A COMPREHENSIVE} APPROACH TO PRINCIPLES OF SYSTEMIC SURGERY 2" Edition Abdul Wahab Dogar Graduated from QAMC Bahawalpur Liver transplant and HPB surgeon, Shifa international hosphal \slamabad Assistant Professor; Shifa a Cones of Medicine, Islamabad doctordogar@hotmail.cor Published by Farooq Kitab Ghar 32, 33 - Urdu Bazar, Karachi - Pakistan Phone : 021-32634791-32216511WARNING This book is protected by copy rights in the name of Dr Abdul Wahab Dogar as per rules and regulations of Govt of Pakistan under the copyright act and registration no is 17218. No part of the book can be reproduced or reprinted by ‘any means without written permission of the author. In case of non compliance strict action will be taken according to copyright act of the Govt of Pakistan. Title: “A Comprehensive Approach to Principles of Systemic Surgery” Author: Dr. Abdul Wahab Dogar Graduated of Quaid-e Azam Medical College Bahawalpur FCPS (Surgery) Liver transplant and HPB surgeon Shifa international Hospital Islamabad ‘Assistant Professor; Shifa College of Medicine, Islamabad Published by: Younus Gaba Farooq Kitab Ghar Year of Publication: 1* Edition: — August 2009 2" Edition —_ January 2014 Number of copies: 2000 Price: ‘Stockiest: Nishtar Books, Nishtar Road, Multan Phone: 0300-8734441-0614584453 Medical Books Shop, Jalal Centre, Lahore. Ph: 0321-9290035 Union Books Anar Kali Lahore 03224362581 \ce Book Depot, Rawalpindi & Islamabad (Sector I-8 Markaz) }51-5502300 :e Book Depot, Peshawar, Saddar. 1333-9372162 Umar Kitab Ghar, B MC, Quetta.Dedicated to Those who have donated their livers to save the lives of their beloved ones at the cost of endangering their own livesIn the Name of Allah Acknowledgement a The production of new edition is always a labor of love and this has been no exception. Even a small endeavor like this has its origin in the help, guidance and assistance of many. ‘The prayers and tears of my parents and constant support of my siblings always led me tothetop. Thanks are due to my supervisors Dr Faisal Saud Dar, Dr Chao Long Chen, Dr Abdul Mannan Babar, Dr Tariq Mehmood Rehan, Dr Gulzar Ahmad Malik and Dr Javed Iqbal for their kind supervision of my academic career. Dr Faisal Saud Dar: my real mentor, teacher and a friend. You have transformed me into what I am now (a liver transplant & Hepatopancreaticobiliary surgeon) which was a dream once. Here I like to mention the real effort Dr Sharjil A Wahid for updating the urology section of this book. I am thankfull to Dr. Syed Abbas Ali Shah and Dr. Minhal Pervaiz for updating, editing and proof reading of this book Tam also appreciative to Dr Haseeb Haider Zia (liver transplant and HPB surgeon), Or Husnain Ali Ilyas, Dr Amna Liagat, Dr Manzar Ali (MMDC), Dr Latif Javed, Dr Zafar Mangal, Dr Sadia Ali, Dr Adnan Nazir Malik and Dr Shereen for their valuable contribution in the book. Lam profoundly thankful to ALLAH Almighty for blessing me with courage and patience to complete such an uphill task. Lastly it is necessary to mention Mr. Muhammad Younas GABA, Muzammil GABA, Javed GABA (Al Faroog Books Karachi) for publishing the book to combat with the international standards and also for composing the book in attractive and colorful manner 1am also thankful to Mr. Noushad, Mr. Salman, Mr. Arsalan, Mr. Noumian (Al-Tasmeem Graphics). The author alone is responsible for all the shortcomings of this book. He welcome the suggestions for further betterment of the book Abdul Wahab Dogar Graduated from QAMC Bahawalpur Liver transplant and HPB surgeon Shifa international hospital Islamabad doctordogar@hotmail.comPreface to the second Edition The overwhelming response and valuable comments of the readers have been immensely encouraging and source of stimulus for me to bring out the second edition in order to fulfill the requirement of the current pattern of professional examination. The chapters on orthopedic surgery, Hepatobiliary surgery and urology have been thoroughly revised, updated and elaborated. Anatomy of liver, liver trauma and bile duct injuries are written in more detai. More illustrations have been added in operative surgery.| In order to impart a long lasting memory and to make the process of learning the art of surgery more convenient colored tables, diagrams and sketches are incorporated in the book where necessary. Abdul Wahab Dogar Graduated from QAMC Bahawalpur Liver transplant and HPB surgeon Shifa international hospital Islamabad doctordogar@hotmail.comTABLE OF CONTENTS General principles of orthopedic surgery Fractures of Upper Limb Fractures of Lower Limb Pediatric orthopedic | Bone tumors | Bone and joint infections Sports injuries T |__ Peripheral nerve injuries Degenerative diseases of the musculoskeletal system The Esophagus Stomach and Duodenum Liver Spleen Hepatobiliary system Pancreas Peritoneum, Mesentery And Retroperitoneal Space ‘Small and Large Intestine Intestinal Obstruction \Vermiform Appendix Rectum and Anal Canal Hernia, Umbilicus and Abdominal Wall Kidney and Ureter Urinary Bladder Prostate and Seminal VesiclesTABLE OF CONTENTS Urethra and Penis Testes and Scrotum Thyroid Gland Parathyroid Adrenal Gland Pituitary gland Pancreatic endocrine tumors (PETS) ‘Thorax & Cardiac Surgery | Bronchogenic Carcinoma Cardiac Surgery Valvular Heart Diseases Congenital Heart Diseases Head Injuries Diseases of The Vertebra and Spinal Cord Se Salivary glands ‘Tumors of the Oral Cavity Neck swellings Cleft lip & palate Maxillofacial Injuries Neck trauma Dental surgeryGeneral principles of orthopedic surgery Fractures of Upper Limb Fractures of Lower Limb Pediatric orthopedic Bone tumors Bone and joint infections Sports injuries > Peripheral nerve injuries Degenerative diseases of the musculoskeletal system 37Fracture: Fracture is a break in the continuity of the bone. Dislocation ‘Complete disruption in the normal relationship of two bones forming a joint (ie, no contact of the articular surfaces). The direction of the dislocation is described by the position of the distal bone (e.g., with an anterior dislocation of the shoulder, the humerus is displaced anterior to the scapula). Distraction: Distraction is a separation of joint surfaces with no dislocation or ligament rupture. Subluxation: Subluxation is a partial dislocation of the joint. Sprain: Sprain is the temporary subluxation of the joint and articular surface returns to normal alignment. Strain: Strain is the tear in the muscle. Vaigus and varus: When the distal part of the limb or deformity is away from the midline it is termed valgus and when it is towards the midline it is referred to as varus. Genu: Itis the Latin word used for knee joint. a ee 4 1 § 7 ie ¥ ) 4 ane 7 \ gy 4 Et \ Sd u § a ‘ ag eat Sree (Knock Knees) (Bow Legged) Figure demonstrating various deformities ofthe knee joint Cavus: Excessive height of the longitudinal arch of the foot. Equines: Plantar flexed position of the ankle. Kyphosis: forward flexion (‘the kyphotic kisses his knees’) or hunch back Lordosis: the opposite, extension, or bent-over- backwards deformity; this represents the normal alignment of the lumbar and cervical spine Scoliosis: a sideward deformity that is normally associated with a degree of rotation Anatomy of Long Bone: Diaphysis: Elongated hollow central portion of the bone located between the metaphyses; it is made of compact tissue and encloses the medullary cavity. Metaphysis: The flare at each end between Diaphysis and growth plate Physis (Growth plate): This is the part of the bone at which metaphysial end of the bone is added. It is between epiphysis and metaphysis. Epiphysis: Enlarged terminal part of the bone, farthest from the center of the body, made of spongy tissue and articulating with neighboring bones.va A comprehensive approach to principles of systemic surgery a Fig: Showing anatomy of long bone: TYPES OF FRACTURE: Transverse Fracture: The fracture is at right angle to the long axis of the bone. Green Stick Fracture: Fracture at one side of the bone causing a bend on the other side of the bone. This fracture occurs in young people where bone is flexible. Spiral Fracture: If the bone is twisted along its long axis spiral fracture occurs. Butterfly Fracture: A butterfly fracture is a wedge shape fracture arising from the shaft of long bone at the apex of the force input. Comminuted Fracture: A fracture that results in three or more bone Greenstick Spinal fragments. This fracture occurs when large amount of energy is dissipated into a bone. Compression Fracture: Compression fracture is used to describe a fracture in which cancellous bone collapses and ‘compresses upon itself. This commonly occurs to vertebral bodies following trauma to spine. Pathological Fracture: This is a fracture when strength of bone is reduced by disease and minor trauma can cause fracture of bone, Pathological fracture can occur in osteoporosis, renal failure, neoplasia etc. Close or simple fractures: This is type of fracture in which the bone is fractured but the fracture is not communicating with the external environment i.e. skin over the fractured bone remains intact. Open or compound fractures: In this the fracture communicates with the exterior i.e. the skin over the fracture site is breached. The micro-organism from the environment can get entry into the bone through this wound so antibiotics and tetanus prophylaxis in needed and the bone is usually fixed with external fixator. After thorough wash and debridement or after cleaning the wound. Comminuted Transverse Compound Vertebra; Compression Fig: Showing types of fracturesAO CLASSIFICATION The AO classification is an internationally agreed classification of the fracture using a simple alphanumeric code. The first number represent the name of the bone (humerus is 1, femur is 2etc), the second number relates to the position of the bone (1 is proximal, 2 diaphysis and 3 distal). The next letter, A, B or C, designates the fracture type. For diaphysis fractures these are simple (A), wedge (8) or complex (C). For proximal and distal segments these are extra-articular (A), partial articular (B) and complete articular (C).See figure below for illustration. For example 13A represents "means fracture of the humerus 3 means distal end of the bone A shows that it is an extra-articular fracture Similarly 12C represent » 1 means fracture of the humerus © 2 means diaphysis of humerus = Cmeans complex fracture SALTER HARRIS CLASSIFICATION OF GROWTH PLATE INJURIES: Type I: Fractures are transverse through the hypertrophic zone of the physis and results in widening of the physis. Growth zone of the physis is typically not disturbed. ee General principles of orthopedic surgery Type II: Fractures involve the metaphysis and physis, without epiphyseal involvement. Itis most common type of physeal fracture, (75% of injuries). Type III: Fractures traverse the physis and the epiphysis, with out metaphyseal involvement. It tends to involve the articular cartilage. It has a greater predisposition for growth arrest. Type IV: Type IV fractures involve the epiphysis, physis, and metaphysis. Type V: Type V fractures result from a crush injury to all or part of the physis. It usually results in impairmentof the growth. Mnemonic: The classification can be remembered by a modified spelling of the word ‘Salter’ as follows: ‘Separation Above Lower T=IV= Through Reduction Disshyss (show oboe) Metapysis phys! dit (Gront pate) Metaohysis Norma Type. ‘A Complete physeal fracture with oF without displacement @ © Type tt Type ML - physeal fracture that A physeal fracture that extends through the ‘extends through the metaphysis, producing a chip exiphysis ‘fracture of tha metaphysis, which may be very smal Twev Type ¥ |Aphyseal fracture plus. A compresson fracture of ceniphyseal and metaphyseal he growth plateCAUSES OF FRACTURE: Trauma. Osteoporosis. Overuse sometimes results in stress fracture. These are common among athletes. CLINICAL FEATURE OF FRACTURE: Pain. Deformity, Dysfunction. DIAGNOSIS: History, examination and X-Ray are key for the diagnosis of fracture. Follow the rule of 2 for obtaining radiographs. Two View — usually anteroposterior and lateral Two Joints —- above and below the injury. Two Limbs — injured and uninjured limb for comparison.(Only For Epiphyseal Injuries In Children) Two Times — before and after reduction. COMPLICATIONS OF FRACTURE Early complications Local: Vascular injury causing haemorthage, internal or external. Visceral injury causing damage to structures such as brain, lung or bladder. Damage to surrounding tissue, nerves or skin. Hemarthrosis. Compartment syndrome (or Volkmann's ischemia) Wound Infection, more common for open fractures, Systemic: Fat embolism. Shock. Thromboembolism venous), Exacerbation of underlying diseases such as diabetes or CAD. Pneumonia. (pulmonary or ‘A comprehensive approach to principles of systemic surgery Late Complications Local: Delayed Union. Non-union. ~ Malunion. Joint stiffness. Contractures. _ Myositis ossificans. ~ Avascular necrosis, Algodystrophy (or Sudeck's atrophy). "Osteomyelitis. ~ Growth disturbance or deformity. Systemic: "Gangrene, tetanus, septicemia. Fear of mobilizing. Osteoarthritis. Iatrogenic complications Casts Compartment syndrome. Pressure ulcers. Thermal burns during plaster hardening. Thrombophiebitis. Traction Traction prevents patients mobilizing causing additional muscle wasting and weakness if kept forlong time. Other Other complications include: Pressure ulcers. Pneumonia/UTIs. Permanent foot drop contractures. Peroneal nerve palsy. Pin tract infection. Thromboembolism. Now we will discuss only the common and important complications in detail NON-UNION, DELAYED UNION AND MALUNION: Non-union is where there are no signs of healing after >3-6 months (depending upon the site of fracture). Non-union is one endpoint of delayed union. Malunion occurs when the bone fragments join in an unsatisfactory position, usually due to insufficient reduction and may lead to deformity. Delayed union is the condition in which bone healing takes longer then the expected time,OE Tes = Causes: ~ Severe soft tissue damage » Inadequate blood supply ~ Infection » Insufficient splintage ~ Excessive traction Interposition of the soft tissue between the two ends of the bone. Presentation: Patient usually present with pain, dysfunction of the limb and restricted movement around the fracture site. Investigations: X-Rays demonstrate absence of callous and the pointed ends of a bone in case of non union. Expectant treatment. Malunion: Mild degree of Malunion can be left as such but if it is causing severe functional and cosmetic problems then it has to be treated by dissipation, reduction and internal fixation, Non-Union: Non union is usually treated surgically. Fracture site is opened the two ends of the bone are trimmed and the gap between the two ends of the bones is bridged with a bone graft. The bone graft can be obtained either from the iliac crest or from the fibula. PRINCIPLES OF FRACTURE MANAGEMENT: General treatment of injured patient includes: Follow the guidelines provided by ATLS 2.9.4, B, C et (for detail reader is referred to chapter #9 of “The comprehensive approach to the principles of general surgery” book by the same author). Transport the patient to the hospital. - Analgesics. Antibiotics and tetanus prophylaxis in case of open fracture. General principles of orthopedic surgery Specific principles of fracture management include: 1. Reduction 2. Stabilization or Fixation 3. Rehabilitation Remember: don't forget to check the neurovascular bundle distal to the fracture site while examining the patient with fracture as it necessitates the immediate action to save the limb. 1) REDUCTION: Reducing a fracture involves trying to return the bones to their normal anatomical position. Reduction can be achieved by closed or open methods. a) Close Reduction: Close or manipulative reduction means that fracture site is not opened and fracture is reduced by traction and rotation. b) Open reduction: Open reduction is obtained by opening the fracture site and restoring bony alignment under direct vision. Indications of open reduction Open fractures. ~ When closed reduction failed. ~ Displaced intra-articular fracture. » Grossly unstable fracture. Why Reduction needed? Pull of the muscle causing overlapping =p» of the fractured segmentsWhenever these is fracture of bone, the fractured segment of the bone may be displaced (translation, angulation or overlapping) so this displacement has to be reduced. This displacement occurs because of the attachment of the muscles and tendons, When there is fracture, the attached muscles contract and pulled the broken piece of a bone and it can result in overlapping, translation or angulation of the broken segments as shown in the diagram above. In order to overcome this displacement the reduction is required. 2) STABILIZATION / FIXATION: When the fracture has been reduced, it is necessary to stabilize in this position to avoid redisplacement. This stabilization can be achieved by various methods e.g. splint, cast, internal fixation or external fixation SPLINT AND CAST; Cast is orthopedic appliance that is composed of plaster of Paris and is used for stabilization of fracture either as a temporary or a definitive treatment. While application of cast, it must be remembered that tight cast can cause compartment syndrome. A back slab is usually used initially followed by complete cast when the swelling subsides. The joint above and below the fracture must be immobilized. After application of cast the limb must be elevated and distal circulation should be checked. Advantages and disadvantages of casting and splinting ADVANTAGES: » Nowound » No interference with fracture site » Cheap » Adjustable » No implants to remove DISADVANTAGES: Limited access to the soft tissues Cumbersome (particularly in the elderly) Interferences with function Poor mechanical stability Plaster disease ‘TRACTION: Continuous traction is applied to the limb distal to fracture to exert continuous pull on the long axisof the bone (which maintains reduction). The traction can be applied by skin or by skeletal (see figure for understanding skin and skeletal traction). Traction can be used for reduction and stabilization of the fracture Advantages and Disadvantages of traction include ADVANTAGES: » Nowound in zone of injury © Nointerference with fracture site » Cheap material » Adjustable DISADVANTAGES: » Restricts mobility of patients « Expensive in hospital time » Skin pressure complications «Pin site infection « Thromboembolic complications.Fig showing skin traction. traction applied by weights which are applied to the leg by adhesive tape or by bandage q se snowing shot rac A Pints passed tg he prox ae ‘Stu woght are sopid iar pasorg sverne suey coraed” ‘Tos nay rodoesracin anda stabs INTERNAL FIXATION: Internal fixation mean synthetic implants are placed inside the body to maintain the reduction Indication of internal fixation. Failure of non operative treatment © Unstable fracture © Pathological fracture © Multiple fractures Methods of internal fixations © Screwsand plates © k-Wires © Intramedullary nails. 1) SCREWS AND PLATES: A screw is normally used to join two things Qg toget her as show in figure. Screw can be used . to fix the malieoli, condyles etc. plates of Screw stewing various size and shapes are available and are fitation'6F thie condyl. applied according to the site and shape of fracture Fig: Showing fixation with a screw:FT) A comprehensive approach to principles of systemic surgery AsaBung s1padoyrio Plate applied to shaft of humerus ig: Showing uation with 2 yam compression pate: Advantages and disadvantages of plate and screw fixation. ADVANTAGES: * Can be used when anatomical reduction is required * Allows early mobilization * Can provide absolute or immobility relative DISADVANTAGES: ® May interfere with fracture site Periosteal/soft-tissue damage * Does not normally allow for immediate ® load-bearing * Potential for infection * Metalwork complications © need for plate removal 2) WIRES: Steel wires like k- wires (kapandji) can be used especially in children where screws and plate can damage the growth plate. Wires can cross growth plate without causing long- term effects. Wires can be used for supracondylar fracture of humerus, fracture of olecranon process etc 3) INTRAMEDULLARY NAILS: The shaft of long bone with its medullary cavity is essentially a tube. Through this tube devices (called nail) can be passed to hold the fractured end of a bone in reduced position Advantages and disadvantages of intramedullary nai ADVANTAGES: © Minimally invasive » Early weight-bearing * Less Periosteal damage than open reduction and internal fixation * May not need removal dvantages Increased risk of fat emboli/chest complications ® Infection difficult to treat * Difficult to remove if broken. EXTERNAL FIXATORS: External fixator is a mechanical construction to the hold the fracture. Each side of the fracture is joined to the fixator and the major part of device is external to the skin. This link to the bone is via pins which are then secured to the frame by clamps as shown below: A great advantage of external fixator is that the wound can be irrigated daily and it stabilize the fracture which reduces the pain to a greater extent INDICATIONS OF EXTERNAL FIXATOR: © Emergency stabilization of long bone fracture in the polytrauma patient. » Complex periarticular fractures. © Open fractures. * Fractures associated with infection. » Treating fractures with a bone loss.Advantages and disadvantages of external fixation. ADVANTAGES: © Noiinterference with fracture site Adjustable after application: alignment; biomechanics * Soft tissues accessible for plastic surgery © Rapid stabilization of fracture » Hardware easy to remove DISADVANTAGES: © Pinsite infection “ Interferes with plastic surgical procedures © Soft-tissue tethering © Cumbersome for the patient FRACTURES WHICH ARE SUITABLE FOR NON OPERATIVE TREATMENT: © Clavicle * Scapula General principles of orthopedic surgery « Isolated fracture of ulna * Scaphoid © Phalangeal and metatarsal bones « Fibular shaft © Undisplaced tibial fracture . Undisplaced Pelvic fracture FRACTURE WHICH ARE UNSUITABLE FOR NON OPERATIVE TREATMENT: © Open fractures * Failed non operative treatment * Displaced intra-articular fracture * Malunion and non-union © Pathological fracture Growth plate injuries where growth arrest is possible (Salter Harris type ili-v )Pea 4 comprehensive approach to principles of systemic surgery [FRACTURES OF UPPER LIMB FRACTURES OF CLAVICLE: Fractures of clavicle are common and males are more commonly affected than females. Mostly fractures involve the midshaft of the bone. Fractures of lateral end of the clavicle may result in displacement of acromioclavicular joint TREATMENT: In majority of cases the fractures of clavicle can be managed non- operatively with limb rested in broad arm sling for 3-6 weeks. Open reduction and internal fixation is needed for open fracture associated with neuro-vascular injury. Dislocation of shoulder joint: Anterior dislocation (the head of the humerus is driven forward and lies in front of the glenoid, Below the coracoid process and it result from or caused by the forced abduction /external rotation mechanism. Dislocation is frequently associated with damage to the glenoid labrum (Bankart lesion). Treatment The dislocation should be reduced as early as possible. Three methods are used commonly to reduce it and are usually carried out under intravenous sedation or general anesthesia 1, Kocher's method: The joint is manipulated as follow remembering the TEAR mnemonic. 1. TRACTION: Traction is applied to arm while flexing the elbow at 90. 2. EXTERNAL : Rotation 3.ADDUCTION: Adduct the flexed elbow across the chest. 4,ROTATION (internal); rotate arm back internally until shoulder is reduced with definite clink. 2. Hippocratic method The patient usually lies on the bed or on the ground. Traction is applied to the arm with elbow extended.Traditionaly the surgeon's heel is applied against the side of the patient's chest to promote counter traction. 3. Hanging arm or gravitational method Tt involves laying the patient prone with sandbag under the clavicle and hanging the arm over the edge of the bed holding the weight, Complications of shoulder dislocation * axillary nerve palsy © Recurrent dislocation Proximal humerus fractures: These fractures may involve the anatomical neck, surgical neck, greater tuberosity or lesser tuberosity. (Neer's classification) and are described in terms of the number of fragments involved (e.g. two part, three part, four part), Mechanism of injury: * A fall on the side or direct blow to the side of arm. © Afall on to outstretched hand. Management: Undisplaced and minimally displaced fractures are treated by conservative measures with broad arm sling. Young patients with displaced fractures are treated with open reduction and internal fixation with a plate and screws. The severely displaced fracture in elderly patients with osteoporotic bones is treated by replacement of humeral head by prosthetic material (Hemiarthoplasty.) Humeral Shaft Fracture: Simple or closed fractures are treated conservatively with sling or splint for 2-3 weeks. Operative treatment is indicated in patients with ‘open fracture associated with vascular injuries and patients with multiple injuries.Fig A. Fracture shaft of humerus Open reduction and internal fixation with plate is most common method, although intramedullary nailing can also be used. Complications of humeral shaft fracture. » Non-Union. » Radial nerve palsy. Distal Humeral Fracture: They are less common. The trochlea at medial column articulates with ulna and contributes to flexion and extension at elbow. The capitellum articulates with radial head and contributes to pronation and supination at elbow. Distal humeral fractures can be condylar, intercondylar, T- Shaped or Y-Shaped and usually result from fall on outstretched hand, Fig B. Stabilized with DCP Fig C. Stabilization by using K Nail IntercondyerFracure of Distal Intercondylar Fractured with Homers Condy Fg showing Y shaped facie of cst Humerus fixed wih plate7 spe fracture Fracture fed wih dynamic compression pate (DCP). Treatment: © Minimally displaced and —_undisplaced fractures are treated non operatively. © Displaced fractures need open reduction and internal fixation. © Displaced fractures in elderly osteoporotic patients may need artificial joint replacement. Supracondylar Fracture of Humerus in Children: This is most common fracture around the elbow in children and it usually result from fall on outstretched hand. Supracondylar fracture can be divided into extension (97%) and flexion (3%) types. The extension type is further divided into three types. © Typel: Fractures are undisplaced. © Typell: Fractures are angulated posteriorly but posterior periosteum remains intact. © Typelll: Fractures are —completely displaced with overlapping of fragments. Treatment: © Typel: Fractures are _ treated conservatively. © Typell: Fractures are treated by dosed reduction and cast fixation with the elbow at 90°, © Typelll: Fracture is reduced under anesthesia by traction and manipulation, but open reduction may be needed if closed reduction failed or if there is vascular injury. The reduction is maintained by k- wires as shown below Complications: © Vascular injuries: Brachial artery * Nerves radial, ulnar, median © Volkmann ischemic contracture * Mal-union, non-union. Radial Head Fracture: This fracture is also caused by fall on outstretched hands. Fracture has been classified by mason as: Typel: Undisplaced partial articular. Typell: Displaced partially articular. TypellI: Comminuted fracture. Treatment: © Small and minimally displaced fragments are treated non operatively by temporary collarand cuff. © Large fragments or major displacement which blocks movements require open reduction with internal fixation (ORIF). © If fixation is not possible radial head can be excised, Olecranon fracture: Itis also caused by fall on the elbow point. Treatment: * Undisplaced fracture is-_— treated conservatively. © Extra-articular and two part _intra- articular fractures are treated by tension band wiring. * Communited fracture is treated by plate fixation, Forearm Fractures: Most of the fractures involve both bones (Radial and Uina). Single bone injuries can occur but areuncommon. These fractures are caused by direct trauma to the bone or by fall on outstretched hand. Treatment: Adults: In adults fractures are usually displaced and open reduction and internal fixation with plates is indicated, Plates are applied to both bones via separate incision. Children: In children close reduction with cast fixation can be sufficient. Complications: © Mal-Union © Non-Union © Compartment syndrome. » Re-fracture (First 6 Months) Montegia Fracture: Fracture of proximal ulna with dislocation of radial head is called Montegia fracture, It is relatively uncommon and occurs during forced pronation of forearm or direct blow on back of upper forearm. Geleazzi fracture: It is fracture of shaft of radius usually at junction of middle and lower third, with dislocation of distal ulna. It often occurs due to fall on hand. Management of Montegia and Galeazzi fractures: Perfect reduction can never be obtained by closed method, so these fractures are treated by open reduction and internal fixation (ORIF). COLLE’S FRACTURE: Fracture of radius with in 2.5 cm of wrist joint. Itis extra-articular fracture with dorsal and radial displacement of distal segment. It usually occurs in elderly females with osteoporotic bones. Dinner fork deformity is classical deformity of Colles fracture. Fractures of Upper Limb Complications of Colles Fracture: » Median nerve injury. * Malunion. * Rupture of extensor pollicis longus tendon. » Sudeck's atrophy. * Joint stiffness. Treatment: Most of the time fracture can be treated by non ‘operative methods. Close reduction is carried out under anesthesia and cast is applied. Operative treatments rarely needed. ‘SMITH FRACTURE: This is reverse of Colles fracture. It is an extra- articular distal radial fracture with ventral (volar) displacement of distal segment. It usually occurs as a result of fall on to the dorsum of the hand. ‘Treatment is same us Colles fracture. ‘Scaphoid Fracture: The most commonly fractured wrist bone is the Scaphoid and is fractured by fall on outstretched hand. The fracture can be easily missed as it causes little pain, swelling and deformity and does not always show clearly on plain radiographs. If the doubt remains the wrist should be immobilized and radiographs should be repeated after two weeks. If there is still doubt, the isotope bone scan and MRI confirm the diagnosis. Treatment: © Undisplaced fracture is treated by plaster immobilization of wrist. © Displaced, unstable and proximal pole fractures are treated by internal fixation. Complications Include Avascular necrosis of proximal pole, osteoarthritis, delayed union and non-union.For the management point of view proximal femur fractures are classified as: i, Intracapsular fracture. (subcapital) ii. Extra capsular fracture. Posterior superior retinacviar vessels Artery of ligamentum teres Posterior capsule insertion. Anterior capsule insertion: Greater trochanter’ cireumflex artery Lateral femoral creumfiex artery Lesser trochanter Subtrochanteric region Intramedullary channels, This classification is important as if you look at the anatomy of proximal femur which is shown in figure above. The blood supply of the proximal femur is from three arteries. i, Lateral and medial circumflex arteries passes within the joint capsule. ii, Ligamentum teres (Small contribution to no contribution in elderiy.) Thus if intracapsular fracture occur, it can cause irreparable damage to the blood supply of the femoral head, whereas this is less likely in case of extra-capsular fracture. This damage of blood supply to head of femur can lead to avascular necrosis of femoral head. Causes of Fracture: In elderly, the bones are osteoporotic and can be fractured by low energy fall. The fracture is rare in, younger patients and usually is the result of a high energy injury. It is also a common site of pathological fracture due to metastatic bone disease. Clinical Features: Pain, tenderness and if the fracture is displaced the limb will be externally rotated and shortened. Treatment: Intracapsular fracture: Undisplaced: Intracapsular fractures are treated by internal fixation with dynamic hip screw (DHS). The dynamic nature of implant allows the fragments impact together as shown below. Displaced: Intracapsular fracture in elderly osteoporotic patients is treated by replacement of compromised femoral head by artificial head (Hemiarthoplasty) as shown below or total hip replacement. In the young patient's urgent reduction and internal fixation by using dynamic Hip screw (DHS) can reduce the chances of avascular necrosis. i \\le Fig: Showing hemiarthoplasty.Extra capsular Fractures: There is no chance of development of avascular necrosis of femoral head. So all cases require surgical fixation of the fracture by using sliding hip screw and plate. 4 Showing intertrochantenc fracture fixed by using shana hip serew: Subtrochanteric Fractures: Subtrochanteric region is defined as area between the lesser trochanter and a point Scm distal to it. This fracture is notorious for being slow to heal, non-union, shortening and angulation. The fracture is best treated surgically by fixation with intramedullary nail or by sliding screw and plate. The most common complication of this fracture is delayed union and non-union, Femoral Shaft Fractures: Fractures of shaft of femur result from high energy with blood loss of 1000-1500 ml. Treatment: Most of the fractures in adults are treated by using intramedullary interlocked nail. In children femoral shaft fractures can be treated with traction (Gallows traction for infants and ‘valanced traction for children.) | Fracture of the shaft of femur fixed with intra medullary Nall Fig showing fracture of shaft of femur the overtap because of pul of the muscleSf: A comprehensive approach to principles of systemic surgery Fractures around the Knee: These fractures can involve distal femur and proximal tibia and are frequently intra-articular and difficult to manage because of risk of osteoarthritis. This group includes: » Supracondylar fracture of femur. » Intra-articularT or Y shaped fracture. » Tibial plateaus fracture. » Proximal tibial fractures. Management: These fractures are usually managed by open reduction and internal fixation as perfect reduction is needed to avoid the risk of osteoarthritis. Supracondyilar Fracture: They are treated by surgical fixation by condylar plate or by intramedullary nailing. The main complication of this fracture is Malunion and non- union Intra-articularT or Y Fracture: These fractures follow severe trauma and are treated by open reduction and internal fixation with screw and plates (ORIF). Tibial Plateau Fractures: The articular fractures of proximal tibia are called tibial plateau fractures. In lateral plateau fractures, the anterior tibial artery may be damaged. If the displacement is less than 2 mm, no reduction is needed but if it is more than 2mm reduction and fixation is needed. Proximal Tibial Fractures: These fractures can be associated with major neurovascular injuries, undisplaced and closed fractures are treated by cast immobilization. Open reduction and internal fixation may be needed in selected cases. Tibial Shaft Fractures: Fig Fracture of proximal an¢ middle fixed with Dynamic compression plate (DCP) These fractures usually occur during road traffic accidents the so-called “Bumper Injuries”. The most common site of injury is at junction of proximal two third and distal one third. Classification: Closed Fractures: Undisplaced fracture is treated by non operative methods such as long leg POP cast etc. failure of non operative treatment require fixation with plates or nail Open Fractures: Tibia is the most common site of open fractures as most of the part of tibia is lying subcutaneously. Skin closure is difficult and plastic surgical intervention is required to cover the exposed bone by flapsete. Open fractures are classified by Gustilo and Anderson as fellow: Grade 1:Skin opening of less than 1 cm, a low eneray and simple fracture. Grade 2:Skin injury greater than 1 cm without extensive soft-tissue damage but mild crushing injury or low energy trauma. Grade 3:Major soft-tissue damage caused by high-energy trauma with severe crushing injury.3A:Extensive laceration but with adequate bone coverage; 3B:Tissue loss with Periosteal stripping and bone exposure; massive contamination requires flap coverage; 3€:Vascular injury requiring repair. Treat 4 © Follow ATLS guidelines. © Debridethe wound. © Analgesics. © Antibiotics. © Tetanus prophylaxis. * External fixation of the bone. Compartment syndrome. Vascular injury. Delayed union. Non-Union. Mal-Union. ‘The pelvis forms a bony ring which is stabilized by ligament. Most of the factures of pelvis are undisplaced and are treated by conservative methods using traction etc. It must be remembered that fracture of pelvis is associated with significant amount of blood loss (1500- 000m!) so hypovolemia must be treated. CLASSIFICATION The AO classification divides fracture of pelvis into three groups (A, B,C) ‘Type A: Stable factures Type B: Fractures are rotationally unstable e.g. open book fracture and lateral compression. Open book fractures implies the separation of pubic symphysis Type C: fractures are vertically unstable MANAGEMENT: General measures © Follow ATLS guidelines © Control hypotension © Stop bleeding «Manage associated injuries e.g. abdominal organs. If laparotomy has to be performed for injury to the abdominal viscera's, apply external fixator to pelvis first to avoid rapid expansion of pelvic retroperitoneal hematoma and it may become difficult or even impossible to close the abdomen after completion of surgery. Fractures of Lower Limb [Py ‘Treatment: Stable fractures are treated conservatively. Unstable fractures are treated by surgical fixation. For example a Plate has to be applied in case of open book fracture if the distance between the pubic symphysis is greater than 25cm. Complications » Hypovolemic shock © Urethral rupture (injury ) followed by stricture © Arthritis ACETABULAR FRACTURE: Acetabulum is cup which forms ball and socket joint with the head of femur The acetabular fracture result from high velocity injuries Classification of Acetabular Fracture These fractures may be elementary or associated. There are six elementary and five associated fractures Elementary Fractures © Posterior wall Posterior column Anterior wall Anterior column Transverse Associated Fractures Posterior column and posterior wall Transverse fracture and posterior wall T-Shaped fractures Anterior column posterior hemi transverse Both column fractures ° Treatment: ‘Stable undisplaced fracture can be treated non- operatively. There are two main indications for internal fixation ® Incongruent hip joint © Instability of the hip joint Complications © Sciaticnerve injury = Arthritis of hip » Avascular necrosis of hip © Superior gluteal nerve and superior gluteal artery injury[PEDIATRIC ORTHOPEDICS DEVELOPMENTAL DYSPLASIA OF HIP (DDH): Developmental dysplasia of the hip (DDH) describes a variety of conditions in which the ball and socket of the hip do not develop properly. Normal hip joint (ATC Fig: Showing left sided dislocated hip joint in which acetabulum is not fully developed: The hip is a ‘ball and socket’ joint. Normally the head of the femur is round ball shape which fits into a cup like socket on the pelvis (acetabulum).In case of DDH the acetabulum May not be develop fully or it may be shallow which may result in displacement of the head of the femur (Dislocation) which may be reducible or itreducible (see figure below).The condition can be unilateral or bilateral. The incidence of congenital dislocated hip is about 2 per 1000 live births and is more common in girls than boys. AETIOLOGY: » Breech presentation » Family history (risk is increased 30 times) © spina bifida » Racial factors CLINICAL FEATURES: © Extra high crease © Limitation of abduction » Painafter exercise * Limp Fig: Showing extra thigh crease in case of DDH: CLINICAL TESTS: Ortolani Test: If hip is abducted, itis reduced with typical clink. Barlow Test: If hips are adducted then dislocation occurs. INVESTIGATION: Ultrasonography has high sensitivity to detect the disease Radiography is also helpful. TREATMENT: ‘Treatment depends upon the age of the patient Neonates: HIP are flexed and abducted and this position is maintained by various splints as shown in diagram below.Infant: Conservative treatment as mentioned in treatment of neonates is stil effective but if failed than open reduction can be carried out at later stage. Toddler and child: Open reduction with bony realignment is necessary surgery for open reduction should be carried out after one year of age. Older child: After the age of 6 years surgery is usually unrewarding. Congenital club foot (congenital Talipes Equinovarus or CTEV) Itisa congenital abnormality in which one or both feet are rotated inwards and adducted. If treated properly most of the patients are able to live a normal life and participate in athletics as effectively as a normal person. Classification 1. Structural CTEV. 2. Postural CTEV. Joint abnormalities © Inversion deformity at subtalar joint © Adduction deformity at talonavicular joint » Varus deformity at ankle joint (toe walking) f ,/ Figure showing CTEV of left foot eee Rt Pediatric Orthopedics Etiology There is no single known cause for clubfoot. It may be found alone asa single defect at birth or may be associated with a number of syndromes including ® Edwards syndrome, » Ehler-Danlos syndrome * And connective tissue disorders like Loeys- Dietz syndrome. Treatment Non surgical treatment » Ponseti method Most of the patients (>80%) are successfully treated with this method and parents should be educated about the disease. In a 2 weeks or at times older child, feet are gently brought into normal anatomical with the help of serial castings (Casts). The cast is removed and reapplied on weekly basis. No more than 8 casts are applied before proceeding to surgical intervention. Surgical Treatment In most of the cases extensive surgical procedures are not required. If non surgical method fails then 2 routinely done procedures are as follows. » Tenotomy Its the release of the Achilles tendon under local anesthesia. » Anterior Tibial Tendon Transfer In this the anterior tibial tendon is removed from the first toe and is attached to third toe to correct the deformity. » Tripple arthodesis: in case of late presentations tripple arthrodesis of subtalar, talonavicular and calcaneocuboid jointsPES PLANUS (FLAT FOOT) Itis a common condition in which the arch of one or both feet is never developed or collapses at a later age and complete sole of foot comes in contact with ground. Itis less common in children who are bare footed as compared to the ones wearing closed shoes. In adults it affects females more than the male population and is common in diabetics, obese and hypertensive patients. Injury or prolonged stress to feet may also cause flat feet. It can be diagnosed easily by “Wet Footprint Test.” (Asking the patient to walk on floor with wet feet, as practiced in army recruitment). Flat feet patients with a flexible arch do not fee! pain and thus require no treatment. Rigid flat feet with pain may be associated with Tarsal Coalition or accessory Navicular bone which can be diagnosed on X-ray and treated accordingly. Arch support and foot gymnastics are also helpful in management. LEGG-CALVE PERTHE'S DISEASE It is a childhood condition that predominantly affects the boys. It is characterized by disruption of blood supply to the femoral head leading to avascular necrosis of a portion of developing femoral head. A number of causative factors have been implicated including hereditary, trauma, endocrine, inflammatory, nutritional, and altered circulatory hemodynamics. The common symptoms are hip, thigh or knee pain and gait abnormalities. There may be a discrepancy in the length of both limbs. X-rays usually demonstrate a flattened, and later fragmented, femoral head. It is a self limiting disease and treatment includes analgesia, traction (to prevent further damage) and physiotherapy to preserve the range of motion of hip joint. SLIPPED UPPER CAPITAL FEMORAL EPIPHYSIS (SUFE) It is a problem of unknown etiology that affects boys of 10-16 years. It commonly affects short, chubby, hypothyroid or hypogonadal individuals. It may be bilateral in up to 25% of cases. The femoral head epiphysis weakens and slips thus femoral neck comes to lie anteriorly and upward Itis characterized by pain and gait abnormalities Treatment includes reduction and pinning of the effected femur. The contralateral side is generally Pry A comprehensive approach to principles of systemic surgery fixed prophylactically and there is a risk of avascular necrosis in severe slips. Corrective osteotomy may be required in cases of residual deformity after healing. x-ray showing slipped femoral epiphysis on left side ACHONDROPLASIA Achondroplasia is amongst the common causes of dwarfism. Itis characterized by short height of the individual. Etiology The disorder is caused by mutation in Fibroblast Growth Factor Receptor Gene 3 (FGFR3) and the disease is autosomal dominant. If both the alleles are mutated then the individual may die in a very early post partum period or is still born. Presentation © Disproportionate dwarfism © Short fingers and toes Large head with prominent forehead Spinal kyphosis or lordosis Varus (bow leg) or Valgus (knock knee) deformity Diagnosis It can be diagnosed before birth through a pre natal ultrasound. ADNA test can be done to look for homozygosity. Treatment © There is no definite treatment of achondroplasia. © Growth hormone therapy has been tried but with no great advantage(> BONE TUMORS Classification Radiologically, tumors can also be classified depending on their site within the bone: © Epiphyseal lesions Giant cell tumor > Chondroblastoma » Metaphyseal lesions Osteochondroma Osteosarcoma © Diaphyseal lesions Ewing's sarcoma Adamantinoma. Bone tumors may be classified according to cell type Bone-forming tumors © Benign: osteoid osteoma, osteoblastoma © Malignant: osteosarcoma Cartilage-forming tumors © Benign: osteochondroma, enchondroma, chondroblastoma, chondromyxoid fibroma © Malignant: chondrosarcoma Giant cell tumors » osteoclastoma Marrow tumors © Ewing's sarcoma, plasma cell tumor, multiple myeloma, lymphoma Metastatic most common tumors of the bones are Metastatic and most common sites of primary tumors are breast, prostate, lung, kidney and thyroid. Osteoid Osteoma: It usually affects the younger age group, mostly between 5 and 30 years. Arise from long bones especially from the femoral neck. Femurtibia and humerus are the other common sites. Pathology: these are the benign bone forming tumors. Presentation: Patients usually present with pain (caused by excess release of PG-E,) which is worst at night, Pain can be relieved by aspirin Bone Tumors [Py Radiological Findings: They are usually small lesions which are less than 2cm in size and seen as a radioluscent nidus. They are composed of woven bone surrounded by reactive bone formation. CT scan can be diagnostic. CT Scan on the left and X-ray on the righ showing typical presentation of osteoid osteoma. Treatment: They may heal over 2-3 years. If non operative treatment fails or is not acceptable by the patient then Radio frequency ablation or Resection can be done. Osteoblastoma: It is same as osteoid osteoma but these lesions are larger in size and involve vertebrae most commonly.Treatment is curretage or excision, depending upon the site of the lesion. Xray showing lesion (osteoblastoma) of the cervical vertebra° a yy S 3 ® 4 a a 4 e o 2 A comprehensive approach to principles of systemic surgery Osteosarcoma is most common primary malignancy of bones in children, The peak incidence is between 9-16 years and most common sites are around the knee and upper arm. Tumor typically effect the metaphysis of long bone and shows mixed sclerotic and lytic lesions. There is periosteal reaction which demonstrates sunray type spiculations. Patient usually present with pain and swelling.Ocassionally the patients may present after minor trauma. Pyrexia is also seen with ncreased WBC's CT, MRI, Bone scan further aid in diagnosis and to see the involvement of surrounding structures. Biopsy confirms the diagnosis and the tumor is treated by surgery, chemotherapy and radictherapy. Itis the most common benign cartilage forming tumor. It most commonly arises from the surface of the long bones, pelvis, ribs. Pathology: These are the bony outgrowths from the surface of the bones capped with a layer of cartilage. It can be single or multiple. These are slow growing tumors and the growth sizes with the skeletal maturity. Although malignant changes are rare but can occur Presentation: It is mostly an incidental finding but pain may suggest malignant transformation Radiological Findings: These lesions range from 2-15cm in size and typically grow away from the the joint. On X-Ray they look like a “mushroom” with calcified stalks and radiolucent cap X-Ray showing @ mushroom like growth arising from distal femur. Mushroom like resected lesion Treatment: Symptomatic lesions should be surgically resected. Asymptomatic lesions can simply be obserced but malignat transformation should be suspected when they become painful.Chondroblastoma: It occurs in 2” and 3” decade of life. It is also known as Codman's tumor and occurs in young adults. Site: Most common site of origin is epiphysis of long bones with involvement of metaphysis when the physis is closing. Pathology: These are benign tumors of hyaline cartilage arise within the physis. They contain lobules of well circumscribed cartillage. They appear as “Chicken-wire" calcified lesions, Presentation: Diagnosis is often delayed and patient typically has a long history of joint pain. Radiological Findings: They appear as lytic lesions in the epiphysis. X-Ray showing chicken wire calcified lesion of the proximal humerus Treatment: Curretage is a better option but it may lead to premature closure of the physis resulting in growth disturbances. Chondrosarcoma: Chondrosarcomas constitute a heterogeneous group of neoplasms that have the production of cartilage matrix by the tumor cells in common Chondrosarcoma is the third most common primary malignancy of bone after myeloma and osteosarcoma. The majority of these tumors grows slowly and rarely metastasizes, and they have an excellent prognosis after adequate surgery. It is generally believed that, because of their extracellular matrix, low percentage of dividing cells, and poor vascularity, they are relatively chemo- and radiotherapy resistant. Wide surgical excision remains the best available treatment for intermediate- to high-grade tumors. GIANT CELL TUMOR (Osteoclastoma) Giant cell tumor affects the epiphysis of long bones, although it is benign tumor but has potential for aggression and local recurrence. It typically affects young adults between 20-45 years. The most common site is around the knee but distal radius and proximal humerus can also be involved, Presences of abundant tumor giant cells are quite characteristic of the tumor. The giant cells are characterized by their large size, multiple nuclei (more than 150 in number) which are distributed throughout the cell. X-Rays of the affected area show osteolytic lesion near the epiphysis with clear margins between tumor and normal bone. The septa of bone traverse the interior of the bone and produce soap bubble appearance. X-rays, CT and MRI are used for staging and diagnosis is confirmed on biopsy. Treatment is surgical resection with adequate tumor free margins. EWING'S SARCOMA: This is second most common malignancy of children. Tumor affects the diaphysis (shaft) of the tubular bones as well as flat bones such as scapula and pelvis. This malignant tumor arises from the endothelial cells of the marrow and is common in children between the age of 10 and 20 years. It usually presents with a huge mass and there may be constitutional symptoms such as fever and malaise. Pain is often more pronounced at night. The lesion may be lytic, sclerotic or mixed. Periosteal new bone formation occurs in layers giving rise to onion peel appearance on X-RAYS. The most characteristic feature of Ewing's sarcoma is the massive extraosseous soft tissue component. Treatment usually involves a combination of radiation and systemic chemotherapy with 5 year survival around 50%. Surgery in combination with radiation and chemotherapy improves 5 years survival.‘A comprehensive approach to principles of systemic surgery Giant cell tumor: effect epyphysis 20-45 years age, around the knee” soap bubble appearance, treated with Surgery Osteosarcoma: typically effect metaphysis, 9-16 year age Sunrays appearance on X-rays treated with surgery, chemotherapy and radiotherapy Ewing's Sarcoma: Involve shaft of the bones 5-15 year age onion peel appearance on radiographs treated by chemotherapy, radiotherapy and surgery mn ‘ig showing common bone tumors(BOREAND Somnrs nrecrions Seeomreltante tes ‘to bacterial infection of bone. Acute Osteomyelitis: Infection of bone that has not yet progressed to an extent of producing dead bone. ‘Chronic jitis: Infection of bone associated with bone death. Sequestrum: A macroscopic piece of dead bone iscalled sequestrum. Involucrum: New bone formed around an area of osteomyelitis in response to periosteal stimulation is called involucrum. ACUTE OSEOMYELITIS: Primarily it is a disease of childhood and often follows a bout of respiratory or skin infection. The infection begins at the metaphyseal ends of long bones, commonly of the lower limb. In children, 90% of cases are due to Staphylococcus aureus. By contrast, adults may present with rare and unexpected organisms as @ result of other co- morbidity, HIV, immunosuppressant therapy, indwelling prosthetic material (e.g. renal dialysis catheters) or intravenous drug abuse. Clinical Features: Pain, tenderness, systemic toxicity and pyrexia. Investigations: White cell count, C-reactive protein and ESR. Radiographs: Changes are not visible for first 10-14 days. Isotope bone scans. CT scan shows bone erosion and fluid collection. MRI is investigation of choice showing edema of the marrow and collection of pus. Blood culture. Microbiology. Management: © Resuscitation © Antibiotics (after culture and sensitivity). Intravenous antibiotics should be given for 2 weeks followed by 4-6 weeks of oral Bone and Joints Infections [Pq antibiotics. © Splintage of affected limb to prevent soft tissue contracture. Radiology guided aspiration of pus. © The cortex of the involved bone may be drilled at two or three sites to decompress the underlying pus which is sent for culture and sensitivity for appropriate antibiotic therapy. ‘Complications: © Recurrence. © Chronic osteomyitis. © Septicarthritis. © Pathological fracture © Damage to growth plate. CHRONIC OSTEOMYELITIS: Causes: Causative organisms of chronic osteomylitis include: © S, Aureus (commonest). © Anaerobes. © Gram-negative bacili © Mycobacterium tuberculosis. Cierny and Mader Staging System for Chronic Osteomylitis Type: Medullary Endosteal disease ‘Type II: Superficial Cortical surface infected ‘Type III: Localized Cortical sequestrum that can be excised without compromising stability Type IV: Diffuse Features of I, II, and III plus mechanical instability before or after debridementPA] 4 comprehensive approach to principles of systemic surgery Risk factors: ® Smoking © Malnutrion © Immunosuppressant © Diabetes ® Steroids * IV drug abusers Presentations: It usually presents with pain, chronic infection and sinus formation. Investigations are same as in acute case and radiographic findings are highly characteristic Treatment: Identify the organism by culture. * Antibiotics for prolonged period. (not less than 8 weeks) * Improve general condition of patient. * Surgical debridement of dead bone. * Amputation may be needed in resistant cases. Septic Arthritis (SA) ‘As the name advocates, septic arthritis is invasion of any joint by micro-organisms. This disease most commonly affects patients at extremes of age, patients with some underlying joint abnormality or immunocompromised patients. It not only destroys the affected joint, but it’s also a life threatening condition as it can progress to systemic sepsis. Acute hematogenous pyogenic infection of the joint usually occurs in infants. The hip is the most commonly involved joint and is known as Tom Smith’ septic arthritis of infancy. Source of infection; © Direct inoculation e.g. in penetration injuries * Local extension from nearby joint infection * Blood borne from distant sites. The most common organisms involved in SA are; * Staphylococcus aureus in all ages * Neisseria gonorrhea in young adults © H, Influenza in neonates and infants * Group B streptococci * Pneumococcus Most of the patients present with a short history of single hot, swollen and painful joint. Such a presentation is Septic arthritis until proven otherwise. The patient holds the joint immobile in the position of comfort and any passive movements may cause severe pain. Knee joint is most commonly affected in children and adults. Diagnosis can be made by aspiration of intra- articular fluid for histology and culture sensitivity. Manageme! Septic arthritis should be treated as a surgical emergency Medical Management: Antibiotics are usually given for 3-6 weeks but after surgical intervention. For the first two weeks the antibiotics are given intravenously. Surgical Management: Prompt surgical drainage is the priority to save the affected joint. Open washout is usually preferred over arthroscopic washout. Complications of Septic Arthritis: Early Complications: Effusion * Soft tissue swelling * Muscle wasting * Periarticular osteoporosis Late Complications * Secondary osteoarthritis * Jointstiffness * Fibrous/tony ankylosis ® Destructicn of physisin children * Growth arrest abnormality Musculoskeletal tuberculosis Tuberculosis (TB) is prevalent in certain developing countries and is of concern in developed countries due to immunosuppression from HIV infections. Patients often present with low grade fever, evening rise of temperature, and los s of appetite, loss of weight along with signs and symptoms of the partaffected. The most common site of musculoskeletal tuberculosis is the spine (‘caries spine’) followed by involvement of large joints, although any joint can be involved. The treatment of tuberculosis as recommended by WHO includes six months of chemotherapy with a combination of drugs given as an initial intensive phase of two months and a subsequent continuation phase. The first line drugs include isoniazid, rifampicin, ethambutoland pyrazinamide of which the first two drugs are not withdrawn during the continuation phase. Spinal tuberculosis Patients with spinal tuberculosis (‘Pott's spine’) present with pain and muscle spasm and have different presentations in different regions of the spine. Patients with cervical spine caries can present with torticollis or may support their chin on their hands (Rust's sign). Thoracic spine caries may have a military attitude while lumbar spine involvement may have a lordotic (Alderman's) gait. Spinal tuberculosis most commonly affects the anterior part of the vertebral bodies adjacent to a common intervertebral disc, the area having a common blood supply. Collapse of the anterior part of the vertebral body due to the destructive pathology may lead to a kyphotic deformity. Bone and Joints Infections Neurological deficits (‘Pott's paraplegia") usually result from involvement of the mid thoracic spine where the spinal canal is narrow. The treatment of spinal tuberculosis includes anti-tubercular therapy and bed rest in the initial period followed by braces, typically the ‘Taylor's brace’ or ASH (anterior spinal hyperextension) brace for the thoracic spine. The SOMI (sterno- occipito-mandibular immobilization) brace or four-post collar is used for the cervical spine and a Halo vest for craniovertebral tuberculosis. The healing in spinal tuberculosis occurs by fibrous or bony ankylosis. Usually cold abscesses are not drained since they heal well with anti-tubercular drugs. A large cold abscess, however, may be aspirated or drained using an antigravity method to prevent formation of a non-healing sinus tract. Pott's paraplegia may require surgical debridement and spinal stabilization.EY y A comprehensive approach to principles of systemic surgery (sPorts insurtes Sports medicine is necessary to understand the mechanism of injuries and how to avoid them. Although some sort of physical activity is good for a healthy body but stressing it beyond its threshold may lead to injuries. Injuries sustained during any sport can be broadly classified in to three broad groups. 1. Acute Extrinsic. 2. Acute Intrinsic. 3. Chronic. Acute Extrinsic injuries: These occur due to direct external blow. Examples are lacerations, bruises, fractures etc. Acute Intrinsic injuries: These occur due to internal structural failure (excessive loading.) Examples include ligament injuries, tendon rupture, menisci injury etc. Chronic Injuries: These injuries are a result of repetitive minor trauma and stress factors. The most common example is stress fractures, jointerosions etc. Now some facts about specific but common structures involved in sport injuries. Tendon Injuries: Factors involved in tendon Injuries can be divided into two groups. 1.Internal: Oxygen supply, nutritional status, hormonal changes, chronic inflammation andageing. 2. External: environment like new running surface, excessive training or exercise, old running shoes etc. In young patients the most common site of tendon injury isits apophysial attachment. In adults, it is the musculotendenous junction which is more commonly injured. In adolescents, the most common sites of injury are the tendon insertions. Muscle Injuries: These can be classified in to sprain, partial tear, complete tear or re-tear. Most of the muscular injuries heal spontaneously but may leave a painless defect in the muscle belly. Ligament Injuries: ‘These are usually acute intrinsic injuries and can be graded according to the severity. Grade 0; Normal Grade 1: No increase in joint laxity but there is tenderness around the ligament. Grade 2: Partial disruption of the ligament fibers with increased laxity. Grade 3: Complete disruption of the ligaments. Grade 1 and 2 injuries can be treated conservatively with analgesics, Splintage and gentle mobilization to avoid stiffness. Grade 3 injuries may require surgical repair. Injuries associated with individual sports: Tennis Elbow: It is a strain or small tear in the common extensor tendon followed by inflammatory reaction. The main complain is pain on the lateral aspect of the elbow. Treatment includes local steroid injections, avoidance of pain provoking movements, only if all the conservative measures fail then surgical exploration of extensor carpi radialis brevis may be advocated. Golfer's Elbow: It is similar to tennis elbow but less common. Pain is localized to medial epicondyle at the site of common flexor tendon. ‘Treatment is usually conservative. Rowing: Rib fractures and intercostals muscle tears are the common problems associated with rowing. Tendon problems such as “Intersection Syndrome" can also occur in which a tendinitis occurs where first and second extensor tendon compartments cross. Football: Multiple types of injuries are associated with this sport including fractures, groin injuries, knee injuries and muscle tears. Specific injuries include turf toe and neuromas of the deep peroneal nerve due to repetitive trauma from kinking the football. Rugby: This sport leads to high intensity contact injuries ranging from concussion dur to head trauma, neck injuries, muscle tears to shoulder and small joint dislocations. Rugger Jersey finger is the tendon injury of flexor digitorum profundus associated with this sport‘Swimming: Shoulder injuries are more common especially in those who perform butterfly stroke in which rotator cuff tendinitis is more common. Weight Lifting: This leads to chronic stress injuries to spine, shoulders and carpel tunnel. Marathon Runners: ilictibial band syndrome, (in which there is a friction injury of the iliotibial band over the greater trochanter proximally and distally over the tibia) and stress fractures of tibia are more common. To conclude; every physical activity when exceeds to a certain threshold can lead to injury of the involved region. Knee Injury Knee injury most commonly occurs in contact sports, applying excessive loads and rapid turing. The most common injuries within the knee are; 1 Anterior cruciate ligament 2. Dislocation of patella 3. Intra-articular fractures 4. Tear of the meniscus Presentation: The knee joint swells immediately and the patient cannot continue to play in anterior cruciate ligament injury and intra-articular fractures. If the patient continues to play and the knee joint swells later, then the injury is more likely to be a tear of a meniscus. Diagnosis: The early diagnosis of a knee injury is very difficult as the knee joint is too painful to examine. Early diagnosis may need joint aspiration. Aspirate will be blood stained in cruciate ligament injuries and will contain fat globules in intra-articular fractures. Joint aspirate in meniscal injury will be clear. Subsequent diagnosis relies on detail clinical examination and MRI of the joint Treatment: Treatment of acute injuries by physiotherapy and analgesics to maintain the muscle strength may allow most acute injuries to settle. Sports Injuries Later when the physiotherapy fails to build the muscle strength of the patient to stabilize the knee joint, then reconstruction of the cruciate ligament may be considered, using a synthetic graft or tendon transfer technique. Ankle Injury Ankle sprains are the most common type of injuries. They mostly occur due to inversion, when the lateral ligament complex, fibula and talus can be injured. Eversion may lead to the medial ligament complex, but are less common. Diagnosis: it is usually clinical and X-Ray should only be done if the Ottawa ankle rules are fulfilled, The Ottawa rules are; © Bone tenderness along the distal 6cm of the posterior margin of the lateral maleolus. © Bone tenderness along the distal 6cm of the posterior margin or the tip of the medial maleolus. » Inability to bear weight at the time of the accident or at the time of the examination. Treatment: Ankle sprains should be treated with analgesics, ice and __ elevation. Physiotherapy is the mainstay of the treatment plan. Principals for the Treatment of all sorts of Sport Injuries: In any sort of acute injury, "PRICE is the initial treatment. © Protect Rest Ice Compression Elevation Analgesics, especially NSAIDS in the acute phase help to control pain, splinting also helps to reduce pain and healing as well. Steroid injections can be used in certain injuries but it should certainly be avoided in Achilles tendon injury. Some patients develop myositis ossificans after muscle injury, and it can be treated with indomethacin to prevent further formation.VE TYPES: Neurapraxia (nerve not working): it is a disorder of the peripheral nervous system in which there is a temporary loss of motor and sensory function due to blockage of nerve conduction, usually lasting an average of six to eight weeks before full recovery. Neurapraxia results in temporary damage to the myelin sheath but leaves the nerve intact and is an impermanent condition; thus, Wallerian degeneration does not occur in neurapraxia. Axonotmesis (axon divided): itis a disruption of nerve cell axon, with Wallerian degeneration occurring below and slightly proximal to the site of injury. If axons, and their myelin sheath are damaged, but Schwann cells, the endoneurium, perineurium and epineurium remain intact is called axonotmesis. Axonotmesis is usually the result of a more severe crush or contusion than neuropraxia. Neurotmesis (whole nerve divided) (In Greek tmesis signifies "to cut”), Itis the most serious nerve injury in the scheme. In this type of injury, both the nerve and the nerve sheath are disrupted. While partial recovery may occur, complete recovery is impossible. Wallerian degeneration is a process that results when a nerve fiber is cut or crushed, in which the part of the axon separated from the neuron's cell body degenerates distal to the injury Clinical features: Impairment of motor function Diminish or loss of tendon reflexes Pain and temperature sensation is impaired more than touch and vibration Paresthesias and dysesthesias are burning, pins and needles and stabbing sensations Deformity and trophic changes * Autonomic dysfunctions such as anhidrosis and orthostatic hypotension Investigations: i. Nerve conduction studies. ii, Electromyography (EMG) By these tests neurapraxia can be distinguished from axonotmesis & Neurotmesis. Treatment: a. Open injuries: ‘When there is clinical evidence of nerve injury associated with wound, surgical exploration of nerves that are vulnerable to injury (damage) should be routinely performed. b Closed Injuries: In closed injuries. Neurapraxia & axonotmesis recover spontaneously. * In case of Neurotmesis there is no spontaneous recovery & following options can be useful © Surgical repair. © Direct nerve suture. © Nerve grafting. SPECIFIC NERVE INJURIES The main principle of checking any muscle's power is to put that particular into action against resistance. Some of the common nerve injuries are described below. Brachial plexus injury: Most common causes a * Birth trauma is the most common cause + Traction as a result of violent displacement of shoulder as in road side accident. © — Open or penetrating injuries. © Malignant infiltration e.g. pan coast tumor. UPPER BRACHIAL PLEXUS PARALYSIS Congenital is known as Erb Duchenne palsy. There is loss of abduction and external rotation at the shoulder joint. There is loss of flexion and supination at the elbow joint. There is sensory loss on lateral surface of forearm and hand.arm is internally rotated anc extended at elbow. Movements of hand and forearm are unaffected.Figure showing features of Erb's palsy Axillary nerve (C5 C6): Most commonly injured in case of shoulder joint dislocation, fracture of neck of humerus. Deltoid muscle is paralyzed and overhead abduction is not possible. There is sensory loss ‘over a small area on outer aspect of shoulder. Clinical Test: Patient is asked to abduct arm once the angle Peripheral Nerve Injuries between side of chest and arm is greater than 15 degrees and less than 90 degree. Long Thoracic Nerve: It supplies serratus anterior muscle. Most commonly injured nerve during surgery of breast (radical mastectomy) or chest wall. Its injury leads to winging of scapula. Clinical Test: The test for identifying a long thoracic nerve injury is the 'serratus wall test’. The patients asked to face a wall, standing about ‘two feet from the wall and then push against the wall with flat palms at waist level. Winging of scapula on affected occurs if nerves injured Figure demonstrating winging of right scapula on performing “serratus wall test” Radial Nerve (C6, C7, C8): Tt is most commonly injured in radial groove in association with fracture of shaft of humerus, causes crutch palsy. Radial nerve innervates the following muscles Triceps Brachioradialis, * Supinator © Extensor muscles of the wristand fingers © Abductor of thumb Clinical Test: Brachioradialis: Paralysis of extension of elbows, flexion of elbow with forearm midway between pronation and supination. Orthopedic Surgery° a “4 S 3 o Auabuns ‘A comprehensive approach to principles of systemic surgery Figure demonstrating brachioradialis muscle testing Extensors of wrist joint: Extensor carpi radialis longus is supplied by the main radial nerve and all other extensors of wrist joint are supplied by posterior interosseous branch of radial nerve. Injury to the radial nerve leads to failure of extension at wrist joint; the condition is called wrist drop. Perea The position of the wrist in “wrist drop” Figure demonstrating wrist drop Extensor digitorum: It is responsible for extension of metacarpophalangeal joints and also helps in extension of interphalangeal joints with lumbricals and interossei. It is tested by asking the patient to extend the metacarpophalangea! joints. Triceps muscle: If radial nerve is injured above the radial groove then triceps is also paralyzed and patient cannot extend the arm against resistance. Median Nerve: Median nerve can be injured at: Elbow joint because of fractures of distal humerus or dislocation of elbow joint Wrist joint (most common) because of lacerations, fractures of distal radius or compression in carpal canal. When injured at elbow joint, it leads to the paralysis of pronators of forearm and flexors of wrist and fingers, flexor carpi ulnaris and medial Part of flexor digitorum profundus are preserved Also there is paralysis of thenar muscles which lead to loss of abduction and opposition of thumb. Sensations are lost over palmer aspect of thumb, index & middle fingers and radial half of sing finger. When median nerve is injured at wrist joint, :he Pronators of tne forearm and flexors of wrist and fingers are preserved. All other findings are same: Clinical Test: Flexor policis longus: This muscle is paralyzed when median nerve is injured at elbow joint or above. Patient is asked to flex distal phalanx of thumb against resistance while proximal phalanx isheld by the clinician, » ae po Cae i, Figure demonstrating flexor polics longus testFlexor digitorum superficialis and profundus (lateral half): Patient is asked to clasp the hands. If these muscles are paralyzed, the index finger of the affected side cannot flex and remains as “pointing index’. Abductor policis brevis: Patient places the hand supine on a table and is asked to touch pen helda little above the palm level with the thumb. Opponens policis: When this muscle is paralyzed, patient cannot swing thumb across the palm to touch tip of finger. Ulnar nerve: Ulnar nerve is commonly injured at the level of medial epicondyl of humerus and by laceration of forearm. Its injury leads to paralysis of the small muscles of hand except thenar muscles and ‘ateral two lumbricals. It results in weakness of flexors at metacarpophalangeal (MP) joint and weakness of extensors at interphalangeal (IP) joints .It leads to claw type deformity of hand. Lesions proximal to elbow joint also cause paralysis of flexor carpi ulnaris and medial half of fiexor digitorum profundus. There is also sensory Joss over the medial one and half finger. Clinical Tests: Flexor carpi ulnaris: when this muscle is paralyzed and hand is flexed against resistance, hand tends to deviate towards radial side Radial Deviation Peripheral Nerve Injuries [Et Interossei: i, Abduction against resistance is checked for dorsal interossei ii, A card is inserted between the extended fingers and patient holds the card while clinician tries to pull it out. It will give an idea about the power of palmer interossei .Interossei and |umbricals cause extension at IP joints through extensor expansion and can be tested by asking the patient to extend the distal phalanges while clinician is. holding the proximal phalanx. First palmer interosseous and adductor policis: patient is asked to grasp a book between extended thumb and index finger; if these muscles are paralyzed patient will flex his thumb to grasp the book which is function of flexor Normal Froment's positive Figure demonstrating forment's sign Sciatic nerve: Sciatic nerve injury is not very common but it can be injured in fracture of the pelvis, posterior dislocation of hip joint, surgery for hip joint replacement or tumors. Flexors of the knee joint are paralyzed and all the muscles below knee are paralyzed. Foot drop occurs.. There is also complete loss of sensations below knee except medial border of foot which is supplied by saphenousnerve Common peroneal nerve: Partial injury of sciatic nerve usually affects the peroneal division more commonly ..it swings around the head of the fibula to anterior aspect of leg. It may be directly injured by fractures and dislocation and surgery around knee joint and presence of cast or splint. Its complete lesion causes paralysis of extensors of ankle joint and peroneal muscles. Foot drop occurs with weakness of eversion of foot.Tibial nerve: deformity of foot and loss of sensation over Tibial nerve supplies all the calf muscles i.e. plantar aspect of foot. It continues as posterior plantar flexors and invertors of foot and toe. It tibial never which may compress in tarsal tunnel can be injured by fracture of proximal cause tingling pain and burning over sole after tibia. Complete interruption cause calcaneovalgus standing or walking for long time. Management Principle 1. Operation is useful only when the muscles supplied by it have not degenerated and cen function if nerve supply is restored. This is confirmed by EMG studies. Principle 2. For motor nerve maximum time is 01 year. For sensory nerve it is 1 V2 year. Nerve injured a ™~ Consérvetive management Incised wound Blunt Injury © Physiotherapy or the injury is “ suggestive that Splints the nerve is cut © TENS (Nerve stimulation) | Monitor progress © Clinically NCS & EMG studies Exploration of the Nerve © Primary repair with ‘AT 03 WEEKS EVALUATE 8 Zeroprolene. © Clinically: + Nerve graft if loss » NCS&EMG ofnerve > 2m. (Forms the base line + Nervetransfer into evaluation) ‘non-functioning ‘group of muscles Note: Useful in ower J injuries. Inhigher injures by the time the nerve AT03 MONTHS EVALUATE grows the muscles have Clinically lost their function to recover ~ NCS&EMG (Decision making evaluation) fe groreere “~~, ‘No Improvement: Improvement Conservative management © Physiotherapy > Splints Tendon transfer * TENS (Nerve _ . stimulation) With permission from » Monitor progress Prof. Brig. Irfan Shukr SI (M) o Clinically NCS &EMG studiesOSTEOARTHIRITIS (OA) Osteoarthritis is the degenerative joint disease. It involves a group of mechanical abnormalities including articular cartilage and subchondral bone abnormalities. Osteoarthritis (OA) of a joint may occur as a primary idiopathic condition or secondary to problems such as malalignment, intra-articular fractures or over-stressing (obesity, overuse). In some patients, there is a strong genetic component. OA may occur in any joint (shoulder, elbow, wrist and hands) but predominantly affects those that are weight- bearing (knee and hip joints) Clinical features: © Pain in joint and surrounding muscles especially after movement. © Swelling of involved joint. Affected joint may produce a crackling sound on movement. ~ Jointeffusion. ~ Asymmetrical joint involvement. Diagnosis Diagnosis is made on history and clinical exam and x ray is the investigation of choice to confirm the diagnosis. The typical changes seen on X rays are as follows joint space loss due to thinning of articular ‘cartilage Subchondral cyst formation Osteophytes. RE ee ee a ORM a Degenerative Bone Diseases Management © Life style modifications including weight reduction and proper glycemic control in obese and diabetics respectively. Off-loading : This involves the use of aids, such as a walking stick and weight loss, aimed at reducing the forces passing through the joint © Moderate exercise and physiotherapy. © Analgesia: acetaminophen is the first choice and if not helpful then switch to NSAIDs in step ladder pattern. © Topical NSAIDs are of great help in reducing pain and have less systemic side effects. ~ Bone and cartilage synthesizers can also be of help. © Injections: introducing a mix of a corticosteroid and local anaesthetic into the joint may reduce inflammation and ease pain. Injections of compounds of hyaluronic acid are increasingly used and are designed to supplement the natural joint levels of hyaluronic acid essential to normal functioning of articular cartilage. They work best in early OA but may have only a temporary effect in late-stage disease © Failure of conservative methods in advanced OA would require surgical intervention .The main operative interventions include osteotomy, joint replacement (arthroplasty) and fusion of the joint (arthrodesis). Rheumatoid Arthritis Rheumatoid arthritis (RA) is symmetrical, inflammatory polyarthropathy with systemic manifestations affecting multiple systems including skin, heart, lungs, nerves, eyes and vasculature. This disease typically presents with early morning stiffness, hand deformities, symmetrical arthritis and rheumatoid nodules in skin. Common joint deformities associated with RAare; » Boutonniere deformity » Swan Neck Deformity » ZthumbAsaGung a1pedoyzyi9o A comprehensive approach to principles of systemic surgery Flexed DIP joint Flexed DIP joint Pictures showing Swan neck deformity in RA The rheumatoid arthritis is the inflammation involving the synovium followed by pannus formation and release of destructive enzymes and cytokines which destroy the underlying cartilage. Inflammation of other synovial structures such as tendon sheath causes tendon rupture leading to deformity and disability. Diagnosis is usually clinical but presence of serum rheumatoid factor (usually IgM but can be IgG, IgE or IgA) and radiological features are confirmatory for this disease. Radiological features include; Loss of joint space Periarticular soft tissue swelling Periarticular erosions Joint deformity/malalignment No osteophytes Periarticular osteoporosis X-Ray findings in Rheumatoid arthritis, Principals of managementin RA are; Stop synovitis, Pain relief Prevent deformity Reconstruct diseased joints Rehabilitate the patient Medical Management of RA includes NSAIDs and analgesics, disease modifying drugs like sulfasalazine, gold and penicillamine immunosuppression using methotrexate and steroids may help to stop the disease progression. Surgical management is advocated mainly for the deformities and improving functions as wel. Options include; Synovectomy (e.g. elbow, wrist etc which improves pain and prevents tendon ruptures) Arthrodesis (e.g. ankle, knee and wrist for pain relief) Joint replacement ( e.g. Hip, knee and shoulder) Excision arthroplasty Tendon reconstructions. Ankylosing spondylitis (AS), spondyloarthropathy, is a chronic, multisysteninflammatory disorder involving primarily the sacroiliac (SI) joints and the axial skeleton, The ‘outcome in patients with a spondyloarthropathy, including AS, is generally good compared with that in patients with a disease such as rheumatoid arthritis. Rotator Cuff Injuries Rotator cuff muscles include Supraspinatus, infraspinatus, Subscapularis and Teres Minor. Injuries related to Rotator cuff muscles can be divided into two groups. Acute: It ranges from small cuff tears to massive tears >5cm. Chronic: Includes Impingement syndrome and cuff arthopathy. ‘Acute injuries can involve both young and elderly patients but chronic injuries are more commonly associated with increasing age. Coracoacromial Ligament Impingement (Painful Arc Syndrome) and Cuff Tendonitis: The cuff of the rotator muscles moves in a narrow space between the acromion and the coracoacromial (CA) ligament. It is due to this reason; a small injury can lead to inflammation, swelling and pain, which results in impingement of the cuff. Impingement may cause further swelling anda vicious circle may start. The other Degenerative Bone Diseases cause of the impingementiis a beak of bone which tends to appear beneath the acromion with increasing age. The painful arcs the result of the jamming of the inflamed supraspinatus tendon under the subacromian beak. Treatment: Local injection of steroid can break the vicious circle of impingement and tendonitis. Arthroscopic excision of the subacromial beak and of the CA ligament can also give 2 good relieve of symptoms, Rotator Cuff Tears: Tears are also more common in the elderly as the cuff does not have a good blood supply, so the degenerative changes weaken itwith time. Tt can also occur in young patients after a major trauma. Diagnosis can be made by injecting a local anesthetic, after which the pain factor is removed but weakness persists. Several clinical methods, can be used to diagnose cuff injury. Ifstill in doubt or to see the extent of the tear (especially if any surgery is planned) then MRI is the investigation of choice. Treatment depends upon the age of the patient, lifestyle and severity of symptoms. Arthroscopic or open repair may be considered for all the tears, Tendon transfer, patch grafts or reverse joint replacement can be considered when the size of the tear is too large to do primary repair. Dupuytren's contracture This is proliferative fibroplasias of the palmer and digital fascia that results in the formation of nodules and cords leading to flexion contracture of the fingers. It is associated with smoking, trauma, epilepsy, AIDS, hypothyroidism and alcoholic cirrhosis. Clinical Features include palmer nodules, skin puckering, cords of the palm and digits. It most commonly occurs on the medial aspect of the hand. Garrod's knuckle pads are the thickened skin on the dorsum of the proximal IP joint. It also Produces cords in the penis leading to Peyronie's disease in which the penis becomes curved. Surgery is indicated when the patient cannot put his hand flat on the table due to the deformity. Great care is needed during the surgery as digital nerves may be trapped in the fibrous cords. Fixed contracture prevents useful function of the hand, and in long standing contracture, excision of the 1 ; 'situations amputation of contracted finger may be required. Carpel Tunnel Syndrome {tis a syndrome associated with compression and ischemia of the median nerve in the carpel tunnel. Causes: Most of the cases are idiopathic but it is also associated with diabetes, obesity, alcoholism, thyroid disease, pregnancy and inflammatory arthritis. / Clinical Features: Patient typically presents with complains of tingling and numbness in the radial three and a half fingers. Patients also complain of being woken up at night due to pain which is relieved by hanging their hand out of the bed. Picking up of objects, combing or carrying heavy objects may also get cumbersome. Diagnosis: Clinically there is may be wasting of the thenar muscles. Various clinical tests can be done to diagnose this clinically e.g. Phalen’s test and Tinel's test Nerve conduction studies (NCS) canalso be done. ‘Treatment: Local steroid injections, conservative measures like reducing weight, controlling diabetes may also help. Surgical decompression by releasing Transverse carpel ligament may be advocated in resistant cases. Pharmacologictherapy Agents used in the treatment of AS include the following: ~ Nonsteroidal (NSAIDs) Sulfasalazine Tumor — necrosis antagonists Corticosteroids anti-inflammatory drugs factor-o (TNF-a) Surgical therapy The following procedures can be used in the surgical management of AS: ~ Vertebral osteotomy - Patients with fusion of the cervical or upper thoracic spine may benefit from extension osteotomy of the cervical spine » Fracture stabilization ~ Joint replacement - Patients with significant involvement of the hips may benefit from total hip arthroplasty RICKETS AND OSTEOMALACIA Rickets in children and osteomalacia in adults, due to the nutritional deficiency of vitamin D, is frequently seen in developing countries. Failure of adequate calcium supplementation in patients undertaking antiepileptic medications may result in osteomalacia. Biochemical parameters of low serum calcium and phosphorus and elevated serum alkaline phosphatase along with radiological evidence of ‘cupping, fraying and splaying' of the metaphysis is diagnostic of rickets. Supplementation of vitamin D and calcium improves the biochemical abnormalities along with the radiological changes of a white line of mineralization of healed rickets, unless there is vitamin D-resistant or renal rickets. OSTEOPOROSIS Osteoporosis represents a reduction in bone density due to @ higher rate of bone resorption compared to bone formation. The physiological peak bone mass attained in early adulthood decreases in the elderly, more so after menopause in women. Thyroid disorders, Cushing's syndrome and steroid intake increase the degree of osteoporosis. A DEXA scan quantifies the amount of osteoporosis. Calcium supplementation along with alendronate (bisphosphonates), nasal calcitonin spray or perathormone (teriparatide) are used to treat severe osteoporosis CEREBRAL PALSY (CP) This is disorder of movement and posture due to a defect in the developing brain. CP is usually caused by adverse birth events, such as hypoxia and infection, and comes in a variety of forms (spastic, athetoid, ataxic, mixed) and extents: monoplegia (one limb - rare), hemiplegia (one side of the body affected), diplegia (both lower limbs affected), tetraplegia and quadriplegia. Different gait patterns such as scissoring, crouch, bunny hop, in-toeing or pigeon gait may be seen in cerebral palsy. Contractures can be treated with regular stretching, botulinum toxin, tendon release or muscle transfer. Bony abnormalities may require osteotomy.Upper GIT The Esophagus Stomach and Duodenum Liver Spleen Hepatobiliary system Pancreas Peritoneum, Mesentery And Retroperitoneal Space 43 57 7¥ 86 90 108 i119 41Anatomy The esophagus extends from the cricoid cartilage (at the level of vertebra C6) to the gastric cardia and is 25 cm long, It has cervical, thoracic and abdominal portions. The esophagus passes through the diaphragm at the level of the 10th thoracic vertebra and the final 2-4 cm lie within the peritoneal cavity. The esophagus has an upper sphincter, the cricopharyngeus, and a lower sphincter that cannot be defined anatomically but is a 3-5 cm high-pressure area located in the region of the oesophageal hiatus of the diaphragm. The esophagus is held loosely in the hiatus by a thickening of fascia, the phreno-oesophageal ligament. Phan: Junction of esophagus with pharyox Esophagus Where esophagus is ‘crossed by arch of ‘aorta Where esophagus 's compressed by J) }etimainbroncias io atm p= Diaphagm ‘The esophagus receives its blood supply from the inferior thyroid artery in the cervical region, the bronchial arteries and branches from the thoracic aorta in the thorax, and the inferior phrenic and left gastric arteries in the abdomen. Venous drainage is to the inferior thyroid veins in the neck, the hemi-azygous and azygous veins (systemic circulation) in the thorax, and the leftgastric (portal circulation) in the abdomen. The connection between these veins is important in the development of varices in patients with portal hypertension. GASTRO-ESOPHAGEAL REFLUX DISEASE: GERD Gastro-esophageal reflux means reflux of gastric contents into the lower esophagus. It is a normal physiological phenomenon and when it causes symptoms, it is called gastro-esophageal reflux disease (GERD).it is one of the major health problem and may affect upto 20-40% of the population What prevent GERD? 1. Lower esophageal sphincter is formed by distal 4cm of esophageal smooth muscles and this lower esophageal sphincter prevents gastric and duodenal contents from reflux in to the lower esophagus. The normal LOS is 3-4cm long and has a pressure of 10-25mm Hg. 2. Lower end of the esophagus lies intra- abdominally which act as a valve and prevent the movement of gastric contents into the esophagus when intra-gastric and intra- abdominal pressure rises. 3, Normal peristalsis allows the rapid clearance of esophagus into stomach. 4. There is angulation between the esophagus and stomach which prevents reflux. What causes reflux? Some degree of reflux is a normal phenomenon. The lower esophageal sphincter relaxes transiently in response to food intake to vent the swallowed air. But when there is increase in transient lower esophageal sphincter relaxations (TLOSRs), the sphincter becomes incompetent and allows abnormal exposure of esophagus to acidic-contents. In 60% of the patients, mechanically defective lower esophageal sphincter is responsible for GERD. Other factors which are associated with reflux are given as: '* Pregnancy and obesity. Fat, Alcohol, Large meal. Spicy diet. Smoking. Hiatal hernia.