ORTHOPED

IC
SURGERY
Dr. Eloise Suan
01. Fractures and Dislocations

02. Joint Injuries

03. Spinal Cord Injuries

04. Tumors of the Bone

 Introduction

Anyone who cares for patients in an

outpatient or emergency room setting
will find that the majority of presenting
complaints involve the musculoskeletal
system.
01.

ORTHOPEDIC TRAUMA

Includes fractures of
bones, damage to joints,
and injuries to soft tissues
Long Bone Fractures
 How are fractures managed?

• Immobilization
• Splints

• Adequate padding on the

underlying skin
• Cast

• Braces
Fractures that are displaced or angulated 
Closed Reduction then splint

Internal Fixation
• Screws
• Plates
• Rods

External Fixators
GUSTILLO-ANDERSON Open Fractures
CLASSIFICATION FOR OPEN
FRACTURES
• Type I: low energy; wounds
are usually <1cm
• Type II: have a wound length
of 2-10cm with moderate
soft tissue damage and
wound contamination
• Type III: high-energy
wounds usually >10cm in
length with extensive muscle
devitalization.
 Treatment

Goal
Immediate administration
Achieve fracture healing of antibiotics
and to prevent wound
infection and
osteomyelitis

Frequently associated Delayed definitive

with injuries to treatment and early
surrounding vessels and wound coverage
nerves
 Medical emergency
usual clinical findings: pain, swelling, and pain with passive
stretch
numbness, paralysis, and pulselessness are late findings
Diagnosis is mainly through clinical examination
Compartment pressure within 30mmHg of the diastolic
pressure

COMPARTMENT SYNDROME
 Treatment

FASCIOTOMY
• Overlying fascia is released through
long incisions
• Must be done as soon as possible to
prevent damage to muscles and
nerves that will result in irreversible
necrosis and Volkmann’s ischemic
contractures with severe loss of
function
 TREATMENT OF
FRACTURES AND
DISLOCATIONS
 CLAVICLE FRACTURES

● Typically occur following a fall onto the shoulder

● MAJORITY OCCUR IN THE MIDDLE THIRD
● Can be treated nonoperatively with a sling, early range of motion
exercises, and gradual return to normal activities
● When to operate? Significant displaced and shortened, or penetrate
or tent the skin
 CLAVICLE FRACTURE

DISTAL ACROMIOCLAVICU
CLAVICLE LAR JOINT
INJURIES
Less common
Displaced and proximal to Occur from either a fall
the coracoclavicular directly onto the shoulder
ligament  SURGERY or onto an outstretched
hand
Majority can be treated
with a sling and gentle
range of motion
 STERNOCLAVICULAR JOINT FRACTURES

Anterior
dislocation
• More common
• Closed reduction
• Recurrence is typical
• Immobilize with sling

Posterior dislocation
• Rare and not grossly visible
• Can result in pulmonary or
neurovascular compromis
• Closed or open reduction
under GA
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 SCAPULA FRACTURES

● Result from significant high-energy

trauma
● 80% are associated with other
injuries (head, ribs, and lungs)
● Treated conservatively
● Involvement of glenoid with a major
step-off or glenoid rim fracture with
subluxation of the joint 
SURGERY
SHOULDER DISLOCATION
• Most commonly dislocated large
joint
• Anterior dislocation is more
common
• BANKART LESION: Shoulder
dislocation associated with injury
to the anterior inferior glenoid
labrum
• HILL-SACHS LESION: Shoulder
dislocation associated with
impaction fractures of the
humeral head
• PE: patient’s shoulder is usually locked in
internal rotation with limitation of
external rotation
• Diagnosis:
• X-ray of the shoulder (APL)
with axillary view (Scapula Y)
• CT scan
• Treatment: Closed reduction followed by
a short period of sling immobilization
REDUCTION OF SHOULDER
DISLOCATION

ANTERIOR DISLOCATION
• Stimson maneuver
• Scapular manipulation
• External rotation
• Milch technique
• Spaso technique
• Davos technique
• Traction-countertraction

POSTERIOR DISLOCATION
• Axial (inline) traction
• Two-step reduction
Perform primary survey. Determine
patient’s general condition and treat
any immediate life-threatening
injury
Anterior VS Posterior Dislocation

X-ray of affected shoulder APL and

axillary view, scapula Y

Associated fractures
 ANTERIOR
SHOULDER
DISLOCATION
 POSTERIOR
SHOULDER
DISLOCATION
 TRACTION -
COUNTERTRACTION
• Patient supine on a securely
locked stretcher, with the bed
elevated to the height of the
operator’s ischial tuberosity
• One sheet or strap is placed over
the patient’s upper chest, under
the axilla of the affected shoulder
and underneath the back, so that
the two ends of the sheet are of
equal length and open at the
unaffected side.
• Standing on the unaffected side,
the assistant takes a firm hold of
each end of the sheet with each
hand
• The physician, with both hands
around the forearm, applies
traction by leaning backwards
with fully extended arms. The
assistant at the same time, while
holding the sheet, provides
countertraction
 Proximal Humerus Fracture
• Occurs most frequently in elderly female patients following
a fall onto the shoulder
• Classified by the number of fracture fragments using
NEER’S CLASSIFICATION
• Diagnosis:
• Xray
• CT scan if with suspicion of intra-
articular fracture
• Treatment is determined by the placement of the fracture
fragment, the amount of angulation of the fracture, and
the amount of comminution
 Proximal Humerus Fracture

● Minimally displaced: treated with sling immobilization, followed by

shoulder motion and pendulum exercises
● Physiotherapy should be started within 2 weeks of the injury
● Displaced fractures
○ Increased risk for osteonecrosis
○ Surgery is recommended - ORIF plating and screw fixation
● Older patients with osteoporosis, comminuted fractures, head-
splitting fractures, 4-part fractures, or fracture dislocation
○ Treated with prosthetic replacement of the humeral head or
hemiarthroplasty
 Humeral Shaft Fractures

• Majority can heal with nonsurgical

management
• Radial nerve spirals around the humeral
shaft
• Careful neurovascular exam
• Check for wrist drop
• Radial nerve injury – NEUROPRAXIA
• Stretching of the nerve; function typically
returns within 3 to 4 months
• HOLSTEIN-LEWIS FRACTURE
• Spiral fracture of the distal 1/3rd of the
humeral shaft commonly associated with
neuropraxia of the radial nerve
 Humeral Shaft Fractures

TREATMENT

• Typically treated with a coaptation splint or functional

bracing
• Consists of clamshell brace with Velcro strap
• Criteria for acceptable alignment
• <20-degree anterior angulation
• Less than 30-degree varus/valgus angulation
• Less than 3cm shortening
• Radial nerve palsy is not a contraindication for
conservative management
• Close follow-up with serial radiograph
• Gentle motion exercises beginning within 1 to 2
weeks
 Humeral Shaft Fractures
TREATMENT

● Fractures with significant angulation

○ ORIF plating – more stable and allows early weight bearing
○ Intramedullary nailing – carries the risk of shoulder pain from the
nail insertion
○ Spontaneous recovery of radial nerve palsy can occur up to 6
months after injury – monitor with EMG
● Open Fractures with radial nerve palsy
○ Should be explored for the possibility of a significant nerve injury
or laceration
 Distal Humerus Fracture
● Results from falls onto elbow or
onto an outstretched arm
● Supracondylar fractures occurring
above the elbow joint are more
common
○ Do not involve the articular surface
● Minimally displaced
○ Posterior long arm splint, with
elbow typically flexed to 90
degrees
 Distal Humerus Fracture
● Fractures involving articular surface
○ Plate fixation
○ Goal of treatment: anatomic
reduction of the joint surface with
stable fixation, restoration of the
anatomic alignment of the joint and
early range of motion
● Severely comminuted
○ Total elbow replacement
● Range of motion should be started
as soon as the patient can tolerate
therapy
• Common and typically occur posteriorly after a fall on an
outstretched hand
• Dislocation results in injury to the joint capsule and
rupture of the lateral collateral ligament, with possible
involvement of the radial head and coronoid  “THE
TERRIBLE TRIAD”
• TREATMENT
Dislocation: short-term immobilization (7-10
days) folloed by early range of motion
Dislocation with fractures: SURGERY (repair
of torn ligament, fixation or replacement
of radial head, and possible fixation of the
coronoid

ELBOW DISLOCATIONS
ELBOW
DISLOCATION
 Radial Head Fractures

• Most can be treated nonoperatively

Sling for 1 to 2 days
followed by motion exercises
• ESSEX-LOPRESTI FRACTURE – radial
head fractures associated with
dislocation of the elbow and wrist pain
Surgery is recommended
• Comminuted fractures – radial head
replacement
• Usually occur following a fall directly
into a flexed elbow
• Nondiscplaced – splint in 45- to 90-
degree flexion
• Displaced fractures must be treated
surgically
• Simple transverse fracture – Tension
band construct
• Wire passing through the ulna, distal
to the fracture, and wrapped in a figure-
of-8 fashion around 2 or
more pins placed proximally into the
olecranon

Olecranon Fractures
• Comminuted fractures – plate and
screw fixation
• Elderly patients (<50% involvement of
joint surface) – excision of olecranon
with advancement of the triceps
• Complication
subcutaneous irritation
elbow stiffness

Olecranon Fractures
 Forearm Fractures

● Results from high-energy trauma or from falls onto an outstretched

arm
● Generally require surgery with plate and screw fixation
 NIGHTSTICK Forearm Fracture
FRACTURE

• Isolated fractures of the ulna

• Occurs from direct blow to the
side of the forearm
• Usually treated with cast, splint,
or brace
• Angulated or displaced fracture –
ORIF
MONTEGGIA FRACTURE Forearm Fracture

• Fracture of the proximal third of

the ulna associated with a radial
head dislocation
• Common in children and rare in
adults
• Require surgery to fix ulna with
plate and screw fixation and to
reduce the radial head dislocation
GALEAZZI FRACTURE Forearm Fracture

• Fracture of the distal third radial shaft

associated with distal radioulnar joint
injury to the wrist
If the fracture of the radius is less than
7.5 cm from the joint, the distal
radioulnar joint is injured in a large
number of cases
• ORIF plating and screw fixation
• DRUJ assessed for stability, may need wires
placed across the joint temporarily
• Commonly occur in older patients
due to a fall or osteoporosis
• Younger patients, usually due to
high-energy trauma

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 Distal Radius Fracture

Colle’s Fracture

● Low energy fracture that is extra-

articular and usually displaced
● Has a characteristic appearance of a
fork – “DINNER-FORK” DEFORMITY
Distal Radius Fracture

Smith’s Fracture

• Reverse Colles fracture

• Usually extra-articular and
volarly displaced
 Distal Radius Fracture

Chauffer’s Fracture

• Involves the radial styloid

process
• May cause occult carpal
disruption
 Distal Radius Fracture

Barton’s Fracture

• Can either be volar or dorsal

• Fracture dislocation of the radiocarpal
joint, with an intra-articular volar or
dorsal fracture
Distal Radius Fracture

• X-ray to identify fractures that extend intra-

articularly into the wrist joint or involve the
DRUJ
• Evaluate for median nerve injury and
osteoporosis
• Assess for involvement and rupture of extensor
pollicis longus tendon (loss of thumb extension)
• Treatment
• Closed reduction and immobilization
• Surgery for unstable fractures and
fractures with significant intra-articular
involvement
● Most common fracture of the carpal bone
Scaphoid Fracture
● Usually occurs in the waist of the
scaphoid but can occur in the proximal
or distal pole
○ Proximal: Higher incidence of avascular
necrosis due to interruption of retrograde
blood supply
● Tenderness in the anatomic snuffbox
● Diagnosis: X-ray; MRI
● Treatment:
○ Thumb spica cast for stable
nondisplaced fracture
○ Displaced fx: open reduction and screw
fixation
ZONES OF THE
HAND
• Extensor zone – 7
zones
 bony prominences are
the odd zones;
 Zone 1 at DIP joint
 Zone 7 at the wrist
• Flexor zone:
 Zone 1: Middle phalanx - From middle of middle phalanx distally (only the tendon of
FDP)
 Zone 2: Proximal phalanx - From MCP joint to the middle of the middle phalanx
(Tendons of FDS and FDP)
 Zone 3: Distal palmar - From the distal end of the flexor retinaculum to the MCP joints
(Tendons of FDS & FDP with the origin of the lumbricals)
 Zone 4: Thenar - Tendons beneath the flexor retinaculum
 Zone 5: Wrist - Tendons proximal to the flexor retinaculum

• “No Man’s Land” – the zone extending from the distal palmar crease to just beyond
the PIP joint (Zone 2). Flexor tendon injuries here have a poor prognosis
FRACTURES AND
DISLOCATIONS
• Nondisplaced fractures – edema
and tenderness to palpation
• Fracture
 Displacement – described as a
percentage of the diameter of the bone
 Rotation - described in degrees of
supination or pronation with respect to
the rest of the hand
 Angulation - described in degrees
BOXER’S FRACTURE

• Angulated fractures of the

small finger metacarpal neck
• Typical history is that the
patient struck another
individual or rigid object with
a hook punch.
• Reduced using Jahss
maneuver
• Fractures of the thumb
metacarpal base
 Bennett fracture
 Displaces the volar-ulnar base of the bone
 remainder of the articular surface and the
shaft typically dislocate dorsoradially and
shorten
 thumb often appears grossly shortened,
and the proximal shaft of the metacarpal
may reside at the level of the trapezium or
even the scaphoid on X-ray
 Rolando fracture
 second fracture line occurs between the
remaining articular surface and the shaft

• Nearly always require open

reduction and internal fixation
FINGERTIP INJURIES

• Initial evaluation should

include: wound(s) including
the nail bed, perfusion,
sensation, and presence
and severity of fractures
• Choice of treatment options
depends on the amount
and location of tissue loss
 MANAGEMENT

ALLEN CLASSIFICATION OF FINGERTIP INJURIES

I Tip with no involvement of the Primary wound closure
nail bed
II <50% involvement of the Advancement flaps – V to Y advancement
nailbed using Atasol or Kutler procedure: Make A
III >50% involvement of the V-shaped incision at palmar distal phalanx
nailbed & pull distally for wound coverage; suture
proximally Completion amputation with
IV Entire nailbed involved
shortening & primary wound closure
 • Compression of the median
CARPAL TUNNEL nerve at the carpal tunnel
SYNDROME • Hx: sleep disturbance due to
symptoms, history of dropping
objects, and difficulty
manipulating small objects such
as buttons, coins, or jewelry
clasps
• PE:
• Tinnel’ sign
• Phalen’s sign
• Applying pressure over the carpal
tunnel while flexing the wrist
• Strength of the thumb in opposition
Treatment

• Splint – keep wrist at 20-degree

extension, worn at nighttime
• Corticosteroid injection (take 3-7
days)
• Surgery
• Open Carpal Tunnel release
• A direct incision is made over the carpal
tunnel, typically in line with where the ring
finger pad touches the proximal palm in flexion
• Endoscopic Carpal Tunnel release
CUBITAL TUNNEL
SYNDROME
• Compression of the ulnar nerve
where it passes behind the elbow
at the cubital tunnel
• S/Sx:
• numbness, paresthesias, and/or pain
in the small finger and ulnar half of
the ring finger
• Weakness in grip
 • PE:
CUBITAL TUNNEL  Wasting in the hypothenar
eminence
SYNDROME  Wartenberg’s sign
 Elbow flexion and shoulder
internal rotation
 Grip strength
 Froment’s sign
• Treatment
 Splinting – to avoid maximal
flexion of the elbow
 Corticosteroid injection
 Surgery – cubital tunnel release
 • contracture of multiple
DUPUYTREN’S fingers due to palpable,
CONTRACTURE cord-like structures on the
volar surface of the hand
and fingers
• Increased collagen
deposition forming cords
• Etiology is unknown
• Treatment:
• Needle fasciotomy
• Injectable clostridial
collagenase
• Surgery
 • Surgery
DUPUYTREN’S  MP contractures greater than or equal to 30°
CONTRACTURE and/ or
 PIP contractures greater than or equal to 20°.
 Pelvic Fractures

• Indicative of high-energy trauma

• May result in massive hemorrhage and can
be life-threatening
• Injury to the venous plexus in the
posterior pelvis
• Large vessel injury (superior gluteal
artery at the greater sciatic notch)
• Immediate resuscitation with fluids and
blood products
• May require surgical exploration or
interventional radiology embolization
 Pelvic Fractures

• 1st line treatment at ED: application of pelvic binder or

sheet wrapped tightly around the pelvis
• Initial management for unstable open book fractures
• Traction pins and external fixators
• Assess for associated injuries (rectum, urethra, bladder)
 Pelvic Fractures

Three main fracture patterns:

● Anteroposterior force
○ Causes an ”open book” injury
pattern
○ pelvis springs open, hinged on
the intact posterior ligaments
with widening of the pubic
symphysis
 Pelvic Fractures
Three main fracture patterns:
● Lateral compression pattern
○ Results from a crush injury that
causes fractures to the ilium,
sacrum, and pubic rami
● Vertical Shear injuries
○ Very unstable; result from
disruption of the strong posterior
pelvic ligaments
○ Associated with significant blood
loss and visceral injuries
 Pelvic Fracture

● Treatment
○ Depend on the fracture pattern
○ Stable, minimally displaced – nonoperative; protected weight-bearing
○ Open book injuries with widened pubic symphysis >2.5cm – anterior
plate
○ Injured posterior pelvic ligament – posterior fixation
■ Screws placed percutaneously through the ilium into the sacrum
○ Displaced sacral and iliac wing fractures – fixation with screws or
plates
○ Pubic rami fractures – can be managed nonoperatively
ACETABULAR
FRACTURES
• ACETABULUM – form the socket of
the hip joint
• Diagnosis:
 Assessment of sciatic nerve function
 Xray
 Judet views
 CT scan
• Management:
 hip dislocation – reduce immediately
 Surgery
HIP DISLOCATIONS
• Almost always result from high-energy
trauma
• Most commonly occur posteriorly
• Can cause injury to the sciatic nerve
• Pipkin Fracture – femoral head fracture
associated with hip dislocation
• Diagnosis:
 Foot drop
 numbness at the top of the foot
 CT Scan (after reduction)
• Management
 Hip dislocations should be reduced
immediately
 Closed reduction with adequate sedation
or under GA
 Surgery – Open Reduction
 Associated with femoral head fracture
- ORIF
HIP FRACTURES
 Most often occur in elderly patients,
women>men
 Complications: deep vein thrombosis,
pulmonary embolism, pneumonia,
deconditioning, pressure sores, death
 Mortality rate in the first year: 25%
 Diagnosis
 Xray
 CT scan
 Types of Femoral head fractures
 Subcapital (Femoral neck)
 Inter-trochanteric
 Sub-trochanteric
HIP FRACTURES
Treatment of choice is Surgery
 Performed within 24 to 48 hours
 Goal:
 Minimize pain
 Restore hip function
 Allow early mobilization
 Type of surgery determined by:
 Anatomic location of fracture
 Fracture pattern
FEMORAL NECK
(SUBCAPITAL)
FRACTURE
 Occur within the capsule of the hip joint
 Main supply of the femoral head: deep
branches of the medial femoral
circumflex artery
 Nondisplaced fractures
 In situ internal fixation
 Displaced fracture
 Prosthetic replacement (Partial Hip
Replacement)
FEMORAL NECK
(SUBCAPITAL)
FRACTURE
Patients with osteoarthritis or
hip pains prior to fracture
 Total hip replacement
Patients can begin weight-
bearing immediately after
surgery.
INTERTROCHANTERIC HIP
FRACTURES

Occur between the greater and

lesser trochanters of the
proximal femur
Osteonecrosis is uncommon
Treated with reduction and
internal fixation
INTERTROCHANTERIC HIP
FRACTURES

Stable fractures
 Sliding hip screw
Unstable fractures
 Cephalomedullary nail
INTERTROCHANTERIC HIP FRACTURES
Reverse oblique intertrochanteric fracture
 Specific type of fracture that exits on the lateral cortex
 Best treated with cephalomedullary nail
KNEE DISLOCATIONS

 Rare but devastating

 May spontaneously reduce and
can be underdiagnosed
 Injuries include:
 Anterior cruciate ligament
 Posterior cruciate ligament
 Lateral collateral ligament
 Medial collateral ligament
 Diagnosis: MRI
KNEE DISLOCATIONS
Close proximity to the popliteal artery
Neurovascular exam (peroneal nerve and vascular status of
extremity)  reduce and repeat neurovascular exam
 Normal pulses  measure Ankle Brachial Index (ABI)
 >0.9 – monitored and serial examination
 <0.9 – CTA or arterial duplex ultrasound
 Diminished pulses  Angiogram
 Absent pulses
 Immediate surgical exploration and repair
 Ischemia time >8 hours – high risk for amputation
 PATELLA/EXTENSOR MECHANISM INJURIES
 Extensor mechanism – functions to extend the knee
 Quadriceps tendon
 Patella
 Patella ligament
 Nondisplaced patella fractures with inactive
 Treated nonoperatively with a cast or knee immobilizer
 Displaced or Comminuted fracture
 Surgery with tension ban wiring and/or screws
 . Quadriceps tendon and patella tendon ruptures with loss of active knee
extension
 Surgery (suture repair),
 Knee held in extension after surgery, and knee flexion is slowly increased over several
weeks using a hinged knee brace
PATELLA/EXTENSOR MECHANISM INJURIES
Patella dislocations
 Typically dislocate laterally and often relocate spontaneously
 Medial patellofemoral ligament – primary stabilizer of the patella
 S/Sx:
 Knee effusion and medial-sided tenderness
 Positive Apprehension test
 Diagnosis
 MRI: classic bone bruise and edema involving the medial facet of the patella and the lateral
condyle of the femur
 Treatment
 reduced by extending the knee and manual reduction and are treated with temporary knee
immobilization
 Fracture or loose bodies - Surgery
TIBIAL PLATEAU Tibial plateau – comprised of
the articular surfaces and
FRACTURES underlying cancellous bone of
the medial and lateral plateau
of the proximal tibia
Fractures can involve the
medial, lateral, or both
plateaus – Schatzker
Classification
TIBIAL PLATEAU FRACTURES
 Meniscal tears occur more on the lateral side
 Diagnosis
 Ankle brachial index
 Laxity: >10-degrees may indicate instability of the fracture (painful and hard to perform)
 CT Scan
 Treatment
 Minimally displaced – nonoperative with non-weight bearing until fracture heals
 Displaced articular fragments – surgery (plates and screws placed medially, laterally, or both)
 Goal of surgery: restore joint stability and alignment
TIBIAL SHAFT FRACTURES
Most common long bone fracture
Occur following high-energy trauma, direct blows, and severe
twisting injuries
Treatment
 Minimal angulation – reduction and casting
 Comminuted and angulated – intramedullary nail with interlocking screws
 Compartment syndrome
 Compartment pressure within 30mmHg of the diastolic pressure
 Pain out of proportion with swelling of the leg and pain with passive stretch
 Treated with Fasciotomy
 Tibial plafond – distal tibial articular
TIBIAL PLAFOND (PILON) surface of the ankle joint
FRACTURE Typically, high-energy injuries that
usually result from axial compression
TIBIAL PLAFOND (PILON) FRACTURE
• Treatment:
Initially treated with external fixation until swelling subsides
 Wrinkle test
CT scan after external fixation
Surgery to restore articular surface (ORIF)
ANKLE DISLOCATION
 Ankle joint – complex hinge joint
 Distal tibial plafond
 Medial malleolus
 Lateral malleolus
 Dislocation results from severe
twisting injury
 Often occurs with fracture
 Prompt reduction followed by
splinting
SUBTALAR DISLOCATION
Can be medial or lateral
Medial dislocation
 More common
Lateral dislocation
 Can be associated with fractures
Treatment: Closed Reduction and splinting
Main complication: subtalar arthritis
ANKLE FRACTURE
Common; result from a twisting injury to the ankle
Goal of treatment:
 Restore the anatomy of the ankle joint
 Restore length and rotation of the fibula
Initial treatment: closed reduction and placement of a well-padded
splint
Definitive treatment: Surgery
ANKLE FRACTURE

 Fractures
 Isolated malleolar fractures – lateral
malleolus or medial malleolus
 Bimalleolar fracture – both lateral and
medial malleolus (deltoid ligament
may be injured instead of the medial
malleolus)
 Trimalleolar fractures – involve the
lateral malleolus, medial malleolus,
and posterior malleolus
LATERAL MALLEOLUS
FRACTURE

 Diagnosis:
 External rotation stress radiograph
 Gravity test
 Isolated fractures with <3mm
displacement and no talar shift – stable
 If with deltoid ligament injury or talar
sublaxation  Surgery
 Anatomic reduction in order to restore
normal ankle joint congruity
 Open reduction and internal fixation
MEDIAL MALLEOLAR
FRACTURE
Usually an avulsion-type injury
Minimally displaced – treated
with a cast or walking boot
Displaced fracture – fixation with
screws
BIMALLEOLAR
FRACTURES
Fractures to both the medial
and lateral malleolus
Unstable and talus will often
sublux or completely dislocate
laterally
Often require surgery
 Treated by reducing and fixing
both malleoli during surgery
  Fracture to the lateral, medial,
and posterior malleolus
 May be associated with
TRIMALLEOLAR syndesmotic injury
FRACTURE  Intraoperative external rotation
stress test
 Widening of the space
between the distal tibia and
fibula after fixing the fractures
 treated with one or two screws
placed laterally from the fibula
into the tibia, parallel to the
ankle joint
 kept non–weightbearing for
several weeks
 screws are often removed after
3 to 6 months
MAISONNEUVE
FRACTURES
Fracture of the proximal fibula
associated with fracture of the
medial malleolus or rupture of
the deltoid ligament
Always associated with
syndesmotic injury
Require surgical treatment with
fixation of the syndesmosis by
screws from the fibula to the
tibia
CALCANEAL
FRACTURE
 Usually occur following a fall from a
height
 Often associated with other injuries,
including lumbar spine fractures
 Injuries are often intra-articular
 Diagnosis:
 Xray
 CT Scan
 Reduced or flattened Bohler angle
CALCANEAL FRACTURE

• Treatment:
• Can be treated
nonoperatively
 Well-padded splint
 Non-weight-bearing for up to 12
weeks
• Displaced intraarticular
fractures
 Treated surgically once swelling
has subsided
 • Commonly result from forced dorsiflexion of the
TALUS FRACTURE ankle, causing the talar neck to impact on the
anterior distal tibia
• May lead to osteonecrosis (artery of the tarsal
canal)
 Hawkin’s sign – subchondral lucency seen in
Xray mortise view at 6 weeks
 Indicates that there is no avascular necrosis
• Treatment
 Nondisplaced fracture – treated with a cast
(15% risk of osteonecrosis)
 Displaced fracture – treated surgically with
screw fixation
• Complication
 Subtalar arthritis
 Varus malunion
FOOT FRACTURE

• Tarsal bone
 Includes: navicular, cuboid, and three cuneiform bones
 Provide mechanical stability to the arch of the foot

• Isolated and often treated nonoperatively

with cast or boot
• Lisfranc fracture
 tarsometatarsal fracture dislocation characterized by
traumatic disruption between the articulation of the
medial cuneiform and base of the second metatarsal
 Treatment: ORIF
FOOT FRACTURE

• Jones Fracture
 Fifth metatarsal fractures at the
metaphysealdiaphyseal junction
(fourth and fifth metatarsal
articulation
 May be associated with cavovarous
hindfoot
 Treated by short-leg cast and non-
weight-bearing
FOOT FRACTURE

• Jones Fracture
 Fifth metatarsal fractures at the
metaphysealdiaphyseal junction
(fourth and fifth metatarsal
articulation
 May be associated with cavovarous
hindfoot
 Treated by short-leg cast and non-
weight-bearing
SPINE
SPINAL TRAUMA
• Spinal stability must be assessed and the patient immobilized until
the spine is cleared
• CT scan is more reliable in assessing spine injury than plain
radiographs
• Compressive symptoms – emergency decompression
OCCIPITAL CERVICAL
DISLOCATION
• dislocation of the occiput on
the condyles of the atlas (C1)
• Traction on the spine is
contraindicated
• Treatment: stabilization and
fusion in situ using a screw
plate from the mid cervical
spine to the occiput
 • Fracture of anterior and posterior rings
of C1 vertebra due to axial loads
• Diagnosis:
• Xray
• Open mouth view: spread of C1
lateral masses
• Lateral view
• CT scan
• Treatment
• Based on the integrity of the
transverse ligament
• Significantly displaced fractures
<7mm
• increase in the atlanto-dense interval
(ADI) (N: <3mm)
FRACTURE OF C1 (JEFFERSON • Displaced: posterior C1-C2 fusion
FRACTURE) • Nondisplaced: Bracing with a
cervicothoracic orthosis or a halo ring
and vest
 • Type I
• avulsion fractures off the tip of the dens
• occur when there is tension applied to the alar
ligaments (which span from the tip of the
FRACTURE OF C2 (ODONTOID odontoid to the skull bypassing the C1
FRACTURE) vertebra)
• stable and managed nonoperatively
 • Type II
• base of the odontoid, results from
lateral loading forces
FRACTURE OF C2 (ODONTOID • Operative stabilization is the
FRACTURE) preferred treatment
• High risk for nonunion
 • Type III
• extend into the body of C2, below
the origin of the odontoid process
FRACTURE OF C2 (ODONTOID • rich in blood supply and usually
FRACTURE) heals well
• treated with a halo brace
HANGMAN’S FRACTURE
OF C2
• bilateral fracture of the pars
interarticularis
• results from sudden extension
forces on the neck
• Treatment
• immobilization in a halo vest
• internal fixation and bone grafting
between C2 and C3
CLAY-SHOVELER’S
INJURY
• can result from a motor vehicle
accident or from shoveling soil or clay
• result of avulsion fracture of the
spinous process by the paraspinal
muscle forces
• C6, C7, T1, and T2
• treated nonoperatively with
analgesics and a soft collar
DISC HERNIATION

• most common between ages of 20 and 50

• can occur in the cervical, thoracic, or the
lumbar spine
• consists of a tear of the annulus
• Treatment
• Supportive: resolve within 8 weeks
• Surgery
• Anterior
• Posterior
• Contraindicated for thoracic, because it
may lead to paralysis
• uncommon and occurs from a central disc
herniation
• TRUE EMERGENCY CAUDA EQUINA
• S/Sx
• back pain with bilateral leg pain
SYNDROME
• Bladder and bowel difficulty such as
incontinence and frequency
• saddle anesthesia
• decreased perianal sensation
• impotence, diminished rectal tone
• motor deficits
• Diagnosis: MRI
• Treatment
• Urgent surgical decompression within 48
hours from onset of symptoms
• Lateral curvature of the spine
• Classified as: congenital,
degenerative, metabolic,
neurogenic, myogenic, and SCOLIOSIS
idiopathic
• Treatment
• Antiinflammatory
medication, therapy, and
activity modification
• Brace treatment – curves
between 20 and 40 degrees
• Large curves – surgery (rods
with grafting and fusion
 ORTHOPEDIC
PATHOLOGY AND
ONCOLOGY
Diagnosis of Malignant Bone Tumors
• History
• unremitting pain unrelated to activity
• pain that interferes with sleep s
• Patient age
• Gender
• Laboratory
• level of cellular turnover (lactate dehydrogenase [LDH])
• bone destruction (calcium, alkaline phosphatase)
Diagnosis of Malignant Bone Tumors
• Imaging
• Where is the tumor (what part of the bone)
• What is the tumor doing to the bone
• What is the bone doing to the tumor
• What is the matrix pattern
OSTEOSARCOMA

• most common primary malignant

bone tumor is osteosarcoma
• classified as osteoblastic,
chondroblastic, fibroblastic,
telangiectatic, round cell, or MFH-
like, according to the predominant
cell type
• present in patients between 10 and
20 years of age
 • most common primary sarcoma of the
bone
• usually occurs in the distal femur or the
proximal tibia in young people
• S/Sx: pain and swelling
• Diagnosis:
Intramedullary • X-ray: Codman’s Triangle, Sunburst
appearance
Osteosarcoma • MRI (entire bone)
• CT chest (metastasis)
• Biopsy
• Treatment: preoperative chemotherapy
and wide resection, followed by
postoperative chemotherapy
 • a low-grade surface
osteosarcoma
• appears as if it were stuck on
the bone, especially in the
posterior distal femoral
Parosteal metaphysis (80%)
Osteosarcoma • Treatment consists of wide
excision
 • high-grade tumor
• occurs on the anterior surface of
the distal femur or proximal tibia
• appears chondroblastic on
histology
Periosteal • X-ray: scalloping of the underlying
Osteosarcoma cortex with a “sunburst” periosteal
reaction
• Treatment is chemotherapy and
wide surgical excision
 • a rare complication of Paget’s
disease
• most often in the pelvis, but
also in the femur, humerus,
spine, and skull
Paget’s Sarcoma • osteolytic areas and loss of
normal fatty marrow and
multifocal lesions on imaging
• Treatment: chemotherapy and
wide surgical excision
 • three criteria for diagnosis
• histology different from the original
lesion,
• sarcoma develops in the irradiated
Radiation- field, and
• a 3- to 5-year latent period
Induced between radiation and sarcoma
development
Sarcoma • Treatment: combination of
chemotherapy and surgery
 EWING’S
SARCOMA
• second most common primary bone tumor in patients under
25 years of age
• tumor in the diaphysis of long bones, especially the femur
• t(11:22) translocation and positive CD99
• Diagnosis:
• pain and fever with an elevated sedimentation rate
• “onion skin” periosteal reaction may be seen on
radiographs
• Bone marrow Biopsy: reveals a small, round, blue cell
tumor
• Treatment
• chemotherapy and surgery or radiation therapy for spine or
pelvic lesions
 CHONDROSARCOMAS
• typically occur in male patients over 40 years of
age
• third most common primary bone malignancies
• May be PRIMARY or SECONDARY
• Pelvis, shoulder, and ribs are common locations
• Imaging: Chondroid or “popcorn” calcifications
• Treatment:
• chondrosarcoma is surgical excision
• High-grade lesions: wide or radical resection
FIBROUS LESIONS
OF BONE
Desmoplastic Fibroma
• rare tumor occurring in the mandible,
femur, pelvis, radius, or tibia in young
adults
• presents as a painful lesion
• Imaging: metadiaphyseal “soap bubble”
appearance and endosteal scalloping
• Treatment: wide excision
Malignant Fibrous
Histiocytoma of Bone
• occurs in the metadiaphysis of long bones
after conditions like nonossifying fibromas
and bone infarcts
• may present with pain or by a pathologic
fracture
• Imaging: destructive lesions with soft-tissue
extension
• Histology: resembles osteosarcoma with
pleomorphic spindle cells, histiocytes, and
giant cells, but no neoplastic osteoid
formation
• Treatment: chemotherapy and wide surgical
excision
 Hemangioendothelioma
• malignant neoplasm arising from vascular
endothelium in long bones
• most often occurs in the lower extremity
Malignant • Imaging: metadiaphyseal lytic lesion with a
“soap bubble” appearance.
Vascular Tumors • Histology: eosinophilic cells in a basophilic
stroma
• Treatment:
• Low-grade: curettage
• High-grade: wide excision +/- radiation
therapy
 Hemangiopericytoma
• usually a solitary lesion occurring
in the soft tissues or the axial
Malignant skeleton and proximal long
Vascular Tumors bones
• middle-aged or older adult males
• Histology: branching “staghorn”
vascular spaces
• Treatment: wide excision
 Angiosarcoma of Bone
• a soft tissue malignancy usually
seen in older adult males
Malignant • chronic vascular stasis is a risk
Vascular Tumors factor.
• Histology: vascular channels with
anaplasia
• Treatment: wide excision or
radiation
MISCELLANEOUS
TUMORS OF THE
BONE
 Giant Cell Tumor of
Bone
• benign aggressive tumor
• Clinical presentation: pain and pathologic fracture
• Imaging: eccentric, epimetaphyseal lytic lesions
eroding the subchondral bone
• Histology: multinucleate giant cells and
mononuclear stromal cells
• DDx:
• Brown tumor of hyperparathyroidism
• Chondroblastoma
• Poor prognosis
• Treatment: curettage and high-speed burr
Adamantinoma
• low-grade malignant tumors usually seen in
the tibia
• capable of metastasizing to the lung
• Clinical presentation: pain and/or bowing
of the tibia
• Imaging: multiple lucent lesions on the
cortex of the tibia
• Histology: biphasic tumor with nests of
epithelial cells and fibrous stroma
• Treatment: treatment of adamantinoma is
with wide surgical excision
 precursor to adamantinoma

Osteofibrous
Dysplasia benign lesion, usually
occurring in children, at the
anterior tibia, which is treated
with observation
Primary
Lymphoma
of Bone
 Chordoma
• arises from notochordal remnants in the sacrum
• usually midline in location
• found in middle-aged to older men
• Clinical presentation: bladder and bowel symptoms due to
involvement of the cauda equina
• Diagnosis
• MRI: destructive extensile midline lesion with a large
soft tissue mass
• Histology: epithelioid cells arranged in cords with
vacuolated foamy physaliferous cells
• Treatment:
• Surgical excision and muscle flap and mesh
reconstruction
• Loss of bowel and bladder control – urinary Diversion
and diverting colostomy
 Multiple Myeloma
• proliferative disorder of B cells with plasma cells
producing immunoglobins
• Histology: classic eccentric nucleus giving a “signet
ring” appearance
• Clinical presentation: range from bone pain and
osteopenia to focal lytic lesions with pathologic
fractures and hypercalcemia.
• Diagnosis:
• serum and/or urine (Bence Jones proteinuria)
• CBC, ESR, calcium levels, renal function assessment
• β2-microglobulin levels
• Skeletal survey (X-ray) : multiple punched out lytic
lesions
Multiple Myeloma
• Treatment
• bisphosphonates, chemotherapy,
stem cell transplantation, and
radiation therapy
• Surgical stabilization and irradiation
is done for pathologic fractures or
impending fractures
• Vertebral compression fracture -
Kyphoplasty
 PEDIATRIC
ORTHOPEDICS
NEONATAL
BRACHIAL
PLEXUS PALSY
GROWTH PLATE INJURIES
 • Talipes equinovarus
• Clubfoot can be classified as
• (1) postural or positional (NOT
TRUE CLUBFOOT) or
• (2) fixed or rigid. Postural
CLUB FOOT • Fixed or rigid clubfeet are either
flexible (ie, correctable without
surgery) or resistant (ie, require
surgical release)
DEVELOPMENTAL
DYSPLASIA OF THE
HIPS
Physical Exam
Ortolani’s test - the contralateral hip is held
still while the thigh of the hip being tested
is adducted and gently pulled anteriorly
+if get the sensation of instability or hear a “clunk”
(due to a dislocated hip reducing into the
acetabulum)

(+) if the hip dislocates out of socket and confirmed

Barlow’s test - adducting the hip while
by doi the Ortolani to reduce the dislocation (push
pushing the thigh posteriorly. Back = Barlow)

Galleazzi sign - the affected limb short in the thigh when the knee is flexed to 90o
with the hips flexed to 45o and the heels at the same level
 • Osteonecrosis of the proximal femoral
epiphysis in a growing child caused by
poorly understood non genetic factors
• Pathophysiology: Alteration in blood supply
LEGG-CALVE- to femoral head with fetal supply from
metaphyseal vessels, lateral epiphyseal
PERTHES vessels running in the retinaculum up the
DISEASE neck and small supply from the ligamentum
teres
• Treatment includes traction, physical
therapy, abduction exercises, and crutches.
• Restoration of range of motion is important.
Osgood-Schlatter
Disease
• most often seen in athletically
active adolescents, especially in
sprinters and jumpers
• characterized by ossification in the
distal patellar tendon at the point
of its tibial insertion
• Treatment for the disease is activity
restriction and antiinflammatory
drugs
END