A.

Bunion(swelling of first metacarpophalangeal joint)

Medial deviation of the first metatarsal
Lateral deviation and/or rotation of the hallux
B. gouty arthritis, rheumatoid arthritis and psoriatic arthritis, as well as connective tissue disorders such
as Ehlers-Danlos syndrome, Marfan syndrome, Down syndrome, and generalized ligamentous laxity

multiple sclerosis, Charcot-Marie-Tooth disease, and cerebral palsy.

C. nonacute onset of deep or sharp pain in the first metatarsophalangeal (MTP) joint during
ambulation, with exacerbation during particular activities. This presentation indicates degeneration of
the first MTP joint.

aching pain in the metatarsal head secondary to shoe irritation that is relieved when the shoes are
removed
pain are progressive and have been present for many years

frequency or duration of pain may recently have begun to increase, and activity may exacerbate the pain.
Patients may even describe a recent notable increase in the size of the deformity or medial bump.

burning pain or tingling in the dorsal aspect of the bunion, which indicates entrapment neuritis of the medial
dorsal cutaneous nerve. The patient may also describe symptoms caused by the deformity, such as a
painful overlapping second digit, interdigital keratosis, or ulceration to the medial metatarsal head, without
complaint of the bunion deformity itself.
 A. Thomas test
B.

1. patient lies supine on the examination table

Place hand under patients lumbar spine to identify lumbar lordosis

2. Passively flex both legs (hips/knees) as far as you are able to obliterate the
lumbar lordosis.

3. Your hand should detect that the lumbar lordosis is now flattened.

4. Ask patient to fully extend the hip you are assessing:

o Incomplete extension suggests a fixed flexion deformity at the hip joint.

5. Repeat the test to assess the contralateral hip joint.

C. lower extremity on the involved side will be unable to fully extend at the hip/fixed flexion
deformity(short iliopsoas muscle)
Schatzker Classification
Type I Lateral split fracture

Type II Lateral Split-depressed fracture

Type III Lateral Pure depression fracture

Type IV Medial plateau fracture

Type V Bicondylar fracture

Type VI Metaphyseal-diaphyseal disassociation

A.Rheumatoid arthritis
B

Morning stiffness lasting more than 1 hour

Wrist and finger involvement (MCP, PIP)
Swelling of at least 3 joints
Symmetric involvement
Rheumatoid nodules (not necessary to diagnose RA)
X-ray abnormalities showing erosions (not necessary to diagnose RA)
Positive rheumatoid factor or anti-CCP
C-reactive protein (CRP) or ESR

D.
Z Thumb
a)lytic lesion, wide zone of transition.single lesion,proximal femur,
(codman triangle)+sunburst apprarecen

medullary and cortical bone destruction

 wide zone of transition, permeative or moth-eaten appearance

aggressive periosteal reaction

o sunburst type

o Codman triangle

o lamellated (onion skin) reaction: less frequently seen

soft-tissue mass

tumour matrix ossification/calcification

o variable: reflects a combination of the amount of tumour bone production, calcified matrix,
and osteoid
o ill-defined "fluffy" or "cloud-like" cf. to the rings and arcs of chondroid lesions

minimize risk of local recurrence, wide excision(save the limb

endoprosthesis/graft)

local staging by MRI (for skip lesions) prior to biopsy and distant staging with bone scan and chest CT.
A.involvement ofdiaphyseal lytic lesion with periosteal reaction ,onion skin
appearance, wide zone of transition

B. distal femur ewing sarcoma

C. Male, present in childhood or early adulthood,

localized pain, swelling, and sporadic bone pain with variable intensity. The swelling is most likely
to be visible if the sarcoma is located on a bone near the surface of the body, but when it occurs
in other places deeper in the body, like on the pelvis, it may not be visible . Occasionally a soft
tissue mass may be palpable.

reatment

o resuscitation

PRBC:FFP:Platelets ideally should be transfused 1:1:1

this ratio shown to improve mortality in patients requiring massive

transfusion

o pelvic binder/sheet

indications
 initial management of an unstable ring injury

contraindications

hypothetical risk of over-rotation of hemipelvis and hollow viscus

injury (bladder) in pelvic fractures with internal rotation compone
(LC)

no clinical evidence exists of this complication occurring

technique

centered over greater trochanters to effect indirect reduction

do not place over iliac crest/abdomen

ineffective and precludes assessment of abdomen

may augment with internal rotation of lower extremities and tapin

at ankles

transition to alternative fixation as soon as possible

prolonged pressure from binder or sheet may cause skin

necrosis

working portals may be cut in sheet to place percutaneous fixati

o external fixation

indications

pelvic ring injuries with an external rotation component (APC, VS

CM)

unstable ring injury with ongoing blood loss

contraindications

ilium fracture that precludes safe application

acetabular fracture
 technique

theoretically works by decreasing pelvic volume

stability of bleeding bone surfaces and venous plexus in order to

form clot

pins inserted into ilium

supra-acetabular pin insertion

single pin in column of supracetabular bone from AIIS tow

PSIS

obturator outlet view

helps to identify pin entry point

iliac oblique view

helps to direct pin above greater sciatic notch

obturator oblique inlet view

helps to ensure pin placement within inner and

outer table

AIIS pins can place the lateral femoral cutaneous ne

at risk

pedicle screws with internal subcutaneous bar may

used

superior iliac crest pin insertion

multiple half pins in the superior iliac crest

place in thickest portion of ilium (gluteal pillar)

may be placed with minimal fluoroscopy

should be placed before emergent laparotomy

 o angiography / embolization

indications

controversial and based on multiple variables including:

protocol of institution, stability of patient, proximity of angiograp

suite , availability and experience of IR staff

CT angiography useful for determining presence or absence of

ongoing arterial hemorrhage (98-100% negative predictive value

contraindications

not clearly defined

technique

selective embolization of identifiable bleeding sources

in patients with uncontrolled bleeding after selective embolizatio

bilateral temporary internal iliac embolization may be effective

complications include gluteal necrosis and impotence

Definitive Treatment

Nonoperative

o weight bearing as tolerated

indications

mechanically stable pelvic ring injuries including

LC1

anterior impaction fracture of sacrum and oblique ra

fractures with < 1cm of posterior ring displacement

APC1

widening of symphysis < 2.5 cm with intact posterior

 pelvic ring

isolated pubic ramus fractures

Operative

o ORIF

indications

symphysis diastasis > 2.5 cm

SI joint displacement > 1 cm

sacral fracture with displacement > 1 cm

displacement or rotation of hemipelvis

open fracture

technique

for open fractures aggressive debridement according to open

fracture principles

o diverting colostomy

indications

consider in open pelvic fractures

especially with extensive perineal injury or rectal involvem

posterior hip dislocation (90%)

hip and leg in slight flexion, adduction, and internal rotation

detailed neurovascular exam (10-20% sciatic nerve injury)

examine knee for associated injury or instability

chest X-ray ATLS workup for aortic injury

o acute pain, inability to bear weight, deformity

Nonoperative

o emergent closed reduction within 6 hours

 indications

acute anterior and posterior dislocations

contraindications

ipsilateral displaced or non-displaced femoral neck

fracture

Operative

o open reduction and/or removal of incarcerated fragments

indications

irreducible dislocation

radiographic evidence of incarcerated fragment

delayed presentation

non-concentric reduction

should be performed on urgent basis

o ORIF

indications

associated fractures of

acetabulum

femoral head

femoral neck

should be stabilized prior to reduction

o arthroscopy

indications

no current established indications

 potential for removal of intra-articular fragments

evaluate intra-articular injuries to cartilage,

capsule, and labrum