Elective Cases2a

13rd EDITION by Anika A Alhambra
PERIPHERAL NERVE INJURY

SEDDON classification: I. NEUROPRAXIA. II. Transient disorder (spontan recovery), several weeks. EMG of the distal lession usually normal. Caused by mechanical pressure, exp: Crutch paralysis Good prognosis.
AXONOTMESIS A discontinuity of the axon, with intact endoneurium. Wallerian degenration on the distal side. There is an axon regeneration : 1 3 mm/day Good prognosis
III. NEUROTMESIS Nerve trunk has distrupted, include endoneural tube Regeneration process neuroma Prognosis: depend on the surgery technique.
SUNDERLAND Classifications: I. II. Loss of axonal conduction. Loss of continuity of the axon, with intact endoneurium.
III. Transection of nerve fiber (axon & sheath), with intact perineurium. IV. Loss of perineurium and fascicular continuity. V. Loss of continuity of entire nerve trunk.
DEGREE 1st 2nd 3rd 4th 5th
DISCONTINUITY None, conduction block (neuroprxia) Axon (axonotmesis) Axon & endoneurium Axon, endoneurium,perineurium Complete (neurotmesis)
DAMAGE Distal nerve fibers remain intact Based on fibrosis Based on fibrosis Fibrotic connective tissue connects Complete
TREATMENT Observation Observation Lysis Nerve graft Graft/transfer
PROGNOSIS Excellent Good Ok Marginal Poor
PATOPHYSIOLOGY on the nerve compression injury:
1. Disturb to microcirculation ischemia 2. Disturb to axoplasmic transport neruroaxonal transport Intravascular edema (Increase of vascular permeability) (Degeneration process) Proliferating fibroblast Separation nerve fiber One week (Demyelination) Note: compression 20-30 mmHg pathology on epineurium >80 mmHg completely stop 30 mmHg (8j); 50 mmHg (2j) reverse after 24 hours 400 mmHg (2j) reverse after 1 week Tinnel sign, is happened on injury and compression, it is sign of regeneration process (continuity sign) Pathological changes on PRIMARY NERVE REPAIR 1. Fragmentation of axon and myelin in distal part 2. Schwan cell proliferation in distal segment, with macrophage phagocytes debris material. 3. Axonal sprouting from proximal segment 4. Axonal connection with periphery and maturation of the nerve fiber. CNS SCHWANNCELL
NERVES AXON MYELIN RESPONSIBLE FOR MYELINATING PERIPHERAL RESPONSIBLE FOR FORMATION OF
PERIFER
OLIGODENDROCYTES
ASTROCYTES SUPPORTING STRUCTURE OF THE BRAIN VASKULARISASI tendon SYNOVIAL FEATURES - Fibrosis capsule - Synovial membrane - Fat pad - Synovial fluid - Articular cartilage ANTIBIOTIK GAS GANGGREN: PARATENON VINCULA
+ +
+ -
PENICILLIN & CLINDAMYSIN
PATOLOGY of peripheral neuropathy:
- Acute interruption of axonal continuity - Axonal degeneration - Demyelination Classification *mononeuropathy & *polyneuropathy Cause of polyneuropathy: A] Hereditary: - hereditary motor neuropathy - Hereditary sensory neuropathy - Friedreich ataxia - Herpes zoster - GBS - Sarcoidiosis -DM - Amyloidosis - Leprosy - SLE - Neurologic Amyyotrophy - Vitamin deficiency - Myxoedema I M T - Lead Others C
B] Infection: C] Inflammation:
D] Nutritional & Metabolic: E] Neoplastic: - Myeloma F] Toxic: - Alcoholism
G] Drugs: various H] IDIOPATHIC Chief complain: sensory disturbance: - numbness, burning, shooting pain,, Compression Mononeuropathy: a) Median nerve : Pronator syndrome Anterior interosseus syndrome Carpal Tunnel syndrome b) Ulnar nerve : c) Radial nerve : Cubital Tunnel syndrome Ulnar Tunnel syndrome Posterior interosseous syndrome Radial Tunnel syndrome Weakness, clumsiness Loss of balance in walking Usually, pathology on the distal part, before proximal part.
Cheiralgia paresthetica (Superficial Radial nerve syndrome) d) Others: Thoracic Outlet syndrome Suprascapular nerve syndrome Meralgia paresthetica (Lat Femoral Cut nerve) Anterior tarsal tunnel Syndrome (Deep peroneal nerve) Tarsal Tunnel syndrome (Tibial nerve)
BRACHIAL PLEXUS INJURY
Elbow flexion (biceps, C5 dysfunction)____ can be restored w/ latissimus dorsi flexeroplasty (ZANCOLLI) or pectoralis major & minor transfer Elbow extension ____ can be restored w/ transfer of the posterior 3rd of the deltoid to the trapezius
ANATOMIC Root level avulsion involves BOTH anterior (plexus) & posterior (dorsal sensory) region, whereas plexus injury spare posterior areas. C4-7 nerve root WELL SECURED to their respective vertebrae & are less prone to avulsion inj. C8-T1 roots are NOT. T1-level preganglionic inj. often includes a Horner syndrome because of disrupting the 1st sympathetic ganglion. Traction inj are most common C5 & C6 level Proximal cord lesion injure supraclavicular branches as well as the distal plexus and lead to winging of the scapula (Long thoracic nerve)
TREATMENT Controversy Mostly observation 3 mo w/ passive ROM & bracing No improvement o o o o Neurolysis Grafting Nerve transfer (usually w/ neurotization of intercostals nerve) Muscle/ tendon transfer
LEFFERT classification I. OPEN (usually from stabbing) II. CLOSED (usually from motorcycle accident) a. SUPRACLAVICULAR i. PREGANGLIONIC _____ Avulsion of nerve roots, usually from high-speed injuries w/ o/ inj. & loss of consciousness. NO proximal stump, NO neuroma formation (negative TINELs sign), pseudomeningocele, denervation of dorsal neck muscles ARE common sequelae. Horners sign (APEM anhydrosis, ptosis, enopthalmus, miosis) ii. POSTGANGLIONIC _____ Roots remain intact; usually due to traction inj. There are proximal stump & neuroma formation (positive TINELs sign); deep dorsal neck muscles intact; NO pseudomeningocele (does not develop)
b. INFRACLAVICULAR ______
Usually involves branches from the
trunks (Suprascapular). Function is affected based on trunk involved. Trunk injured Upper Middle Lower III. Radiation therapy induced IV. Obstetric Injury a. ERBs (upper root C5-6) --- waiters tip hand b. KLUMPKE (lower root C8-T1) c. Mixed MOI : Open injury Close (traction injury): pre/post ganglion Radiation injury Obstetrical injury ## ] Open Injury: o o o o Life or limb threatening vascular injury Pro: immediate operative exploration (just markering and mapping) After the wound has healed and no infection repair If failed plan to tendon transfer. Functional loss biceps, shoulder muscles wrist & finger extension wrist & finger flexion
##] Close Injury: o o o o Caused by stretch on the elements of the plexus. Determined there was pre or post ganglion Post ganglion the prognosis is better. At first treat with conservatively, if after 3-6 month no recovery need operative-exploration.
Diagnose LOOK Muscle test Sensation Tinnel sign Myellografi EMG NCV Axon response (histamine test) Preganglioner Fail arm, winged scapula, Horner-Sy Paralysis: Ser.ant,rhomboid,limb muscle Absent in involved dermatome Absent Traumatic pseudomeningocele, and obliteration of root Paravertebral muscle & limb muscle denervation Motor conduction absent sensory conduction Normal Postganglioner Fail arm Limb muscle Idem Present Normal Limb muscle denervatio Motor & sensory conduction absent Absent
##] Radiation Injury: o o o o o Radiation neuropathy Neoplastic brachial plexopathy Prognosis is not good Operative treatment: Neurolysis, with omentum transplant Prevention: long term of low dose radiation
##] Birth palsy (Obstetrical Injury): o o Cause: traction injury during labor. Lesion: C 5-6 : Erb paralysis C 8-Th 1 : Klumpke palsy Entire plexus or diffuse partial involvement o Tx: conservative, after 3 month : EMG-NCV Manual muscle chart Myelogram Exercise & splinting If no contraction of biceps: need exploration-operative o Complication : Posterior dislocation of glenohumeral. Fixed contracture Posterior subluxed of radial head Urinating contracture of the forearm o Management: Open reduction of the joint (if any dislocation) Need astronomy prox humeri Tendon transfer (4-5 years old) Nerologic reconstruction (3 6 mo)
Operation Technique: Microsurgery. Need operating microscope/loupes Landmark of approach: mid point of the posterior border of the sternocleidomasteoid and downward to the clavicula (angle at the medial portion) Location of plexus: between anterior and middle part of scalene muscle. Timing of operation: more than 6 month after injury. Advantage: minimize scarring and muscle atrophy.
Kinds of NEUROLOGICAL RECONSTRUCTION 1. NEUROLYSIS. For distal rupture not avulsion type (per ganglion) Release neuroma & fibrotic tissue in continuity 2. NERVE GRAFTING There is a gap Source : Sural nerve / Medial coetaneous nerve 3. NEUROTIZATION Indc: a totally fail, unaesthetic limb as a result of complete avulsion. Primer: Secondary: Source: like a nerve graft insertion as new motor end plate n. intercostals /n. thoracalis longus /n. accessories /n. phrenicus
Kinds of RECONSTRUCTIVE SURGERY OF IRREPAIRABLE INJURIES Timing: more than 1-year post injuries, without any recovery/improvement. Need Tendon transfer !!!!!!!!!
a. SHOULDER reconstruction : SAHA procedure: transfer of the trapezius to the proximal humerus. LEpiscopo procedure: insertions of latissimus dorsi & teres mayor are transposed poster laterally to enhanced active lateral rotation. If no chance for tendon transfer Arthrodhesis ! Position : Abduction : 20-30o Flexion : 30o Endorotation : 30-40o
b. ELBOW Flexion restoration: 1. STEINDLER Flexorplasty. Principle: Flexor-pronator muscle arising from the medial epicondyle are transposed to a more proximal site on the anterior aspect of the humerus. Origo of : FCR, FCU, FDS, PT, PL The patient may achieve elbow flexion by flexing wrist and fingers and pronating the forearm Immobilization-position : elbow flexed 130o & forearm supinated. 2. CLARKS transfer Principle: Sternocostal portion of the pectoralis major muscle for restoration of elbow flexion.
Technique : muscle pedicle elevated from chestwall reroute subcutaneous down the arm to be inserted to the biceps tendon at the elbow. Usually for male, not female patient (problem cosmetic) Need immobilize/splint: 4 weeks 3. Latissimus dorsi transfer. M. Latisimus dorsi transferred to the arm 4. Triceps transfer Triceps brought forward and attached to the biceps tendon. 5. Sternocleoidomastoid transfer Sternocleidomastoid, reroute by bunnel technique. c. WRIST reconstruction. - Maintain the mobility of the wrist whenever possible, if not arthrodhesis. But maintain the tendon must be able to glide. - JONES transfer : FCU EDC PL EPL PT ECRB - Technique arthrodhesis (Haddad & Riordan): use illiac graft slotted between radius and the basis of MC II&III FLAIL-ANAESTHETIC ARM still a dilemma!!! Surgical reconstruction or amputation?? Surgical reconstruction: Arthrodhesis shoulder Posterior bone-block at the elbow Arthrodhesis & tenodhesis for the hand/wrist
TENDON TRANSFER
1. DEFINITION To move a functioning muscle and tendon from their normal position to a new location, in order to replace a muscle that is paralyzed. Recipient tendon is more important for the function of the limb than the donor. Tendon transfer, used to : Substitute Replace Correct : for a paralyzed or a weakened muscle. : for a ruptured, avulsed, plastic tendon/muscle. : for imbalanced muscle caused by nervous disorder.
Disadvantages of tendon transfer: a. Loss of original function of donor muscle b. Inability of transfer to effectively perform new function c. Scarcity of available donor muscle. 2. PRE REQISITES a. Patients Educations Understand the goals and risk of treatment. Advise pre operative muscle educations the best cooperate satisfactory result. b. Timing All swelling had subsided and all wounds had healed Mild contracture maybe compatible Tendon bed must glide supple, or used silicon-rods Sensibility has returned
3. CHOICE OF DONOR MUSCLE a) Availability Potential donor maybe demonstrated b) Muscle strength. o Muscle-force : measured with dynamometer (pounds/dynes/pounds) o Physiologic cross section: o Weber & Fick : Contracted muscle force (CMF) 3,6 kgf/cm2 The greatest force contraction, is due to the muscle in resting length. o Viscoelastic force (VEF) : Resistance to stretch produce by cell, fascia, and connective tissue. Blix-curve = CMF + VEF o Contracted = min + min Resting = max + min best sutured (Brand) Stretched = zero + max
Work capacity: force x distance The ability of a muscle to exert its force over a distance. Its proportionate to its mass (cross sectional x length) greater volume greater work capacity. Power = Force = Strength Work per unit time.
Selections of donor muscle must be appropriate force. Each muscle had each potential force. c) Amplitudo/Excrusion. o o o Total excursion=excursion tendon traction + active contraction Each muscle had each amplitudo Effectiveness of amplitudo, influenced by: d) Direction Should pass straight from the origin to the new insertion. e) Integrity Integrity of function should be preserved; o f) Its must be considered on : - Multiple transfer of recipients - Multiple intercalary joints transfer Synergy To contract simultaneously to achieved a desired function (same action) g) Others must be considered: o Function of the transfer : Grasp must be strong Digit posture maybe relatively weak o o Strength of the antagonist; avoid causing of over correction. Mobility of the joint : acceptable mobility has been restored. Position of the intercalary joint Freeing the soft tissue
4. PLANNING TENDON TRANSVER Step I : What works? Muscle testing Step II : What is available? Step III : What is needed? Step IV : Matching Step V : Alternatives arthrodesis/tenodhesis/capsulodhesis/releaase Step VI: Staging; dorsal or volar lies to the axis 5. SURGICAL TECHNIQUE Depend on : Note : a. Under tourniquet control b. Should permit free gliding transferred tendon, skin incision should not parallel to the route of the transfer. c. Should be a straight line from the origin to the new insertion. d. A traumatic handling during surgery, dressing must not be constrictive o Proper surgical technique Appropriate transfer
e. Post operative :
Safe active ROM exercise after 3-4 weeks Given a schedule of manual activity Protective splint is worn until 6 weeks
f.
End result depend on Proper surgical technique: Preoperative planning A traumatic handling Postoperative rehabilitation Appropriate transfer
6. TEN CONDITIONS OF TENDON TRANSFER 1) Atraumatic: atraumatic handling during surgery 2) Correct 3) Good 4) Balance 5) Free 6) Tension 7) Synergy 8) Smooth 9) Straight : : : : : : : : the bone had healed and no deformity muscle test strength minimal 4 action of synergism/antagonistic no contracture, inflammation, scarring avoid of under/over correction equal of power, amplitudo, direction, action tendon bed should permit free gliding from the origin to the new insertion
10) Subcutaneous
ARM 1. Musculocutaneous BBC : biceps, brachialis, coracobrachialis 2. Radialis Triceps Brachii FOREARM 1. Medianus a. Medianus PT, FCR, PL, FDS b. AIN FDP, FPL, PQ 2. Radialis a. Radialis ECRL, ECRB, BR (Mobile web), A b. PIN E3SAE3 (EDC, EDQ, ECU, S, APL, EPB, EPL, EIP) 3. Ulnaris FDP, FCU HAND 1. Medianus AFO (AbdPB, FPB, OP), L 2. Ulnaris PAFO (PB, AbdDQ, FDMB,ODM ), deep palmar branch : FPB (medial), AddP, IO, L IO DAB 4 & PAD 3 L 2 radial o/ medianus , unipeniform , 2 ulna o/ ulnaris, multipeniform NEUROLOGIC LEVELS IN UE MOTORIC o C5 o C6 o C7 o C8 o T1 SENSATION o C5 o C6 o C7 o C8 o T1 REFLEX o C5 o C6 o C7
: shoulder abd. : elbow flexion & wrist extension : elbow extension & wrist flexion & finger extension : finger flexion : finger abd / add
: lateral arm : lat forearm, thumb, index finger : middle finger : medial forearm, ring & small finger : medial arm
: biceps : brachioradial : triceps
SPINE
I. INJURY The patient with neurology deficit, better if given IV line, because: o Spinal shock: Means : A dysfunction of the nervous system of the spinal cord occurs after spinal cord injury Spinal shock neurogenic shock. Neurogenic shock means: A vascular hypotension with bradycardi as a result of spinal injury. Its disruption of sympathetic outflow (T1-T2). (SYMPATETIC BLOCK) o o Observe until 72 hours or the recover of bulbocavernosus reflex (BCR) and anal reflex. BCR (+) its mean if the tractus is still intact. GOOD PROGNOSIS Motor examination (myotome) motor power (0-5) Sensory examination (dermatome) sensation (anaesthetic, hypaesthetic, normal, hyperaesthetic, dysaesthetic). Reflex, include rectal examination (BCR reflex) : loss, hypo, n, hyper. Photo cervical AP/lateral (yang dinilai A, B, C, S) Photo dynamic cervical instability? Photo AP open mouth view suspect fracture C 1-2 Tomography Myellograph (if suspected a disc herniation) CT scan dan 3D-CT MRI White test by traction the cervical (3-5 kg) evaluate is there any widening of interdiscal (lateral projection) Electro diagnostic: EMG Electromyography) NCV (Nerve conduction velocity) MEP (Motor Evoked Potential) SSEP (Somatosensory Evoked Potential) Procedure diagnostic: Neurologic examination consist of: The patient have stomach dilatation Dangerous of spinal shock Patients in starvation INTODUCING : o
LEG TRUNK ARM
LEG TRUNK ARM
o 1.
Classification of Neurologic injury: According site/part of injury: Root injury Peripheral nerve lesion (LMN) recover (prognosis good) Motoric deficit > sensory deficit.
Spinal cord injury : Incomplete: 1) Brown Sequard Syndrome

Injury limited the either side (hemisectional injury) Ipsilateral muscle paralysis (UMN), bellow the lesion Paralysis and loss of proprioseptive sensation, vibration & light touch bellow the level on the side of cord Contra lateral hypaesthesia (pain & temperature), below the level Good prognosis to recovery.
2) Central cord syndrome.

Caused of whiplash injury, no bony damage in elderly The most common incomplete cord injury. Compressed between bony osteophyte anteriorly and bulging the lig flavum posteriorly Flaccid LMN paralysis (ext sup) Spastic UMN paralysis (trunk & lower extremity) Variable of sensory loss Bladder dysfunction injury retention.
Disproportionately greater loss of motor power in the upper extremities as compared to the lower extremities. Bladder dysfunction & varying degree of sensory loss below the lesion Prognosis : poor recovery of hand function good recovery for motoric & sensory for LE
3) Anterior cord syndrome:

Caused by hyperflexion injury Complete motor paralysis sensory anaesthesia at level below the lesion (pain & temperature) Proprioseptive sensation, vibration & light touch intact Prognosis is good, if in 24 hours there is any evident.
4) Posterior cord syndrome

Caused by hyperextension injury Loss of proprioceptive sensation (position, vibration, light touch, deep pressure).
5) Complete Transection SCI

Complete anaesthesia below the injury of level. Complete absence of voluntary motor power distal the level. (total flaccid paralysis) Deep tendon reflex (-), babynski sign (-), BCR&cremaster (+) Usually irreversible.
6) Conus medullaris syndrome
Flaccid paralysis of the lower extremities (LMN) and spincter dysfunction, in chronic phase UMN Sensory deficits are variable Fracture disloc & burst fr are common at the T11 to T12 & T12 to L1, because the change in spinal anatomy from the stiff thoracic spine to move mobile lumbar spine
7) Cauda Equina Syndrome
Proximal anesthesia numbness of: buttocks, back of leg, soles of feet Spinchter dysfunction paralysis bladder & bowel Normal leg strength Absence of radicular pain pain in back of thigh & leg Atrophy calves
Urgent surgical decompression
2.
According cause of injury: 1. Contusion : 2. Compression : - Irreversible neuronal death poor prognosis - Associated with vascular injury & intramedular haemorhage. - Direct neuronal dysfunction - Spinal vasculatory problem - Good prognosis 3. Stretch : - Flexion distraction injury - Cappilary & axonal collapse - Good prognosis 4. Laceration : - Retropulsed bone fragment In fracture dislocation - Poor prognosis
PRIMARY :
SECONDARY : Caused by edema, haemorhage, and ischemia
PATOPHYSIOLOGY Of SCI Theory :
Free radical theory. :Rapid depletion of antioxidant, oxygen free radical accumulate in injured central nervous system tissue and attack membrane lipid protein, and nucleic acid. Calcium theory : Influx of extra cellular Ca into nerve cells in the propagation of secondary injury. Ca activates phospholipase, protease, and phosphates, resulting in both interruption of mitochondria activity and disruption of the cell membrane. Opiate receptor theory : Endogenous opiate maybe involved in the propagation of secondary spinal cord injury. Inflammatory theory : Inflammatory substance (prostaglandin,
leukotrine, PAF, serotinin) accumulates in acutely injured spinal cord tissue and are mediator of secondary tissue damage.
Stability of the spine. 1. The three column C spine of Dennis Anterior Column : ALL, Anterior annulus fibrous, Anterior half of vertebral body Middle Column: PLL, Posterior annulus fibrous, Posterior half of vertebral body
Posterior column: Supraspinosus lig, Infraspinosus lig, Facet joint capsule 2. Coefficient stability by Renee Louis Corpus : 1 Facet R/L : each 1 instable 2 Ligamentous : each Stable means : able to resist a physiological load, without any progressive deformity or any neurological injury. Instability : Ligamentous instability: permanent, absolutely need operation. Bony instability: transient/temporary, healed 2-3 month, except: vertical fr/burst.
MOI in spinal trauma : Flexion - Fracture of vertebral bodies - Acute disc rupture Extension - Fracture of part bony element, (tear drop) - Rupture of ALL & PLL Axial-compression - Burst fracture of vertebral body - Rupture of lig Rotational - rupture of ligament
Goal of treatment :painless stable spine: Presume the life Prevent complications & further spinal cord injury Restore alignment & stability Provide maximum functional & early immobilization Minimize residual deformity, by doing: o o o o Reduction of fracture Stabilization of the fracture Decompression Fusion/spinal arthrodesis
The method of stabilization is depend on the biomechanics feature of the injury and the most logical procedure is to approach at that lesion site of the spine injury
Modalities of treatment: 1. Physiotherapy : target for ADL 2. Psychotherapy : Consultation-Liaison Psychiatry acceptability to the new condition without stress.
3. Nursing : respiratory care, prevent ulcer sore, CIC/bowel training 4. Dietary : early enteral feeding (high protein) 5. Surgery : painless stable spine (posterior/anterior stabilization)
Complications after spine injury: a. Ulcus decubitus b. Spasticity joint contracture c. CV system : o Hypotension orthostatic o Autonomic Hyperreflexia (injury above Th 6 level) = SYMPATHETIC BLOC hypertension, hyperhydrosis, hyperemia, bradicardi. o e. Back pain f. Metabolic problem : osteoporosis disuse g. Bladder problem : UTI h. Bowel problem : constipation and diarrhea i. CNS BECAUSE : Bladder constriction Lead of renal calculi Early renal failure Indwelling catheters is Contra Indication DVT (Deep Vein Thrombosis) d. Respiratory system : Pneumonia headache,
CERVICAL INJURY
Suspect to cervical injury: Impaired consciousness Head and facial/supra clavicula injury Localized deformity &swelling in the neck Un explained hypotension Criteria of cervical instability: 1. Upper Cervical:

ADI > 3mm (AP sublux) Ranawat vallue < 13mm (vertical sublux) Power ratio : > 1 mm Widening body mass VBA > 11o on flexion position (vertebra Body Angle) Anterior/posterior translation > 3,5 mm (20%) Facet dislocation >50% Loss parallelism of facet joints Widening of interspinosus space
2. Lower cervical

FLEXION INJURY: Clay-Soveler fracture: Avulsion fracture of processes spinosus (C6-C7-Th1) Stable, caused by blunt trauma. Tx: collar brace, bedrest, analgetic.
Unilateral facet dislocation: MOI: flexion & rotation force Potential unstable Gx: neck pain and torticollis (chin pointing the opposite) Ro: anteriorly displaced of VB 25% Bilateral facet dislocation: MOI: hyper flexion Common site : VC 5-7 Complete disrupt of posterior lig complex unstable! Gx: neck pain, stiffness, instability rotated the head, quadriplegia. Tx: Cervical traction with crutchfield ORIF posterior stabilization. Sublaminar wiring + b graft, plate & screw fixation Flexion tear-drop fracture: MOI : flexion Fracture of anterior-inferior corner, triangular shape, of VB unstable. Gx: Anterior cord syndrome Tx: crutchfield ORIF (anterior stabilization)
EXTENSION INJURY
Pillar fracture MOI: hyperextension & rotation Tear of anterior long lig, vertical fracture line Hangmans fracture (Traumatic spondylolysthesis of axis): o o MOI: hyperextension & axial compression Vertical fr of pedicle C2, displacement/angulations of C 1-2 Potentially unstable. o Type: I : bilateral pedicle fr, little displace (translation < 3mm), no angulations. II : bi-pedicular fr, anterior translation >3mm, angulations of C2, ALL IIa : minimal translation but severe angulations unstable
stable Pot.unst intact.
Unstable III: type II & and disruption of ALL Severe angulations & displacement or bilateral facet disloc at C2-C3 o o Gx: occipital neuralgia Tx: conservative: crutchfield minerva cast/halo traction Operative: posterior stabilization. (type III)
AXIAL INJURY Jefferson fracture (VC 1) MOI : axial loading Lateral mass fracture stable Four each fracture potentially unstable Gx : neck pain, and on the vertex, torticolis, occipital neuralgia Ro: prevertebral soft tissue swelling & ADI (lat projection) Need AP open mouth view : displacement of body lateral masses < 7mm : stable > 7mm : potentially unstable (rupt. of lig. transversum) Tx: conservative: halo traction Operative: posterior fussion (occipital-C1-C2) Anderson fracture (Odontoid fr) Type : I : avulsion fr of the tip of dens, at site of attachment alar ligament stable II: transverse fr of the base of odontoid unstable & nonunion (60%) III: fr throught the body of axis stable / unstable Gx : Occipital / suboccipital pain / neuralgia ~ n. occipitalis major, sense of Instability, torticolis Brown Squard syndrome (rare) RO : Retropharygeal tissue swelling & ADI (lat) AP open mouth view Need tomography Tx : conservative: crutchfield minerva cast Operative : -altanto-axial fusion Burst fracture (lower C spine) MOI : axial loading Ro: fr comminutive of VB, decrease of disc space potentially unstable Gx: neck pain and on vertex Need CT scan canal encroachment?? Tx : Posterior technique: Wiring (Rogers technique) or Brook technique Lateral mass plate (Roy Camille) Reconstruction plate, Louis plate Anterior technique: - plate : - CSLP or S plate Orogco/Lieman or Odontoid screw fixation
OTHERS Atlanto-occipital disruption: Always fatal, comatose Ro: retropharyngeal soft tissue swelling Displacement of the occipital condyle from facet C1 Horizontal displace 1mm unstable Vertical distance (basion-tip of dens) > 5mm unstable. Tx: Occipito-cervical fussion: Anterior technique Posterior technique: - Y plate - Reconstruction plate Atlanto-axial disruption: MOI: - Anterior disloc + rupture transverse lig - Anterior disloc + fr base of odontoid - Posterior disloc - Rotatory sublux Ro : ADI, if 3-5mm : transverse lig disruption > 5mm : rupture transverse & alar lig Gallie procedure Brooks & Jenkins proc Sontag modification Gallie modification (Sby)
Pada open mouth view : wink-sign (narrowing of joint space C1-C2) Tx: C1-2 posterior procedure :
NECK SPRAIN Injury of soft tissue in cervical region (muscle, ligament, disc, nerve, vasa) MOI: Hyperextension (whiplash) : Mild (spasm, tenderness, restriction) Moderate (referred pain) Severe (spasm, weakness of neck, inability control position of the head) Ro : retropharyngeal soft tissue swelling Hyperflexion: mild/moderate/severe Common site : C5-T1 Ro : - Prevertebral soft tissue swelling - Widening of inter spinosus Cervical disc disorder: acute/chronic
Need: discography/myelography/CT myello Tx: Immobilization : cervical collar (6 weeks) Bed rest Medicamentosa (NSAID/analgetic) Physiotherapy In cervical disc disorder: need immediate decompression
SCIWORA (Spinal Cord Injury With Out Radiology Abnormality Principal of management: 1. Supportive: - 02 saturation 100% (nasal canule) - Maintenance of systolic blood pressure > 90 mmHg 2. Drugs: Methylprednisolene: 30mg/kg BB (bolus) dilanjutkan infusion at rate 5,4 mg/kg/hours (24-48 hours) 3. Immediate traction immobilization 4. Surgery, indicated if : Residual cord compression Permanent instability
THORACO LUMBAL
NEUROLOGIC LEVELS IN LOWER EXTREMITY MOTORIK L1-2 L3 L4 L5 S1 : hip flexion (m. iliopsoas) : knee extension (m. quadriceps rectus femoris, vastus lateralis, vastus medialis, vastus intermedius) : foot inversion (m.tibialis anterior) : toe extensor / foot dorsoflexion (m. ext hallucis longus) : foot eversion / foot plantar flexion (m.peroneus longus & brevis) REFLEX L4 L5 S1 : KPR : : ATR
SENSATION T12 L1 L2 L3 L4 L5 S1 S2 : lower abd : upper thigh : mid thigh : lower thigh : medial leg medial side foot : lateral leg dorsum of foot : lateral side of foot : posterior thigh
S3-4-5 : perineum
Criteria of thoracal instability:

Criteria of lumbal instability: VBA > 22o Sagital plane translation > 4,5m m
VBA (sagital plane angulations) > 5o Sagital plane displacement > 2,5mm
Indication of operation in TL spinal fracture (King): Problem of instability (coef instab 2) Problem static/biomechanics : Canal encroachment > 30% Progressive deficit neurology Kyphotic > 300 Compression wedge > 50%
Type of fracture : Frans Dennis & Fergusson Compressive (anterior/lateral) Burst (A, B,C,D,E) Fracture dislocation Tear drop
Burst A B C D E : BOTH ENDPLATE :ONLY SUPERIOR ENDPLATE : ONLY INFERIOR ENDPLATE : INVOLVED ROTATION : WITH LATERAL WEDGING
MOI : flexion : axial loading : flexion rotation : shearing : flexion distraction : flexion distraction : extension distraction
Flexion rotation Shear/translation Flexion distraction
Seat belt (Chance)
DENNIS Compression fr Burst fr Flexion distraction injury : seat belt / change fr Fracture dislocation
Principle management of specific fracture : Compression : Stable hyperextension orthosis Unstable : Conservative Operative Burst : Stable hyperextension cast Unstable Anterior stabilization + graft Posterior stabilization by distraction system Fracture dislocation: Posterior stabilization Chance: Conservative Hyperextension cast : hyperextension cast : posterior stabilization
Operative
Posterior spinal fusion by compression system
Type of instrumentation: A. For posterior instrumentation principle: Tension band system Rod : Harrington roads (flexible) Jacobss roads (rigid) Cortel-Duboussete rods (very flexible) B. Plate : Pedicle Screw Plate system (by Roy Cammile / Rene Louis) Sublaminar wiring: Segmental Spine Instrumentation (by Luque) Modified SSI w/ K-Nail For anterior instrumentation : Note :
Dunn device Kaneda device Dwyer instrumentation Zielke instrumentation Louis plate
On burst Fr, neurological grading Frankle A, is caused by, Spinal shock Flexion distraction injury
Constipation on TL cause Sympathetic-dysreflexia, so need bowel training and compressed the plexus Aurbach for stimulates the gastrocolic reflex. Cause of DYSREFLEXIA Full of bladder Cysts or calculi Pressure sore infection Constipation Headache Sweating on the head/scull Dyspnea Bradicardi Hypertension
Sign of DYSREFLEXIA
NOTE : L2-3-4 N. FEMORALIS

M. Rectus Femoris
QUADRICEPS FEMORIS
M. Sartorius M. Pectineus
M. Vastus Lateralis M. Vastus Medialis M. Vastus Intermedius
L2-3-4 N. OBURATOR
M. Adductor Longus M. Adductor Brevis M. Adductor Magnus M. Gracillis M. Obturator Externus M. Oburator Internus
L4-5 N. COMMON PERONEAL N. SUPERFICIAL PERONEAL

M. Peroneus Brevis M. Peroneus Longus SCIATIC NERVE
N. DEEP PERONEAL
M. Tibialis Anterior M. Extensor Digitorum Longus M. Extensor Hallucis Longus M. Peroneus Tertius M. Extensor Digitorum Brevis
N. TIBIALIS
M. Gastrocnemius M. Soleous M. Popliteus M. Plantaris M. Tibialis Posterior M. Flexor Digitorum M. Flexor Hallucis Longus
HIP FLEXOR HIP EXTENSION
: Iliopsoas, Pectineus : gluteus maximus Obturator Ext, Gamelli Inferior, Quadratus femoris)
HIP EXOROTATOR (short) : PGOGQ (Piriformis, Gamelli Superior, Obturator Int & HIP ADDUCTION HIP ABDUCTION KNEE FLEXION KNEE EXTENSION FOOT DORSO FLEXION : Adductors (4) + Gracillis : Gluteus Medius, Gluteus Minimus, TFL : HAMSTRING (biceps femoris, semimembranosus, semitendinosus, N.Ischiadicus L5-S1) : QUA DRICEPS FEMORIS + sartorius : Tibialis anterior, Ext.dig.longus, Ext.hallucis longus longus, Tibialis posterior PES ANSERINUS: GSS ( Gracillis, Sartorius, Semitendinosus)
FOOT PLANTAR FLEXION : Gastrocnemius, Soleus, Flex.dig longus, Flex. Hallucis
THORACOLUMBAL SPINAL STABILITY 1. HOLDSWORTH: posterior ligamnetous complex as the major structure providing stability. Only fracture-dislocations and shear injuries as unstable. 2. DENIS : three columns and anterior half of the vertebral body b) Middle column: Posterior longitudinal ligament, posterior annulus fibrosis and posterior half of the vertebral body. c) Posterior column: pedicles, facet joint, lamina, spinous processes and interspinous & supraspinous ligament Unstable if: Loss of greater than 50% of vertebral body height Angulations greater than 20o Failure of at least two of Denis three columns
a) Anterior column: anterior longitudinal ligament, anterior annulus fibrous
3. WHITE and PANJABI: under normal physiological loading, the spinal column is capable of maintaining its pattern without displacement, no additional neurological deficit, no major deformity and no incapacitating pain.
4. RENE LOUIS
: three vertical and one horizontal - Intervertebral disc (1) b. Two posterior column : Right facet joint (1) Left facet joint (1)
Three vertical : a. One anterior column : - vertebral body (1)
One horizontal :
a. Pedicles (R + L) (1/2) b. Lamina (R + L) (1/2)
Unstable if : Coefficient os instability 2
Surgical approach of the spine: Anterior approach: Disadvantages: A major surgery Need ICU for post operative care Advantages: Directly through the effected vertebra Perform a short stabilization
Posterior approach: Disadvantages: Need more long stabilization than anterior
Advantages: Technically easier
II.
INFECTION SPONDILYTIS TUBERCULOUSIS (Potts disease)
Deff : is a chronic Granulomatous infections cause by specific bacteria, which attack the spinal column ETIO-PATHOLOGY Cause by Mycobacterium tuberculosis (bovine, africanum/ levine) Spreading by: hematogenous, limphogenous, direct extension Predisposition Factor : - IV drug abuse - Intraarticular steroid injections - Chronic systemic disease - Systemic use of immunosupresent The common site: Lower thoracal & upper lumbal. BATSON PLEXUS Specific pathology destruction of the anterior vertebral body Kyphotic
Stadium of Spondylitis TB: Stadium I Stadium II (implantation) (early destruction) : 5-6 weeks : 8-12 weeks : 3-5 years
Stadium III (late destruction) Stadium IV (neurological deficit) Stadium V (permanent deformity) 7 PROBLEMS 1. Eradical infection 2. Instability 3. Kyphotic deformity 4. Deficit neurology 5. Fracture pathologies 6. Spasm 7. Social Control SIGN & SYMPTOM: General Local Laboratory
: Anorexia malaise weight loss night sweating : Back pain Gibbus Cold abscess parasthesia weakness. : increase of ESR Slight anemia ICT Infection test Urine : sediment & culture & pulasan Bilas Lambung Hypoalbuminemia Mantoux test (+) < 5 mm : 5 9 mm : ? >10 mm : +
Diff count shift to the left
RADIOLOGY: Plain radiography: Destruction of anterior vertebral body (anterior wedging) Collapse/compressed vertebrae (60%) Lytic lesion (40%) Sclerotic vertebrae edge (30%) Narrowing of discuss intervertebral. Paravertebral abscesses (30%) : Trigonum of Petit Lig Pauparti Illiac crest Abnormal chest X-ray (60%) USG : good for distinguish the abscess
MRI : good for examine compression cord by abscess or other material
HYSTOPATOLOGY: FNAB / Open Numerous of Langerhans giant cells with nodular collections of hystiocytes and infiltration of chronic inflammatory cells (granulornatous-tissue) TREATMENT: Goal Eradicated the disease Prevent or correct deformity Prevent or treat the complication Sembuh klinis membaik : nafsu makan meningkat, BB naik, keringat malam hilang, ESR normal RO : resolution, fusion a. Conservative : Drugs : Tuberculostatica (start 2 weeks before operation) EHRZ (SHRZ) : 2 months HE : 6 months (bila KP + ) If no KP, regiment is 7H3R3 Bactericide: Isoniasid (INH) Rifampicin Pyrazinamide Streptomycin Bacteriostat: Ethambutol Ethionamide : 15 20 mg/kgBW/day : 3 x 250 mg Second line of tuberculostatica: Para aminosalicylic acid (PAS): 10-20 gr Aminoglycoside (Amikasin, kanamycin, Capreomycin) Quinolon (Ofloxacin, Ciprofloxacin) Rifabutin (derivat Rifampicin) Clofazimin Thioacetazone (T) : 2,5 mg/KgBB/day Immobilization : Cervical minerva cast, 3-4 month T-L Body jacket, 3-4 month : 5-10 mg/KgBW/day : 10 - 15 mg/kgBW/day (max 600 mg) : 20-25 mg/kgBW/day : 15 mg/kgBW/day according WHO
b. Operative : debridement & bone grafting (ribs, illiac, fibular) or allograft
ADSF (Anterior Decompression Spinal Fusion) Indication: Evidence of progressive neurological deficit (acute/chronic) Evidence of cold abscess (large) Back-pain intractable Problem static : Kyphotic deformity > 40o COMPLICATIONS: Paraplegia, acute: caused by: Edema/absences compressed to SC Vascular thrombosis ischemia of SC Granulomatous, inflammation of the arachnoid (patchy meningitis) Psoas abscess Spine deformity : Kyphotic-scoliosis
III. SPONDYLOARTHROPATHY DISEASE

A. OPLL (Ossification of the Posterior Longitudinal Ligament) Cause : unclear, suspected: Decrease of absorption of Ca in the gut Insufficient metabolic-hormone for vit D Autosomal dominant inheritance trait. Pathology : As a heterotrophic bone ossification as a response to the mechanical stress enchondral ossification canal encroachment Nerve compression Spinal cord compression Sign & Symptom: Asymptomatis or neck stiffness & pain, paresthesia, spastic gait. Need : JOA SCORE myellopathy : - Upper ext function - Lower ext function - Sensory function - Bladder function Total point: 17, means : < 7 : severe myellopathy 8-12 : moderate myellopathy >13 : mild myelopathy Diagnosis: - Ro cervical lateral : type : - continuous - segmental - mixed - localized Tomograph CT-scan
Treatment: o o
Myellography or CT-myello MRI Electro diagnostic (EMG, NCV, SSEP)
Conservative: collar brace, NSAID Operative, bila: - Score JOA: 6-12 point (moderate - severe) - Canal stenosis >50% Decompression: Anterior : decompression + fussion Posterior : laminectomy (bilateral laminar excision) laminoplasty : expansive lamina Z-plasty open-door laminoplasty Combined posterior-anterior
B. SPINAL CANAL STENOSIIS Def: Narrowing of the bony spinal canal irritation of the nerve root Sign & Symptom: LBP + radiation down to both legs (posterior aspect of the thigh) radicular Pain, equal w/ dermatome, claudication Increase with: walking/ standing/extend position Decrease with: sitting, slight flexion/raclining chair. Tenderness at the site of the affected lumbar spine (not always) ROM of the spine decrease (mild, moderate, severe) Diagnosis: - Ro photo of lumbosacral AP/Lat: Narrowed & hypertrophy of the facet joints Osteophytes on anterior/posterior of vert bodies - CT scan : mid sagital diameter <12 mm - Myellography apple core lession - MRI Treatment: Conservative: - NSAID - Back exercise Operative: Laminectomy decompression
C. HNP (HERNIATED OF NUCLEUS PULPOSUS) Deff: Herniation of the disc material into surrounding tissue. Machnabs classification: Grade I Grade II Grade III Grade IV Sign & Symptom : Specific radiculat pain (irritation on the nerve root as its exist the spinal canal), pain radiate downward to the lower extremity and below knee. Increase by : sneezing, coughing, lifting, bending, jumping, sitting, straining. Decrease by : lying down in the supinatine position. MRI on firm matras - Inj. Methylpredisolone (Medrol) : 5 days - Lumbar traction (controversial?) Operative : disectomy if : Motor weakness Reflex changes Sensory changes Loss of ladder & bowel control Persistent severe pain after conservative treatment (3 wk) NEUROLOGICAL DEFICIT Lasseque test/straight leg raising test (+)/ Bragards test o o Diagnosis : Myelography 6 wk Treatment : Conservative : - bedrest (2 weeks), with flexion hip & knee, lay down : protrusion : prolapsed (sub ligamentous extrusion) : extrusion (transligamentous extrusion) : sequestration
D. SPONDYLOLYSIS & SPONDYLOLYSTHESIS Spondylolysis : defect on pars articularis of the VB without displacement Spondylolysthesis : displacement to the anterior portion of the affected segment of the body vertebra, common site : - L 4-5, L5-S1 Six type Spondylitis: 1. Lytic (isthmic) : 50% Defect at interarticularis region Increase with aging Cause suspected by repeated stress 2. Degenerative (25%) 3. Dysplastic (20%) Generalized OA Defect congenital
4. Traumatic 5. Pathologic (tumor) 6. Iatrogenic Pathology: It can due to pressure of : durameter, nerve root, cauda equina or disc prolapsed. Sign & symptom : asimptomatic (painless) : in children Intermittent LBP (exp after exercise/strain) Sciatica Pecular/spondylolythic gait : Limited hip flexion Short stride length Wide base support Protruding abdomen Square buttock/sweetheart pelvis Palpable step Hamstring tightness Neurologic sign (paresthesia, weakness, incontinent bladder & bowel) Diagnostic: X-ray Lumbosacral (AP/Lat/Oblique and dynamic) Lat : Forward shift (Meyerding) : Grade I : 25% Grade II : 25-50% Grade III : 50-75% Grade IV : > 75% (Meschant) : 10o = slight 11-20o = moderate > 20o = severe (Marique) percentage of AP shift Lumbar index Slip angle/LS Kyphotic angle (L5-S1) AP : - elongation Oblique : broken neck of Scotty dog Scotty dog : Nose : transverse process Ear : superior facet Body : lamina Any bone destruction post operative instability
Tail : superior facet Eye : pedicle Neck : pars intrarticularis Fore & hind leg : inferior facet CT scan Caudography or MRI : to examine nerve involvement Treatment: Conservative : Activity modification Muscle strengthening / back exercise Antilordotic brace NSAID Weight reduction Operation : if, Persistence or recurrence symptom Symptom increase with mild activity Slip 50% Slip angle 40-50o (in growing child) Progressive neurological deficit Goals: Reduction of back & leg pain Prevention of further slip/further neurological deficit Stabilization of normal spine mechanic, posture and gait Technique : Fussion in situ laminectomy (decompression) ALIF (Anterior Lumbar Interbody Fussion) PLIF (Posterior Lumbar Interbody Fussion) Combined PALIF On severe case (Spondyloptosis) Resection of VL 5 Reduction & fussion of VL 4 to sacrum
E. ANKYLOSING SPONDYLITIS Def: A from of spinal arthritis, with end result calcify bridging of intervertebral spaces, cause stiffness the spine (bamboo-spine) Pathology Inflammatory process (RA) in the pelvic joints & costovertebral articulations.
The differences :
Predominance in young man (17-35 years) Absence of rheumatoid nodules Absence of rheumatoid factor Presence of chronic inflammatory cells & granulations tissue. Occurrence of perispinosus calcifications (fibrous tissue ossify bony ankylosis).
Inflammation erosion ossification
MARIE STRUMPELL MORBUS BACTHEREW
downup up down
Sign & symptom: LBP (morning stiffness & pain), extend: buttock, hip, and thigh. Palpable tenderness of Sarco illiac joint & lumbar spine. Flattening of the normal lumbar lordosis Motions are lost Schober test (+) Pain : chest wall, neck Severe: iritis, aortitis, carditis, atlanto-axial instability The patient can heard his/her steps
Laboratory: HLA B 27 Ag (+) ESR increase Mild anemia
Radiology : defect after 3-6 months First : S I J : ill defined margins widening of joint space irregular bridging obliteration bony ankylosis Spine : Spur formations : Osteophyte Marginal syndesmophyte Erossion sclerosis Ossification of the anterior long lig bamboo spine ! Atlanto-axial instability : dynamic cervical ADI ? Treatment: Conservative: NSAID: Phenylbutazone or Indomethacin Corticosteroid (severe case) Exercise program: breathing & NBW exercise Avoid Kyphotic activity Surgical intervention is uncommon
IV. CONGENITAL SCOLIOSIS

A. Definition: Lateral bending deformity of the spine (abnormal curve > 10o) B. Type of scoliosis: I. Non structural/functional/compensator/postural II. Structural: a. Idiopathic (65%) : Infantile : 0-3 years Juvenile : 4-14 years Adolescent : 15-mature Adult : after mature b. Congenital (15%) : Defect of formation Hemivertebra Wedge vertebra Sacral agenesis Defect of segmentation Unilat unsegmented bar c. Neuromuscular (10%) : UMN : CP LMN : Poliomyelitis, syringomelia, spina bifida, SMA Myopathy : DMP - EDS - AMC - Marfan Sy d. Others : Neurofibromatosis (5%) Post injury (mechanical, radiation, post operative) Tumor Infection Metabolic : rickets, osteoporosis, OI Arthritides disease C. Diagnosis Include : Severity - location - Direction - Etiology Anamnesis : Chief complaint Age of first present Family history Menarche status Sign & symptom: Cosmesis? Back pain? Respiratory impairment? Associated symptom
Px: Standing: From anterior : Shoulder level Pelvic obliquity --. Block test From posterior : plumb line & body arm distance
From lateral : Lordosis/Kyphotic Forward bending: Rib-hump : measure with scoliometer Others : distraction test flexibility? LLD Joint hyperlaxity? Neurologic examination? Lung function? In severe cases X-ray: - (AP, lat, R/L bending) Measurement: 1. Cobb-Lipman angle 2. Reisser-Fergusson angle 3. Nash & Moe (rotation) : 0-4 4. Risser sign : 1-5 Stagnara view D. Treatment : Key of treatment : Early diagnosis & treatment to prevent progression of deformity Principle: 0-20o : observation 20-40o : brace (worn at least 23 hours/day) 40-50o : borderline, if still mobile trial with bracing > 50o : operative a. Conservative : Observation Electric simulation (not effective) Bracing: No for correction, just prevent the progressive of curve Indication : Risser >4 Long flexible curve, without structural changes. Milwaukee (apex above Th IX) Boston (apex bellow Th IX) Traction : Non skeletal: Cotrell traction Skeletal : Cranio/halo femoral Cranio/halo pelvic Cranio/halo gravity Exercise without brace : Postural training Crawling, sit up, push up EDFL (Extension, Derotation, Flexion, Lateral) Bending Curve stretching
With brace : Pulling away of pad Body shifting Casting : Risser localizer cast Cotrell EDF plaster b. Operative: Goal of operation: Minimize deformity Limitation stress on vertical column To keep the curve <50o by the end of adolescent Indication : Curve >50o in idiopathic adolescent Curve >40o, progressive during bracing Curve >40o, neglected, not flexible. Kind of instrumentation: 1. Posterior instrumentation: Harrington rods Luque rods Cirorth rod & hook 2. Anterior instrumentation: - Dwyer system 3. Combined: Herrington Luque Dwyer Herrington 4. In congenital scoliosis: Epiphsiodhesis (convex growth arrest) Hemivertebra excision Vertebrectomy Combined procedure Note: Progressively of curve, depend on: o o Weight action force above the apex level Bowstring effect of the muscle at concave side
Without adequate treatment, curve progressively: 1o/year In lumbal scoliosis more severe, because no tension like ribs in thoracal region. In congenital scoliosis, progressively is more than idiopathic (2-5o/year) Associated anomalies, in congenital scoliosis: VATER syndrome (Vertebral Anomalies, Anal malformations Cardiac defect, Tracheo Esophageal fistula, Renal & Radial (limb) anomalies) CRANKSHAFT phenomenon : deformity caused by operation only posterior fusion and the anterior side still growth
DEVELOPMENTAL DYSPLASIA OF THE HIP (DDH)

Definition: A developmental abnormality of the hip joint, in which the capsule, the proximal femur, and the acetabulum are all defective. Incidence: 1-2/100 (Male: Female = 1:7)
Classification: I. Teratologic/teratogenic : - It develops early in uterus with severe contracture. - At birth, the dislocated hip cant be reduced by Ortholanni maneuver. II. Typical: a. Dislocated hip: The femoral head is completely outside of the acetabulum b. Dislocatable hip : The femoral head is in the acetabulum, but can easily displaced out of it, by Barlows provocative test. c. Subluxatable hip: The femoral head can be passively displaced partially out of acetabulum not completely dislocated.
Etiology: A. Prenatal : Ligamentous hyperlaxity (hormonal-imbalance) Intra uterine malposture Mechanical force resulting from anatomic instability Genetic influence. B. Postnatal : Environmental factors The capsule is very stretched out and very loose The lig teres is elongated The labrum is everted The femoral head is spherical Excessive antetorsion of the proximal femur The acetabulum has become shallower
Pathology :

Sign (Symptom: A. 1 months : Ortholani test (+) : clunk of entry sign Barlows test (+) : clunk of exit sign B. 1-3 months

Asymetrical gluteal/thigh fold Limitation of hip abduction

Relative shortening of the femur (Galleazi sign (+)) Ortholani test present, but soft.
C. 3-6 months

Contracture of the hip (Thomas test post) Limitation of abduction Galleazi sign (+) Telescoping sign (+) Ortholani sign decrease (no reduction is possible)
D. After walking age

Waddling gait/Sailor gait Trendellenburg test (+) Widened of perineal space Greater trochanter are prominent Buttocks are broad & flat Hyperlordosis
Radiographic Findings 1. X-ray of the hip AP view : Hilgenreiners line/ Y line Perkins line/Onbredonnes vertical line Shentons or Menards line Von Rossen line Acetabular index/acetabuler roof angle Y coordinate of Ponseti C E angle of Wilberg 5 8 y 9 12 y 13 20 y 2. USG : 19O : 12 - 25 : 26 - 30
Treatment (depend on : age, stage, type) Goal: Stable concentric reduction Principle: To create a normal upper end of the femur To provide adequate acetabular coverage of the femoral-head To establish normal biomechanics of the hip
a. At birth 3 months. - Closed reduction of the hip - Maintain the reduction with : Pavlik Harness Frejka Pillow Von Rossen splint (On the save zone concept : 30-65) - Duration : twice of the age (in weeks) of the infant when the PH is first applied. (min 6 week). b. 3 months 3 years Preliminary traction Close reduction Retained of the reduction with hip spica cast After removal cast followed by : night splint with : Pavlik Harness Dennis Brown hip abduction splint Scottish Rite brace
c. Above 4 years Prelimenary traction Open reduction : medial or anterolateral approach If needed, combined with: Femoral osteotomy : - intertrochanter/subtrochanter Innominate osteotomy : salter or pemberton Lateral transfer of the greater trochanter d. Adolescent Indication of surgery : hip instability severe OA (abn bone condensation in acetabular roof). Classification: Grade I : stable, congruous, but dysplastic Grade II : Un stable, sub luxated Grade III: subluxated, slightly uncongruous, reducible Grade IV: subluxated, marked uncongruity, irreducible. Grade I : observe (Conservative) II-IV realignment osteotomy of prox femur
(CONTAINMENT)
Innomiate osteotomy: Chiari (is the best) Shelf Salter Sutherlands (double) Triple innomiate Wagner
Resume
3 months Close reduction Palvik Harness Frejka Pillow Von Rossen splint 3 months 3 years Preliminary traction Close reduction Hip spica cast Night splint Palvik Harness Dennis Brown splint Scottie rite brace Above 3 years Preliminary traction close reduction open reduction: Femoral osteotomy Innominate osteot Salter Pemberton Lat transfer of the greater trochanter Adolescent Open reduction Femoral osteotomy Innominate osteotomy: Chiari Shelf Salter Sutherlands
Limping Child with pain on the hip

I. IRRITABLE HIP (TRANSIENT SYNOVITIS) Def: Syndrome of transient hip pain and restriction of movement. Etiology : unknown (trauma, allergic) Most common : 6-12 years. Sign & symptom: o o o Pain & limp (intermittent & following activity) All movement are restricted Long lasting : 1-2 weeks
Lab : all normal Roentgen: normal USG : small joint effusion Treatment : Bedrest with immobilize under traction Analgetic/NSAID Follow up until 1 1,5 y (early Perthes)
II. SEPTIC/PYOGENIC ARTHRITIS Note : - common age : < 2 years Cause : Staphylococcus Destruction the joint by proteolytic enzyme of bacteria. Sign & symptom: ill & pain All movement of the hip are restricted Soft tissue swelling Sign of dislocation of the femoral head Aspirating pus of the joint : (+)
Lab: Leucositosis & slight anemia Roentgen : widening of joint space USG : joint effusion !!! Treatment : Cito arthrotomy, with Antibiotic installed locally Decrease intraarticular pressure Evacuation the pannus Antibiotic depend on culture Immobilization the joint by traction or splinting. Complications: o o Pathological dislocation Necrotic of the head
III. TUBERCULOUS ARTHRITIS (Early stage) Cause : Mycobacterium Tuberculosis Sign & Symptom: Lab : Soft tissue swelling Mild pain & limping Mantoux test (+)
Increase of ESR Slight anemia Leukocyte : normal/decrease
Roentgen: Treatment:
Cartilage & cortical destruction Subchondoral osteoporosis
Chemotherapy: Triple drugs Operative: Synovectomy debridement arthrodesis.
IV. SLIPPED CAPITAL FEMORAL EPIPHSIOLYSIS (SCFE) Def: Displacement of the proximal femoral epiphysis Common age : - pubertal growth spurt (14-16 years), Boy > girls Cause : Hormonal imbalance pituitary hormone physis unable to resist the shearing stress impossed by the increase of body weight. Exp: Hypogonadal Frohlich type child Juvenile hypothyroidism Craniopharyingioma Trauma (30%): mechanical stress. Pathology: Disruption occur at the hypertropic zone of the physis premature fussion permanent exorotation coxa vara Sign & symptom : o o o o pain in the groin, thigh, or knee limping, the leg is turning-out exorotation and 1-2 cm short of normal limb all movement are limited AP view : - widen of epiphseal plate Trethowan s sign (+) Lat view: femoral epiphyseal angle with neck femur < 90o) Slipping at the opposite site Avascular necrosis
Roentgen: o o o
Complications:
Coxa vara Articular chondrolysis Treatment : Depend on the degree of slips !!! Minor slip (AP : < 1/3 of width; Lat < 20o of tilt) grade I Needs no correction Fussion in situ with 2-3 threaded pins Moderate slip (AP: 1/3 - 2/3 of width; Lat 20-40o of tilt) grade II Fussion in situ and then wait. 1-2 years later corrective osteotomy Severe slip (AP: > 2/3 of width; lat > 40o of tilt) grade III (acute stage) close reduction under immage intensifier open reduction by Dunns method
V. LEGG-CALVE PERTHES DISEASE Def: Painful disorder of childhood characterized by avascular necrosis of the femoral head. Common age: 4-8 years (boys > girl) Pathogenesis : unknown Maybe: Vascular theory : Block off the arterial flow Venous stasis Growth arrest theory Effusion following trauma avascular tamponade Inflammation theory non specific synovitis Viscosity theory (Bleck) coagulation abnormality Pathology: takes 2-4 years (3 stages) 1. Ischemia & bone death 2. Revascularization & repair 3. Distortion & remodeling Sign & symptom: Pain & limping All movements are diminished Muscle atrophy
Classification 1. CATTERALL: I. Epiphysis has retained, half of nucleus is sclerotic., such widening of joint space II. Up to half the nucleus is sclerotic, any fragmentation & some collapse of central portion III. Most of the nucleus is involved, sclerosis, collapse of the head, metaphseal resorption IV. The whole head is involved, metaphyseal resorption is marked. 2. SALTER-THOMSON Type A Type B = = Caterall I / II Catteral III / IV
3. LATERAL PILLAR (HERRING) height of lateral of the epiphysis Type A : Normal height of the lateral pillar is maintained Type B : More than 50% height of lat pillar is maintained Type C: Less than 50% height of lat pillar is maintained Note : head at risk : Lateral calcification Gages sign Lateral subluxation Metaphyseal cyst formation Horizontal growth plate X-ray after healing: Mushroom shaped of the head Larger than normal & laterally displaced 4. CONWAY DIAS (1997) Bone Scintigrafi for prognostic value A pathway : 4 stages B pathway : 4 stages A1 whole head involved A2 early lateral A3 medial extension A4 complete revascular A : potential form B : true form (head at risk 90%) Treatment : According the age and stage !!! B1 idem B2 base filling B3 mushroom B4 idem Waldenstorm 1 : n Waldenstorm 2 :subchondral collapse Waldenstorm 3 : fragmentation Waldenstorm 4 : remolding x- ray modified Waldenstorm Dysplastic acetabular socket Sagging rope sign
Goal : Painless hip Full ROM Round head - NSAID 5/6 years : all types : symptomatic : - Traction (2 weeks) - NWB (crutch) - Decrease activity follow up every 1-3 months good response healing poor response containment AGE BENTY Lat pillar (A) : symptomatis : same above Caterral I - III > 5/6 years ` Abd.brace/cast Lat Pillar B/C type B/C : Containment: Caterral IV (head at risk) Operative Add release Psoas release VDRO Salter Osteotomy
Residual after healing Coax magna Coax brevis Hinge abduction Osteochodritis dissecans Step acetabulum Non spherical head
epihyseal extrusion index IF > 20% Need COAPTATION
KLISIC SALTER
VI. JUVENILE RHEUMATHOID ARTHRITIS Def: A systemic disease, with fever, lymphadenopathy, and a progressive bone destruction of both side of the joints without any reactive osteophyte formation. Cause: Autoimmune disease Heredity Climatic factor Stress reaction Dietary factor (abN immunology response) (genetic factor HLADRA) (environment) (physiological)
Classification Pauciarticular < 3 joint Polyarticular > 3 joint Polyarticular + systemic sign
Pathology: Not specific : Synovitis & joint changes Bone & cartilage change Specific : Rheumatoid nodule (rare) Other inflammation : pleura, pericardium, iris, sclera, etc Sign & symptom : (Pauciarticular : 3 joints) Pain in the groin & limp. All movement are restricted & painful. Limb usually : exorotated & fixed flexion
Laboratory : no pathognomonic !!

DL normal / slight anemia, eosinophilia RA factor : pos (10% in child) IgG & IgM (increase) CRP (+) ANA (+)
Roentgen: Acute/early stage : no specific acute synovitis Articular space narrowing Destruction of articular cartilage pannus Late stage : Acetabulum & femoral head are eroded Protrusio acetabuli Articular space (-) fibrous/bony ankylosis
Treatment : depend of stage/severity of the disease 1. Rest in acute stage : immobilization in traction Bivalve cast, plastic splint, etc. But still need exercise/physiotherapy 2. Drugs : NSAID 3. Operative (rare !!) Soft tissue procedure : synovectomy, Tenotomy, Capsulotomy Bone & joints procedure : Osteotomy, Arthrodesis, Arthroplasty Salvage procedure
The CHILD w/ COXA VARA DECREASE OF THE NECK SHAFT ANGLE 1. DEVELOPMENTAL COXA VARA
2. METAPHYSEAL DYSPLASIA 3. MORQUIO SYNDROME 4. PFFD 5. MALUNION FRACTURE 6. OI 7. TUMOR FIBROUS DYSPLASIA 8. SCFE
PAINLESS LIMP WADDLING GAIT LUMBAR LORDOSIS INTERTROCHANTER/SUBT ROCHANTER OSTEOTOMY
IN GENERAL SYMPTOM AND SIGN HIP PROBLEM Delayed milestone Limp Pain & stiff LLD Complain at birth
Tumor w/ pain at hip in children Lytic process
Eosinophilic grnulomatosus Leucemia
LIMPING GAIT IN CHILDREN

UPS
A limp: ASYMMETRIC DEVIATION FROM THE NORMAL GAIT DD/ Trauma Inflammatory Neuromuscular Neoplasm Normal gait: SWING PHASE 40% STANCE PHASE 60% Infection Congenital Developmental disorders
Disturbance Gait: ANTALGIC GAIT o o o o Pain related Stance phase DD/ Diskitis Walks slowly or refuse Weakness of abductor muscle Common in DDH Pelvis tilts away from the affected Stance phase N Walks on the toes LLD > longer extremity may remain flexed at the hip and knee (stance phase) SPASTIC GAIT o o HYSTORY Onset and duration Association w/ pain Getting better or worse Older patient Worse in the morning rheumatologic Night pain malignancy Growing pain, 3 critea : o o Bilateral No symptom at the day Occurs only at night Self limited unknown reason Hypertonicity and Muscle group Imbalance between the muscle
TRENDELENBURG GAIT o o o o
SHORT LIMB GAIT o o
Sign of infection fever +/Family history of : Rheumatologic Inherited Neuromuscular disease
PHYSICAL EXAMINATION Stance phase Stiffness +/ Trendelenburg Gait Torso shift over the pathologic limb Neurologic examination Spine examination : : Walk on the toe and heel Test for reflexes and clonus Bending forward Spondylolysis & Spondylolisthesis Bending Backward Sacroiliac joint : Faber test Hip examination : o o o o o o o Most important Fluid production in the joint capsule transient synovitis Abduction and external rotation and flexion Extension and internal rotationpressure Asymmetry abduction hip DDH Galleazy test SCFE external rotation DD/ Transient synovitis Septic arthritis All joint examination Active & passive ROM Palpated tenderness and warm Lost of ROM Localized pathological site Patellar ballottement effusion Pain the extreme flexion & extension sign of meniscus pathology Ankle joint examination include careful palpation HIP ROTATION
LABORATORY FINDINGS
BLOOD
: White cell >>> ESR & CRP monitor improvement AB therapy CRP more sensitive & earlier elevated
ASPIRATE JOINT gram stain + culture protein and glucose analysis - Serum Rheumatoid anti nuclear antibody HLA typing (Human Leucocytes Antigen) usually (-)
RADIOLOGICAL : Plain film AP & Lateral Pelvic X- Ray : Fragmentation in perthes disease Joint space widening in perthes and sepsis Structural ab n in hip dysplasia Hip lesion special position In non verbal patient x ray from the hip to the feet, detect fracture through the growth plate Hip infection (septic arthritis ) o o o o USG more sensitive for identify the effusion fluid in the soft tissue Bone scan if physical examination history (-) CT scan bone structure MRI best highlight for soft tissue lesion
Need For Immediate Attention 1. Septic arthritis : intra articular pressure poor blood supply femoral head AVN 2. Bone tumor 3. Leukemia 4. Multiple fracture possibility of child abuse rare but should Be Ruled Out
DILLEMA If no constitutional symptoms, no localized abnormalities (by history and physical examination) plain film to rule out fracture observation & reevaluation in a few days (depending on the severity and family situation) if symptom not resolve / localized after 2 4 weeks bone scan
DIFFERENTIAL DIAGNOSIS OF THE ACUTELY LIMPING CHILD TRAUMA o o o o o Fracture Stress Fracture Toddlers Fracture (minimally displaced spiral fracture of tibia) Soft tissue contusion Ankle sprain Cellulites Osteomyelities Septic arthritis Lyme disease TBC of bone
INFECTION o o o o o
o o
Gonorrhea Post infection of reactive arthritis Spinal cord tumors Tumor of bone Benign : osteoid osteoma, osteoblastoma Malignant : osteosarcoma, Ewings sarcoma Lymphoma Leukemia Juvenile Rheumatoid Synovitis Transient Synovitis Systemic Lupus Erythematosus DDH Sickle cell Congenitally short femur Clubfoot LCP SCFE Tarsal coalitions Osteochondritis dissecans (knee, talus) CP, especially mild hemidiplegic Hereditary Sensory Motor Neuropathies Septic arthritis Osteomylitis Cellulites Stress fracture Neoplasm (including leukemia) Neuromuscular
TUMOR o o o o o o
INFLAMMATORY o o o
CONGENITAL o o o o
DEVELOPMENTAL o o o o
NEUROLOGIC o o
ALL AGES o o o o o o
DD/ OF THE ACUTELY LIMPING CHILD BY AGE
TODDLER (ages 1 to 3) Septic hip DDH Occult fractures LLD
CHILD (ages 4 to 10) LCP Transient synovitis Juvenile Rheumatoid Arthritis SCFE AVN of femoral head Overuse syndromes Tarsal coalitions Gonococcal Septic Arthritis
ADOLESCENT
CORRELATING HISTORY EXAMINATION & DIAGNOSTIC STUDIES

Category History Physical examination may show Localized pain, swelling. Loss of motion Rigid guarding, warmth, erythema Mass Laboratory studies None unless infection is possible CBC, ESR, CRP, joint aspirate CBC, ESR, CRP, AFP, calcium, electrolytes, joint aspiration None Creatine kinase (if DMD is in DD/) Radiology
TRAUMATIC
Fall Fever, chills, erythema Night pain which unrelated to activity Problem since birth Ataxia, loss of balance, disorganized gait Pain > 6 mo, family history of rheumatoid arthritis Painless limp (LCP), Knee pain (LCP, SCFE)
Plain film, bone scan Plain film, MRI, bone scan Plain film, MRI/CT, bone scan, staging work-up Plain film Plain film
INFECTIONS NEOPLASM
CONGENITAL NEUROLOGIC
INFLAMMATORY
Deformity, LLD, loss of ROM High/low muscle tone, deep tendon reflex / , cavus foot or claw toes Warmth/erythema, 1 / more joints Loss of ROM in joints, asymmetric ROM, pain w/ ROM
Plain film
DEVELOPMENTAL
None
Plain film
THE CHILD WITH BOW LEGS

Physiologic ( 4 years, wait until 10 years for correction) Pathologic (trauma, metabolic, congenital, tumor, infections)
I. RICKETS Def: Inadequate mineralization of bone in child Cause : 1). Dietary Rickets (Ca deficiency) Nutritional lack Intestinal malabsorbtion (fat malabsorbtion) 2). Renal Rickets (tubular / glomerular) Renal disease (decrease of 1 hydroxylase) 3). Familial rickets (Hypophosphatemic) = Vit D resistant Others predisposing factor: Under exposure of sun ligt Liver disease defect metabolic pathway of vit D
METABOLIC PATHWAY OF VIT D
Diet (Vit D2)
Sign & Symptom: craniotabes ricket rosary (enlargement of costo-chondral junction) Harrison sulcus (lateral indentation of the chest) spinal curvature coxa vara
Frontal broasing Tibia bowing Bending & fracture of the long bone Muscular flaccidity Tetani/convulsi
Laboratory: Ca (serum & urine) decrease, except: Renal rickets ALP (serum) increase 25. OHCC (serum) decrease depend on the cause
Treatment:
If caused by deficiency of Vit D dietary rickets Vit D: 400 1000 IU.day Ca supplement
II. BLOUNT DISEASE Def: A progressive bowleg deformity associated with abnormal growth of the posteromedial part of the proximal tibia physis.
Sign & Symptom: Bowing leg bilateral & internal rotation of tibia Common in obese male
Roentgen: Langenskioid I. Irregularity of ossification zone of metaphysis, with medial beaking, metaphysis III. Depending of the depression in the metaphseal beak, with small area of calcification. IV. Thickening of the epiphseal plate and bony epiphysis enlarges V. Partially double epiphseal plate VI. Ossify of the double medial part of the epiphyseal late (metaphyseal-epiphseal bony bridge). II. Sharp medial beaking, posteromedial depression in ossification line of the
Treatment : depend on age & stage !!!

Langenskiold I-II < 2 years Observe MD angle 2-4 years Bracing (Modf KAFO) Langenskiold III-V Valgus Derotation Osteotomy (VDRO) MD ANGLE > 11 Langenskiold VI Resection of the bony-bridge
III. OSTEOGENESIS IMPERFECTA (Brittle-bones) Cause : defective in synthesis of collagen type I defect in : bones, teeth, ligament, skin, sclera Sign & symptom: Osteopenia Prominent to fracture Bowing of the long bone ` Laxity of joints Inheritance sclera joint laxity teeth hearing impairment age blue sclera crimbling teeth (dentigenous-imperfecta) humpti-dumpty face (broad forehead)
Classification : by Sillence et all Depend on:
Defect Inheritance Fracture
I Autos-dom (+) with minor trauma (+) Deep-blue (-)
II Autos-res Multiple fracture
III Autos-res Multiple fracture (+) Blue-gray * Large scull
IV Autos-dom Less frequent of fracture Less frequent Pale-blue Hearing impairment
Joint laxity Sclera Other abnormality
No identify Normal Large scull Respiratory Difficulty
Prognosis
Note :
Mild/quite good
Worst lethal !!
Bad
Best/good
- Type B = as above with crimbling teeth - Fracture can heal as a normal
Goal of treatment: 1. Gentle nursing during infants (to prevent fracture) 2. Mobilization (to prevent osteoporosis) 3. Prompt splinting (to prevent deformity) 4. Corrective osteotomy realignment IM rod fixation 5. Reposition & immobilization to treat the fracture 6. No specific treatment
The Child with KNOCK-KNEE
Physiologic Until 4 years
Pathologic Renal rickets (renal osteodystrophy) Tumors (osteochondroma) Infections Injury
Indication of operation: on age 10 years. Valgus > 15o need hemiepiphsiodhesis (physeal stapling) on medial side
Patient with (Anterior) Knee Pain

DD: 1. Chondromalacia patella 2. Trauma : Soft tissue injury : # Torn meniscus # Torn of ligament Fracture/dislocation : 3. Osteochondritis dissecans 4. Pre patellar bursitis 5. Arthritis (RA, OA, HA) 6. Patellar cyst or tumor # Fr of the tibia spine # Patelo-femoral sublux
1. CHONDROMALACIA PATELLA Deff: Softening and fibrillation of the articular surface of the patella. Cause mechanical overload of the patellofemoral joint. Physical examination malcongruence of patella femoral surface Malaligntment of the extensor mechanism Weakness of the vastus med patella tilt or subluxate
Sign & symptom - Pain (increase by climbing stairs, standing after sitting) - Malalignment or squinting of patella (Q angle, N < 20o) - Qwasting, effusion (squeeze test + ballottement of patella), crepitus (friction test +) Roentgen : Genu : AP, Lat, Skyline (Merchants) view CT scan Sulcus angle Congruent angle
Treatment: Conservative : Education Physiotherapy : Q strengthening Drugs : NSAID SMOAD Operative : improve patellar alignment & patello femoral congruence !! Soft tissue procedure : - Lateral release & medial plication - Proximal realignment
Bony procedure : - Excision of diseased area Shaving (by scope) Maquets procedure tibia tubercle alignment Hauser operation release & transfer of entire extensor insertion Goldthwait operation release & transfer part of lig. patella Patellectomy
2. TORN MENISCUS Cause: Injury with weight is being taken on the flexed knee and there is a twisting strain Note: Usually in young adult Medial > lateral Type: Vertical tear (75%) Bucket handle tear Anterior/posterior horn tear Horizontal tear Pain & tenderness Locking (inability extend the knee fully) Swelling (effusion)
Sign & symptom:
Special test Mc. Murray test or Apieys grinding test Imaging Arthrography & MRI & Arthroscopy (dx & tx) Treatment Conservative: backslap in straight position for 3-4 weeks mobilizing with crutch & QE Operative: Indication The joint is locked Recurrent symptom Periphery tear, have capacity to heal (red-Zone) should be sutured. If no capacity to heal (white-zone) should be excise (meniscectomy), by open or arthroscopic procedure.
3. OSTEOCHONDRITIS DISSECANS Def: A small well demarcated, avascular fragment of bone and overlying the cartilage loose body Cause: trauma (single impact or repetitive microtrauma) Common site : lateral part of the medial femoral condyle. Sign & symptom: Intermittent pain or swelling Given way or locking Q wasted, small joint effusion Localized tenderness Wilsons sign Genu AP/Lat/Tunnel view MRI: low signal intensity in T1 weight image Bone scan: increased activity around the lession Arthroscopy
Imaging:

Treatment: Early stage : no treatment is needed, activity decreased (6-12 months) Late stage : - small fragment removed by scope - big fragment: fixed with pins or Herbert screw.
4. PRE PATELAR BURSITIS (HOUSEMAIDS KNEE) Def: An uninfected bursitis is caused by constant friction between skin and patella. Sign & symptom: Swelling is circumscription & fluctuant Secondary infection warm, pain/tenderness Treatment: Aspirated & bandaging Kneeling is avoided Lump is best excised If infection antibiotic
5. ARTHRITIS A. RHEUMATHOID ARTHRITIS Def: A type of chronic inflammatory disease in which abnormal immunological reactions are prominent. Cause: Abnormal immunological reactions synovial inflammation (T-cell infiltration & B cell reactivity). Physical examination : Genetic factor (HLA DR4) Environmental trigger factor Others factors (multiple) : Hormones Diet Psychological stress Pathology : 3 stages
1. 2. 3. Synovitis Destruction Deformity
Sign & symptom: Intra articular o Early stages : sign of synovitis: swelling & pain & ROM Joint stiffness is morning/inactivity Local warm, joint effusion o Late stage : Joint deformity: valgus knee Restricted of joint motions & painful Extra articular features : o o o o X-ray : Early : sign of synovitis : soft-tissue swelling & peri articular osteoporosis. Later : marginal bony erosions & narrowing joint space articular destructions & joint deformity. Sub cutaneous nodules (25%) Lymphadenopathy Iridocyclitis Vasculitis
Laboratory: Normocytic hypochromic anemia ESR increased CRP (+); RF (+) : 80% ; ANA (+) : 30% - Clinical features - Laboratory (not specific) - Biopsy (close/open): not specific
Diagnose :
Treatment:
Conservative: NSAID, local splintage, steroid in severe Operative : if conservative treatment has failed Synovectomy Supra condyler osteotomy (valgus knee) Arthroplasty
B. OSTEOARTHRITIS Def: A degenerative joint disease (DJD) non inflammation, with specific process, hypertropic of hyaline cartilage, bone, and soft tissue around the joint. Pathogenesis: 1. Biomechanics theory Structural weakness of joint supporter, cause by aging, trauma, matrix changes Mean normal stress mechanic - abnormal cartilage (structure) 2. Homeostasis theory Disorder of synthesis & degradation matrix balance 3. Stress (extra-articular) theory Abnormal stress mechanic, normal cartilage. (structure)
Predisposing Factor : Unchanged 1. Genetic 2. Gender 3. Ethnic 4. Age Change 1. Obesity 2. Overuse/trauma 3. Hormonal 4. Diet (Fusarium) 5. Metabolic (Gout) 6. Muscle weakness 7. Congenital dis (DDH) Classification: MOSKOWITZ : A. Primary (idiopathic) B. Secondary: Trauma, Metab, Endocrine, Charcot joint, Dysplasia, Others MOLL (the stage of OA by radiologically) Grade 1 : Doubtful OA : Osteophyte minimal Grade 2 : Mild OA : Osteophytes at two points Subchondoral sclerosis Good joint space & no deformity
Grade 3 : Moderate OA :
- moderate Osteophytes - Narrowing of joint space - Some deformity of bone ends
Grade 4 : Severe OA : - Large Osteophytes - Loss of joint space - Sclerosis & subchondoral cyst - Deformity of bone ends
KELLGREN LAWRANCES criteria : Grade 0 : normal Grade 1 : narrowing of joints space Grade 2 : osteophyte & sclerosis subchondral Grade 3 : postural deformity Grade 4 : large osteophyte & joints destruction ALTMAN criteria
AHLBACK criteria 1. Rongga sendi normal 2. Rongga sendi menyempit > 3mm pada satu sisi dan tdp osteophyte 3. Rongga sendi menyempit shg condylus dan tibia plateu bertemu 4. Tdp destruksi sendi yg jelas shg tdp perubahan alignment baik varus/valgus
OUTERBRIDEGE criteria Grade I Grade II Grade III Grade IV : tdp pelunakan lapisan sendi rawan : adanya borok / Ulcus yg luasnya < 2 cm : borok dg ukuran 2 5 cm : adanya lapisan rawan sendi yg telepas eburnated
Sign & symptom: Usually over 50 years old & over-weight. Dull pain (during WB) Swelling, Q wasted Patello-femoral crepitus with pressure pain Giving way or locking, ROM is decreased Joint stiffness (in the morning & after rest) Deformity Loss of function: limping, difficult climbing stairs Deformity Loss of function: limping, difficult climbing stairs Correction the deformity to restore function 1. Conservative : Education : control of BW Drugs : 2. Operative: Indications : Consist of : a. Abrasioplasty (lavage & debridement) b. Pridie procedure (Drilling) c. Microfracture d. Osteochondral autograft : Mozaic-plasty e. Osteochondoral allograft f. Autologous chondrocyte implamation (A C I) g. Osteotomy (for distributing of load) : HTO/SCFO h. Artificial joint arthroplasty TKR & THR i. Arthrodhesis
Open Scope
Treatment: goals Pain relieve & prevention of deformity
NSAID with specific COX-2 inhibitor SMOAD (Structural Modifying OA Drugs): Glucosamine sulfate, Chondroitin sulfate
Physiotherapy: QE, TENS, USD, SWD, JRR, etc a. Persistent pain with conservative tx (3months) b. Progressive deformity & instability
INDICATION OF HTO Age < 60 (young patient w/ good bone stock) Active Varus deformity < 15 if > 15 SCFO ROM is good No joint laxity
Complication THR/TKR Osteolysis Loosening Implant failure Dislocation Heterotopic bone Thromboemboli disease Infections Other : nerve injury
C. HAEMOPHILIC ARTHRITIS Def: Chronic synovitis & progressive articular destruction cause by recurrent intra articular bleeding. Cause: Deficiency of factor VIII (hemophilia A-classic), if platelet dysfunction Von Willbrand Deficiency of factor IX (Haem B/Christmas disease)
Pathogenesis: Hemorrhage in the joint synovial irritation, inflammation and sub synovial fibrosis & pigmented. avascular pannus & produce cartilage degrading enzyme joint destruction sub periosteal hematoma cystic resorbtion
Sign & symptom: Pain, warm, swelling, limited movement Temporary loss of power & sensation (nerve pressure)
Radiography (Arnold-Hilgartner) I. Soft-tissue swelling II. I + Osteoporosis + squaring III. II + Narrowing of joint space & squaring of P-F joint IV. III + Joint disorganization V. IV + Joint disintegration
Treatment: In acute bleed: Immediate factor replacement Analgesic Immobilization Chronic stage: Continuous factor replacement Intermittent splintage Physiotherapy Operative : Release contracture Realignment osteotomy Arthrodesis Synovectomy is rare Aspiration, just only in tension hemarthrosis and one week after conservative treatment failed
The Patients With Intoing Gait

1. METATARSUS ADDUCTUS Def : Forefoot is adducted at the tarsal metatarsal joint. Age : 1 year Treatment : Passive stretching Serial casting (LLC) Operative ( > 1 year, resistant case ) : Medial release if need with MT osteotomy.
2. TIBIAL TORSION The most common cause of intoeing, cause of excessive medical ligamentous tightness. Age : 2 years Treatment : Dennis Brown night splint In severe case need : supramaleollar osteotomy
3. FEMORAL ANTEVERSION Def : Internal rotation of the femur Age : 3 6 years Cause : television sitting position / sit in W position Treatment : Observe until 10 years If still < 100 of internal rotation FDRO in intertrochanteric.
Pemeriksaan pada intoeing gait 1. Foot Progression Angle (FPA) The angle between footstep w/ the straight line 2. Medial / endorotation 3. Lateral / exorotation 4. Thigh foot angle (TFA) The angle between foot axis w/ femoral axis
4. CLUBFOOT
Definition: A congenital anomaly with deformity, ankle equinus, varus heel (sub talar, and abduction forefoot.
Classification: I. Non rigid/postural clubfoot: packing syndrome II. Rigid (true congenital): moderate severe III. Resistant rigid/secondary clubfoot: ec/ Spina bifida, Arthrogryposis Constriction band syndrome STREETER DISEASE Etiology: Chromosome theory Embrionyc theory Otogenic theory Foetal theory Neurologic theory Myogenic theory : hereditary germ plasma defect : defect during fertilized germ cell : arrest of foetal development : abnormal intra uterine force/packing : defect on nerve fiber : abnormal of muscle and tendon - Talocalcaneus - Talonaviculare - Calcaneocuboid Posterior displacement of lateral malleoli Contracture of plantaris and spring ligament pes cavus Paralellism axis of talus and calcaneus Shortened and contracture of triceps sure, tom-dig-herry, Collateral lig and post capsule. Navicular and calcis displace & rotate medially Fore foot adducted & supinated Poor prognosis if Small high heel Deep plantar mid foot creases Thin calf Coleman Block Test rigidity
Pathoanatomi: Abnormal rotation on joints:
Radiographic examination At last the age 3 months View: AP Talocalcaneal (Kite) angle : 20-40o Calcaneo-second metatarsal angle 15-20o
Talo-first metatarsal angle Naviculare positioned centrally TMT angle Lateral Talocalcaneal angle Tibio-talar angle: Dorsoflexion :
0-20o 45o 35-50o 70-100
Plantar flexion : 120-180o
Treatment Goal : Reposition of pathologic structure to perform plantigrade foot Restore alignment of the joints to near anatomical structure To get a normal muscle balance To perform pain free, mobile, and stable foot A. Conservative: Stretching and gentle manipulation Serial plastering Adhesive strapping physiotherapy The manipulation is done as soon as possible, shortly after birth, it is better if still in golden period (three weeks after birth). Complications: pressure necrosis, rocker bottom foot, flattening of talus, cavus deformity, joints-stiffness, longitudinal breach. B. Operative Indication Rigid type & resistant rigid Failed after 3 months conservative treatment Recurrent deformity Neglected cases Time of surgery : 6-12 months (before the patients walked) Because : - Clear anatomical structure - Weight bearing after surgery promote the correction
Technique: Posteromedial release (Cordovillia) Turco Subtalar release (Cincinnati) Bensahel suggest that operation on CTEV is a la carte approach Illizarov technique
After 8 years: need addition procedure: Lichtblau : resection of distal calcaneus/anterior end of calcis Simon : resection of lateral calcaneo-cuboid Evans resection of calcaneo-cuboid Dwyer open medial osteotomy of the calcis Cuboid decancellation
Plastering (LLC) 10-12 weeks, after open the cast perform night splint: Dennis-Brown splint Passive stretching (Physiotherapy) Correction shoes follow up the patients until nature age In adolescent patients: need triple arthrodhesis or telectomy.
Complications: Infections, skin necrosis, joint stiff, over/under correction, flattening or beaking of talar head, talar/calcis/navicular, skew foot.
CTEV, important Definition Classification Etiology Pathoanatomy Diagnostic: clinical & RO Management: goal Principle Complication Technique
AMC, important Definition Classification Etiology Pathoanatomy Diagnostic: clinical,EMG/NCV, biopsy, Lab : CPK Management: goal Principle Complication Technique
5. ARTHROGRYPOSIS MULTIPLEX CONGENITAL (AMC)

Definition: A non progressive disorder with multiple congenital rigid of many joints. Incidence : 3/10.000 Etiology: Multifactor I. Intrinsic : defect of collagen II. Extrinsic : Mutagenic agent Drugs Chemical agent Hypothermic Neuromuscular blocking agent Intra-uterine immobilization Infections (virus)
Defect of Cranio spinal-motored axis
Foetal Hypo/akinesia
AMC
Classification : A. Myogenic : congenital muscular dystrophya B. Neurologic : defect of lower motor neuron
Sign/symptom : Normal facies, normal intelligence, normal sensory Multiple joints contracture Absence of skin crease, cylindrical shape of extremities Muscle atrophy Absence of deep tendon reflex UE: add & int. rot of humerus, elbow ext, wrist flex ulnar dev. LE: hip disloc, knee contracture, rigid clubfeet Spine: scoliosis, torticollis
Laboratorry: CPK Chromosome analysis Electrophysiology (EMG-NCV) Muscle biopsy
Treatment : Goal independent self ambulation and have optimal limbs functions. Principle: Release the contracture as soon as possible Restore the result by physiotherapy Promote during ambulation with orthosis For muscle balance need tendon transfer Modalities: 1. Physiotherapy passive stretching plastering night splinting 2. Surgery Foot & ankle : soft tissue release & bony procedure if needed planti grade feet Knee : Flexion deformity Hamstring lengthening Posterior capsulotomy Shortening of the femur Extension deformity : Quadriceplasty Hip: if dislocated need open reduction/containment if contracture: release illiotibial band, illiopsoas, tensor in flexion fascia lata (all hip flexor) Elbow: extension position tendon transfer for flexion Wrist: flexion position tendon transfer for dorsoflexion Fingers: need volar release, web space plasty, etc Antebrachii: pronation contracture release insertion of PT Spine: need spinal fusion & instrumentation (curve > 40)
Patients With Kyphotic Deformity

Def : Excessive dorsal curvature of the spine. DD : 1. Compensatory Kyphotic (cause other deformity) 2. Congenital Kyphotic (missing/fused anterior segment) 3. Adolescent Kyphotic (Scheuermanns disease) 4. Ankylosing Spondylitis 5. Tuberculosis Spondylitis 6. Osteoporosis Kyphotic 7. Fracture (post traumatic) pathologies (tumor/etc) Adequate trauma Note : Gibbus / kyphos is a sharp posterior angulations due to localized collapse or wedging of one or more vertebrae.
A. SCHEURMANNS DISEASE Def : A growth disorder of the spine which the vertebrae become slightly wedge shape. Cause : Unknown Sign & symptom : Backache & fatigue Smooth thoracic Kyphotic & compensatory lumbar lordosis Tight hamstring limit SLR If severe cardiopulmonary dysfunction Radiography : TL lat Irregular/ fragmentation of endplate (T 6-10) One/more w/ wedge shaped of vertebrae School nodes Measure Kyphotic angel abnormal if : Wedging individual segment > 5 Overall Kyphotic angle > 40 Treatment Conservative back exercise & postural Kyphotic in skeletal mature bracing Operative : indication : Rigid curve >60, in young adult Painful severe Kyphotic in skeletal mature Impending spastic paresis CORRECTION & FUSION using : HARRINGTON COMPRESSION ROD
B. OSTEOPOROTIC KYPHOSIS Cause : 1. postmenopausal Age : 60 70 years (5 year after menopause) Chief complain LBP Treatment : hormone replacement Symptomatic 3. Senile 4. Age 75 years (15 years after menopause) 5. Chief complain : back pain & spinal deformity X ray : multiple vertebral fracture Treatment : - symptomatic spinal bracing
Patients With Joint Laxity

DD : 1. Marfans Syndrome 2. Ehlers Danlos Syndrome 3. Larsens Syndrome 4. Osteogenesis imperfecta 5. Generalized (familial) joint laxity
6. Muscular dystrophia
SIGN : Hyperextend of elbow Hyperextend of thumb Hyperextend fingers Genu recurvatum Flat foot Palm on the floor
CHIEF COMPLAINT Recurrent dislocation of the joints Frequent fall & Rapid fatigue Flat feet
Patients with Wryneek

Pterygeum colli Unilateral absemce of m. sternocleido Postural torticolis
Congenital (wryneck) Soft tissue
Acquired (wryneck) Atlantoaxial Sublux/trauma - JRA - Grisels disease - Cervical adenitis - Syringomyelia Ocular dysfunction - Bulbar palsy WRYNECK
Kleiple Feil Sy Occipitocervical anomaly Fam Cervical dyspl Unilat absence facet Osseous Tumor Osteoid osteoma Aneurismal bone cyst
EMERGENCY IN ORTHOPAEDIC
CRITICAL CARE
I . COMPARTEMEN SYNDROME Definition : A complex symptom in which caused by elevated pressure in an Volkmanns Ischemia Volkmanns contracture enclosed osseofacial space, can damage irreversibly the contents of the space.
Cause : a. Decrease size of compartment : - Tightened fascia - Tight dressing - Local compression b. Increase the contain of the space : - Primary edema - Blood accumulation - Combined Patophysiology : Vascular congestion capillary beds occluded muscle & nerve Ischemia transudation of colloid plasma into the surrounding tissues increase of tissue pressure arterial flow impaired The worst on the central portions : (Ellipsoid theory) Diagnosis: (7P) : - Pain on passive stretching - Pain at rest - Paresthesia - Paralysis Gold standard for measurement : Wick catheter technique Slit catheter technique Stic catheter technique Continuous infusion technique Needle manometer technique normal : 20 30 mmHg > 30 mmHg need fasciotomy - Pallor - Uselessness - Paoikilothermia
Necrosis of the muscle happened, 8 hours in 30 mmHg intra compartment pressure. Others examinations: Blood: CPK, BUN, creatinine, aldolase, SGOT, LDH. Urine: myoglobinuria, oligouria EMG SSEP
Proper initial management: Constrictive dressing should be removed or split. Circumferential cast should be bivalved Limb should be placed at the level of the heart
Definitive treatment: Fasciotomy, skin and fascia are left open; skin is grafted at a later date. Prophylactic fasciotomy should be performed on : - Tibia osteotomy - Leg lengthening - Arterial repair - Open tibia fractured
II. FAT EMBOLISM Definition: A syndrome due to the entry of neutral fat into the vascular system. The syndrome usually develops 24 48 hours.
Pathophysiologi: Fat in the myellum into vascular system obliterated vascular in lungs and brain ventilator distress & brain function disorder. Theory: 1. Mechanical (marrow globular) : Bauss 1924. It is caused : damage of the adipose tissue damage of venous system higher pressure in the bone marrow than in the venous system. 2. Biochemistry Disorder of the stability chylomicron emulsion 3. Cathecolamine adrenal steroid pathway stress mobilization of fat from the depot increase of FFA & triglyceride. Clinical Symptoms: Sevitt a. Major (min 1) : Respiratory disorder Brain (CNS) disorder b. Minor (min 2) : Pyrexia Tachicardi Renal disturbance Icterus Retina disorder Ptechie emboli of microglobules
c. Laboratory (min 1) Fat macroglobulin Urine
Anemia Thrombocytopenia Increase of ESR blood
Radiology: fluffy infiltrate of the lungs (snow storm) ECG : Cardiac failure, Base of treatment : 1. Proper and adequate of fracture management 2. Adequate shock management 3. Adequate pain control with analgetic 4. Respiratory support 5. Corticosteroid administration: - Decrease of cerebral edema - Anti aggregation of thrombosis - Decrease of FFA in plasma - Prevent decrease of pa O2 6. Restore of fluid and electrolyte balance 7. Others : - Antibiotic prophylaxis - Digitalis - Bronchodilator Abnormal T wave cause of ischemia
III. OPEN FRACTURE Definition: Fracture with open wound, which the bone fragment had been exposed with the other space. Classification: Gustillo Anderson : depend on :- Mode of injury - Soft tissue damage - Bone comminution Grade I : 1 cm wounds or less Grade II : > 1 cm wound with moderate soft tissue damage Grade III : Extensive soft tissue damage and crushing due to high velocity trauma. Type III is further subdivided into three subtypes : A : Adequate coverage B : Bone exposed with periosteal stripping C : Circulation distrupted, arterial repair required Management: Principal: - Prevent infection - Bone and soft tissue healing - Restore the limb functions
Consist of: 1. 2. 3. 4. 5. 6. 7. Ensure the ABCs are stable Complete examination include all of system organ Close the wounds with the clean gauze Immobilization the fracture Recognition the fracture by the X-ray Determined the vascular status Preoperative debridement : - Fluid replacement - Antibiotic prophylaxis - Debridement & Irrigation 8. 9. Reposition & fixation to secure the stability Closure the wounds: - Grade I & II Primary closure - Grade III 10. 11. Note : If there is with vascular involvement :

- Anti tetanus
Delayed primary closure (3 5 days) or early free-flap
Early bone grafting if necessary (1 6 weeks) Recognize and treat the complications adequately
< 4 hours : Stabilization fracture first than vascular repair > 4 hours : repair vascular first than stabilize the fracture
To determine the vascular by: clinical / Doppler / arteriography 6 12 H
Muscle fibers edema 4 8 H Muscle fibers die
IV. MULTIPLE TRAUMAS Definition: Patients with more than one organ system had been injured and they influenced to life threatening. Steps of ATLS (INITIAL ASSESMENT) 1. Preparation: pre hospital & in hospital phase 2. Triage: sorting the patients 3. Primary survey: - Airway maintenance with cervical spine control. - Breathing and ventilation - Circulation with hemorrhage control. - Pupil size & reaction
Alert Verbal Pain Unresponsive
- Disability and neurological status : - Level of conscious: AVPU
- Exposure / environmental control : - completely undressed - warmed environment 4. Resuscitation. 5. Roentgenogram 6. Secondary survey - a head to toe evaluation - GCS scoring - peritoneal lavage - Other radiologic evaluation - Laboratory - AMPLE history 7. Re evaluation 8. Definitive care.
Allergies Medication Past illness Last meal Environment
RULE OF PRIMARY AND SECONDARY SURVEY 1. Used of personal protections apparatus (gloves, goggles, mask, head cover, shoe cover, gowns or aprons) 2. Examine the airway with cervical control, if : obs (-) or obs (+) chin lift / jaw thrust Free oropharyngeal (unconscious) nasopharyngeal (conscious) endotracheal intubations or cricothyroidotomy 3. Oxygenation - Evaluation: Blood pressure, pulses, Respiratory rate - Evaluation: breathing sound, heart beat sound. if none * Tension pneumothorax: contraventile * Hematothorax : chest tube * Cardiac tamponade : pericardiocentesis 4. IV line administration: - 2 (two) IV line with big and short needle, by taking blood sample (cross match, pregnancy test for female, others) - Bolus 1-2 liters of ringer lactate - If need with venasection - Rule: 2Lev 2L ev type spes with cross match ev PRCO
Apply the collar brace
5. Re-evaluation: I P P A, completely with: - ECG observation - Pulse oxymetry - RT DC & MS - Evaluate: AVPU and pupils 6. Open all of dress (undress), find the all source of external bleeding, Stop the bleeding with clean / sterile gauze. Remember, preventing iatrogenic hypothermia by coverage the patients. 7. Re-evaluation again : - All the vital sign - Blood gas analysis - Urine output
V. ACUTE HEMATOGENOUS OSTEOMYELITIS Definition : acute infection of the bone (metaphysis) & marrow Cause : - Staphylococcus aureus !!! - Streptococcus pyogenes / pneumoniae (infant) - Haemophylus influenza (child < 4 years) - E.coli, Pseudomonas, Proteus (gram neg) - Bactericides (an aerobe) - Salmonella Predisposing Factor: - DM, malnutrition, drug addict, very elderly, debility - Immunosuppressive therapy, immunodeficiency. Site or infection: metaphysis area because: - Area of growth cells - Rich of vascular - Thin cortex - Slow blood flow Pathology: depend on :- Age - Site of infection - Virulence of organism Stage of infection Pathology (Hobo s theory) 1. INFLAMATION (72 hours) Vascular congestion Exudation Infiltration by PMN - Host response - Immune system - Malnutrition
2. SUPPURATION Sub periosteal abscess 3. NECROSIS Sequester: pieces of dead bone separated 4. REACTIVE NEW BONE REACTION Involucrum : new bone thickened surrounding the sequester Cloacae : perforated area from the infolucrum 5. RESOLUTION - Sclerosis and thickening of the bone - Remodeling Stage of clinical (Trueta, 1968) * Stage I : process in the bone : tenderness * Stage II : pus in medullar cavity & sub periosteal malaise, fever, pain, headache * Stage III : pus in the soft tissue (abscess) with inflammation sign (calor, dolor, tumor, rubor, functionless) Sign & Symptom : - Pain, malaise, fever, tenderness - Local redness, warmth - Swelling / edema - Restrict of joint motions (refuse to move the limb) - Lymphadenopathy - Swelling of subcutaneous tissue & muscle - Periosteal reaction / bone formation / thickening of periosteum - Patchy rarefaction of the metaphysis - Bone destruction / destroy bone trabecullae - Osteoporosis bone - Small crack epiphyseal plate Laboratory: - Leucositosis, increased of ESR - Blood culture (+) - Antistaphylococcal ab
Roentgen :
Treatment: A. General supportive treatment: - IV line (dehydration?) - Analgetic B. Immobilization affected part: - splintage - Skin traction C. Eradication infection: Antibiotic, depend on culture & sensitivity test Adult / child: - Flucloxacillin 3 4 days ( IV ) continued with 3 6 weeks (PO) < 4 years: Cephalosporin 2nd generation Amoxicillin & clavulanic acid
D. Drainage Must be done, if in 36 hours without better improvement with antibiotic. (Monitoring LED, temperature, CRP). Drained by open operation under GA (drilling into the medullar cavity) - Suppurative arthritis - Altered bone growth - Chronic osteomyellitis
Complications:
VI. GAS GANGRENE Def : Septic condition caused by microorganism producing gas due to damage soft tissue during the open fracture of bones. Causes : Clostridium perfringen / welchii Clostridium septicum Clostridium tertium
Pathogenesis: Contaminated of tissue with (spores / vegetative forms) of Clostridia sp & transient hypoxia (low tissue oxygen tension) Bacterial growth Toxin produce : (enz hyalluronidase & collagens ) (Clostridia myositis) Local edema Tissue destruction Thrombosis local vessels Gas produced (H2S & CO2) Distant spread (More edema & more thrombosis) 32 48 hours Moribund state
Sign & symptom:
- General : toxic, irrational, mild shock - Local : bronze color until black discoloration blebs & bulla (sero sanguineous ), crepitating.
Laboratory: - Hemolysis of blood droop in hemoglobin ( 12 24 hours ) - Hemoglobinuria - ATN (decrease of RFT) - Leucocytes - Spore / in gram stain X Ray gas in soft tissue Treatment : - Secure ABC (life saving ) - Surgical debridements, irrigation, leave the wound open/amputation - Antibiotic (triple drug) penicillin/ metronidazole - Antitoxin ( globulin modified polyvalent ) - HBO increase of oxygen content in the soft tissue. Complication : pneumothorax / air embolism Note : Gas producing microorganism * An aerob : - Gram ( - ) - Gram ( + ) * aerob : - Gram ( - ) - Gram ( + ) : - Bactericides sp : - bacilli - coccus :- E.coli - Klebsiella : Clostridium sp : Peptostreptococcus - Proteus - Enterobacter
: - Streptococcus pyogenes - Staphylococcus aureus
DIAGNOSTIC PROCEDURE (INVESTIGATION)

I. MAGNETIC RESONANCE IMAGING Principle: * Magnet field * Transmitter * Receifer * Computer dysplay Electrical signal Signal intensity depend on strength of radio wave of soft tissue Degree of brightness of the structures High signal intensity (Bright / white) low signal intensity (Dark / black)
cell nuclei (proton / neutron) (ion Hydrogen)
The intensity depend on concentration of ion hydrogen (State of tissue water molecule) Weighted T1 Longitudinal relax time (No pulse) Good anatomical detail Note: contrast of MRI : Gadolinium Magnet field force TESLA: HIGH LOW
No 1 2 3 4 5 Structure Fat & bone marrow Hematoma Cortex bone, lig/tendon, fibro cartilage, air Muscle, nerve, hyaline cartilage Fluid T1 High signal High signal Low signal Intermediate Intermediate
T2 transversal relax time (Application of pulse) Good contrast
: 1 1,5 T : < 0,5 T

T2 Intermediate High signal Low signal Intermediate High signal
MODERATE : 0,5 1 T
T 1 FAT IMAGING T 2 WATER IMAGING
II. CRP A kind of protein is produced by hepatocyte as a response of body to an acute Condition such on : - trauma - Inflammation - ischemia stage - neoplasm
Its showed there is a tissue injury. Peak level: 24 48 hours after trauma, and rapidly change 24 48 hours after better clinical condition.
III. PCR Amplification method for synthesis a specific DNA sequence in vivo.
IV. Various technique of bone mass measurement (Bone densitometry) : SPA : Single photon absorbtiometry site: forearm & heel DEXA : Dual Energy X-ray Absorbtiomtry site: lumbar & femur QCT: Qualitative Computed Tomography site: spine
V. BONE SCAN Principle : - Rate of production of new hydroxyapatite ( osteoblastic activity ) - The blood flow to the certain area - Photon emission by radionuclides taken up in specific tissue can be recorder by either a simple rectilinear scanner or a gamma camera Isotope: - Technetium 99m - Gallium 67 : specific for inflammation - Indium 111: specific for infection
Stages of isotopes: Blood pool phase: shortly after injection Bone phase: 3 hours later
Types of abnormality: Increase activity in the perfusion phase: Inflammation Decrease activity in the Perfusion phase: local vasc insufficient Increase activity in the bone phase: newly forming bone (Fracture, injection, tumor, healing after necrosis) Decrease activity in the bone phase: absent blood supply
Indication: 1. Early detection of bone metastases 2. Confirmation of equivocal lession (stress fr, small bone abscess) 3. Assessment of the extent of disease (loosening of prosthesis) 4. Monitoring the progression or regression of active disease 5. Diagnosis of changes caused by metabolic disease.
VI. SYNOVIAL FLUID ANALYSIS Indications: Acute joint swelling after injury Suspected joint infection Synovitis (acute / chronic)
Technique : joints aspirated under aseptic conditions. Examination : Macroscopic / Gross Microscopic Biochemistry : appearance & viscosity ? : Cells & crystals & Bacteriology ? : Glucose, K, Na, etc
VII. ARTHROSCOPY Indication: - Diagnostic - Therapeutic Technique: By a rigid telescope fitted with fibreoptic illumination. Tube diameter : - 2 mm (small joints) - 4 5 mm (big joint) Carried out under general anaesthesia, guided by image. The joints is distended with fluid (paraffin fluid, Nacl, Rl) Use various instruments (probes, curettes, forceps)
Complications: Haemarthrosis Thrombophlebitis Infection Joint stiffness
VIII. ELECTRODIAGNOSIS Electro diagnostic testing is an objective method to assess for neurogenic lesion. The goal: to identify and ultimately localize the neurogenic lesions (demyelination Or axonal loss ) Note: Clinical expression of peripheral nerve dysfunctional: - Muscle atrophy - Muscle weakness - Sensory loss - paresthesia - pain - dysesthesia
A. ELECTROMYOGRAPHY (EMG) A diagnostic procedure is used to record motor unit activity at rest and when attempts are made to contract the muscle. - At rest: normally there is no electrical activity - On voluntary contraction: determined of: number, shape, amplitude, and duration of the muscle action potential The EMG examination parameter for diagnosis include: 1. Insertional activity: decrease / normal / increase 2. Spontaneous activity: * Fibrillation, positive sharp wave; means denervation * Fasciculation - anterior horn cell disease (ALS) - Radiculopathy - Nerve entrapment - Cervical Spondylitis myelopathy - Metabolic disease: tetany, thyrotoxicosis, and anticholinesterase intox * Complex retetttive discharge: Muscular dystrophia, myositis, chronic denervating, polyneuropathy 3. Motor unit morphology 4. Interference pattern Can to distinguish: * Myopathy : small action potential on contractions, silent / increase spontaneous activity at rest. Both amplitudo and duration are diminished. * Neuropathy : no action potential on contraction, fibrillations and positive sharp waves at rest. Both amplitudo and duration are increased (Earliest sign usually after 4 weeks)
B. NERVE CONDUCTION STUDIES A diagnostic procedure to determine the nerve conduction velocity. Normally: about 40 60 m/s Nerve impulse are stimulated & recorded by electronic surface electrodes. Latency is the time between the onset of the stimulus and response Note: - Neuropathy : latency increase conduction N / - Myopathy: latency / conduction normal - Anterior horn cell disease: latency / conduction normal - Neuropraxia : Pox to lesionabsent, Distal to lesion N
C. SOMATOSENSORY EVOKED POTENTIALS (SSEP) A diagnostic procedure by measuring sensory nerve conduction velocity. The response can be electrodes placed on the spinal cord, on the skin over one of the vertebrae on the scalp over the cerebral cortex. SEP technique has the advantage in evaluating: * Proximal neuropathies: GBS, CIDP (Chronic inflammatory Demyelinating Polyneuropathy, Brachial & Lumbosacralplexopathy * Proximal sciatic nerve lesions * Thoracic outlet syndrome * Cervical Spondylitis myelopathy Disadvantage can be used for identified level of radiculopathy
IX. BIOPSY The goal of biopsy is to confirm the diagnosis by histological examination. Divided : - Open Biopsy - Close biopsy: - Core Needle biopsy - FNAB Technique of open biopsy : - Done in operating theatre with GA - Incision longitudinal, located in line with operation plan - Dont use tourniquet - Make a little window by curretaged at metaphysic area - Take a viable tissue, dont the necrotic area - Good hemostasis - Avoid: neurovascular structure, through more one compartment, Codman triangle, post radiation area, drainage. - Close the wound with edge uninterrupted suture.
Advantage of close biopsy: - Less of contamination - Less risk of infection & fracture - Relative cheaper - Able perform in difficult and deep location (use imaging guide) - Radiation can be perform early after FNA Note: Specimen must be sent immediately without any fixation
REHABILITATION
I. DEFINITION A. Rehabilitation: The restoration of an individual handicapped to the fullest physical, mental, social, vocational and economic, which he or she was capable. The process of restoring a persons ability to live and work as normally as possible after a disabling injury or illness B. Impairment : Any loss or abnormality of anatomical structure physiological or psychological of function C. Disability : Any lack or restriction as the result of the impairment of ability to perform an activity as abnormal function
D. Handicap : A disadvantage for a specific individual as the result of an impairment or a disability that limit the achievement of a role that is normal milieu (depend on the environment) E. Orthotics : A device applied externally to the patients body used to
supporting, correcting, protecting or compensating for an anatomical deformity or weakness of the body part.
F. Prosthesis : A device used to replace a missing part of the body
Note: Used of a splint / appliances / device: 1. To provide immobilization and local rest 2. To provide fixed traction (Thomas splint) 3. To prevent deformity / retain correction / correct mild deformity 4. To stabilize joints and to protect weak muscle 5. To maintain extension (spine, hip, knee)
II. ORTHOTIC and PROSTHETIC A. According the law / dictum: OP must be prescribed properly, it must be rationally. * Appropriate indication * Appropriate patients * Appropriate device * Appropriate dose * Beware of adverse reactions B. Conditions for Prescription: Material: strong, light, durable, available and non traumatic * Metals : iron, duralumin ( aluminum and steel ) * Non metals : leather, rubber, wood, foam, plastic, polypropylene Easy for maintenance Accepted by the patients / community Technology, which we have: low, medium, high Price C. Purpose of OP : Protection / immobilization: fracture, RA Correction (by three point compression / pressure ) : CTEV, Scoliosis Supportive / Stabilization: paresis / paralysis, Myopathy Motorization / Functional: drop foot Substitution: after amputation D. How to prescription ? Consist of : The name of device Specification in detail
Steps / Stages of make a prosthesis : A. Pre Surgical Stage. Explanation about: INFORMED CONCERN Phantom limb/sensation Phantom pain (immature psychology) Kind of amputation Stump amputation Strengthened the upper-ext muscle for preparing mobilization with crutch.
B. Post Surgical Stage. Temporary prosthesis ( Pillon Leg ) Immediate after surgery (in the Op Theatre) For proprioceptive sense Pre prosthetic phase Shaping of the stump, with proper bandaging Exercise all of the important muscle. Exercise the entire joint to prevent contacture Prosthetic phase ( Fabricating of prosthesis ) Measurement and making negative model with plaster cast. Making the positive model. Fabrication of the soft insert (leather, rubber, polyethylene foam). Making a socket system Make alignment with BK adjustable shank Shaping and finishing Post prosthetic phase Initial checkout OP training Final checkout and evaluation Vocational training Placement
III. ORTHOSIS Upper extremity : Very complicated, because to promote the function of the hand ( grasping, pinching, hooking ) Divided in static and dynamic. Principle : Place the wrist joint in appropriate position ( 450 dorsoflexion ) Flexion MCP and PIP joint Apposition of the thumb with II and III Exp : Knuckle bender use for loss of ulnar and medianus nerve, ( intrinsic muscle palsy intrinsic minus ) Note : intrinsic muscle : 14 1/2 ( 3/4 ) innervated by ulnar 4 1/2 ( 1/4 ) innervated by median 2 lumbrical : index & middle 2 1/2 thenar :
Abductor pollicis brevis Opponens pollicis Flexor pollicis brevis ( superficial head )
Lower Extremity : For support the body and ambulation not so complicated 1. Anatomy of the SHOE - Sole - Counter - Vamp - Closer system Purpose of the shoes : - to protect ( strong counter ) - to correct ( promote normal gait ) Depend to purposes : * short quarter : oxford type * high quarter : cover the malleoli * very high : lars 2. Anatomy of AFO Control alignment and motions of the foot & ankle joint. Shoe / foot attachment, consist of: - shoe insert - Caliper - Stirrup Ankle joint mechanism: - ankle joint - Ankle stop ( plantar or dorsal stop ) - Correction T strap ( valgus / varus ) Calf band Up right ( single / double ) 3. Anatomy of KAFO. AFO Knee joint mechanism Single axis Extension stop * Drop ring lock * Adjustable lock * Pawi lock Correction strap Kneecap Thigh band Upright : single / double - shank - toe box - hole - heel - quarter - throat and tongue
4. Anatomy of HKAFO KAFO Hip joint mechanism Single axis with hyperextension stop Double axis Pelvic band unilateral bilateral pelvic girdle ( double pelvic bands )
Spine : 1. Cervical collar : Soft : no correction , just reminding for minor injury. Semi rigid : Thomas cervical collar some protection for flexion /ext/lateral but NO rotation Rigid : two/three/ four poster SOMI ( Sternal Occipital Mandibular Immobilization ) Philadelphia brace 2. SIO ( Sacro llilac orthosis ) To stabilize SIJ in Ankylosing Spondylitis or Sacroilliitis. 3. LSO ( Lumbo Sacral Orthosis ) Knight brace ----> for FEL control 4. TLSO ( Thoraco Lumbo Sacral Orthosis ) General anatomy , consist of : - pelvic band - thoracic band - abdominal support - up right (anterior / posterior / lateral) Jewet Brace Taylor Brace Knight Taylor Brace Combined Boston Brace 5. for F control for FER control for FEL control for FELR control for scoliosis, apex bellow Vth IX
CTLSO ( Cervico Thoraco Lumbo Sacral Orthosis ) Milwaukee Brace Indication : Scoliosis , apex above Vth IX Resist : FE some L no R Correction pad is on the just bellow the apex To be used 23 hours, every day until bone mature
Most routinely exercise in side the brace ( day time ) - Ask the patient avoid the pressure of the pad Just only some correction to the curve Need ADF Ex ( Alongation Derotation Flexion Exercise ) KLEP Ex
Special Orthosis : 1. 2. 3. Dennis Brown Splint Indc : angular & rotation deformity : CTEV, pronated foot, abnormal tibia torsion. A-framed orthosis Torsion shaft orthosis, for : - mild scissor gait - Spastic hemiplegia - abn toe in / toe out 4. 5. 6. 7. 8. Von Rossen Splint Palvik Harness Ilfeld splint Scottish Rite orthosis, Toronto orthosis, Trilateral orthosis for LCP Severe paralytic disorder, used : - DHJ ( Detachable Hip Joint ) - Standing frame orthosis - Parapodium - Reciprocation Gait orthosis
IV. PROSTHESIS Upper Extremity: Elections depend on functional or cosmetic reason. Functionally but cosmetic is bad: hook prosthesis * Voluntary closing, by APRL (Army Prosthesis Research Lab) * Voluntary opening, by DORRANCE Cosmetic good but functional is bad (semi mobile). The latest generation is myoellectric hand Electrode influenced with bio feedback through the oscilloscope in the scene. Lower Extremity . to support the body weight and mobilization. FOOT # Non articulated : - SACH ( Solid Ankle Cushioned Heel ) The cushioned replace the ankle joint by altering the body weight - SAFE ( Stationary Attachment & Flexible Endoskeleton )
- STEN ( Stored Energy ) - Seattle foot - Special : Jaipoor - foot # Articulated : Single axis or double axis Anatomy of BK Prosthesis. - FA - assembly - Shank : Endoskeleteal ( metal or plastic tube ) Exoskeletal ( plastic foam ) - Socket : containment of the stump & transmission of body weight PTB socket = muenster socket in LE prosthesis hard on ISNY ( Icelandic Swedish New York ) - Suspension : Cuff system Supracondylar system Supracondylar / Supracondylar system With tight corset Anatomy of AK Prosthesis. FA - Assembly Shank Knee Ass : * axis : singe or polycentric * extension stop : internal or external aid * knee block * friction device : Thigh piece Socket : Quadrilateral Ischial containment Suspension device suction alone (negative pressure) partial suction + silessian bandage no suction ( using pelvic belt ) SYME prosthesis (James Syme) The kinds : OSP ( Original Syme Prosthesis ) CSP ( Canadian Syme Prosthesis ) VAPC Syme Prosthesis ( Veterans Administration Prosthetics Center ) - Sliding system : constant / variable - Fluid control : hydraulic / pneumatic
STUBBY prosthesis for bilateral above knee amputee Hip Disarticulation Prosthesis Canadian hip disarticulation type Characteristics: Socket design to provide total contact * Basic socket: extensive socket waistband * Diagonal socket * Hemipelvictomy socket Added with: * Hip extension stop * Stride length control strap
V. WALKING APPARATUS CRUTCH Handgrip on the level of major throchanter Elbow mild flexion ( 300 ) Axillary pad : 2 3 finger-breadth below axillary fold Long 15 cm lateral of the foot 10 cm in front of the foot Kind of walking : two point gait three point gait four point gait swing to swing through ( the pathologic level not higher than V th XII )
MACAM MACAM
4 R Recognition Reduction Retain Rehabilitation 5 R Receive Review Revive Re-Review Revive Rehabilitation Bryant triangle fracture femur proximal
MPS
PROPORTIONATE
Diastrophic dysplasia Cleidocranial dysplasia
SHORT STATURE (DWARFISM)
Short trunk spondyloepiphyseal dysplasia

DISPROPOTIONATE
Rhizomelic Achondroplasia Short limb Mesomelic Acromelic
ORTHOSIS
PROTHESE
EMERGENCY ORTHOPAEDICS THE SPINE
Actual injury to the cord resulting in neurologic dysfunction rarely occurs from transection. The cord and tough meninges remain intact. Injury occurs from compression of the cord & disruption of the blood supply. Experimental studies demonstrate that trauma inflicted on spinal cord will produce an initial increase in blood flow that latter falls to 70 to 80% of he pre trauma flow. It is felt that this relative cord ischemia results in neurologic cell death. Although the mechanism for these blood flow changes is unknown, present investigation show release of vasoconstrictive substance and improving mean arterial pressure. Since cell death occurs within 4 hours of the original injury, future hope of reversing permanent neurologic dysfunction will require prompt & definite action on the part of emergency personnel. The sections of vertebra column that have the greatest mobility are also the areas of most frequent injury Cervical spine is the most flexible, ___ bounded above by relatively heavy head and below by the more fixed thoracic spinal column the most common SCI occurs between C5 C6, but at this level the spinal canal is 30 % larger than the cord itself Thoracic spine requires significant force to disrupt or dislocate and if it occur will result thoracic cord injuries that are usually complete & irreversible. Lumbar spine, ______ the canal is relatively large and the spinal cord narrows & end opposite the L2 vertebra. The cauda equina loosely fills the reminder of the spinal cord and tolerates compression better than the cord itself. Although T12 to L1 SCI at the interface of the fixed thoracic and more mobile lumbar spine in the 2nd most common injury ___ incomplete lesions of the cord at this level and below are common
Prehospital treatment
a Initial scene at scene is crucial primary survey ABCD a Primary importance is an assessment of the scene of the accident to determine the extent of possible further danger to the patient or to the rescuer. If the Px/ should be moved, do it w/ extreme care.
a Emergency medical technicians & paramedic should: 1. Assess ABC 2. Assess vital sign 3. Question the px/ w/ regard to pain or numbness 4. Palpate the neck for sign of injury, record any paralysis, motor weakness, or sensory deficit 5. Assess for impaired level of consciousness 6. Check pupil size, equality, and reactivity to light 7. Examine the eyes and ears for sign of injury 8. Palpate the head, arms, legs chest and abdomen for injuries a Respiratory insufficiency should be expected in the px/ w/ CCI The C4 LEVEL, n. PHRENICUS innervated the diaphragm, injured at this level will result hypoventilation due to paralyses of the intercostals muscles abdominal breathing. CCI above C4 will cause complete respiratory paralysis ventilator a Hypotensive Hypovolemic shock : rapid heart rate and cool & clammy skin vascular collapse which will lead to hypotension, but w/ a normal or slow heart rate and the skin warm & dry) a 2 large IV line & MAST a Hypotensive SC shock : Loss of sympathetic nerve function (vasodilatation,
Fractures, Dislocations & Subluxations

CLASSIFICATION
STABILITY Suspicion of rupture of transverse ligament CI doing flexion-extension views. PX w/ greater than 3 to 5 mm separation between the dens and the anterior ring of the atlas should be suspect of a transverse rupture until proven otherwise. Clinical instability the loss of the ability of spine under physiologic loads to maintain relationships between in such a way that there is neither damage nor subsequent irritation to the spinal cord or nerve roots, and in addition, no development of deformity w/ excessive pain a Upper Cervical Spine o Fracture of the ring atlas C1 can be stable or unstable depend on the integrity of transverse ligament & alar ligament o R: open mouth view simple Displacement of the lateral masses fr. C1 will exhibit minimal lateral displacement of the lateral mass o Displacement of the lateral masses of the atlas o Displacement of the lateral masses overriding C2 < 5,7 mm: indicate that the transverse ligament is intact > 7 mm is evidence of a ruptured transverse ligament. Unstable injury: allowing odontoid process to compress the cord and cause neurologic damage, Fr. Base Prc. Odontoid o Atlantoaxial instability occurs w/ rupture of the transverse lig. alone can be detected w/ lateral cervical spine film. Normal distance between dens & the anterior ring of the atlas should between 0 3 mm 3 5 mm : suggest rupture of the transverse lig. > 5 mm : strongly suggest rupture of the transverse & alar lig.
Traumatic
spondylolisthesis of the axis (hangmans fr) is manifested by a fr.
Through the posterior arch
a Lower Cervical Spine Instability should be suspected when there is > 3,5 mm distance between the adjacent vertebral bodies Instability should be suspected when angular measurement between vertebra is > 11 Injury to both anterior & posterior elements should be presumed unstable
Excessive angulations of the cervical spine
Instability in the lower spine, faced w/ an overriding vertebra measurement between the posterior inferior corner of the upper vertebral body and posterior superior corner of the inferior vertebral body should < 3,5 mm
> 3,5 cm suspect instability > 7mm bilateral faced dislocation
Overriding of the superior vertebral body by a distance equal to or > of its AP diameter If no associated neurologic damage under supervise do flexion-extension views to assess instability
NEUROLOGIC INJURY
TREATMENT
FLEXION
1. Hyperflexion Sprain Stable Injury
2. Simple wedge (Compression) fracture
Potentially Unstable injury
3. Clay Shoveler Fracture
Stable Injury
4. Bilateral Facet Dislocation
Very Unstable Injury
5. Flexion Teardrop Fracture
Extremely Unstable Injury
FLEXION ROTATION Unilateral Facet Dislocation Generally Stable Injury ______ Potentially Unstable if Chronic
EXTENSION ROTATION
Pillar Fracture
VERTICAL COMPRESSION
1. Jefferson Burst Fracture Stable, Rarely Unstable Injury
2. Burst Fracture Potentially Unstable Injury
EXTENSION
1. Hyperextension Sprain Stable, Potentially Unstable Injury
2.
Avulsion of the Anterior Arch of the Atlas
Potentially Unstable Injury
3.
Extension Teardrop Fracture of the Axis
4.
Fracture of the Posterior Arch of the Atlas
Stable Injury
5.
Laminar Fracture
Stable Injury
6.
Traumatic Spondylolisthesis of the Axis (Hangmans Fracture)
7.
Hyperextension Fracture Dislocation
Unstable Injury
LATERAL FLEXION
Uncinate Process Fracture Stable Injury
DIVERSE MECHANISMS
1. Atlanto Occipital Disruption Extremely Unstable Injury
2. Atlanto Disruption, C1 and C2 Potentially Unstable Injury
3. Odontoid Fracture Potentially Unstable Injury
PEDIATRIC CERVICAL SPINE
Fractures, Dislocations & Major Ligamentous Injuries of the Back
FLEXION
1. Pure Flexion a. Anterior Wedge Fracture Stable Injury
2. Flexion with Rotation a. Slice Fracture
Unstable Injury
b. Fracture dislocation through disc
c. Posterior ligamentous disruption wo/ wedge fracture
d. Posterior ligamentous disruption w/ wedge fracture
DISTRACTION (TENSION)
a. CHANCE Fracture b. Ligamentous Disruption
Unstable Injury
c. Ligamentous Disruption With Posterior and/or Element Fracture
AXIAL LOAD
1. Pure Axial Load a. Burst Fracture wo/ Posterior Element b. Burst Fracture w/ Posterior Element Unstable Injury
2. Axial load w/ Rotation a. Sagital Slice Fracture
Unstable Injury
EXTENSION
Extension Injury
Unstable Injury
SHEARING
Type A Shear Fracture
Type B Shear Fracture
Type C Shear Dislocation
LATERAL BENDING
Pure Lateral Bending a. Lateral Wedge Fracture Stable Injury
Lateral Bending w/ Axial Load a. Lateral Burst Fracture
Unstable Injury
MINOR FRACTURES
PENETRATING INJURY
TYPES OF SYMES PROSTHESES
A. CANADIAN SYME PROSTHESIS
B. REMOVABLE-WINDOW DESIGN
C. FLEXIBLE POSTERIOR BUID-UP PROSTHESIS
FOOT ANKLE ASSEMBLY FOR LOWER LIMB PROSTHESES A B Nonenergy storing nonarticulated prosthetic feet A. SACH Solid Ankle Cushion Heel B. SAFE Stationary Attachment Flexible Endoskeleton foot
C H Energy storing nonarticulated prosthetic feet C. Seattle foot D. STEN STored ENergy E. Carbon copy II foot
F. Quantum modular foot G. Flex foot H. Flex - walk
I J Articulated prosthetic feet I. Single axis prosthetic foot J. Multiple axis prosthetic foot
ENDO- VS EXOSKELETAL LOWER LIMB PROSTHESIS A. Endoskeletal transtibial prosrhesis
B. Exoskeletal transtibial prosthesis
C. Endoskeletal transfemoral prosthesis (covered w/ soft rubber foam)
D. Exoskeletal transfemoral prosthesis
TRANSTIBIAL SOCKET
A. Patellar tendon-bearing ( PTB ) socket
B. Icelandic Swedish New York University ( ISNY )
Pressure tolerant (A C) & Pressure relief (D F) areas in PTB socket
Narrow mediolateral (narrow ML) or Ischial Containment (IC) socket a Mediolateral dimension narrower than AP measurement a The ischial tuberosity (which lies lies outside the socket in the quadrilateral design) is contained within narrow ML/IC socket a Weight bearing focused primarily through the medial aspect of the ischium and the ischial ramus instead of the ischial tuberosity a The ischial tuberosity is locked in the socket and resulting bony block between ischium, trochanter, and lateral distal aspect of the femur gives more stable mechanism for acceptance of perineal biomechanical forces thus providing increased comfort in the groin and better control of pelvis and trunk. a The narrow ML design is intended to maintain the femur in adduction although this may not always be feasible if the amputae has uncorrectable deformity because of poor surgical technique by keeping the femur in relative adduction during the stance phase, the hip abductors are kept more stretched and efficient position. a The narrow ML socket can decrease NV bundle compression and can be fitted to short residual limb more expensive difficult to fabricate than Quadrilateral socket Transfemoral socket A & B Quadrilateral transfemoral socket
A
C & D Ischial containment or Narrow ML transfemoral socket The ischial containment socket has bony block
ELECTIVE CASES

THORACOLUMBAR FRACTURES FRACTURE CONFERENCE OCTOBER 31, 1990
JOSEPH B. SCARCELLA, M.D

I. ANATOMY, THORACOLUMBAR SPINE
A. Posterior of vertebral body with attached posterior bony complex ( attached via pedicles ) is the border of vertebral canal B. Can be arranged in a column type fashion C. Holdsworth proposed 2 column theory : Anterior Posterior body and disc
posterior bone - ligamentous complex
Rupture of posterior column created instability. D. Denis proposes 3 column : Anterior Middle anterior longitudinal ligament
anterior one half of body and annulus fibrosis
posterior longitudinal ligament, posterior one half of
annulus and body posterior bone / ligamentous complex Rupture of 2 or 3 creates instability. II.
FRACTURE CLASSIFICATION A. Minor articular process fractures
transverse process fractures spinous process fractures pars interarticularis fractures B. Major 1. Compression fractures ( anterior or lateral )
failure under compression anterior end plate most often involved L-1 most common
Radiographic sign : 2. Burst failure under axial load of interior and middle columns - can also affect posterior column Radiographic signs : lateral film shows fracture of posterior wall of body, loss of posterior height tilting and retropulsion of bone fragments AP shows increase in interpedicular distance may have vertical lamina fracture with splaying of posterior joints CT characteristic break in posterior wall with expulsion of fragment into joints Five sub types : 3. Fracture both end plates Fracture superior end plates ( most common ) Fracture inferior end plate burst rotation burst lateral flexion posterior height unchanged posterior cortex intact no subluxation of bodies interspinous distances increased CT scan shows middle and posterior columns intact
Seat Belt Type failure of posterior and middle columns by tension
Radiographic signs : increase interspinous distance horizontal split transverse process horizontal split pedicles
pars fracture tomos are best to delineate
4. Fracture Dislocation failure of all columns under tension, rotation compression or shear Three sub types : Flexion rotation most common - posterior and middle column fail under tension and rotation - anterior fails under compression and rotation Shear type - all columns distrupted including A.L.L. Fracture dislocation of flexion distraction type - similar to seat belt type but annulus is also completely ruptured - A.L.L. is intact but stripped
III.
ASSOCIATION WITH NEUROLOGIC IMPAIRMENT Compression type - no association Seat belt type - no association Burst - 53% no neurological sequelae ; 47% partial impairment Fracture dislocation rotation - 52% complete, 25% intact Fracture dislocation shear - all complete Fracture dislocation distraction - 3/4 were incomplete
IV.
TREATMENT A. Denis - Three degrees of instability
1.
First degree ( mechanical instability ) - compression and seat belt fractures - neural elements not acutely threatened - nonoperative
2.
Second degree ( neurological instability ) - burst fractures despite initial presentation are at risk - treatment still controversial
3.
Third degree ( first and second ) - fracture - dislocation - burst with neurological injury - needs decompression and stabilization
B. Operative Options : laminectomy with posterior decompression does not address anterior component of injury posterior instrumentation with fusion without anterior
decompression has no improvement in neurological function compared to nonoperative reduction and external support anterior decompression has shown improvement in ultimate neurological functioning
PATELLA FRACTURES
FRACTURES CONFERENCE FEBRUARY 13, 1991
I.
General : Patella fractures constitute about 1% of all skeletal injuries Mean age is reported between 40 and 50 years of age
II.
Function : to increase the mechanical advantage of the quadriceps tendon
III.
to aid in nourishment of the articular cartilage of the femur to protect the femoral condyless from injury
Anatomy : The patella is the largest sesamoid bone in the body It lies within the quadriceps tendon The ossification center usually appears at age 2 3 An anomaly of ossification can occur and when it does, it usually is supero lateral bipartite patella Superior border receives the rectus femoris, vastus medialis, vastus lateralis and vastus intermedius The apex of the patella is directed distally and provides the origin of the patellar tendon A thin layer of quad tendon passes anteriorly to the surface of the patella and joins the patellar tendon distally With the knee extended, the lower portion of the cartilaginous surface articulates with the interior surface of the femoral condyles With increase in flexion, lst the middle then upper portion comes in contact with the femur There are 7 articular facets with a longitudinal ridge dividing the patella into medial and lateral. There are then the upper, middle and lower facets. The 7th is a thin longitudinal strip in the medial aspect of the patella The medial and lateral retinaculum insert directly into upper tibia and are fibers of the vastus medialis litelilis, and fascia lata that bypass the patella Patellar plexus : branches of superior, medial, inferior genicular arteries. The 10 blood supply enters the patella centrally and distally and thus transverse fractures may lead to AVN of proximal pole.
IV.
Mechanism of Injury Indirect : this occurs when the intrinsic strenght is exceeded by the pull of the musculotendinous units attaching to it. ( typically occurs with stumbling ) falling usually follows with tearing of the retinacula as the quadriceps continues to pull. Direct : e.g. striking a dashboard
- These fractures are stellate, in complete or undisplaced as retinaculum usually doesnt tear. ( maybe able to extend againts gravity ) V. Classification : 50 80% transverse or oblique 30 35% stellate or comminuted 12 27% longitudinal
VI.
Signs and Symptoms : diagnosis made by hx, P.E. and confirmed with X ray palpable defect may be present hemarthrosis presence or absense of active extension
VII.
Radiography : AP & Lateral views. laminograms may be helpful skyline or axial view if AP and lateral dont slow the fracture
VIII.
Treatment : Goal : To restore quadriceps mechanism to provide strenght and function to knee. Historically : 1) up until 1870 s splint extremity with hip flexed and knee extended, Fibrous union resulted with some degree of disability. 2) Loops of metal or leather to hold fragments together 3) 1877, sir Hector Cameron og Glasgow Scotland performed the 1 st open reduction by inserting silver thread through drill holes 4) Late 1800s early 1900s cerclage wiring and wiring through longitudinal holes became popular 5) 1935 Thompson introduced partial patellectomy Current Concepts : 1) Nonoperative treatment : Recommended for nondisplanced fracture with preserved extensor mechanism and minimal disruption of articular surface (2 4 mm) Cylinder cast 4 6 weeks. Straight leg raising to begin 2 days post injury
2) Operative treatment : Recommended for fracture separation >4mm, comminuted fractures with displaced articular surface, osteochondral fractures with displacement into the joint, longitudinal fractures with displacement. a) Cerclage b) hemicerclage c) wire through drill holes e) tension band wiring f) partial d) screw fixation or complete patellectomy The principal of tension band wiring for transverse fractures involves placing wires anteriorly ( tension side ) through insertions of quadriceps and patellar tendons. The gap that exists posteriorly will close down by compressive forces of quadriceps. 3) jhjj IX. Prognosis : - Full flexion usually returns except in total patellectomy - extensor leg may be present - full function of knee after fracture should occur within 6 12 months - post traumatic arthritis may occur - weakness climbing stairs, walking downhill, and kneeling - refracture incidence 1 5% - AVN is rare ( radiographically seen 1 2 months post fracture and generally revascularizes within 2 years )
EXTENSOR MECHANISM RUPTURE OF THE KNEE

Barry Cromer M.D.
I. A.
Quadriceps tendon rupture Occurrence 1. a) b) 2. a) b) 3. 4. a) b) c) B. 1. 2. a) Diagnosis Symptoms = inability to extend @ knee with minimal suprapatellar pain or tenderness Complete disruption profuse hemarthrosis secondary to tearing of synovial lining in suprapatellar pouch; subcutaneous extension of hematoma into rupture b) c) d) patellar easily mobile ; patella baja x ray: bilateral knees show patella baja quad deformity = with active contraction of quad a bulge proximal to rupture and a void area @ rupture site ; hematoma may obscure bulge acutely 3. a) b) c) d) Incomplete rupture display weakness of incomplete extension of leg palpable continuity of fibers without rigidity of proximal muscle mass with medial and lateral margins of quad tendon less patellar freedom may not develop hemarthrosis Age 90% . 40 Y/o Peak age : 60 70 Y/o bilateral rupture : > 70 Y/o Predisposing factors obesity, gout, hyperparathyroid, DM, syphylis, nephritis, arterioscerosis Bx local degenerative changes Mechanism = sudden forceful contracture of quads with knee in semi flexed position ; direct trauma Location most common @ central portion of tendon, @ superior pole of patella may be 4 5 cm proximal to patella aponeurotic expansions of vastus medialis and vastis leteralis may not be involved = partial rupture
C. D. 1.
Surgical indication Late repair ( > 2 wks ) direct reopposition if contracture < 5cm a) b) c) reapproximate Scuderi flap retention bands with iliobital tract fascia or dacron tape = reinforce from base of scuderi flap through drill holes across proximal patella 2. Codivilla technique - > 5cm gap
3. a)
Anterior hamstring transfer indicated for elderly or debilitated pt.
E. 1. 2. 3. 4.
Post operative management cylinder cast with drop lock joint or bledsoe brace WBAT in full extension passive ROM after 1 wk active assist ROM after 3 wks
F. 1. 2.
Results acute repair excellent in majority late repair lack FROM
TIBIAL NON-UNION
September 12, 1990 FRACTURE CONFERENCE C. Callewart
DEFENITION : Non union = failure to unite after 8 months or failure to progress tward union after a Delayed Union CLASSIFICATION : Hypertrophic - good blood supply, abundant callus, good healing potential Atrophic - poor vascularity, little callus, minimal healing potential prolonged period of time.
= failure tu unite after 20 26 weeks
Serial radiographs, bone scan used to differentiate Fracture July 18, 1990 B. Brackett,
Initial Management and Evaluation Conf. of Cervical Spine Injuries MD
Approximately 8000 to 10.000 acute cervical spine injuries are sustained each year. Of all spinal cord injuries, 82% affects males ; 66% of these injuries involve patients 30 years of age or younger. MVAs, falls, sports, and violence account for almost all cases of spinal injury. Quadriplegia is the outcome in greater than 50% of spinal injuries. C4, C5 and C6 are the most commonly involved sites. ATLS protocol ABCs. AMPLE history Allergies, Medications, Past illnesses, Last meal, Event preceding injury.
History
Mechanism of injury Sensory and motor deficits, pain and its radiation. High velocity. Windshield injury, hx of transient paralysis.
Physical
Exam Facial / head trauma. Voluntary movementof the extremities. Cervical rigidity. The spine should be immobilized during this exam. Perianal sensation.
Neurological Exam A brief motor / sensory exam will help isolate the level of the injury Radiographic Examination Cross table lateral with the collar in place should be the initial evaluation. If one was suspicious enough to obtain a lateral, AP and adontoid views should be obtained. Chech list for the lateral C spine : 1. A smooth line should be able to be drawn along the anterior / posterior vertebra body border. A 0 to 3.5 mm anterior subluxation may be normal (Fig. 1). Soft tissue swelling is an important indication of an occult fracture. The retropharyngeal space at C3 should be no greater than 3mm and no greater than 5 6mm at C6. 2.
CALCANEUS FRACTURES
8 / 8 / 90 Fracture Conference Callewart
ANATOMY Identify : Anterior 1/2 articular, posterior Achilles insertion Medial and lateral processes on plantar surface Sustentaculum tali, 3 facets, interosseous ligament Tarsal sinus, canal Flat lateral surface, peroneal groove, tarsal sinus Medial concavity, T.A. , FDL, FHL grooves Radiographically - - - - thalmic portion, Critical angle of posterior facet, Crucial angle of Gissane, Bohler angle 25 400
MECHANISM Falls from height, causing talus to wedge into calcaneus and / or avulsion of tubercle from posterior 1/2. 5% - 10% bilateral, 10% assoc with D/L spine compression fractures, 25% - 50% assoc with other L.E. fractures.
CLASSIFICATION (Essex - Lopresti ) Extra articular 25% - subtypes : anterior process tuberosity medial process, sustentaculum Intra articular 75% - subtypes : Tongue joint depression comminuted
FADIOGRAOHIC FINDINGS
EXTRA ARTICULAR Most can be treated closed, compressive dressing & elevation for 720, followed by 6 wks. NWB ambulation in plaster. Essex Lopresti technique may be helpful ( p. 1730, Chapman ) INTRA ARTICULAR Untreated fractures cause a wide hindfoot, inpingement of peroneal tendons, and pain upon ambulation. This is due to limited subtalar motion. Most pronounced on uneven ground. Indication for surgical treatment is a displaced posterior facet fracture. Generally speaking, anatomic ORIF produces greater motion, active patients. Good results in 75%

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13rd EDITION by Anika A Alhambra

PERIPHERAL NERVE INJURY

DEGREE 1st 2nd 3rd 4th 5th

TREATMENT Observation Observation Lysis Nerve graft Graft/transfer

PROGNOSIS Excellent Good Ok Marginal Poor

PATOPHYSIOLOGY on the nerve compression injury:

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PENICILLIN & CLINDAMYSIN

PATOLOGY of peripheral neuropathy:

33rd EDITION by Anika A Alhambra

D] Nutritional & Metabolic: E] Neoplastic: - Myeloma F] Toxic: - Alcoholism

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BRACHIAL PLEXUS INJURY

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Usually involves branches from the

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: biceps : brachioradial : triceps

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LEG TRUNK ARM

LEG TRUNK ARM

Spinal cord injury : Incomplete: 1) Brown Sequard Syndrome

2) Central cord syndrome.

173rd EDITION by Anika A Alhambra

3) Anterior cord syndrome:

4) Posterior cord syndrome

5) Complete Transection SCI

6) Conus medullaris syndrome

7) Cauda Equina Syndrome

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Urgent surgical decompression

SECONDARY : Caused by edema, haemorhage, and ischemia

PATOPHYSIOLOGY Of SCI Theory :

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stable Pot.unst intact.

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Criteria of thoracal instability:

Flexion rotation Shear/translation Flexion distraction

Seat belt (Chance)

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Posterior spinal fusion by compression system

283rd EDITION by Anika A Alhambra

NOTE : L2-3-4 N. FEMORALIS

M. Vastus Lateralis M. Vastus Medialis M. Vastus Intermedius

L4-5 N. COMMON PERONEAL N. SUPERFICIAL PERONEAL

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HIP FLEXOR HIP EXTENSION

FOOT PLANTAR FLEXION : Gastrocnemius, Soleus, Flex.dig longus, Flex. Hallucis

a) Anterior column: anterior longitudinal ligament, anterior annulus fibrous

303rd EDITION by Anika A Alhambra