in bed in swing support(hanging) instable fx surgical : pelvic clamp ( stops bleeding ), ORIF Fractures of acetabulum - usually assoc.with hip joint luxation, painful movement, shortening of leg, haematoma - Xray AP and 2 diagonal - AO : stable x instable - lesion of sciatic nerve, damage of artery for caput femoris - ther: nondislocated skeletal traction, dislocated-ORIF(nails, plates) 49. Fractures of the vertebral bodies - spine divided into 2 basic columns ventral (lig.longit.ant, verteb.body, discus), dorsal (lig.longit.post, spinal cord canal, pedicles, procc.transversi et spinosi, ligg.interspinosum et supraspinosum) -71-dorsal column important for fracture stability C spine : upper part=C0(occipital condyli)to C2 Lower part=C3 to C7 a)trauma of C0/C1 joint usually fatal, luxation of head b)atlas force to the top pf head, fx of anterior, posterior or both arcs, Jeffersons fx=fx of both arcs, lateral fragments dislocated, instable; ther: halo fixation(metal circle nailed into head to stop moving neck)or surgical C0-C2 stabilisation(spondylodesis) c)axis fx of dens: Anderson and dAlonso classif.: I. fx of dental apex, conservative ther. II. fx of dental body, ther:reposition, fixation with 2nails from front III. fx of dental basis, conservative ther.with halo traction -72-fx of axis body typical hangman trauma=spondylolysis(in arc isthmus),ther:spondylodesis d)trauma of lower C spine luxation: complete(severe neurological defect), partial(subluxation) - ther: reposition, stabilization, halo traction, internal fixation-metal fixation - typical whiplash injury in car hit from behind, symptoms usually after 2nd day!! Th-L spine : Th = Th1-Th10, Th-L junction=Th11-L1, L=L2-L5 a)Th fx not often, fixated by ribs(in patients with M.Bechterew, Th spine usually broken) b)Th-L the most movable, most of fx; c)L quite stable AO classif.: A fx of ventral column, dorsal ok ( usually stable ) B fx of ventral column+dorsal distracted C fx of ventral column+dorsal rotated B,C instable fxs - types : 1)compressive most common, reduction of vertebral body, stable; ther: support, functional (rest in bed, early rhb and muscle exercise), operation need when more than 50%compressed, or angle>20deg 2)burst body wider, lower, fragment moved into spinal canal, can be A,B or C, ther:surg. 3)pincer split of body in frontal plane so 2 next disci can communicate, always instable, must be operated or pseudoarthrosis may occur 4)flex-distraction type B, very instable, need surgery 5)luxation fx = spondylolistesis, vertebra moved in front over body of lower one, instable, neurological lesion usual!! Ther: avoid neurological lesion, spine stabilization, early mobilization -73-conservative : in stable fx, normal neurology, in old osteoporotic patients : 3points supports(Jewett), plaster corset, functional ther -74-surgery : always in types B, C, in A when big compression, burst, pincer, always when neurological lesion - from behind nails through pedicles, reposition with internal fixation, spondylodesis, spondylofusion 50. Fractures of the foot
a)talus fall onto foot in maximal dorsal flexion, severe due to blood supply failure - fx of head: fragment moved dorsaly, big deformity, huge oedema, pain, dysfunction - ther: reposition as soon as possible!!, PF in plantar flexion, event,Ki wires or talonavicular arthrodesis when head damaged - fx of body : deformity, oedema, reposition, fixation, arthrodesis when necrosis - fx of neck : 1 no dislocation 2 subluxation in talo-calcanear joint 3 dorsal dislocation of body 4 ventral dislocation of head, risk of damaged blood vessels in sinus tarsi causing avascular necrosis of bone, ther: in dislocated reposition, PF for 12wks, observe fragments, when sign of necrosis PF for 18wks, so-called Hawkins sign = normally on Xray,visible line of decalcification(if not susp.necrosis) b)calcaneus Essex-Lopresti classif.: 1)intraarticular=into talocalcanear joint (tongue type, joint depression pressure of tibia) 2)extraarticular - check Boehler angle(between horizontal line and long axis of calcaneus, normal is 30deg) - big oedema, compartment sy, dysfunction - ther: simple fx only leave in rest, ice, elevation;dislocated reposition, Ki wires,PF for 6wks, abrupted tuber fixated with spongious screw c)navicular top of foot arch!!, when ant.tibial muscle tendon abrupted foot arch can fall down, fx with dislocated fragments need reposition with Ki wires, event.talonavicular + naviculocuneiform arthrodesis d)metatarsi fx of head, subcapital, of body, of basis; head usually dislocated, bodies dislocated ad latus, fx of 5th MT basis-fragment dislocated by m.peroneus brevis traction, must be nailed!!, so called stress(fatigue)fx most common in 2nd,3rd MT; ther:PF, support, Ki wires fixation, 5th MT basis fixed with intramedular nail e)phalanges most common prox.Ph of 5th toe, proximal Ph of big toe needs Ki wires fixation, others only taping - on Xray : accessory bones can be seen ( dif.dg. of fxs!!) Luxation in foot joints - talus luxation total separation of ligaments - Chopart joint( talus, calcaneus, cuboideum, naviculare ) deformity, shortening of foot, oedema - ther: reposition, PF - Lisfrank joint ( tarso-metatarsal ) can be total, partial, associated with fx or soft tissue damage, - ther: reposition by traction of MT, event.Ki wires, PF for 8wks 51. Malleolar fractures - most common injuries in lower limb - Weber classif.: ( very important to know!!!) in accord.to position of Ti-Fi syndesmosis A under syndesmosis, B in syndesmosis, C above syndesmosis A1 fx of fibula; A2 fx of Fi + fx of medial ankle or medial collateral ligament rupture; A3 the same + fx of dorsal part of Ti B1, B2, B3 the same as A but in the level of syndesmosis C1, C2, the same as A or B but above syndesmosis, C3 high fx of Fi+fz of dorsal part of Ti+rupture of interosseal membrane -75-associated with talus luxation, soft tissue damage, can be also open -76-ther: exact reposition and OS necessary ( Ki wires, miniplates, soft binding wire, suture of syndesmosis, suprasyndesmal screw, malleolar screw etc.) Distortion foot in inversion, damage of lateral collateral ligaments -77-can be distortion, acute instability, total luxation -78-ther: maximum conservative ( taping, elastic bandage, support, early rhb) operation when acute instability and in sportsmen -79-dg drawer test : when positive(pathological movement) = instable, PF for 6wks or surgery negative = stable 52. Traumatic lesions of the soft tissues of the knee - contains ligaments, menisci (very important blood supply from periphery, M divided into 3 zones = red-red-3mm from margin, well supplied, red-white- 5mm from margin; white-white-more poor supply which means poor
healing!!) - signs : oedema, filling (can dg using patellar balotement test = push down suprapatellar area and if any liquid, patella will dance on it, or press lateral part of knee and liquid will make lump on the other side, arthropunction tells what kind of liquid, do it only when necessary-high chance of infection!!); pain ( when in flexion-more likely ligg injury, in extension-likely in menisci) immobility (when part of meniscus incancerated in knee-called blocked knee )pathological movement, loose (in ligg rupture, tests see down) - ACL : usually in skiing, ice skating, rotation when femur fixed; pain, pathological movement; Tests: abduction/adduction test=try abd and add with patients shin, in 0deg for ACL, in 30deg for collateral ligaments (ACL is relax in this position) Lachmans=knee in 30deg flexion, hold leg with both hands and try to move tibia ventrally against the femur, positive when moving without obvious stop ventral drawer test= knee in 90deg, sit in patients foot to fix it, try to move tibia towards you, positive when moving pivot shift test= inner rotation and abduction of shin in extension causes subluxation of lateral tibia condylus, moved to flexion causes spontaneous reposition with typical click - PCL : usual in car accident when knees hit dash board or in hyperflexion of knee Test : dorsal drawer sign= knees in 90deg flexion, tibia is sunken, no continuity - menisci : medial more often, lateral is more flexible and more closed and stronger usual in torsion force when femur fixed, lesion horizontal, peripheral or lobular; in peripheral lesion central part can be incancerated in joint=bucket handle lesion, blocked knee; tests: McMurray= move flexed shin from abduction and outer rotation to inner rotation and adduction, positive when click phenomenon Appley= patient prone, knee in flexion, traction of the foot painful when ligg affected, pressure onto the foot painful when menisci affected Payr = sit on crossed legs, push knee down, positive when painful Steinmann I = sit on bed, legs down, produce strong abduction and adduction Steinmann II = pain when palpation of meniscus moving in according to movement of knee(flexion and extension) Boehler = knee in extension, shin into adduction, pain in medial joint fissure means medial meniscus affection -80-combined injuries (med.collat.lig, ACL, med.meniscus) abruption fx in intercondylar area, med.collat.lig attachment or joint capsule abruption(Segonds sign)
- ther: ACL plastic using BTB graft(bone-tendon-bone) from patellar ligament, with piece of bone from patella and tibia, 10cms long, 9-10mms wide; or tendons of m,semitendinosus and gracilis, folded so it makes 4tendons arthroscopy and suture of meniscus ( successful only when rupture in red-red zone ), insideout=knot outside, outside-in=knot inside, all inside(very difficult), when meniscus can not be saved use partial meniscectomy event.total meniscectomy(that leads to secondary arthrosis, then replacement required) inlay plastic=transplant of osteocartilagenous material from part of bone not used so much -81-complic.: postoperative infect, phlebothrombosis ATB and anticoagulants required, early arthrosis when menisci damaged 53. Fractures of the tibia and fibula - proximal part : mainly tibia ( fibula is not carrying bone), called a bumper fx AO classif.: A extraarticular A1 avulsion of tuberositas tibiae A2 metahpysis fx A3 many fragments B partially intraarticular B1 pure split B2compressive B3 combined(compressive+split), fragments dislocated C intraarticular C1 complete dislocation of condyli=diacondylar fx C2 the same but more fragments in metaphysis
C3 more fragments in metaphysic and epiphysis too -82-often associated with Fi head fx or luxation - !!!peroneal nerve lesion!!! -83-also ligaments often damaged -84-fx of intercondylar area no dislocation, mild dislocation(50%), total dislocation - dysfunction, pain, oedema, pathological movement - always check pulse on ATP, ADP and innervations, knee joint - ther: conservative, for dislocated use screws, Ki wires, plates, for cominutive use open OS, screws, wires and always spongioplastic!! - diaphysis : AO classif. A1 simple spiral A2 simple diagonal A3 simple transverse B1 spiral fragment B2 fragment in angle B3 burst fragment C1 spiral cominutive C2 segmental C3 burst with many fragments - usually indirect torsion mechanism ( skiing, bike) - oedema, pain, crepitation, dysfunction - complic.: compartment sy!!, check pulse, innervations, temperature of leg - open fxs classif.in according to Tscherne(see above)or Gustilo-Anderson : I bone inside out, soft tissue damage <1cm, slight contamin. II soft tissue damage<10cm, middle contamin. III A soft tissue damage >10cm, high contamin. B the same + blood vessels damage C total amputation! - ther: most used is UTN ( unreamed tibial nail), also in Tscherne O1-O2 external fixation for soft tissue damage, when risk of compartment sy, in Tscherne O3-O4 for reoperation also when pseudoarthrosis occurs(often complic!!): reamed nails, plates and spongioplastic - distal Ti : A1 simple spiral, diagonal, transverse B1pure, partially intraarticular A2 angle ( fragments still in contact ) B2 split with depression A3 cominutive B3 more fragments and depression C1 intraarticular, simple line in meta- and epiphysis C2 simple line in epi- but cominutive in metaphysic C3 cominutive in meta- and epiphysis - ther: PF in simple ones, for dislocated ORIF ( special plates and screws), spongioplastic in burst fx, then PF for 3wks
54. Fractures of the distal femur, patella and upper tibia - distal Fe : often intraarticular, fx of condyli or supracondylar (dislocation of proximal fragment up by adductor muscles traction, distal fragment down by traction of m.gastrocnemius ) - knee and soft tissue often affected too, also vessels, nerves - AO classif. A1-3,B1-3,C1-3 - Hoffs fx=frontal fx of condylus + fragment moved upwards - Segonds fx=avulsion of medial epicondylus by med.collat.lig attachment - ther: for supracondylar condylar plate, DCS ( dynamic condylar screw ), stable intramedular nailing, DFN ( distal femoral nail, from knee joint up); for condylar- screw OS, condylar plate, DCS - patella fx : intra- or extraarticular, associated with rupture of m. quadriceps, rupture or patellar ligament also with fragments -85-luxation of patella ( can be habitual ), enucleation (completely out of its capsule) - upper tibia : see above 55. Diaphyseal femoral fractures
- hard force to leg, car accidents, fall - pain, deformity, oedema, big haematoma, be aware of severe blood loss(in thigh fascia can be 1,5litre of blood!!!can lead to shock!!), pathological movement - can be closed or open, AO classif. for diaphysis fxs A simple, B with fragment, C cominutive - always check peripheral blood supply (damage of femoral arteries ) - ther: intramedular nailing using un- or reamed femoral nail with safety screws; in open fx or with severe soft tissue defect use external fixation 56. Fractures of the upper femur a)fx of femoral head : usually in hip joint l Pipkin classif.: I - Posterior dislocation of the hip with fracture of the femoral head caudad to the fovea capitis femoris (only small fragment, spontaneous healing possible) II -Posterior dislocation of the hip with fracture of the femoral head, foveolar part completely abrupted III- type I and/or type II with associated fx of femoral neck IV type I and/or type II with associated fx of acetabulum -86-ther: young people extirpation of fragment, OS using screws older people usually indicated for replacement -87-compl.: avascular necrosis of head b)fx on femoral neck : usual in old people with osteoporosis - 1)intracapsular = subcapital, transcervical, basal - Pauwels classif.: I has an obliquity ranging from 0 to 30deg II an obliquity from 30 to 50deg III an obliquity > 50deg -88-Garden classif.: I incomplete, so-called abducted or impacted II complete with no dislocation III complete with partial dislocation IV complete with total dislocation - blood for head is from medial circumflex femoral artery, the closer to head fx is the higher chance to damage blood supply causing avascular necrosis!!! -89-ther: Garden I,II only conservative, PF dislocated need surgery, OS using DHS (dynamic hip screw), 3traction screws, in children Ki wires, in older patients cervicocapital replacement (CCEP)suitable - 2)extracapsular = pertrochanteric(intratrochanteric), subtrochanteric - pertrochanteric: quite often in adults and older patients, classif.in accord.to stability: stable = with 2fragments; instable = more fragments, damage of lesser trochanter ( Adams arch ) - ther: always indication for surgery as soon as possible, using stable angle plates, DHS, gamma nail, PFN=proximal femoral nail) - subtrochanteric : need urgent surgery as well, using condylar plates, DCS, gamma nail, PFN - treatment of proximal femur fx is very important, helps early mobilization; these fx used to be fatal for old people who had to stay in bed for very long time ( pneumonia, decubital ulcers, thrombosis; mortality used to be 30%) 57. Traumatic dislocations of the hip joint and acetabular fx - caused by strong force in femoral long axis - can be associated with fx of acetabulum or fx of femoral head - types : dorsal superior = iliac; dorsal inferior = ischial; with or without fx; from frontal force ventral pubic(above acetabulum); ventral obturator; wrest mechanism central= head into acetabulum; in lateral compression -90-ther: urgent reposition in total anaesthesia(max into 6hrs) to avoid necrosis!! then traction for 3wks -91-complic: avascular necrosis, early ( secondary ) arthrosis

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ORTHOPEDICS

MCCQE 2006 Review Notes

MCCQE 2006 Review Notes

FRACTURES - GENERAL PRINCIPLES

CLINICAL FEATURES OF FRACTURES

RADIOGRAPHIC DESCRIPTION OF FRACTURES

successful stabilization cast external fixation traction rehabilitate

unsuccessful open reduction stabilization internal fixation

Figure 1. Fracture Management MCCQE 2006 Review Notes Orthopedics OR3

FRACTURES - GENERAL PRINCIPLES. . . CONT.

MCCQE 2006 Review Notes

FRACTURES - GENERAL PRINCIPLES. . . CONT.

MCCQE 2006 Review Notes

FRACTURES - GENERAL PRINCIPLES. . . CONT.

MCCQE 2006 Review Notes

FRACTURES - GENERAL PRINCIPLES. . . CONT.

Painful Very painful

Figure 4. Mercedes Benz Sign

ACROMIOCLAVICULAR (AC) JOINT SPRAIN

ANTERIOR SHOULDER DISLOCATION

MCCQE 2006 Review Notes

POSTERIOR SHOULDER DISLOCATION

ROTATOR CUFF LESIONS

MCCQE 2006 Review Notes

supraspinatus infraspinatus subscapularis joint capsule

Figure 5. Muscles of the Rotator Cuff and Position at the Glenoid

process which involves adhesive capsulitis

MCCQE 2006 Review Notes

PROXIMAL HUMERAL FRACTURE

Figure 6. Fractures of the Proximal Humerus

MCCQE 2006 Review Notes

Figure 7. Anatomy of the Elbow

Figure 8. Displaced Supracondylar Fracture of Humerus

RADIAL HEAD FRACTURE

MCCQE 2006 Review Notes

COMPLICATIONS SPECIFIC TO FOREARM FRACTURES

NIGHTSTICK FRACTURE(see Figure 9)

(see GALEAZZI FRACTURE Figure 10)

Figure 9. Nightstick Fracture

Figure 10. Galeazzi Fracture

2nd ed. Churchill Livingstone, New York, 1989.

MONTEGGIA FRACTURE(see Figure 11)

MCCQE 2006 Review Notes

Figure 12. Scaphoid Fracture

Fracture Treatment, 2nd ed. Churchill Livingstone,

New York, 1989.

cast 2 weeks (thumb spica) repeat x-ray ve +ve

cast off fracture healed yes no

clinical exam ve STOP +ve bone scan

COLLES' FRACTURE(see Figure 14)

Figure 14. Colles' Fracture and Associated Bony Deformity

MCCQE 2006 Review Notes

SMITHS FRACTURE(see Figure 15)

Type a Figure 15. Smiths Fracture

BARTONS FRACTURE(see Figure 16)

Dorsal Figure 16. Bartons Fracture

COMPLICATIONS OF WRIST FRACTURES

DEGENERATIVE BACK PAIN

Table 6. Types of Low Back Pain

CAUDA EQUINA SYNDROME

Table 8. Lumbar Radiculopathy/Neuropathy

MCCQE 2006 Review Notes

Figure 17. Dermatomes of the Upper and Lower Limbs

Figure 18. Alignment of Cervical Spine