‫‪Surgery‬‬

‫‪Essay of Surgery‬‬
‫أعداد وتصميم ‪-:‬‬
‫‪-‬خلــيـــل ســـراج‬
‫شكر وتقدير لكل من ساهم ‪-:‬‬
‫‪ ‬اللجنة العلمية لدفعة ‪ 31‬ودفعة ‪33‬‬
‫‪ ‬الجـــــــــــعــــــدي (دفعة ‪)33‬‬ ‫‪‬ابراهيم شداد ( دفعة ‪)33‬‬
‫‪‬مهيب غيالن ‪‬هاشم المسوري ‪‬عبدالقادر الغبري‬
 SURGERY EXAM
orthopedic SURGERY
1. Open bone fracture (definition , classification and management) 28 ‫مكرر دفعة‬ ‫دفعة‬
33

Definition: site of fracture and or hematoma in communication with outside due to soft tissue injury.
Classification:

•Type I: open fractures with a small, less than one cm clean wound with minimal injury to the musculature,
simple with minimal comminution
•Type II: open fractures with 1–10 cm wounds but no significant soft tissue damage or avulsion. Moderate
comminution.
•Type III: open fractures with larger wounds and associated extensive injury and significant contamination of
the wound. The fracture may be segmental.
IIIa: extensive contamination or injury to the underlying soft tissues, but adequate viable soft tissue is present to
cover the bone and neurovascular structures.
IIIb: extensive injury to the soft tissues requiring a rotational or free muscle transfer to achieve coverage of the
bone and neurovascular structures. These usually have massive contamination.
IIIc: open fractures with associated vascular injuries that require arterial repair.
Management:
General measures
1- ABC’s “primary survey”
2- Assess entire patient by C. Examination
3- Anti tetanus
4- Local irrigation 1-2 liters
5- Sterile Compressive Dressing.
6- Realign Fracture & Splint.
7- Recheck Pulse, Motor, and Sensation.
8- Appropriate IV antibiotics.
9- Meticulous injury zone excision (Debridement & Irrigation).
10- Fracture stabilization.
11- Soft Tissue Care.by vacuum assisted closure or graft or flab
12- Second look Early soft-tissue cover after soft-tissue recovery.
Definitive Treatment:
Type I: After proper tissue management can be treated as a closed fracture
Type II: Soft tissue managment (excision, cleaning), unreamed nailing or plate fixation.Primary closure is possible.
 Type III: Soft tissue management (excision, cleaning), unreamed nailing or plate fixation: up to III/B; OR external
fixation.Cover of the wound / bone: plastic surgery, flaps reconstruction of vessels / nerves.
2. Q7 Osteomyelitis (definition,diagnosis, and management) 29 ‫مكرر في دفعة‬ ‫دفعة‬
33
Definition: infection of bone
Diagnosis :
Clinical picture:
-Acute: -Chronic:
•The patient is usually a child with severe limb pain, •History of acute osteomyelitis may be given.
malaise and fever. • The commonest presentation is a sinus
• The child refrains from using the limb. which discharges pus.
• The earliest sign is severe localized • Pain and swelling in the affected bone.
tenderness over the inflamed bone.
• Later, there is warmth, oedema and the skin is red.

Investigations :
A. Lab :
•Polymorphonuclear leukocytosis and raised ESR.
• A blood sample for culture should be obtained before starting antibiotic therapy
B. Imaging:
1. X ray:
Acut chronic
normal during the first two the most important. It
weeks. Rarefaction and periosteal new reveals that the bone is thickened with
bone formation are late radiological patchy and irregular sclerosis
findings surrounding a bone cavity that may
contains sequestra.

2. Radioisotope scanning
3. MRI can detect osteomyelitis before theappearance of radiological changes on plain radiography.
C. The most certain way to confirm the clinical diagnosis is to aspirate pus from the metaphyseal subperiosteal
abscess or the adjacent joint.

Management:
Acute osteomyelitis: Chronic osteomyelitis:
1- Antibiotic therapy. Surgery is the main line of treatment It
-The core of treatment is early administration of mainly involves removal of dead bone
high-dose IV antibiotic that is effective and drainage of the cavity
against S. aureus, after taking a blood or
abscess sample for culture. 1- Sequestrectomy (removal of dead bone)
-These include clindamycin, first-generation 2- Saucerization (to provide adequate drainage)
cephalosporins and oxacillin. 3- Excision sinuses
4- Obliteration of the dead space by cancellous bone
2- After about 5 days when the condition chips or local muscle flaps enhance healing
of the patient improves, oral antibiotics
are prescribed and are continued for 3-6 weeks. 5- Postoperative support of the limb to avoid a
3- SUPPORTIVE TREATEMTN :- pathological fracture until healthy strong bone
-pain  analgesic regenerates
-dehydration  IV fluids”
4- Splinting of the affected part. Splinting
is continued until the inflammation
subsides and the X-ray shows that there is
no risk of a pathological fracture.
6- Surgical drainage of overlying abscess
3. Q5 Septic arthritis 27+29‫مكرر في دفعة‬ ‫دفعة‬
32
Definition:- Infection of the joint space.

Epidemiology:- Etiology
-children are the MC age -causative organism:-
-Hip and knee joints are the most common affected Staph. Aureus is the MC organism
joints H.Influenza Is the MC organism in infants
N.gonorrhea is common in sexually active females

-Routes of Spread
1- Hematogenous route is the MC
2- Direct contamination either by incidental trauma
or iatrogenic
3- Contagious Spread either from osteomyelitis or
near soft tissue Infection

-Risk factors:- Clinical feautures:-

1- chronic skin infection 1- acute pain and joint swelling are the 2most
2- intervention in joints common symptoms
3- IV drug use – 2- immobility and loss of function
4-underlying joint disease 3- in neonates symptoms of sepsis predominate
5- immune compromised 4- red,swollen,flexed,warm,tender,joint
6- prosthetic implant 5- may be discharging sinus or fluctuation
6- both active and passive movement are restricted .

Investigations
LAB:-
1-There is leucocytosis and elevated ESR.
2- blood culture positive in 50%
3- Aspiration of the synovial fluid : turbid, wBC>50000,PMN>75% ,Gram stain to guide empiric therapy. Culture
and sensitivity test reveals the causative organism guiding the targeted therapy.
Imaging
1- X-ray: In early cases (first 2 weeks)non specific. Later, there is rarefaction of the
articular ends of bones followed by narrowing of joint space, irregularity of joint surfaces and subchondral
sclerosis.
2- US: very sensitive to detect effusion, define the extent of S.A ,differentiate it from other dd
3- Radio isotope scan and CT-Scan: used in sternoclavicular and sacroiliac joint
4- MRI: most useful in assessing the presence Of acute osteomyelitis as a cause.

Treatment :-
1- Arthrocentesis
2- analgesic and splinting until inflammation subside
3- fluid replacement and nutritional support
4- other foci Of infection and medical conditions must be identified and treated
5- I.V antibiotics: flucloxacillin,3rd cephalosporins
6- surgical drainage
Indications :-
A- if not respond to daily Arthrocentesis and antibiotics
B- any joint with limited accessibility
C- pt with underlying disease like D.M, RA, Immunosuppression
4. Q7 Bone metastases ‫دفعة‬
32
Epidemiology:
•the MC malignant tumor of the bone
•Is third MC Site for metastasis
•Metastases usually appear in areas containing red marrow
A- Spine. C- ribs. B- Pelvic bone D- upper ends of femur

Classification:
a. Osteolytic deposits. These destroy and replace bone eg : thyroid cancer , melanoma,MM ,RCC
b. Osteoblastic (bone-forming) deposits are uncommon. They usually occur in prostatic carcinoma, SCLC
C. Mixed Breast cancer
Clinical features:
1. Patients are usually aged 50-70 years.
2. Pain is the commonest and often the only clinical feature.
3. pathological fracture may occurs.
4. Symptoms of hypercalcaemia may occur (often missed).
5. Spinal cord compression

Investigations
A, Laboratory tests
•ESR. • haemoglobin. • serum alkaline phosphatase. • acid phosphatase and calcium
B. Imaging
1- X-ray: the best initial test for extremity cases.
• Most skeletal deposits are osteolytic and appear as rare areas in the medulla or produce a mouth-eaten
appearance in the cortex.
• with or without pathological fracture.
2- Contrast-enhanced MRI: is the first line in spinal lesion.
3- PET-CT scan for staging
4- Radioscintigraphy with 99mTcHDP is the most sensitive method of detecting
II) silent metastasis and indicated if a metastatic bone lesion is identified by x-ray to detect the other sites.
C. Biopsy for confirmation.

Treatment: is palliative.
1. Pain management local thermal ablation or radiation are used in addition to pharmacotherapy.
2. Systemic therapy
A- Chemotherapy
B- Osteoclast inhibitors (e.g., bisphosphonates ): inhibit resorption
3- localized tumor radiation
4- Surgery
•If pathologic fractures have occurred or are likely: stabilize and restore function by a combination of internal
fixation and radiotherapy.
•If spinal instability or spinal cord compression has occurred or is likely: immediate decompression and
stabilization.
5. Q5 Osteosarcoma ‫دفعة‬
31
Definition :-
Is a highly malignant primary tumor arising from the multipotent mesenchymal tissue and characterized by the
formation of bone osteoid tissue.
Epidemiology
• It is the most common primary cancer of the bone.
• Male > Female
• Incidence:- bimodal distribution 1ry in young 10-20yo. 2ry in older than 60yo.
Rule of 80 Etiology
80% of osteosarcoma occur in teenagers Primary is unknown
80% in the lower limb Secndery has predisposing factors
80% around the knee 1- Irradiation.
80% in the lower end of the femur 2- Paget's disease of bone
80% in the metaphysis. 3- Fibrous dysplasia
Spread:-
1- locally but never pierce epiphyses
2- Hematogenous mainly to lung & liver

Pathology Clinical features:-

Macroscopic
1- osteoblastic type:- grayish white gritty
2- Chondroid type :- bluish opaque
3- Fibroblastic type:- fish-flesh app.
4- Telangectic or osteolytic:- necrosed filled with
blood
Microscopic
Osteoid spindle cells,giant cells,blood
cells,sarcomatous cells.
1- Pain is the predominant and usually the first
symptom; it is constant, worst at night
2- may be swelling and may rapid grow
3- warm,red,slightly tender,firm tumor
4- pathological fracture rarely occur
5- Signs and symptoms of metastasis Cough and
hemoptysis or jaundice and Abd. discomfort

Investigations
Laboratory : 1- The ESR 2- in serum alkaline phosphatase.
Imaging
1- X-ray may show : •
Streaks of new bone formation, radiating outwards from the cortex (sun-ray appearance).
• Reactive new bone formation at the angles of periosteal elevation (Codman's triangle).
• Hazy osteolytic areas affecting the cortex (ghost of cortex)”Moth eaten appearance”
2- CT and MRI reliably show the extent of the tumour.
3- Bone scan for Intramedullary spread.
4- Chest X-ray and Abd. CT for metastasis. Biopsy is essential to establish the diagnosis
Treatmen
A- local treatment B- Chemotherapy C- Immunotherapy
1- limb sparing strategy Methotrexate, endoxon, and Portion of excised tumor inject to
In early cases with radical excision cisplatin are the common used tumor survivor pt for 14 days then
of tumor with 10 cm safe margin drugs. Indications taken and inject the lymphocytes
and fills with bone graft or 1- pre or post operation to pt to prevent recurrence
prosthetics 2- pts reject surgery
3- inaccessible site
2- High amputation with
disarticulation of the above joint
6. Mangement of open fractures and pathological fractures ‫دفعة‬
31
Management of open fractures see Batch 33 Q5

Management of pathological fracture :

Goal of Treatment: To provide pain-free maintenance of normal daily function

Definition: a spontaneous fracture following mild physical exertion or minor trauma (e.g., lifting something,
bending over, or sneezing/coughing) due to abnormal weakness of the bone that is

caused by an underlying condition.

1. Management of pain : Non-narcotic analgesics NSAID's Narcotic analgesics Interventional anesthetic techniques
2. Avoiding the fracture (Fixation, Cement) Bone stabilization (Fixation, Cement)
3. Conservative measures By treatment the underlying medical disease to prevent recurrence and improve the
healing (Hormonal Therapy, Bisphosphonates)
4. Radiotherapy / Chemotherapy if the cause is cancer metastasis
5. Surgical (Resection, Amputation) If the cause is primary cancer

7. The fracture of the femur neck 25+ 26 ‫مكرر دفعة‬ ‫دفعة‬

27
 ‫اعادة الموضوع بطريقة كتابية مختصرة‬
Fracture neck femur may be intracapsular or extracapsular
A. Intracapsular fracture of neck femur:
Clinical picture:
I. In unimpacted displaced fracture (horizontal &
abducted):
- The hip is adducted and externally rotated
- The greater trochanter is raised
- The patient is unable to raise the leg
- The movement of the hip are painful Shortening of
the limb
Complications:
1- Avascular necrosis (15-35%):
2- Non-union may occur due to:
a- Difficulty of adequate immobilization.
b- Poor blood supply to the proximal fragments
c- Little or no periosteum or surrounding soft tissue.
d- Lysis ofthe blood clot by the synovial fluid
3- Thromboembolism (25%)
4- Mortality in elderly 20%: during the first 3 months
after fracture in elderly person
5- Secondary osteoarthrosis
II. In impacted fracture (vertical & adducted):
-Tenderness over the fracture site
-No rotation occurs
-The fracture is abducted
-There may be no abnormal physical sign
-Thes e fractures are missed on clinical examination
and even on X-ray
Treatment
: invariably operative
a. Impacted (in all ages): no reduction is required
internal fixation with plate & screw preferably
b. displaced: under the age of 65 years :- closed
reduction followed by internal fixation,open
reduction if closed one cant be performed
above age of 65 :- replacement with
prosthesis (hemiarthroplasty), early
mobilization is required as avascular
necrosis is common
 B. Extracapsular fractures:
Definition:-
Fractures extending from the base of the neck of the femur to 8cm below the lesser trochanter
Types divided into:
1-trochanteric fracture down to the level of lesser trochanter .
2- subtrochanteric fracture from the lesser trochanter to 8cm below.
•clinical picture :-
1- External rotation and shortening of the limb
2- Tenderness over the affected side
3- Inability to raise the leg
•Complications:
1- Thromboembolism
2- Malunion leading to shortening, adduction and external rotation
•Treatment:
a. in elderly: internal fixation by dynamic hip screws
b. in young patient:
1- Trochanteric may be ttt by immobilization and limb traction
2- Sub-trochanteric: ttt by internal fixation by plate and screws.
8. Complications of internal fixation? ‫دفعة‬
30

1- Post surgical Infection

2-. Complications from anesthesia
3-. Blood clots and fat embolism

4. Implant failure
5. Non union
6. Malunion
7. Refractur

8. Compartment syndrome
9. Nerve injury
10. Bleeding
11. Irritation of the overlying tissue from the hardware.
9. Complications of bone fractures:- ‫دفعة‬
26

A. General complications:

1-Shock:
a- Hypovolemic shock:Due to excessive bleeding in major fractures.
b- Neurogenic shock:Due to pain
2- Respiratory complications:  prolonged recumbency aspiration pneumonia and pulmonary embolism
3- Deep venous thrombosis
4- Fat embolism:May follow multiple or major fractures:
5-Urinary calculi:  prolonged immobilization demineralization of the skeleton and formation of calcium -
phosphate calculi
6- bed sores: may develop 2ry to prolonged immobilization, especially in elderly.
7 Tetanus: may occur in compound fractures

B. Early local complications:

1- Skin injury: fractured bone ends may injure the skin from inside “internal compound fracture
2- Vascular injuries: by fractured : injury of brachial vessels following supra-condylar Fracture of humerus
3- Nerve injuries: 
- This will lead to: Neuropraxia, axonotmesis, or less commonly neurotmesis “cutting of the nerve “
4- Tendon or muscle injury
5- Avascular necrosis of a bone: due to damage of blood supply to some areas of a bone
- Commonest example is: intra – capsular fracture neck of femur -> may lead to Avascular necrosis of head of
femur
6- Visceral injury: As in fracture pelvis -> injury to bladder or urethra.
7- “Volkmann’s ischemic contracture “:- permanent shortening of the forearm muscles resulting in a claw-like
deformity of the fingers, hand, and wrist.developed when cast are too tight or bloo3-vessels or
nerves have been damaged as in supra-condylar Fracture of humerus.
8- infection:
serious complication may complicate
compounds fractures
- It may lead to -> delayed healing, nonunion, or osteomyelitis

C. Delayed local complications:

1-Mal-union: it is occurrence of union but with some deformity as angulation.
2- Delayed union and non-union
3- Joint stiffness and osteoarthrosis:
4- Sudek’satrophy: It is a syndrome of unknown etiology, in which there is: -Osteoporosis.
-Swelling of soft tissue.
-vascular stasis -pain -Joint stiffness
- It may be due to reflex vascular stasis, or reluctance of the patient to use the limb after removal of The splint
- It mostly seen after Colle’s fracture
5- Myositis ossificans: - Mostly seen after elbow dislocation, shoulder, or hip - It may be due to:
a- extensive stripping ofthe periosteum and ossification ofsub-periosteal hematoma.
b- or heterotopic bone formation in adjacent muscle
6- Growth disturbances: in children, if the fracture affects the epiphyseal growth plate.
7- Osteoporosis: due to prolonged immobilization.
10.