Page 1 of 1 Orthopedics /epcapul UPCM09

ORTHOPEDICS




STRAIN
An injury of the musculo-tendinous unit.
Grade1 (mild): non-traumatic tightening, pain on stretching.
Grade 2 (moderate): + pop/snap with spasm.
Grade 3 (severe): dramatic, often with audible snap/pop, then pain.

SPRAIN
A ligament injury. Ligaments stabilize joints by preventing abnormal motion.
Grade 1: no laxity and good end point.
Grade 2: laxity, but good end point.
Grade 3: no end point, needs referral for repair within 5 days. Can evaluate with stress radiographs. Rehab with isometric
exercises that are begun immediately. Goal is to re-establish strength and motion while protect from re-injury.

Treatment of Strain/ Sprains:
NSAIDs, consider muscle relaxer.
PRICEMS Protection (padding and changes in technique to avoid further injury. Rest. Ice. Compression. Elevation. Modalities
(U/S, electrical stimulation, heat)/ Meds (NSAIDs, steroid injections). Support (braces). Rehab to re-establish both strength and
flexibility together.

FRACTURE
Fracture- soft tissue injury complicated by a break in the bone
Nomenclature: Fracture, [closed/open], [completeness], [configuration], [displacement], [location], [laterality]

I. Closed / Open not seen radiologically
a. Closed intact skin over fracture
b. Open soft tissue injury in the region of the fracture with exposure to the external environment
How to detect an open fracture:
1. bleeding is not proportional to the size of the wound (bleeding from the marrow)
2. wound is over the fracture
3. bone seen
4. presence of fat globules
Gustilo Classification of Open Fractures
Type Definition Bacteria Management
I Skin opening <1cm, quite clean, minimal muscle
contusion
Gram (+) Debridement + Cefazolin
II Laceration >1cm, extensive tissue damage,
flaps, or avulsion
Gram (+) & (-) Debridement + Cefazolin + Gentamicin
IIIA Extensive soft tissue laceration, adequate bone
coverage
Gram (+), (-), &
anaerobes
Debridement + Cefazolin + Gentamicin +
Penicillin G
IIIB Extensive soft tissue injusty with periosteal
stripping and bone exposure
Gram (+), (-), &
anaerobes
Debridement + Cefazolin + Gentamicin +
Penicillin G
IIIC Vascular injury requiring repair Gram (+), (-), &
anaerobes
Debridement + Cefazolin + Gentamicin +
Penicillin G + Vascular repair



II. Completeness
a. Complete break in 4 cortices in at least 2 views (AP and lateral)
b. Incomplete

III. Configuration
a. Transverse fracture line perpendicular to long axis of bone; caused by tapping injury
b. oblique fracture line creates an oblique angle with long axis of bone; moment force
c. spiral rotational / torsional stress; e.g. child abuse

NPO now
D5NR 1L X 8
ATS 3000 Units IM ( ) ANST & TeAna 0.5mL IM
Cefazolin 1g IV LD ( ) ANST, then 1g IV q8 thereafter
Gentamicin 240mg IV OD
Penicillin G 4 Million Units LD ( ) ANST then 4 M units IV q6 thereafter
OR Scheduling [Debridement, Vascular repair]
TRAUMA
Sample Chart Entry

Page 2 of 2 Orthopedics /epcapul UPCM09

d. segmental in different parts of the bone
e. comminuted - >2 breaks in part of the bone
f. torus axial loading / compression. Usually in children: perosteum not broken, buckle fracture
g. longitudinal
h. green stick fracture with plastic deformity less than 3 cortices are affected;bend in the long bone
Type Bone Involvement Other Description Management
I Transverse physis In young children, growth arrest is
unlikely, results in malalignment
Closed reduction / GA
Cast immobilization II Through physis &
metaphysis
III Through physis &
epiphysis
Intraarticular Open reduction and fixation to align growth plate
IV Through physis,
metaphysic & epiphysis
Results in migration & growth arrest
V Crush injury of the physis Growth arrest, usually not identified earlier, with complication rate,
cartilaginous growth plate heals ~50% of the time VI Injury to perichondrium Bridging / Angular deformity
SALTER: S=Slide,straight through the growth plate, Type 1, A= above, Type 2, L= Low to the growth plate, Type 3, T= Through
the growth plate above and below, Type 4, ER= Erasing the growth plate, Type 5

Harris-Park growth arrest line seen on late radiography of minor injuries, transversely oriented

IV. Displacement
a. displaced - < 50% cortical contact
b. minimally displaced
c. undisplaced

V. Location
a. anatomic: proximal third, middle third, distal third
b. physiologic: epiphysis, physis, metaphysic, diaphysis
VI. Laterality left or right, not seen radiologically

Supracondylar Fractures
a. Extension anterior fracture
b. Flexion posterior fracture
When fracture is undisplaced, there is bleeding which accumulates within the periosteum
Fat pad sign fat / marked lucency detected anterior &/or posterior to paper-thin bone (between coronoid & olecranon fossae);
indicative of a fracture
Gartland classification of supracondylar fractures
Type Description Management
I Incomplete & undisplaced Arm sling or LAPS
II Complete & undisplaced, intact
periosteum
A. with rotatory component
B. without rotatory component
Closed reduction +/- pinning, LAPS
III Complete & displaced Open / closed reduction with pinning on lateral side or open fracture site with X-
pinning

Garden classification of Femoral Neck Fractures
I impaction
II complete, undisplaced
III complete, displaced without contiguous trabeculations
IV complete, displaced with contiguous trabeculations

Lange-Hansen Classification (Initial position direction of injury)
a. supination adduction
b. pronation abduction
c. supination external rotation
d. pronation external rotation

Forearm Fractures
Colle distal radius, dorsal
Smith distal radius, volar
Page 3 of 3 Orthopedics /epcapul UPCM09

Barton fracture/dislocation or subluxation in which the rim of the distal radius, dorsally or volarly, is displaced with the hand &
carpus
Chauffeur fracture radial styloid
Monteggia proximal half of ulnar shaft & dislocation of radial head
Galeazzi - dislocation of distal radioulnar joint
Nightstick Fracture - fracture of ulnar diaphysis alone from a direct blow

Management of Fractures
A. Casting / Splinting
Immobilize one joint above & one joint below
Deforming forces in radio-ulnar fractures (fractures of necessity operate because closed reduction wont work)
Location Deforming Forces Cast in
Proximal third Supinator Supinated position
Middle third Supinator + pronator teres Neutral (raise your hand position)
Distal third Supinator + pronator teres + pronator
quadratus
Pronated position
B. Debridement 4Cs of proper debridement
1. color beefy red
2. consistency firm
3. contractility
4. capacity of bleed
C. Reduction should hold ragments in place
1. Closed reduction (under vocal anesthetic)
2. Open reduction
a. Plating more rigid, load sparing: plates carries axial load, sparing the bone leads to delayed healing
b. Intramedullary (IM) nailing w/ or w/o screws
Nailing more stable & better biomechanically, load sharing: nail shares load with bone better healing;
enhances blood supply by centripetal circulation
Screws prevents rotation & tilting of nail; bone closer to joint is cancellous, hence requiring screws with bigger
threads
c. External fixation preferred if with open wound & infected
d. Pinning also in closed reduction
Acceptable reduction of supracondylar fractures:
a. anterior humeral line should bisect or lie posterior to the capitulum
b. intact figure of eight
c. >30 angel of capitellum with humeral line at lateral view
d. angle between humeral line & base of humerus (Bowmans angle) 82 5 at AP view
D. Correction of malrotation with regard to radial fractures, check the following:
a. radial styloid should be in the same plane as the radial tuberosity, but on opposite directions
b. proper interdigitation at the fracture site
c. no difference in the diameters of the apposed bone
d. presence of the radial bow

Fracture Healing
Requires 8-12 weeks of healing
Stages:
a. Inflammatory 1-5 days
b. Proliferative 5 days to 2 weeks
c. Remodelling 2 weeks to 6 months
Motion in joints squeezes synovial fluid during flexion
Pt should do partial weight bearing activities after 1 day of open reduction if the pt is stable. Weight bearing is important in bone
formation because disuse can lead toosteoporosis.
Long bone fractures predispose pt to fat embolism
Tibia has poor capacity to heal because it is subcutaneous with high chances of malunion
Full weight bearing started at 6 weeks specially if patient is young
Possible complications
a. Limb length discrepancy
b. Malunion (Fx not in the right position)
c. Non-union (not healed at the specified amount of time)
Hypertrophic ends of bone are broad
Atrophic ends of bone are sharp e.g. penciling
d. Post-traumatic arthritis
e. Fat embolism (in long bone fractures may present as dyspnea)

Golden period of surgical intervention
Open long hand injury within 6-8 hours
Hand injury within 12 hours
Tendon repair within 10-14 days

Page 4 of 4 Orthopedics /epcapul UPCM09

COMPARTMENT SYNDROME
Sxs usually begin within a few hours of injury, may be delayed up to 64 hrs (6 Ps)
a. Pulselessness (unreliable pulses, late sign)
b. Pain (with passive stretching is an early sign, yet diminishes secondary to pressure ischemia)
c. Pallor (if any arterial injury or in affected compartment)
d. Paresthesias (discomfort out of proportion to injury and unrelenting, late sign)
e. Paralysis (secondary to ischemia, late sign)
f. Poikilothermy
Causes:
a. compartment size (crush, closure of fascial defect, application of exessive traction to fractured limb)
b. contents (swelling, bleeding, extensive use of muscles in sz/ exercise/ tetany/ eclampsia, burns, venous obstruction)
c. Externally applied pressure (tight cast/ dressing, lying on limb, pneumatic anti-shock garment, congenital bands)

Leg
a. Anterior tibialis anterior, extensor digitorum longus, extensor hallucis longus, peroneus tersius. Deep peroneal nerve sensory
loss at 1st web space. Weakness of toe extensors, tibialis anterior. Pain on passive toe flexion.
b. Lateral peroneus longus, peroneus brevis. Pain of active or passive eversion and inversion of the foot, superficial peroneal
nerve (hypesthesia of lateral foot).
c. Superficial Posterior gastrocnemius, soleus. Weakened soleus/ gastroc, pain with foot dorsiflexion.
d. Deep Posterior tibialis posterior, flexor digitorum longus, flexor hallucis longus, poplitus. Posterior tibial nerve sensory loss
(plantar surface), weakness of toe flexors and tibialis posterior. Pain on passive toe extension.

Upper arm:
a. Flexor/ Anterior Compartment sensory loss of ulnar & median nerves, weak biceps and distal flexors, pain on passive elbow
extension.
b. Extensor/ Posterior sensory loss of radial nerve (dorsum of hand), weakened triceps and forearm extensors. Pain with passive
elbow flexion.

Forearm:
a. Dorsal Compartment weakened digital extensors, pain of passive digital flexion.
1. Abductor pollicis longus (APOL)
Extensor pollicis brevis (EPB)
2. Extensor carpi radialis longus (ECRL)
Extensor carpi radialis brevis (ECRB)
3. Extensor pollicis longus (EPL)
4. Extensor digitorum communis (EDC)
Extensor indicis proprious (EIP)
5. Extensor digiti minimi (EDM)
6. Extensor carpi ulnaris (ECU)
b. Volar Compartment sensory loss of ulnar/ median nerves (palm of hand), weakened digital flexors, pain on digital extension.

Compartment Pressures: normal: <10mmHg from DBP. Abnormal: 10-30mmHg. Compartment Syndrome: >30mmHg or MAP-
CP <30-40mm.

Tx: Fasciotomy if unequivocally positive clinical findings. If pt has an altered MS, is unreliable due to intoxication or has polytrauma
with inconclusive physical findings--> check pressures. Fasciotomy if >30-40mmHg or if pressure 20mmHg below DBP or
worsening clinical signs. If <30, monitor pressures serially along with clinical eval.

MANGLED EXTREMITY SEVERITY SCORE (100% specific)
Skeletal / soft-tissue injury
1 Low energy (stab; simple fracture; pistol gunshot wound)
2 Medium energy (open or multiple fractures, dislocation)
3 High energy (high speed MVA or rifle GSW)
4 Very high energy (high speed trauma + gross contamination)
Limb ischemia (* Score doubled for ischemia > 6 hours)
1* Pulse reduced or absent but perfusion normal
2 Pulseless; paresthesias, diminished capillary refill
3* Cool, paralyzed, insensate, numb
Shock
0 Systolic BP always > 90 mm Hg
1 Hypotensive but responsive to fluid challenge
2 Hypotensive not responsive to fluid challenge
Age (years)
0 <30
1 30-50
2 >50
0-6 Probable viable limb, > 6 Increased risk of amputation

Page 5 of 5 Orthopedics /epcapul UPCM09


CHRONIC OSTEOMYELITIS
Mostly hematogenous vs. direct spread
Locus of minora resistencia blood goes to the area of low resistance
Acute - ~2 weeks; presents as pain, fever, malaise
Chronic - ~6 weeks; sudden drop of pressure, decreased pain, fever, malaise.Do serieal ESR (sEnsitive measures inflammation
not infection) & CRP (sPecific) monitoring
Etiology: Staphylococcus aureus most common organism in all age patients (90%). Direct trauma: Staph, Strep; Trauma to foot
through shoe: P. aeruginosa; Hematogenous: Strep pneumo, H. influ type B, Hgb SS: Salmonella
Risks: smoking, DM, extremes of age , chronic hypoxia, immune def, malignancy, malnutrition, RF, liver failure, alcohol abuse,
corticosteroid therapy, arteritis, chronic lymphedema, extensive scarring, radiation fibrosis, venous stasis, major vessel compromise.

S/s: warmth, swelling, pain, +fever, dec ROM, limp, h/o trauma. Draining sinus, open wound. Continuous bone pain, point
tenderness and well-localized. +Pain at infection site with percussion of the bone away from the area of tenderness. Possible
sympathetic effusion.
Pathophysiology:
Stasis

Accumulation
Acute
Increase in pressure gets walled off (radio-opaque) abscess

Rupture of cortex (cloaca)

Periosteum (sudden drop of pressure, decreased pain)

Sequestrum (dead bone with infection that is devoid of blood supply)

Involucrum (shell of new bone formed by the peiostum that surrounds the sequestrum

Draining sinus
Types
Type 1 (medullary): limited to the endosteum. Most hematogenous cases. Tx: Abx alone effective in 85%, if recalcitrant, then to
surgery. Often can tx for 2-4weeks with PO Quinolones unless a child (need initial IV Abx).
Type 2 (superficial): involves the bone surface. Decubital ulcers, venous stasis sores, skin breakdown (burns, trauma). Can
progress to Type 3&4 in compromised host.
Type 3: localized, but have medullary and superficial characteristic resulting in full thickness cortical sequestration, which requires
removal of the nidus.
Type 4: diffuse with unstable bone/limb. Often from infected nonunion, endoprosthetic infection, chronic sepsis, or progression of
other types.

SEPTIC ARTHRITIS
Pus would adhere to the cartilage
Emergency
Endotoxins released by bacteria causes the inflammation
Gold standard for diadnosis: Arthrocentesis (+) result in Gram staining
Treatment: Debridment (joint kept in fixation, very sever pain in any movement within any range); for TB arthritis: fusion, splint, anti-
Kochs

NEOPLASMS
Principal Questions
1. Where is the mass?
2. What is the size of the mass? Compare the lesion relative to the size of the affected bone
3. What is the tumor doing to the bone? Lytic, sclerotic, blastic
4. What is the bone doing to the tumor? Margins
Permeative ill-defined bordersl aggressive
Geographic bone walls off the tumor; slow-growing
5. What is the matrix?
Osteoid radiologically: cloudlike or ill-defined amorphous densities with haphazard mineralization. This pattern is seen in
osteosarcoma. Mature osteoid, or organized bone, shows more orderly, trabecular pattern of ossification. This is
characteristic of the benign bone-forming lesions such as osteoblastoma.
Mixed
Chondroid - Radiologically, it is usually easier to recognize cartilage as opposed to osteoid by the presence of focal stippled
or flocculent densities, or in lobulated areas as rings or arcs of calcifications. They are best demonstrated by CT.
Whatever the pattern, it only suggests the histologic nature of the tissue (cartilage) but does not reliably differentiate
between benign and malignant processes.
6. Is there a cortical break? If with soft tissue injury, then there is cortical break
7. Is there soft tissue involvement?
ADULT
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Features of aggressive tumours
Cellular atypia
Frequent mitoses
Extensive necrosis
Significant vascularity
Small amounts of immature matrix
Grade (assessment of biological aggressiveness)
G0 Histologically benign (well differentiated and low cell to matrix ratio). May be latent , active or aggressive benign lesions
G1 Low grade malignant (few mitoses, moderate differentiation and local spread only)
G2 High grade malignancy (frequent mitoses, poorly differentiated and frequent mitoses)
Site (anatomic setting of the lesion)
T0 Confined within its capsule (does not extend beyond the bounds of the compartment of origin, may be distorted but
remains intact)
T1 Extra capsular extension but contained within the anatomic compartment (eg cortical bone, joint capsule or fascia)
T2 Extending beyond compartmental barriers (spreads beyond fascial plane without longitudinal containment)
Metastasis (nodal or blood borne tumour spread)
M0 No evidence of regional or distant metastases
M1 Regional or distant metastases evident
Age Most common benign lesions

Most common malignant tumors
0 - 10

simple bone cyst, eosinophilic granuloma

Ewing's sarcoma, leukemic involvement,
metastatic neuroblastoma
10 - 20 non-ossifying fibroma, fibrous dysplasia, simple bone cyst,
aneurysmal bone cyst, osteochondroma (exostosis), osteoid
osteoma, osteoblastoma, chondroblastoma, chondromyxoid fibroma
osteosarcoma, Ewing's sarcoma, adamantinoma

20 - 40 enchondroma, giant cell tumor chondrosarcoma

40 &
above
Osteoma metastatic tumors, myeloma, leukemic
involvement, chondrosarcoma, osteosarcoma
(Paget's associated), MFH, chordoma
Diagnostics
1. ESR sensitive measure of inflammation; goes up later, decreases in 2-3 weeks but does not decrease with improvement
of infection
2. CRP specific measure of acute inflammation; peaks in 2-3 days, decreases in 10 days with resolution of inflammation
3. Alkaline phosphatase measure of bone formation, significant if 3-4X elevated
4. MRI important for staging
5. Bone scan or skeletal survey for metastasis
6. Biopsy aspiration, tru-cut, open
Therapeutics
1. Excision of mass
a. Intralesional - leaves macroscopic tumour, not therapeutic; within the bounds of the mass, for benign lesions, curette
the mass
b. Marginal through the reactive zone pseudo-capsule of tumour, residual extensions or satellites, controls non-invasive
benign tumours
c. Wide - excise tumour, reactive zone and cuff of normal tissue, skip lesions left; with 2-3 cm cuff of normal tissue
d. Radical - removal of entire compartment or compartments, distant metastases left; disarticulation
2. Limb salvage involves excision & reconstruction (autograft, allograft, isograft, xenograft)
3. Amputation
4. Post-op chemotherapy methotrexate, doxorubicin, cisplatin

OSTEOSARCOMA
Primary tumor arising from bone and producing bone with variants depending on the appearance of the prominent cell type
Male : Female 2:1
Peak incidence 10 - 20 years, with a second peak at 50 - 70 years (80% less than 30 and those more than 40 years usually
secondary to Pagets)
Commonly seen at the axial skeleton proximal to the knees and elbow joints
Location: Distal femur (32%), proximal tibia (16%), proximal humerus
Codmans triangle, sunburst pattern

EWINGS SARCOMA
Lytic lesion with calcified periosteal layering (onion skin)
TKO: Twenty years or younger, Knee, Onion Skin

MULTIPLE MYELOMA
Most common primary malignant bone tumor

METASTASIS
Usual primaries: Breast in women, lung, thyroid, prostate, kidney
Page 7 of 7 Orthopedics /epcapul UPCM09


FEMORAL NECK FRACTURES
Usually in the elderly
Parts of the femur from proximal to distal
1. femoral head
2. femoral neck
a. subcapital
b. transcervical
c. basicervical if fractured, has best prognosis
3. greater trochanter
4. lesser trochanter
5. subtrochanteric area (5cm below the superior margin of the lesser trochanter)
isthmus narrowest portion of the femoral canal
intertrochanteric fracture extracapsular
femoral neck fracture intracapsular
test for pelvic obliquity TLL and ALL
Synovial Ring Blood Supply
1. medial circumflex artery (from deep femoral artery)
2. lateral circumflex artery (from deep femoral artery)
3. medial epiphyseal artery supplies inferior part of femoral head
4. lateral epiphyseal artery supplies superior & anterior part of femoral head
Management
Apply traction then pinning if <65 y.o.; do arthroplasty if >80 y.o.
May save femoral head by using pins / screws / plates / bone cement / antibiotic-laden spacer (40g bone cement: 2.4g heat-
stable and water-soluble antibiotic)
Replacement:
a. Total hip arthroplasty replace head & acetabulum
b. Partial hip arthroplasty replace head only
Complications: avascular necrosis, poor healing, non-union

OSTEOPOROSIS
Seen as radiolucency with thinning out of the cortices
Medical treatment
1. Calcium supplements
2. Estrogen prevents bone resorption of calcium by osteoblastic stimulation
3. Low-dose parathyroid hormone induces negative feedback ( transfer of calcium from bone to blood) to restimulate bone
formation

PATHOLOGIC FRACTURE
Caused by normal stresses applied to normal bone; with predisposing factor
CRP, ESR, Alk phos




Difference between pediatric & adult patients
Bone still growing in children
In children, ligaments are stronger than bones
Children have hyperlaxity of joints
For elbow injuries: elbow dislocation in adults, supracondylar in children

Pediatric Milestones
4 months turn around
6 months crawl
9-10 months stand on their own
12 months first step, broad-based gait

Closure of Physis in Different Bones
C Capitellum 2 y.o.
R Radial head 4 y.o.
I Internal epicondyle 6 y.o.
T Trochlea 8 y.o.
O Olecranon 10 y.o.
E External epicondyle 12 y.o.

Collagen Type I skin, tendon, ligaments & bone
Collagen Type II Hyaline cartilage

PEDIATRICS
Page 8 of 8 Orthopedics /epcapul UPCM09

Congenital abrupt disruption in embryonal development
Developmental partial disruption; progressive defect

ORahilly
1. Terminal distal parts, e.g. aphalangia
2. Intercalary before the distal, e.g. phocomelia (flipper limbs
3. Para-axial 2-bone portions, as in radio-ulna, congenital absence of the tibia
Most common polydactyly, syndactyly

Growth plates
A. Physis horizontal, stress-riser
B. Epiphysis spiral
Epiphyseal Growth Plate
1. Zone of reserve cartilage - Typical hyaline cartilage with chondrocytes
Cartilage would store lipid (proteoglycans)
Lysosomal storage
Gauchers disease
2. Zone of proliferation - Cartilage cells undergo successive mitotic divisions to form columns of chrondocytes
Matrix: Inorganic (calcium hydroxyapatite) and Organic (Collagen tensile strength, Proteoglycans
compressive strength)
Longitudinal growth
3. Zone of maturation - Cell division stopped, chondrocytes increase in size
4. Zone of hypertrophy Chondrocytes greatly enlarged and vacuolated; Matrix becomes calcified
Cartilage Bone
Cartilage would store lipid (proteoglycans)
a. Zone of provisional calcification
b. Zone of cartilage degeneration chondrocytes degenerate & lacunae of calcified matrix invaded by
ostogenic cells & capillaries

Fractures which are absolute indications of surgery for children
1. Supracondylar
2. Medial condyle
3. Lateral condyle
4. Medial head
5. Femoral neck

CLUB FOOT
Talipes equinovarus
Clubfoot can be classified as (1) postural or positional or (2) fixed or rigid. Postural or positional clubfeet are not true clubfeet.
Fixed or rigid clubfeet are either flexible (ie, correctable without surgery) or resistant (ie, require surgical release).
Measurement Normal Foot Clubfoot
Tibiocalcaneal angle 60-90on lateral view >90(hindfoot equinus) on lateral view
Talocalcaneal angle 25-45on lateral view, 15-40on DP view
<25 (hindfoot varus) on lateral view,
<15(hindfoot varus) on DP view
Metatarsal convergence Slight on lateral view, slight on DP view
None (forefoot supination) on lateral view,
increased (forefoot supination) on DP
view

DEVELOPMENTAL DYSPLASIA OF THE HIPS
broad spectrum of conditions characterised by instability of the hip with subluxation or dislocation due to acetabular or femoral
dysplasia.
Females more than Males, Siblings of affected children: 10 times increased risk of DDH, 60% left, 20% right and 20% bilateral
Ortolanis test - the contralateral hip is held still while the thigh of the hip being tested is adducted and gently pulled anteriorly. +if
get the sensation of instability or hear a clunk (due to a dislocated hip reducing into the acetabulum). High pitched clicks are
normal. (Out = Ortolani)
Barlows test - adducting the hip while pushing the thigh posteriorly. (+) if the hip dislocates out of socket and confirmed by doing
the Ortolani to reduce the dislocation (push Back = Barlow)
Galleazzi sign - the affected limb short in the thigh when the knee is flexed to 90o with the hips flexed to 45o and the heels at the
same level

LEGG-CALVE-PERTHES DISEASE
Osteonecrosis of the proximal femoral epiphysis in a growing child caused by poorly understood non genetic factors
Male : Female 4:1; Onset usually 2 - 12 (the majority are 4 - 8 and mean 7 years); ~ 10 - 12% are bilateral
Birth weight usually lower than normal children; Skeletal age often delayed
Pathophysiology: Alteration in blood supply to femoral head with fetal supply from metaphyseal vessels, lateral epiphyseal vessels
running in the retinaculum up the neck and small supply from the ligamentum teres. Metaphyseal supply gradually decreases (by
the age of 4) vessels in the ligamentum teres are not developed until about the age of 7 and between the age of 4 and 7 blood
supply to the head may depend solely on lateral epiphyseal vessels which are susceptible to external pressure from an effusion


Page 9 of 9 Orthopedics /epcapul UPCM09

LIMB LENGTH DISCREPANCY
Eval: pt supine, fully extend the lower extremities keeping the pelvis level and note the relative relationship of the medial malleoli. If
any abnormality measure the limbs from the ASIS and then remeasure as standing on blocks placed under the shorter limb to level
the pelvis. Observe the pts gait w/o shoes. Leg length discrepancy: check pelvic tilt, secondary to scoliosis.
True leg length discrepancy measured from the ASIS to the medial of the lateral malleoli
Apparent leg length discrepancy measured from the umbilicus to the medial or lateral malleoli
Tx: No tx if <2cm difference. Shoe lift if 2-5cm.Surgery if disparity exceeds 5-6cm.

CEREBRAL PALSY
Non-progressive motor dysfunction due to hypoxia during vertebral development (1-3 y.o. myelinization)
Types: spastic, athetoid, flaccid, hypotonic



Zones of the hand
Extensor zone 7 zones, bony prominences are the odd zones; Zone 1 at DIP joint, Zone 7 at the wrist
Flexor zone:
Zone 1: Middle phalanx - From middle of middle phalanx distally (only the tendon of FDP)
Zone 2: Proximal phalanx - From MCP joint to the middle of the middle phalanx (Tendons of FDS and FDP)
Zone 3: Distal palmar - From the distal end of the flexor retinaculum to the MCP joints (Tendons of FDS & FDP with the origin of the
lumbricals)
Zone 4: Thenar - Tendons beneath the flexor retinaculum
Zone 5: Wrist - Tendons proximal to the flexor retinaculum

No Mans Land the zone extending from the distal palmar crease to just beyond the PIP joint (Zone 2). Flexor tendon injuries
here have a poor prognosis.

Wrist Bones: Some lovers try positions that they cant handle
Proximal Row: Scaphoid, Lunate, Triquetrum, Pisiform.
Distal Row: Trapezium, Trapezoid, Capitate, Hamate.

?ALLENClassification of Fingertip Injuries
I Tip with no involvement of the nailbed Primary wound closure
II <50% involvement of the nailbed Advancement flaps V to Y advancement using Atasol or Kutler procedure: Make A
V-shaped incision at palmar distal phalanx & pull distally for wound coverage; suture
proximally
Completion amputation with shortening & primary wound closure
III >50% involvement of the nailbed
IV Entire nailbed involved
Felon abscess on finger pulp
Paronychia abscess under nailbed
Collar button web space abscess
Paronas space continuity between hypothenar and thenar eminences. Hence abscess may spread.

Cardinal Signs of Kanavel for Tendon Sheath Infection
1. Fingers held in flexion
2. Uniform swelling of fingers
3. Intense pain on finger extension
4. Sensitivity upon palpation

Tendons and Nerves and Functional Testing:

Median Nerve (M): lay hand of dorsal surface, hold radial border of thenar eminence and resist pts palmar abduction of the thumb.
Intact TIP-TIP Vs pulp-pulp pinch (if ant interosseous nerve is damaged).
Ulnar Nerve (U): abduct fingers or pinch paper between thumbs and fingers.
Radial Nerve (R): extend fingers and wrist against resistance.
Interossei: (U) spread hand (dorsal), hold paper btwn fingers (ventral).
Lumbrical: (M,U) extend wrist and DIP/PIP as fingertips held.
Flexor Dig Profundus (FDP): (M,U) flex DIP while MCP and PIP extended.
Flexor Dig. Superficialis (FDS): (M), flex PIP all other digits are extended, have thumb and index finger pinch.
Flexor carpi radialis (FCR): (M), flex and radial deviate the wrist.
Flexor carpi ulnaris (FRU): (U), flex and ulnar deviate the wrist.
Abductor pollicis longus (APL): (R), ext and abd thumb.
Extensor pollicis brevis (EPB): (R), ext and abd thumb.
Ext carpi radialis brevis (ECRB): (R), make fist while extending wrist.
Ext carpi radialis longus (ECRL): (R), make fist while extending wrist.
Ext pollicis longus (EPL): (R), lift thumb off flat surface while palm flat.
Ext. Digitorum communis (EDC): (R), extension of fingers at MCP joint.
Ext. indicis proprius (EIP): (R) ext of index finger at MCP as others in fist.
Ext digiti minimi (EDM): (R), ext of 5th digit while making a fist.
Ext carpi ulnaris (ECU): (R), ext and ulnar deviation of wrist.
HAND
Page 10 of 10 Orthopedics /epcapul UPCM09


Management of Hand Injuries
1. Repair tendon & nerves
2. Replantation depends on muscle metabolism
3. Revascularization limb: 4-6 hours ischemia time



Motor Muscle Sensory
C2 Back of head
C3 Front of neck
C4 Pt breaths
diapragmatically
lat and inf over clavicles down to 2nd
interspace
C5 Arm abduction Deltoid
Elbow flexion Biceps brachialis Lateral arm
C6 Wrist extension Extensor carpi radialis longus &
brevis
Lateral forearm
C7 Elbow extension Triceps Middle finger
C8 Finger flexion Flexor digitorum profundus Medial forearm
T1 Finger abduction Intrinsics Medial arm
Finger adduction Intrinsics
L2 Hip flexion Distal third of thigh
L3 Knee extension Middle third of thigh
L4 Ankle dorsiflexion Tibialis anterior Medial maleolus
L5 Big toe extension Extensor hallucis longus
Peroneus
Dorsum of foot
S1 Plantar flexion Sole
Radial nerve Thumbs up Snuff box
Ulnar nerve Apposition Small finger
Median
nerve
Index finger





SPINE
Page 11 of 11 Orthopedics /epcapul UPCM09

Spinal Reflexes (D-deep; S-superficial)
Reflexes Methods of elicitation Normal results Segment(s)
traversed
Corneal (S) Touching cornea with cotton Contraction of orbicularis oris Pons
Pharyngeal (S) Touching posterior wall of pharynx Contraction of pharynx Medulla
Palatal (S) Touching soft palate Elevation of palate Medulla
Biceps (D) Tab biceps tendon Flexion of the forearm at the elbow C5-C6
Triceps (D) Tap triceps tendon Extension of the forearm at the elbow C6-C7
Bracioradial (D) Tap styloid process of the radius,
with forearm held in semipronation
Flexion of the forearm at the elbow C5-C6
Finger flexion (D) Flick palmar surface of the tip of
the finger
Flexion of the fingers C7-T1
Scapular (S) Stroking skin between scapulae Contraction of scapular muscles C5-T1
Abdominal muscle
stretch reflexes (D)
Tap lowermost rib, tap finger
placed on rectus abdominis or tap
symphysis pubis
Contraction of the abdominal wall or, when the
symphysis is tapped, adduction of the legs
T8-T12
Epigastric (S) Stroking downward from nipples Dimpling of epigastrium ipsilaterally T7-T9
Abdominal skin-muscle
reflexes (S)
Stroke skin of the upper and lower
abdominal quadrants
Contraction of the abdominal muscles
andretraction of the umbilicus to the stimulated
side
T8-T12
Cremasteric Stroke skin of the upper and inner
thigh
Upward movement of the testicle L1-L2
Adductor (D) Tap medial condyle of the tibia Adduction of the leg L2-L4
Quadriceps (D) Tap tendon of the quadriceps
femoris
Extension of the lower leg L2-L4
Gluteal (S) Stroking skin of buttock Contraction of glutei L4-L5
Triceps surae (D) Tap Achilles tendon Plantar flexion of the foot L5-S2
Plantar (S) Stroke sole of the foot Plantar flexion of the toes S1-S2
Clitorocavernous (S) Pinching clitoris Insert gloved finger to palpate anal contraction S3-S4
Bulbocabernous (S) Prick skin of the glans penis
(dorsum of glans)
Insert gloved finger to palpate anal contraction;
Contraction of the bulbocavernosus muscle and
constrictor urethrae
S3-S4
Anal (S) Prick skin of the perianal region Constriction of the anal sphincter anal wink S4-Coccygeal


SPINAL CORD INJURY
Incomplete spinal cord lesions
Any sparing distal to the injury = incomplete lesion= possible recovery
The greater the sparing the greater the prognosis
a. Brown- Sequard - an injury to either side of the cord (hemisection)
ipsilateral: muscle paralysis and jt position/ vibration loss
contralateral: pain and temperature loss
good prognosis, 90% regain bladder / bowel function + walk
b. Central cord syndrome - most common incomplete cord injury, assoc with extension injury to Cx spine in middle aged pt
Impact direct to the central grey matter severe flaccid LMN paralysis of the upper limbs
Damage to the central portion of the corticospinal and spinothalamic long tracts in the white matter UMN spastic paralysis
of the lower limbs and trunk
The sacral tracts are peripheral and are usually spared and the pt has sacral sparing
Prognosis : 50-60% have progressive return of motor and sensory function to lower limbs- but poor recovery of hand
function due to irreversible damage to the central grey matter
c. Anterior cord syndrome - complete motor and sensory loss apart from dorsal column sparing with deep pressure/
proprioception/ vibration as only remaining modality
Prognosis : good if recovery progressive within 24 hrs ; after 24 hrs prognosis poor; 10-15% have recovery
d. Posterior cord syndrome - loss of deep pressure/ proprioception/ vibration only
e. Conus Lesion - involves long tract and anterior horn cell damage of varying degree with a mixed LMN and UMN paralysis in
the lower limbs. If complete loss of bladder contraction, bladder reflex, bulbo-cavernous reflex and anal wink, loss of
voluntary anal tone and absent sensation. Often incomplete however with normal peri-anal sensation and variable bladder
tone

ASIA Impairment Scale
A Complete. No motor or sensory function is preserved in the sacral segments S4-S5
B Incomplete. Sensory but no motor function is preserved below the neurological level and includes the sacral segments S4-S5
C Incomplete. Motor function is preserved below the neurological level and more than half of key muscles below the neurological
level have a muscle grade less than 3
D Incomplete. Motor function is preserved below the neurological level and more than half of key muscles below the neurological
level have a muscle grade of 3 or more
E Normal. Motor & sensory functions are normal

Page 12 of 12 Orthopedics /epcapul UPCM09

Key Muscles:
1. Elbow flexors
2. Wrist extensors
3. Elbow extensors
4. Finger flexor ( distal phalanx of middle finger)
5. Finger abductors (little finger)
6. Hip flexors
7. Knee extensors
8. Ankle dorsiflexors
9. Long toe extensors
10. Ankle plantar flexors

SPINAL SHOCK
Physiologic period of areflexia, flaccidity, loss of sensation & autonomic dysfunction below the level of lesion immediately
following spinal cord injury
May last for several hours to several weeks but typically subsides within 24 hours. Within 48 hours, 90% are already (+) for
bulbocavernous reflex spinal shock has terminated
Early resolution of spinal shock is an important prognostic sign

AUTONOMIC HYPERREFLEXIA
Medical emergency seen in pts with SCI lesions above T6
Characterized by mass sympathetic & selected parasympathetic response
Triggering stimuli: filled bladder (most common), filled colon, pregnant SCI pt in labor, ingrown toenails, decubitus ulcers, pressure
sores, urinary tract infection
Symptoms:
1. Hypertension (most common & life threatening)
2. Headache
3. Nasal stuffiness
4. Above the lesion: sweating & flushing
5. Below the lesion: piloerection, dry, pallor, cold & clammy skin

SCOLIOSIS
F>M, idiopathic
Cobbes angle
Functional Curves: due to leg length differences, painful conditions, resolve when problem is remedied.
Structural Curves: Idiopathic scoliosis the most common type. Also seen with congenital spinal abnormalities, NM dz (polio, CP,
MD, spinal bifida), Marfans, neurofibromatosis, dwarfism.
Forward bending test: most sensitive (arms hanging with palms together, feet together, knees straight. Best viewed standing in
front of pt. Look for elevation of rib cage/ paravertebral muscles on one side and depression on other or asymmetry. If any
asymmetry >5-7 deg --> get x-rays. Check AP of thoracolumbar spine. Use Cobb method (draw lines parallel to the two most
angled vertebra and drop a perpendicular, measure the angle at the intersection) to measure magnitude. 2-3% of pop has a curve
of 10 deg.

LOW-BACK PAIN
Types:
1. Discogenic back pain herniation of nucleus pulposus
2. Radicular nerve root irritated, (+) straight lef test
3. Referred may be secondary to UTI, PID, aortic aneurysm, infection , hip arthritis
Management
1. Conservative NSAIDs, bed rest for 1-2 days, physical therapy
2. Surgical Laminectomy, Laminotomy

CLAUDICATION
Neurogenic Claudication (Lumbar Spinal Stenosis) Vascular (Intermittent) Claudication
Most in elderly (60-70yo) with severe DJD-osteophytes (usually
at L4-5 or L3-4), bulging annuli decrease the cross-sectional
area of spinal canal spinal stenosis leg pain with
commonly bilateral sciatic, insidious onset neuro deficit
(dermatomal weak/ numb). Worse with any activity that
extends the spine, walking down-hills, variable amount of
walking, prolonged stand, back extension, lift/bend, cough.
Able to walk longer at grocery store Vs mall, can lean on cart
and flex spine.
Due to ischemia in exercising muscles. Pain is sclerotomal
(vascular supply distribution), occurs with a fixed amount of
activity, may occur with standing alone resolves almost
immediately with rest. Not improved with grocery shopping with
cart Vs shopping mall (neurogenic claudication is).
Atherosclerotic dz of iliofemoral vessels, often with impotence,
dystrophic skin changes (nail atrophy, alopecia), foot pallor,
decreased pulses, arterial bruits. Check: ABI and Doppler if
suspect.

SPONDYLOSIS
Non specific degenerative process of the spine, in cervical region it is synonymous with stenosis.
Usually seen in age >50, presents as dull nagging LBP, morning stiffness, worse with activity, relief with gentle exercise,
hydrotherapy. All movements restricted. Tends to cause spinal stenosis with neurogenic claudication.
Tx: analgesics, exercise, TENS.
Page 13 of 13 Orthopedics /epcapul UPCM09


SPONDYLOLISTHESIS
Anterior subluxation of one vertebral body on another, usually L5 on S1. Grade 1-4 (<25-75%). 5% pop. Pain with extreme
stretching of the interspinous ligaments. Risk for progression if early onset (10-15yo), female, recurrent sxs, postural deformity.
Tx: strict flexion exercise program for at least 3 mo (avoid hyperextension). If have <25% slippage: counsel on avoiding vocation
that necessitates heavy lifting or strenuous activity. If >50%: avoid contact sports.

SPONDYLOLYSIS
A failure of the neural arch, manifesting as a defect in the pars interarticularis (neck of the Scotty Dog seen on oblique L spine).
May be congenital, degenerative, traumatic, pathologic. 6% men, 9% females, many asymptomatic. Presents with dull, nagging
LBP in age >50, AM stiffness, worse with activity, Dec ROM.
Tx: NSAIDs, exercise, hydrotherapy, TENS, acupuncture. LBP In Children: Age <10yo: infection, tumor, psychogenic. Age >10yo:
spondylolysis, spondylolisthesis, Schaumanns dz, overuse, postural, HNP, tumor/infection, spinal dysraphism.

NEOPLASM
Spine metastasis most common CA of the spine
Faster progression of symptoms means worse prognosis

Signs & symptoms:
1. night pain
2. instability of spine most painful
3. stretch of the periosteum
4. motor weakness, then sensory loss, then bladder & bowel incontinence
Radiologic features
1. collapse of the vertebral body requires 30-50% destruction before this is detected radiographically
2. owl wink sign destruction of the pedicle, usually seen posteriorly
Indications for surgery
1. Rapid onset that you can decompress right away
a. anterior decompression preferred
b. posterior decompression with instrumentation
c. laminotomy / laminectomy not indicated for unstable spine
2. Intractable pain
3. Impending fracture




References:
Class 2005. Orthopedics Reviewer.
DeMyer, W. Technique of the Neurologic Examination
eMedicine
Ryu, R. Orthopedics.
http://www.wheelessonline.com
http://www.umdnj.edu/tutorweb/pdf/bone_tumors.pdf