PT 302 6.

MULTIPLE MYELOMA
- Malignant bone cancer that started in the
LOWER ORTHOPAEDIC CONDITIONS
bone marrow (over production of abnormal
 PELVIS myeloid cells)
- MC METASTESIS: innominate bone
1. DUVERNEY’S FRACTURE
- Isolated iliac wing fracture - SIGNS & SYMPTOMS:
- Stable fracture  Nocturnal, nagging pain
 XRAY: mickey mouse lesion (punch out
2. MALGAIGNE’S FRACTURE appearance)
- Double vertical fracture of anterior and
posterior pelvic ring 7. INNOMINATE SYNDROME
- Unstable fracture - LLD due to muscle imbalance
*** MC complication of pelvic fracture: BLEEDING  True LLD
- Damage to internal organs (urethra, bladder)  Apparent LLD
Sig: 72cm difference
3. AVULSION FRACTURE - Special Test: Supine-to-sit Test
- Traction apophysitis secondary to forceful - 2 types:
muscle contraction a. Anterior Innominate Syndrome (AISUP)
(Inflammation of apophysis- part of bone Supine: Affected leg is LONGER
where muscle attaches) Sitting: Affected leg is SHOERTER to
- SARTORIUS: ASIS become
- RECTUS FEMORIS: AIIS
- HAMSTRING: ISCHIAL TUBEROSITY b. Posterior Innominate Syndrome (PPSUP)
Supine: affected leg is SHORTER to become
4. OSTEITIS PUBIS Sitting: affected leg is LONGER
- Inflammation of symphysis pubis
- Causes are UNKNOWN but related to overuse 8. ISCHIOGLUTEAL BURSITIS
- Male > female - Inflammation of ischiogluteal bursa
- Self-limiting - CAUSES:
- Highly linked causes:  Prolonged sitting on a hard surface
 Pregnancy- increased relaxin  Direct trauma to the buttocks
 Hyperactive adductors- equestrians, motor - AKA: B – boatman’s bottom
bikes, gymnasts T – Tailor’s bottom
- SIGNS & SYMPTOMS: W – Weaver’s bottom
 Dull aching pain -> sharp stabbing pain
 “groin burning pain”
 XRAY- moth eaten appearance  HIP
 Tight adductors- LOM of abductors
1. SLIPPED CAPITAL FEMORAL EPIPHYSIS (SCFE)
*** SYMPHYSIS PUBIS DYSFUNCTION (SPO) - Downward slippage of femoral head from
- Lax ligaments growth plate
- CAUSES: - MC hip disorder in adolescent (10-16 yo)
 Overactive adductors - Male > female
 Underactive abductors - Adolescent (10-16 yo)
 Weak spinal stabilizing muscle - TALL and OBESE
- PAIN: Lateral Hip
*** DIASTASIS SYMPHYSIS PUBIS (DSP) - LOM: ABIR
- Ruptured ligaments - GAIT: Trendelenburg or Wadding
- Presents with hip EXTENSION and EXTERNAL
5. HIP POINTER INJURY ROTATION
- Contusion due to direct trauma to ASIS - Management: Surgical Fixation with pins and
screws
2. LEGG-CALVE-PERTHES DISEASE (LCPD) 3. HIP DISLOCATION
- AVASCULAR NECROSIS of femoral head in a. CONGENITAL HIP DISLOCATION
children
- FOR ADULT: Chandler’s Disease (secondary  CONGENITAL HIP DISLOCATION
fracture of femoral neck fracture)  Dislocated @birth
- Male > female  ST: Ortolani’s Test
- Average: 7 yo (4-8 yo)
- SHORT and THIN  CONGENITAL DISLOCATABLE HIP
- PAIN: groin and thigh area  Intact @birth, but dislocatable
- LOM: ABIR  ST: Barlow’s Test
- GAIT: psoatic gait (FADER/ TRENDELENBURG)
 CONGENITAL SUBLUXABLE HIP
**LALAKE- CHILD-PAYAT- DI MAGTATAGAL  Intact @birth, but subluxable
- MANAGEMENT: orthosis  Partial hip dislocation due to lax
Toronto (ABIR) ligament
Trilateral (ABIR)
Scottish- rite (FAB) MC  TERATOLOGIC HIP DISLOCATION
 Fixed dislocation prenatally
(AB + IR: position to keep femoral head inside to hip  Arthrogryposis Multiple Congenital
socket) -Multiple joint fracture and
contractures

WALDENSTRUM STAGES OF LCPD  ACETABULAR DYSPLASIA

I. Initial/ avascular/ necrosis  Absent acetabular labrum (cotyloid
- (+) sagging rope sign (sclerotic line) ligament)
 Shallow hip socket
II. Fragmentation  MANAGEMENT: VIP with PILLOW
- (+) crescent sign (thin radioluscent line) o V – Von rosen (FAB)
I-> develop to coxa plana o I – Ilfeld (FAB)
o P- Pavlik Harness (FABER) MC and
III. Reossification MOST stable position)
-remodeling o FREJKA PILLOW
- Revascularization
-IMPERFECT HEALING: b. ACQUIRED HIP DISLOCATION
 COXA MAGNA- enlarged femoral - Trauma
head - MOI: young: MVA/ dashboard injury
 COXA BREVA- short and broad Elderly: Falls
femoral neck - MANAGEMENT: THA (Posterolateral
approach) MC INCISION
IV. Healing - TYPES OF FIXATION:
 CEMENTED
o Elderly and sedentary
o Polymethyl methacrylate
o WB as tolerated (<24 hours
(start))
 NON CEMENT
o Young and active
o Porous coating
o WB is limited (up to 3 months-
atleast 6 weeks (start))
 - POSITIONS TO AVOID
 POSTEROLATERAL APPROACH
o HIP FLEXION BEYOND 90deg 6. COXA SALTANS
o ADDUCTION - AKA. “Snapping hip syndrome”
o INTERNAL ROTATION
 INTERNAL SNAPPING HIP
 ANTEROLATERAL APPROACH o Tight iliopsoas and iliofemoral
o HIP FLEXION BEYOND 90deg ligament
o Hip extension, adduction, o Hits iliopectineal eminence/ hip
external rotation beyond capsule
resistance
o Combined motion of FABER  EXTERNAL SNAPPING HIP (MC)
o If g-med is incised, avoid hip o Tight ITB
adduction o Hits greater trochanter of
- GOLDEN RULES: femur
 no hip flex beyond 90 deg/ do not over
bend hip  INTRACAPSULAR
 do not cross leg beyond 90 deg o Loose bodies secondary to
 do not twist in either sitting or stand trauma cf? or arthritis

4. COXA VARA vs. COXA VALGA 7. MERALGIA PARESTHETICA

 Neck Shaft Angle < - Impingement of Lateral Femoral Cutaneous
@ birth: 150- 160 deg Nerve (LFCN) @ inguinal ligament
Adult: 120 – 135 deg - Pain and tingling sensation @ anterolateral
NORMAL: 125 deg thigh
- CAUSES: pregnancy
P – Pronated foot P- PPT Tight belt
I – IR Hip L – Longer Leg Tight jeans
S – Shorter Leg E – ER Hip - SIGNS & SYMPTOMS: Burning, tingling pain on
A – APT S – Supinated Foot anterolateral thigh
* decrease NSA (<125 deg) *increased NSA (>125
deg) 8. MUSCLE STRAIN
- “ PULLED” muscle
5. ANTEVERSION vs. RETROVERSION - Overstretched or form muscle
 Angle of Torsion < - CAUSED BY: overuse and underconditioned
@ birth: 30 deg muscles
Adult: 8 – 15 deg - HAMSTRINGS ( MC strained in the body)
NORMAL: 15 deg Ex. LH- hurdles and sprinting
** “W” Sitting / TV sitting - QUADS
- Increased anteversion and medial knee pain Ex. Rectus femoris- forceful kick
- ADDUCTORS
Increased angle decreased angle Ex. Adductor Longus – forced abduction
Internal rotator of hip external rotation of
Hip 9. MUSCLE CONTUSION
Internal tibial torsion external tibial torsion - Hematoma due to direct trauma to muscles
In toe out towing - MC contused muscle: QUADS ( charley’s Horse)
Subtalar pronation subtalar supination
Squinting patella grasshopper’s eye patella
Or frog’s eye patella
10. HETEROTOPIC OSSIFICATION (HO)
- Abnormal bone growth in joint
- CAUSE: prolonged immobilization
- SITES: CVA, TBI (shoulder)
SCI (Hip)
BURNS (Posterior Elbow)
- SIGNS & SYMPTOMS:
 Pain
 Hard end feel
 LOM- hallmark
 Increased alkaline phosphatase ( increased
rate of ossification)
- MANAGEMENT: Early mobilization & Frequent
stretching
- MEDICATIONS: disodium etidronate (dissolves
heterotopic ossification)
11. MYOSITIS OSSIFICANS (MO)
- Abnormal bone growth in muscles
- CAUSE: trauma/ contusion to muscles
- SITES: UE- brachialis> biceps
LE- Quads
General: QUADS
- SIGNS & SYMPTOMS: (PaPaFlat Mo)
 Pain
 Palpable Mass
 Flexion Contracture
- MANAGEMENT: gentle AROM
- C/I: Passive stretched & massage
- IMAGING:
o bone scan (early)
o XRAY (late)
 Identify hype vascular parts of bone/
muscle increased rate of bone mineral
turnover
 To monitor growths of MO
 SURGERY is ONLY p growth stops
 KNEE
1. OSQOOD- SCHLATTER DISEASE
- Inflammation of patellar tendon @tibial
tuberosity
- Bilateral enlargement of tibial tuberosity
- Male > female
- Adolescent
- C/I: Ultrasound- hinder growth at growth
plate
2. PATELLAR TENDINITIS
- Inflammation of patellar tendon @ insertion
- AKA “jumper’s knee”- insertional tendinopathy
- Difficulty with descending stair/ ramp
(eccentric contraction of QUADS)
PATELLAR TENDON TEAR
- Patella Alta
- Patella still able to move
QUADS TENDON TEAR
- Patella Baja
- Patella is unable to move
3. OSTEOCHONDRITIS DISSECANS
- Lesion at subchondral part of femur
- MC site lateral aspect of medial femoral
condyle
4. HOFFA’S DISEASE
- Inflammation of infrapatellar fat pad below
femur and tibia
5. SINDING-LARSEN JOHANSSON DISEASE
- Lesion at the inferior pole of the patella
6. CHONDROMALACIA PATELLA
- Aka “PFPS” Patellofemoral Arthralgia Runner’s
Knee
- Degeneration of artigulationg surface of
patella
- ST: clarke’s test
Waldron’s Test
- Signs & symptoms:
 Pain with knee flexion
 Pain with prolonged sitting
 (+) camel sign
 (+) cinema sign/ theater sign/ movie goer
sign
 VMO weakness (patellar lateral malt
racking)
 INC Q-ANGLE
  TIGHT ITB 2. Semitendinosus- Gracilis Graft

 STRENGTHENING PROTOCOL
1. ACL- hamstring immediately before quads
2. PCL- quads immediately before hamstring

7. KNEE OSTEOARTHRITIS
- Degeneration of knee joint due to wear and
tear
- MC affected joint (OA) – KNEE
- WB condition that causes medially knee pain
- DEFORMITY: Genu Varum (bow-legged)
- ORTHOSIS: CARS-UBS ORTHOSIS (knee)
** Canadian arthiritis and rheumatism society
University of British Columbia 9. KNEE DEFORMITY
***** LATERAL HEEL WEDGE (foot)
a. GENU VARUM
- “bow legged”
8. LIGAMENTOUS INJURIES - Patella is laterally located in relation to hip and
A. COLLATERALS ankle
Medial Collateral Ligament MCL - NORMAL: 18 to 19 months
 Cause: increased valgus stress
 Unhappy triad/ terrible triad of b. GENU VALGUM
o’donoghue: MCL, ACL, MEDIAL MENISCUS - “Knocked knee”
 Pellegrini Steida – ossification of MCL - Patella is medially located in relation to hip
and ankle
Lateral Collateral Ligament LCL - NORMAL: 3 to 4 years old
 Cause: increased varus stress
 Palpable: FABER (fig of 4) c. GENU RECURVATUM
- “Sober legs”
B. CRUCIATES - Knee is hyperextend
Anterior Collateral Ligament - CAUSE: (polio) weak/ prolonged quads
 Causes: hyperextend (CVA) spastic quads
 Excessive of anterior translation of tibia on Plantarflexion spasticity
fixed femur
10. MISERABLE MALALIGNMENT SYNDROME
Posterior Collateral Ligament (back at one)**
 Causes: hyperflexed - You have a broad pelvis
 Excessive of posterior translation of tibia - Increase ang anteversion
on fixed femur - Increase ang Q angle
 Dashboard injury - Ang 4 nag genu valgum
 Fall on a flexed knee and plantarflexion - Patella alta
ankle - External tibial torsion
 Kick or shin? - Subtalar pronation
 SIGN & SYMPTOMS: difficult in extending - Patellofemoral pain syndrome
knee
 ST: posterior sag sign 11. BURSITIS
Posterior drawer test a. PRE PATELLAR BURSITIS
- MC
RECONSTRUCTION: - “housemaid’s knee” ( quadruped knee)
 Graft
1. Bone- Patellar- Tendon- Bone Graft b. SUPERFICIAL INFRAPATELLAR BURSITIS
 Gold standard for ACL reconstruction - “Nun’s knee”
 - “clergyman’s knee” - Bony enlargement at tc? Back of heel
- “Vicar’s knee” - CAUSE: chronic wearing of thigh boot/ high
***FALL KNEEL heels

c. POPLITEAL BURSITIS
- “Baker’s cyst”
d. Pes Anserine Bursitis
- Pain at inferomedial knee 2. SERVER’S DISEASE
- “CALCANEAL APOPHYSITIS”
- Inflammation at growth of calcaneus in
 LEG growing children (insertion of Achilles tendon)

1. BLOUNT’S DISEASE 3. PLANTAR FASCIITIS

- Aka: TIBIA VARA - Inflammation of plantar fascia
- Growth errest? at the tibial shaft of medial - CAUSE: P – PREGNANCY
tibial physis O – OBESITY
P – PROLONGED SITTING
2. ANTERIOR COMPARTMENT SYNDROME C – CHRONIC WEARING OF FLAT
- Impingement secondary to increase pressure SHOES
- > DPN: tibialis anterior - SIGNS & SYMPTOMS:
- SIGNS & SYMPTOMS:  First step pain
 Pain  Pain at medial calcaneus (plantar aspect)
 Paresthesia  Tight heels cords
 Paralysis - MANAGEMENT: stretching towards
 Pulselessness dorsiflexion + toe extension
- MANAGEMENT: fasciotomy - ORTHOSIS: Resting Night Splints (best initial
management)
3. MEDIAL TIBIAL STRESS SYNDROME - Analgesics/ anti-inflammation meds
- “SHIFT SPLIN”/ “Tibialis posterior overload” - Surgery
- Pain at posteromedial ligament due to over
activity of Tibialis posterior. 4. FOOT DEFORMITY
- CAUSE: toe-running Tali (ankle) PES(foot)
 Talipes caunes- high arch foot
4. TIBIAL STRESS FRACTURE  Talipes Equinus- PF foot
- Hairline fracture in distal tibia due to increase  Talipes Calcaneus- DF foot
stress to bone  Talipes Valgus- eversion + ABD
- XRAY: (+) dreases black line  Talipes Varum- Inversion + ADD
- MC LOCATION: tibia- fibua;- MTT- Femur  Talipes Equinovarus- PF + INV + ADD
o Aka “clubfoot deformity”
5. ACHILLES TENDINITIS o Pos’tn: PF+INV+ADD
- Inflammation of Achilles tendon (insertional o MANAGEMENT: Dennis-Browne
tendinopathy) Spllint & serial casting (DF+ EV+
- Pain @ calcaneus ABD)
- MC: Midportion (hypovascular) o MC SEEN: CP and spina bifida
- Difficulty ascending stairs (stretched heel  PES PLANUS
cords) o Aka “flat foot deformity”
- ST: Thompson Test o CAUSE: collapsed MLA (medial
longitudinal arch)
Laxity of spring ligament/ plantar
 ANKLE AND FOOT calcaneal ligament (PlaCaNa)
o MC SEEN: Down syndrome
1. HAGLUND’S DEFORMITY o MANAGEMENT: orthosis
- (+) Pump bump deformity S – SCAPHOID/ NAVICULAR PAD
 T - THOMAS HEEL - Pain at metatarsal heads (bell of foot)
U – UCBL insert (university of - CAUSES: chronic wearing of high heels
California biomechanical - MANAGEMENT: Metatarsal pads proximation
laboratory) to MTT heads
 PES CAVUS
o High arched foot/ hollow foot
o MC SEEN: CMTD
o Mngmt: Shoe inserts/ modification
5. SPLAY FOOT 6. Diabetic foot
- Weakness of intrinsic muscles; widening of - “Charcot’s foot/ neuropathy”
foot ( forefoot) - Nerve drug-> loss of sensation of foot
- Decrease transverse arch secondary
- MANAGEMENT: Towel Toe Curls Decreased blood supply to vasa neuroma
(blood supply in nerves)
- Early: warm, erythematosus, swollen joint
 TOE - Late: fracture, st. dislocation
1. HALLUS VALGUS - Major/ MC complication: Foot Ulceration
- Outward angulation of big toe
- NORMAL valgus angle: 15 DEG
- Increase valgus angle: >15 deg SEMMES- WEINSTEIN MONOFILAMENT TEST
- CAUSE: chronic wearing of pointed shoes and - Sensory assessment for diabetic foot
rheumatoid arthritis
- MC COMPLICATION: (NORMAL) 4.17 gauge monofilament (exerts 1 gram of
o BUNION- 1st MTP force)
o BUNIONETTE: 5TH MTP (TAILOR’S (LOSS OF PROTECTIVE SENSATION) 5.07 gauge
BUNION) monofilament (exerts 10 gram of force)
(Severely insensible foot) 6.10 gauge monofilament
2. HALLUX RIGIDUS (exerts 75 gram of force)
- Osteophyte formation at the dorsal aspect of
big toe
- Apropulsive gait (difficulty during the push off WAGNER ULCER CLASSIFICATION
phase of gait) 0 – INTACT
I – SUPERFICIAL (LOCAL ULCER)
3. II – DEEP (with exposure of bone, tendon, ms, lig)
III – DEEP (with osteomyelitis & abscess)
IV – GANGRENE (partial foot)
V – GANGRENE (entire foot)

7. TURF TOE
- Hyperextend injury to big toe -> FHL rupture
- Common in football players

8. DERVER’S TENDINITIS
4. MORTONS NEUROMA - Inflammation of FHL tendon secondary to
- Benign tumor formation at the 3 rd interdigital overuse
nerve - Common in ballet dancers
- Pain between 3rd and 4th toes
- CAUSES: chronic wearing of pointed shoes
- ST: metatarsal squeeze test

5. METATARSALGIA
LOWER ST
 HIP

HIP PATHOLOGY
1. Nelaton’s Line
- Position: Supine, ASIS to ischial tuberosity
- A: palpate G. trochanter
- (+) GT is superior to nelaton’s line
- INDICATION: Hip dislocation or coxa vara
-

2. Bryant’s triangle
- Position: supine; deep a angle line from ASIS to
table
- A: measure distance force GT to perpendicular
line and compare both side
- (+) difference of both side
- INDICATION: hip dislocation or coxa vara

3. Flexion Adductors (FAD) Test

- Position: supine with hip and knee flexion
- A: passively adduct the hips
- (+) LOM, Discomfort/ pain
- INDICATION: Hip pathology