ORTHOPEDICS

( PART 2 )

#MisiLegasi MD ZAKI MEDICAL NOTES

RECURRENT SHOULDER DISLOCATION

Features Treatment & management

Bankart lesion • Injury to ANTERIOR (inferior) • Pain – in front CONSERVATIVE
GLENOID LABRUM of shoulder shoulder ✓ Acute reduction –
• Impaction AGL→ pocket at front • Clicking/ catching/ traction
of glenoid → humeral head slipping shoulder ✓ Immobilization – in
dislocate into it • Onset → after external rotation
• Bony bankart→ + # trauma ✓ Physiotherapy –
shoulder muscle

Hill –sach • Cortical DEPRESSION in
lesion posterolateral head of humerus
• Shoulder dislocated anteriorly +
Forceful impaction of HH against
anteroinferior glenoid rim
OPERATIVE
✓ Freq dislocate
Hx PE ✓ Fear recurrent dislocate
Xray AP/ axillary view – athlete
MRI/ MR arthrography – bone
lesion + labral tear
Arthroscopy – labral tear Type OP
✓ Repair / reattach GL
✓ Putti Platt - Shorten +
tighten ant capsule and
muscle
✓ Bristow – reinforce
anteroinferior capsule
using adjacent muscle
 Anatomy Mechanism of Injury Features Investigation Management

ANTERIOR CRUCIATE LIGAMENT INJURY

✓ Noncontact deceleration → ✓ “POP” – feel/hear Xray CONSERVATIVE

Valgus twisting injury ✓ Pain + unable to cont. - usually normal - RICE ( rest ice compress
o Lands on leg pivot to xtvt - segond # → not elevate )
oppose direction ✓ Swelling exclusive to ACL tear - Bracing
o IR tibia on femur ✓ Instability (avulsion # proximal - Rehabilitation
o Hyperextension ✓ Hemarthrosis lateral tibia) - Pain relieve ( NSAIDs )

✓ ++ meniscal tear L>M PE MRI

▪ origin : Posteromedial LFC ✓ Lachman’s test - accurate + confirm SURGICAL (ACL
▪ insertion : Ant between ICE ✓ Anterior drawer test - sagittal view reconstruction)
▪ A – middle geniculate artery Pivot test enlarged ACL, hyperintense Indication
▪ N – post articular n (tibial n) - Young age
- High demand sport
(athlete)
!! FAM – EPL - Assc injury
Abnormal laxity

POSTERIOR CRUCIATE LIGAMENT INJURY

▪ origin : anterolateral MFC ✓ Direct blow – ant tibia +
▪ insertion : posterior tibial flex knee
sulcus below articular surface ✓ Hyperextension
▪ A – middle geniculate artery ✓ Fall on flexed/ bend knee
✓ Extreme VV
!! AL flex – PM ext
Injuries assc
✓ MCL
✓ PM capsule
✓ ACL
Meniscal tear
✓ Pain posterior knee Xray CONSERVATIVE
✓ Swelling + stiffness - AP + supine lateral - RICE
✓ “Pop” - Bony avulsion PCL - 1&2 – quadriceps rehab
✓ Instable jt (knee extensor
MRI strengthening)
PE - Diagnosis complete - 3 – immobilize (ext
✓ Posterior drawer test injury bracing + limited daily
Posterior sag test Enlarged PCL, hyperintense ROM exercise) →
quadriceps
strengthening
 SURGICAL (PCL
reconstruction)
Indication
- Combined ligamentous
injury
- Isolated 2/3 + bony
avulsion
Isolated ch PCL + fx unstable
knee
PCL injury classification – posterior Grade 1 partial – tibia ant to FC , 1-5mm posterior tibial translation (PTT)
subluxation tibia relative to femoral Grade 2 complete isolated – complete injury where ant tibia flushed with FC, 6-10mm PTT
condyle (knee fex 90’) Grade 3 combine PCL + capsuloligamentous – tibia posterior to FC + associated ACL and/or PCL injury, >10mm PT

Anatomy Mechanism of Injury Features Investigation Management

ROTATOR CUFF TEAR

Rotator Cuff Muscles : Anatomic Classification : Symptoms : X ray : Non-operative :

S.I.T.S - Pain exacerbated by
1. Supraspinatus, infraspinatus, teres overhead activities - AP view : Calcific - Physical therapy (ROM, rotator
Supraspinatus minor (SIT) tears (Most common) - Night pain tendonitis, spurs, proximal cuff strengthening, scapular
Infraspinatus migration of humerus / stabilization)
Teres minor - Associated with subacromial Physical examination humeral head elevation - NSAIDs
Subscapularis impingement - Pain and weakness : (chronic) - Subacromial steroid injection (If
- Mechanism is often a degenerative 1. Supraspinatus – impingement is cause)
The primary function of tear in older patients or a shoulder Elevation , Empty can - Outlet view : Type III
the rotator cuff : to dislocation in patients > 40 yrs test (hooked) acromion Surgery :
provide dynamic (Abduction + Internal - Athroscopic or open rotator cuff
stability by balancing the 2. Subscapularis Tears rotation ) MRI repair
force couples about the - Associated with subcoracoid - Diagnostic - Tendon transfer (if massive tear)
glenohumeral joint in both impingement 2. Infraspinatus – External - Size , shape and degree of
the coronal and - Mechanism is often an acute rotation, Hornblowers retraction of tear
transverse plane. avulsion in younger patients with a test
hyperabduction/ external rotation
injury (Overhead throwing atheletes) 3. Subscapularis –
or an iatrogenic injury due to failure Internal rotation , Lift off,
of repair belly press, Increase
passive external rotation

ARCHILLES TENDON RUPTURE

Achilles tendon Episodic athletes,’ weekend warriors’ Hx : “Pop” Sensation, Non operative : Casting /
- largest tendon in body – mid aged men weakness and difficulty X ray : Standing AP/Lateral Functional bracing (in equinus -
- formed by the walking, pain in heel (Rule out other pathology) plantar flexed)
confluence of soleus Traumatic injury – Sudden forced
muscle tendon + medial plantar flexion / violent dorsiflexion PE : US : Complete vs partial Surgical : Surgcal repair
and lateral gastrocnemius in plantar flexed foot - Increase resting rupture
tendons dorsiflexion, weakness
- blood supply from plantar flexion
posterior tibial artery - Palpable gap
- Thompson test (Lack of
plantar flexion when calf
is squeezed)

TENNIS ELBOW (LATERAL EPICONDYLITIS)

Lateral epicondyle is the Activities with repetitive pronation Hx : 30 – 60 , chronic pain Clinical Diagnosis Non- operative :
origin of common and supination with elbow in at lateral elbow
extensor tendon extension -> microtear -> tendinosis X ray : - Activity Modification
and inflammation at origin of PE : - AP/Lateral of Elbow - Apply Ice
Common extensor origin Extensor Carpal Radialis Brevis - Pain with resisted wrist - Rule out other pathology - NSAIDs -> Steroid injection
- muscles that originate extension - Physical
from lateral supracondylar Common in tennis players - Pain with gripping
ridge : extensor carpi
radialis longus
- muscles that originate on
lateral epicondyle :
extensor carpi radialis
brevis , extensor carpi
ulnaris, extensor
digitorum , extensor digiti
minimi , anconeus
Flexor-pronator mass
includes
- Pronator Teres
- Flexor Carpi Radialis
- FDS
- Palmaris Longus
- Flexor Carpi Ulnaris
GOLFER ELLBOW (MEDIAL EPICONDILYTIS)
Repetitive wrist flexion/forearm
pronation
Common in golfers, pithers, racquet
sports, plumbers
May affect ulnar nerve
activities / decrease grip Operative (Failed conservative 9-
strength 12 months)
- Point tenderness at
ECRB insertion lateral - Release and debridement of
epicondyle ECRB origin
Hx : Pain over medial X ray Non-operative :
epicondyle , worst with - Rule out other diagnosis - Rest, Ice
wrist and forearm motion - NSAIDs -> Steroids injection
MRI - Activity modification
PE : - Tendinosis of pronator - Bracing
- Tenderness over the teres and FCR
origin of Pronator Teres Operative : Failed nonoperative mx
and Flexor Carpal Radialis (6months)
at medial epicondyle - open debridement of PT/FCR,
reattachment of flexor-pronator
- Pain with resisted group
forearm pronation and
wrist flexion
 MENISCAL INJURY

Anatomy Mechanism Features Treatment

- 2 menisci – lateral + - Flexed knee towards - Acute pain → knee Conservative
medial extended position locked flexion → - Medical
- Fibrous - Squat + twist knee swollen → subside - RICE
- Shallow indentation on →tear (a week) - PCM
top tibia - Older - NSAIDs
pt→degenerative M Recurrent hx
Red zone (outer 1/3) tear - Locking knee
Red white zone (middle 1/3) - Knee gives way
White zone (inner 1/3 , Medial tear (ER) - Pain
avascular) - Abduction external - Swelling Type meniscus tear
rotation violence on - Clicking at knee - Longitudinal
flexed knee - Horizontal
Test - Oblique
Lateral tear (IR) - McMurray Test - Radial
- Abduction internal - AppleyTest - Flap
rotation violence on - ThessalyTest - Degenerative
flexed knee Non –conservative
Investigation - Meniscal repair
- Xray - usually - Partial menisectomy
Most common
normal - Menisectomy surgery
- Location : post horn M
Function - Arthroscopy –
- Type : longitudinal
- Lubricate+ nutrition Therapeutic +
- Assc : soccer
- Shock absorbers diagnostic
- Distribute wt - MRI – tear missed
Smoother motion F/T by arthroscopy
 Risk Factor
Def: Location
❖ Joint dysplasia : congenital Pathogenesis
➢ Chronic degenerative ✓ weight-bearing acetabular dysplasia and  Involve destruction and repair
disorder of synovial joints joints (Knees, Perthes disease
➢ Progressive softening and hips, cervical and ❖ Occupation : repetitive stress
disintegration of cartilage lumbosacral spine) Ageing Stress
work
➢ Osteophytes, and capsular ✓ Interphalangeal
❖ Bone density
fibrosis (DIP), proximal
❖ Obesity : Increased joint
➢ Primary – Idiopathic and interphalangeal
Loss of proteoglycans matrix & damage to chondrocyte
(PIP), and loading
aging process
➢ Secondary – disease of carpometacarpal ❖ Family History : First degree
synovial joints that results (CMC) joints relative (Women)
from predisposing condition
that has altered the joint Cx: - Capsular herniation Loss of cartilage & Increase force on subchondral bone
tissues
- loose body
OA - spondilolystasis
- Rotator cuff dysfx
Focal Bone
degeneration ->
Compensation ->
Clinical feature Unstressed area
- spinal stenosis Subchondral cyst proliferate and
(clinical)
 PAIN + Reactive ossifies ->
 Joint stiffness sclerosis Osteophytes
 Joint swelling
 Gait disturbance Shedding of cartilage
 Clicking or grinding sensation with + Enzyme from
joint motion damage cell ->
 Loss of muscle bulk – Inactivity Synovitis -> Capsular
secondary to pain Fibrosis
 Limb deformity – Knock-knees
(Valgus) or bowing (Varus) Ix Management Late Tx
Kellgren-Lawrence Grading system ➢ Lab Ix : Not usually required Early tx: ❖ RECONSTRUCTIVE SURGERY :
Grade 1 – Doubtful narrowing of -Inflammatory markers
❖ Physical therapy I) Realignment osteotomy
-Synovial fluid analysis
joint, possible osteophytic lipping - Maintain joint mobility and High tibial osteotomy
(TRO) diff diagnosis : Septic arthritis, improving muscle strength
Grade 2 – Definite osteophytes, Joint still stable and mobile
Inflammatory arthritis and crystal ❖ Load reduction
possible narrowing of joint space arthropathy Prevent further damage to articular
- Weight loss in obese patient
Grade 3 – Moderate multiple ➢ Imaging : cartilage and dramatic pain relief
- Wearing shock-absorbing
osteophytes, definite joint space -Plain Radiography :Support diagnosis and II) Arthroplasty
shoes
narrowing, sclerosis, possible bone Assess severity - Avoiding activities like III) Arthrodesis
deformity of bone ends -A P standing, Lateral, Sky view climbing stairs - apply to small joints (Where stiffness
Grade 4 – Large osteophytes, marked - Walking stick is not a drawback)
joint space narrowing , severe
4 Classical Features of OA : ❖ Analgesic (Pain Relief) ❖ TOTAL KNEE REPLACEMENT
❖ Loss / Narrowed joint space - Paracetamol -> NSAIDs, ➢ Indicated in patients with severe
sclerosis and definite bony end ❖ Osteophytes (Bone spur) Celecoxib symptoms, marked loss of
deformity ❖ Subchondral bone sclerosis functions and significant
❖ Supplement : Glucosamine
❖ Subchondral cyst restriction of daily activities
and Chondroitin sulphate
Type of crystal deposition disoder:
❖ Gout- monosodium urate
monohydrate crystals
❖ Calcium pyrophosphate
dihydrate (CPPD) deposition
disease (pseudogout)
❖ Basal Calcium
Phosphate(BCP) deposition
disorders
Acute attack
➢ Sudden onset of SEVERE
JOINT PAIN
➢ Spontaneous or precipitated by
minor trauma, operation,
alcohol consumption.
➢ The commonest site-
metatarsophalangeal joint of
big toe, ankle and finger joints,
olecranon bursa.
➢ The skin looks red, shiny,
swelling, joints feel hot &
extremely tender.
Chronic attack
➢ Recurrent acute attack
➢ Tophi can be at joints, over
olecranon, pinna of the
ear.
➢ Joints erosion cause
chronic pain,stiffness,
deformity.
➢ Large tophi can ulcerate &
discharge its chalky
material.
Cx
➢ Cartilage degeneration
➢ Renal dysfunction-
parenchyma disease
because of percipitation
of urate.
➢ Uric acid urolithiasis.
Purine metabolism disorder
Characterized by:
➢ Hyperuricemia
➢ Deposition of monosodium
urate monohydrate crystals in
joints and periarticular tissues
➢ Recurrent attack of the acute
synovitis
Treatment
Acute attack
❖ Resting the joint
❖ Applying ice packs in
severe pain
❖ Give full doses of a
non-steroidal anti-
inflammatory agent
❖ Tense joint effusion –
require aspiration and
intra-articular injection
of corticosteroids
Interval therapy
➢ Dietary modifications
such as reduce purine
rich diets (seafood etc),
alcohol reduction,
➢ Losing weight
➢ Urate lowering drug
therapy
Chronic attack
❖ Allupurinol (xanthine
oxidase inhibitor) –
most preferred
❖ Probenecid – use in
normal renal function
Classification Clinical features
Factors
✓ Primary gout
 Older age, male gender
- genetic  Genetic enzyme defects ➢ usually men
- under-excretion or -glucose-6-phosphatase(G6PT) >30 years old
overproduction of urate deficiency ➢ has family
✓ Secondary gout - Hypoxanthine- guanine history of gout
- Due to prolonged phosphoribosyltransferase (HGPRT)
hyperuricaemia deficiency
- due to myeloproliferative - Elevated 5'-phosphoribosyl-1'-
diseases pyrophosphate synthetase (PRPP
- administration of synthetase) activity.
diuretics or renal failure.
 Myeloproliferative disorders
 Obesity, diabetes, hypertension
ACUTE GOUTY  High consumption of red meat,
hyperlipidaemia
ARTHRITIS  Long-term use of diuretics
 Alcohol abuse
X-ray
Pathogenesis ❖ Acute attack:soft tissue
swelling.
❖ Chronic attack:
◼ Joint space narrowing
and secondary
osteoarthritis.
◼ Tophi appear as
characteristic punched-
out ‘cysts’ or deep
erosions in the para-
articular bone ends.
Synovial fluid analysis
 Urate crystals are
needle-like, 5–20 μm
long and exhibit strong
negative birefringence.
 Pyrophosphate crystals
are rhomboid-shaped,
slightly smaller than
urate crystals and show
weak positive
birefringence.
SEPTIC ARTHRITIS/INFECTIOUS ARTHRITIS - an inflammation of a joint that is caused by infection

-bacterial inoculation in
direct-penetrating injury -children/elderly -S. aureus
synovial membrane
adjacent spread -immunosuppressed -H. influenzae (child)
-activate inflammatory
reaction hematogenous -comorbid diseases -anaerobes
-cause damage to the lymphatic -male>female *polymicrobial
cartilage & produce
serous/purulent exudates -use of prosthetic joints
into joint space

-chondrolysis
-pain aggravated by -arthrotomy washout
movements
joint aspiration -ankylosis
-antibiotics -joint instability
-swelling -purulent
-children- subluxation &
-warm & tender -WBC>50 000
dislocation
-reduce ROM FBC-leucocytosis - Children- damage to
Blood culture +ve cartilaginous
physis/epiphysis
Imaging- evidence of
effusion
OSTEOMYELITIS

Definition : Inflammation of the bone caused by an infecting organism

Etiology :

Mechanism of spread Causative Organism Risk Factor

• Indirect via the blood stream from distant
site
• Direct introduction through the skin
• Direct spread from contiguous focus of
infection
• Staphylococcus Aureus (70%) • Recent trauma/surgery
• Streptococcus Pyogenes • Immunocompromised patients (DM, IV
• Hemophilus influenza (<4y/o) drug user)
• Poor vascular supply : PVD
• Peripheral neuropathy
• Malnutrition and general debility

Pathophysiology :
 Inflammation Suppuration –
process will pus form initially Necrosis due to
increase giving blood supply New bone Resolution :
Intraosseous
Pressure leading to subperiosteal compromised - formation healing and
pain, blood flow abscess and >sequestra(dead (Involucrum) sclerosis
obstruction & septic spread along bone)
thrombosis shaft

Clinical Features
Symptoms Signs
• Severe Pain • Erythema
• Fever • Tenderness
• Infants : FTT, drowsy, Irritable • Edema common ± abscess/draining sinus tract;
• Child : pseudoparalysis impaired
• Adult - backache • Restricted movement
Investigation
Laboratory Imaging
• FBC : High WBC (in Acute only), Low Hb Plain Film Findings of Osteomyelitis
• High Inflammatory markers : CRP & ESR U/S : subperiosteal abscess
• Blood Culture MRI : differentiate Soft tissue infection,extent of bone
• Aspirate culture : Gramstain, C&S , Ab Sensitivity Test destruction and reactive oedema

Acute Osteomyelitis Chronic Osteomyelitis

Duration < 4 weeks ➢ 4 weeks
Age Group Children Adult
Mode of spread Commonly Hematogenous spread Post trauma or Post Operative Spread
Risk factor Infants : Hx of birth difficulty or Umbilical artery Common in Diabetes Mellitus
catheterization Surgical Implants
Children : Minor skin abrasion, boil, septic tooth
Xray findings • Soft tissue swelling • Cortical Thickening
• Lytic bone destruction / Presence of lytic lesion • Sclerotic changes
• Periosteal reaction / Periosteal elevation • Irregularity of cortices
• Sequesterum of bone
• Cloaca
Treatment • Supportive treatment for pain and dehydration • Antibiotics (bactericidal) 4-6weeks
• Splintage affected part o Intravenously (2 weeks)
• Appropriate antibiotics o Orally (4 weeks)
• Intravenously (2 weeks) o Eg: Fusidic acid, clindamycin,
condition improved /until CRP returns to normal cephalosporins,
• Orally (4 weeks) o vancomycin and teicoplanin--MRSA
• Surgical drainage • Local treatment
o dressing
o acute abscess need urgent incision
and drainage
 • Operation (removal of implant,
debridement, filling the dead space, soft
tissue cover and aftercare)
• Amputation in stage IV

Complication • Spread – joint (septic arthritis), other bone • Same as in acute

(metastatic osteomyelitis) • Toxic Shock Syndrome
• Pathological fracture – the site of bone is • Chronic Drainage
weakened • Amputation
• Growth disturbance - if physis is damaged
→shortening or deformity
• Persistent infection - chronic osteomyelitis

Cierny-Mader Classification
 SPONDYLOLISTHESIS SPONDYLOSIS
Definition defect in pars interarticularis causing a defect in the pars interarticularis with no movement of the
forward slip of one vertebra on another vertebral bodies
usually at L5-S1,less commonly at L4-5

Mechanism Congenital Present of dysplastic • Genetics (Heredity)

superior sacral facet People born with thin vertebrae → at higher risk for
allowing forward fractures.
translation • Acquired
Isthmic Development of stress Trauma : gymnasts, weightlifters, backpackers, loggers,
fracture labourers
Degenerative Intersegmental instability
produced by facet
athropathy
Traumatic Fracture or dislocation of
the lumbar spine , not
involving the pars
Pathologic Malignancy ,
infection,other types of
abnormal bone
Post operative Excessive bone removal
in decompression
operation
Pathophysiology

Lumbar hyperextension activities

When the lumbar spine extends, the inferior articular process of the cranial
vertebra impacts the pars interarticularis of the caudal vertebra. Repetitive impacts
→ stress fracture of the pars interarticularis.

CF • lower back pain radiating to buttocks relieved • activity-related back pain

with sitting • pain w unilateral extension (Michelis' test)
• neurogenic claudication
• L5 radiculopathy To differentiate
• Meyerding Classification (percentage of slip) Spondylolysis ( + )
Spondylolisthesis ( - )
IV • x-ray : AP, lat, obliques flexion-extension • X ray :
views AP &Lat view - detection of pars fracture
Oblique x-ray - determine vertebral stability

“collar” break in the “Scottie dog’s” neck

• bone scan - Identify acute stress reaction in the pars

interarticularis.
• CT scan - Detect very small fractures.
To rule out other conditions
• MRI : axial and sagittal planes
Tx non-operative non-operative
ƒ activity restriction, bracing, NSAIDS ƒ Bed rest, back brace, NSAIDs, oral steroid prednisolone,
operative Physical therapy
ƒClassification and Treatment of
Spondylolisthesis

Class Percentag Treatment

e of Slip
1 0-25% Symptomatic operative
fusion only for
intractable pain
2 25-50 Same as above
3 50-75 Decompression for
spondylolisthesis and
spinal fusion
4 75-100 Same as above
5 >100 Same as above
Compx caudaequina syndrome
spinal stenosis
HERNIATED NUCLEUS PULPOSUS

-Herniated nucleus pulposus is a condition in which part or all of the soft, gelatinous central portion of an
intervertebral disk is forced through a weakened part of the disk, resulting in back pain and nerve root irritation.

**Provocation of radiating pain down the leg is the most sensitive test for a lumbar disc herniation
 -Sciatic scoliosis
-Pain (worsen by coughing or -Tenderness in midline of low back
straining) -Smoking-reduce
oxygent tension in -Paravetebral muscle spasm
-Leg and/or foot pain (sciatica)
avascular disc -Straight leg raising is limited and
-Numbness or a tingling sensation painful on affected side
in the leg and/or foot -chronic cough
-Crossed sciatic tension positive
-Muscle weakness in the leg and -stresses on the disc- -Femoral stretch test positive (L3/L4)
/or foot e.g driving
-Muscle weakness
-Loss of bladder or bowel control
-Reflexes loss
-Sensory loss

-Rest : kept in bed with hips and knees

-Spine x-ray may be done to rule out other causes of back or neck
slightly flexed
pain
-Pharmacological : anti- inflammatory
-Myelogram may be done to determine the size and location of
medication
disk herniation.
-Reduction : continuous bed rest and
-Spine MRI or spine CT will show
traction for 2 weeks
->herniated disk is pressing on the spinal canal &
-Pain relief : epidural injection of
->loss of disc height corticosteroid and local anaesthesia
->facet deterioration such as sclerosis/hyperthrophy -Surgical : discectomy
-Rehabilitation
CLAUDICATION

Definition : Intermittent pain in the legs associated with walking

Types : Neurogenic (Pseudo-) and Vascular (True) Claudication

TRUE CLAUDICATION PSEUDOCLAUDICATION

Origin Vascular Neurogenic

Cause Lack of blood supply Nerve root compression/stenosis

Site Buttocks, hip, thigh, calf, foot

Exercise induced Yes Variable

Discomfort with standing No Yes

Distance walked Same Variable

Relieved by Rest Sitting, squatting, bend forward

Pedal pulses Diminished/Absent Intact

Lower back pain No Yes

VERTEBRAL FRACTURE
Type Column Cause Neurological X ray Treatment
affected deficits
Wedge Anterior Flexion No - Wedged shaped vertebrae Majority –
Compression # compression (Loss of vertebral height) Obeservation,
bracing,
bisphosphonates

Severe pain >6w -

Kyphoplasty
Burst Fracture Anterior + Axial Compression Yes - AP view: spreading of Neuro intact –
Middle vertebral body with an Thoracolumbosacral
increase of the orthosis (TCSO)
interpedicular distance.
- Lateral view: retropulsion Neuro deficits –
of bone into canal Surgical
decompression &
spinal stabilization
Fracture- Posterior + Severe flexion + No AP: horizontal fractures in Neuro intact –
Distraction @ Middle Posterior the the pedicles @ Immobilization in
transverse processes cast/TCSO
Chance fracture Distraction
: maybe increase
apparent height of vertebral Neuro deficits –
body Surgical
Lateral: opening up of the decompression and
disc space posteriorly stabilization
Flexion- All three Flexion + Yes Fracture through vertebral Posterior open
Dislocation column Compression + body, pedicles, articular reduction with
process and laminae instrumented fusion
rotation, shear
With subluxation or even
bilateral facet dislocation

DENIS THREE COLUMN CLASSIFICATION

 NERVE INJURY

1. Classification:

I) SEDDON CLASSIFICATION :

Seddon Type Degree Myelin Intact Axon Intact Endoneurim Intact Wallerian Degen. Reversible
Neurapraxia 1st No Yes Yes No reversible
Axonotmesis 2nd No No Yes Yes reversible
Neurotmesis 3rd No No No Yes irreversible

II) SUNDERLAND :

Sunderland
Myelin Sheath Axon Endoneurim Perineurium Epineurium
Grade
I Disrupted Intact Intact Intact Intact
II Disrupted Disrupted Intact Intact Intact
III Disrupted Disrupted Disrupted Intact Intact
IV Disrupted Disrupted Disrupted Disrupted Intact
V Disrupted Disrupted Disrupted Disrupted Disrupted

2. Investigation

I) CT Myelography :

➢ Evaluate level of nerve root injury

➢ Done at least 3-4 weeks after injury
➢ Look for pseudomeningocele
II) MRI :
➢ Indication: suspected injury is distal to nerve roots
➢ Visualize whole brachial plexus, cord injury and neuroma formation

III) Electromyography (EMG) :

➢ tests muscles at rest and during activity

IV) Nerve Conduction Velocity (NCV) :

➢ performed along with EMG

V) Other Ix :
- Chest X Ray
➢ fracture of 1st and 2nd rib
- Shoulder X Ray
➢ Fracture of clavicle and dislocation of shoulder
- Cervical spine X Ray
➢ Transverse process fracture indicate root avulsion

3. Management

I) General

Conservative :

✓ Observation alone waiting for recovery (spontaneous)

o most managed with closed observation

o advancing Tinel sign is best clinical sign of effective nerve regeneration
✓ Physiotherapy , Immobilization

Surgical :
A. Acute surgical exploration (<1 week)

- Vascular injury
- Open injury
- Crush / contaminated wound
➢ Technique : nerve repair (Suture the nerve), nerve grafting (Gap > 1-2 cm, Sural nerve), nerve transfer (Transfer functioning nerve)
Nerve exploration : When nerve seen divided/need to be repair/recovery is inappropriate/diagnosis in doubt

B. Early surgical exploration

- Total plexus involvement

C. Delayed surgical exploration (3-6 months)

- Complete injuries with no recovery
➢ Technique: muscle/ tendon transfer

II) Specific

INJURED CONSERVATIVE OPERATIVE

NERVE

AXILLARY Recover spontaneously If 6-8 weeks deltoid show no sign of recovery, repeat EMG

NSAIDs, arm sling, physiotherapy Nerve exploration (within 3 months)

Excision and grafting

RADIAL NSAIDs, physiotherapy Open injury – nerve exploration,nerve repair/ grafting as soon as possible

EMG repeated if no recovery after 6 weeks

ULNAR NSAIDS, physiotherapy, splinting Exploration and suture of divided nerve

 Tendon transfer in case of loss of function.

MEDIAN NSAIDs, physiotherapy (wrist extension prevented) Suture and nerve grafting of divided nerve

Tendon transfer in case of loss of function.

4. Post-Op

- After repair, an advancing Tinel's sign should be elicited after adequate time has elapsed for the regenerating axons to bridge repair site

- Length of the latent period is related to the technical success of repair, usually equally one month;
- then the nerve advances 1mm each day

SPINAL SHOCK VS NEUROGENIC SHOCK VS HYPOVOLEMIC SHOCK

Spinal Shock Neurogenic Shock Hypovolemic Shock

BP Hypotension Hypotension Hypotension
Pulse Bradycardia Bradycardia Tachycardia
Reflexes / Bulbocavernosus
Reflex Absent Variable/independent Variable/independent

Motor
Flaccid Paralysis Variable/independent Variable/independent

Time ~48-72 hours immediately after spinal Following excessive blood

cord injury ~48-72 hours immediately after spinal loss
cord injury
Mechanism
Peripheral neurons become temporarily
unresponsive to brain stimuli.
Disruption of autonomic pathway leads Decreased preload leads to
to loss of sympathetic tone and decreased cardiac output.
decreased systemic vascular
resistance.

RED FLAG SYMPTOMS FOR BACKPAIN (B.A.C.K.P.A.I.N)

Bowel / Bladder dysfunction , Anesthesia (Saddle), Constitutional Symptoms/ Malugnancy, “K”ronic disease, Paresthesias, Age > 50
years old, IVDU, Neuromotor deficits
Bulbocavernosus reflex :
- anal sphincter contraction in response to squeezing the glans penis or tugging on the foley
- First reflex to recover from spinal shock (24-48 hours)
FAT EMBOLISM

Def : Syndrome caused by response / presence of embolized fat globules in lung parenchyma and peripheral circulation
Subclinical event (Syndromes appear 1-2 days after injury/ IM nailing)

Cause : Management:
- Fracture of long bone 1.Oxygenation.
- Intramedullary instrumentation 2.Fluid resuscitation
6 pints NS/3 hours followed by
Pathophysiology : 3 pints of NS/2 hours followed by
1 pint NS over 1 hour x 3
I) Mechanical theory
3.Surgical Care - early stabilization of long bone
- Embolism is caused by droplets of bone marrow fat released into venous system fractures
II) Metabolic theory
- Stress from trauma causes changes in chylomicrons which result in formation of fat emboli

Sign and Symptoms / Diagnostic Criteria (GURD CRITERIA)

• Major (1)
o Respiratory Insufficiency hypoxemia (PaO2 < 60) – Pt complaint of SOB
o Neuro : depression (changes in mental status)
o Skin : Petechial rash (Axillary region, oral mucosa)
o Pulmonary edema
• Minor (4)
o tachycardia
o pyrexia
o retinal emboli
o fat in urine or sputum
o thrombocytopenia
o decreased HCT
NECROTIZING FASCIITIS

- Infection of the soft tissue (fascia, with secondary necrosis of subcutaneous tissue) – Rapidly progressing
- Risk Factors :
o Immune suppression : diabetes, AIDS, cancer
o Bacterial introduction : IV drug use, hypodermic therapeutic injections, insect bites, skin abrasions, abdominal and perineal surgery
o Other host factors : obesity
- Diagnosis (need high suspicion) :
I) H/O antecedent trauma or surgery
II) Intense pain over the involved skin and underlying muscle; over the next several
hours to days, the local pain progresses to anaesthesia.
III) Fever, malaise, and myalgia
IV )Edema extending beyond the area of erythema, skin vesicles, and crepitus.
V)Comorbid factors, including DM

- Classification : Bacterial type, LRINEC Scoring system

- Clinical Features :
I) Early : localized abscess / cellulitis with rapid progression
II) Late : Severe pain, fever, skin bullae, gangrenous discoloration, subcutaneous emphysema

- Investigation : Biopsy, Lab ix based on LRINEC Scoring system

- Treatment :
I) Emergency radical debridement with broad spectrum IV antibiotics (Empirical -> Definitive)
II) Amputation (If life threatening)

- Complication :
• Renal Failure
• Septic shock / Sepsis
• Scarring
• Limb loss
• Toxic shock syndrome
COMPARTMENT SYNDROME
- A condition where osseofascial compartment pressure > Perfusion pressure

- Location : Leg (Most common), Forearm, hand, foot

- Cause :
I) Traumatic : Fracture (Most common), crush injuries, contusions
II) Tight casts, dressings
III) Burns, extravasation of IV infusion

- Pathophysiology :

- Clinical Features :

First Symptoms : Pain out of proportion , Tight swelling

Physical exam (5P)

o pain w/ passive stretch

▪ is most sensitive finding prior to onset of ischemia
 o paresthesia and hypoesthesia
o paralysis (late finding)
o palpable swelling
o peripheral pulses absent (late finding)

Treatment :

I) Initial Management

•Remove all circumferential dressings/casts

•Ensure leg is at level of the heart - the affected part should not be elevated above the level of the heart because this maneuver does not
improve venous outflow and reduces arterial inflow
•Remove any traction

II) Definitive : Emergency fasciotomy – 2 incisions (Bivalve), 15cm long

Complication :

Irreversible muscle and nere damage to

compartment, Rhabdomyolysis, Kidley failure

OPEN FRACTURE

GUSTILO-ANDERSON CLASSIFICATION FOR OPEN #

 • Type I
o wound < 1 cm
• Type II
o 1-10cm
• Type III A
o > 10 cm, high energy
o adequate tissue for coverage
o includes segmental / comminuted #
(even if wound <10cm)
• Type IIIB
o extensive periosteal stripping
& requires free soft tissue transfer
• Type IIIC
o vascular injury requiring vascular
repair

4 KEY MANAGEMENT OF OPEN FRACTURE

I) Antibiotic Prophylactic (+ Tetanus prophylaxis)

II) Urgent wound and fracture debridement
III) Stabilization of fracture
IV) Early definitive wound cover

CONUS MEDULLARIS VS CAUDA EQUINA SYNDROME

- Note that sign and symptoms of cauda equine syndrome are mostly LMN , while conus medullaris is combination of LMN + UMN.

- Key features in Cauda Equina Syndrome :

1. Bilateral sciatica 2. Bowel and bladder dysfunction 5. Crossed straight-leg sign

Prognosis of bone cancer depends on the following
3. Saddle anesthesia / Perineal numbness 4. Lower limb weakness
variables :

1. overall stage of disease (incorporates

all of the below)
2. presence of metastasis
3. skip (discontinous) lesions within the
same bone
Bone Tumor Classification :

Staging under MALIGNANT lesion :

• Stage I All low-grade sarcomas.
• Stage II Histologically high-grade lesions.
• Stage III Sarcomas which have metastasized.

Osteoid Osteoma vs Osteoblastoma

 OSTEOID OSTEOMA OSTEOBLASTOMA
Incidence 10% of benign tumors 3% of benign tumors
Size < 2 cm (typically <1.5cm) >2 cm (average, 3.5 - 4.0 cm)
Site > 50 % in long bone diaphysis > 35% in posterior elements of the spine
Location Proximal femur > tibia diaphysis > spine Vertebral column > proximal humerus > hip
Natural Self-limited Progressive
History Benign appearance. No growth potential. Benign appearance. Localized growth, with aggressive
potential
Investigation X ray (AP and Lateral + 1 view) X ray (AP and Lateral)

- Reactive bone around radiolucent nidus -Well-defined, Lytic /mixed lytic-blastic lesion
with radiolucent nidus > 2cm
CT Scan : Extent of tumor - Reactive sclerotic bone

Bone Scan : Hot are at nidus, low uptake at reactive CT Scan – Extent of tumor
zone (Double-density sign) Bone scan – Intense focal uptake
Symptoms Pain : Constant, Nocturnal pain, relieved by NSAIDS Dull ache, not relieved by NSAIDS + Neuro symptoms,
scoliosis
Palpable swelling/deformity

If at spine : Muscle spasm/scoliosis

Management 1st line : Clinical Observation and NSAIDs administration 1st line : Curettage / marginal excision with bone grafting

2nd line : Percutaneous radiofrequency ablation 2nd line : Radiation therapy (Inoperable spine lesion)
- If failed medical management / periarticular lesions

NOTE
Nidus - central nodule of woven bone and osteoid with osteoblastic rimming
Reactive zone - area of thickened bone and fibrovascular tissue

Simple Bone cyst vs Aneurysmal Bone cyst

Type SIMPLE/UNICAMERAL BONE CYST ANEURYSMAL BONE CYST
Epidemiology Serous-filled cavities in the bone Multiple blood-filled cavities

Age : Children (<20y/o), B>G Age : <20 y/o, G>B

Site : Proximal humerus @ metaphysic (Most common), prox. Site : Spine (25%), Long bones (20%) @ Metaphysis
Femur, distal tibia
Associated with other tumors 30% of time (giant cell
Classification : tumor, chondroblastoma, fibrous dysplasia, NOF)
- Active : If cyst adjacent to physis
- Passive : If normal bone separates cyst from physis

Clinical Asymptomatic Pain, swelling / Palpable lump

Features Pathological Fracture (50%) Pathological Fracture
Neurological deficits (Spine lesions)
Investigation
X Ray : X Ray :
- Narrow zone of transition - Well defined radiolucent cyst (Sharply defined/narrow
- Centrally located zone of transition) + Bony septae -> ‘Bubbly Appreance’
- Cystic expansion (Expand the bone) with thinning of the - Marked ballooning of bone end (Expansile osteolytic
endosteum /cortices lesion)
- No periosteal reaction or soft tissue component Thin rim of peristeal new bone

Pathological fracture : "fallen leaf" sign (pathologic fracture with
fallen cortical fragment in base of empty cyst is pathognomonic)
Management Asymptomatic : Observation, Avoid injury
Actively growing : Aspiration, Injection of methylprednisolone
Pathological fracture- Surgery :
MRI/CT : multiple fluid line, soft tissue involvement
Symptomatic without acute fracture : Curettage and bone
graft
If acute fracture : Non-operative fracture management
first
 1. remove the tumor- by curettage( scrape the tumor out of the
bone)
2. bone graft- after curettage, the cavity is filled with a bone graft
to help stabilize the bone.

Osterosarcoma vs Chondrosarcoma vs Ewing Sarcoma vs Giant cell tumor

Type / OSTEOSARCOMA CHONDROSARCOMA EWING SARCOMA GIANT CELL TUMOR

Description
Epidemiology Most common primary bone ca Second most common primary Second most common malignant Not malignant, locally
bone cancer bone tumor in children aggressive tumor
Age : Bimodal distribution (15-25
y/o and >60 y/o) Age : Older patient (40 – 75 y/o) Age : 5 – 25 y/o Age : 30 – 50 y/o

Site : Distal femur/Proximal Tibia
@ diaphysis (Most common),
prox. Humerus, prox femur
Clinical Hx : Pain (Most common ) –
Features Constant, worse at night, increase
in severity. Can also present with a
lump
PE : Regional swelling and
tenderness
Investigation
1. Lab Investigation : ALP , ESR
2. Imaging :
X ray :
- ‘sun burst’ or ‘hair on end’
perosteal reaction
- Codman’s triangle
Site : Pelvis, Proximal femur,
scapula @ metaphysis
Hx : Pain (most common) , slowly
growing mass, Bowel/bladder
obstruction (pelvis)
- Pathologic fracture
Radiographs (X Ray)
- lytic or blastic
lesion with reactive thickening of
the cortex
- Intra-lesional "popcorn"
mineralization may be seen
MRI or CT
- Cortical destruction, marrow
Site : Pelvis, femur, tibia,
humerus @ diaphysis
Hx : Throbbing pain, fever
(Mimics infection)
PE : Swelling, Tenderness
Lab : Increase ESR, LDH, FBC
(Leucocytosis, Anemia)
Imaging :
X ray :
- large destructive lesion with
a moth-eaten appearance
- ( moth-eaten appearance in
Site : Distal femur, Prox.
Tibia, radius, scaral ala @
metaphysis
Hx: Pain referable to
involved joint (Knee)
PE : Palpable mass,
Decreased ROM of
affected joint (knee)
Radiographs (X Ray) :
- eccentric lytic lesion
Bone scan : Very hot
MRI : Soft tissue
involvement
 - Blastic with alternate lytic lesion
CT / MRI : Extent of tumor, Soft
tissue involvement
Chest CT Scan : Staging
(Pulmonary mets)
Bone Scan : Very hot
Management - Multi-agent chemotherapy (Neo-
adjuvant 8-12 w) -> Surgical
resection (If possible) ->
Maintenance of chemotherapy (6
– 12 m)
- Wide surgical resection (Low
grade)
- Amputation (Pathologic #,
Neurovascular bundle affected)
involvement, and the soft tissue
involvement
Bone scan
-Very hot
NO chemo/radiotherapy
- Wide surgical resection
- Amputation (If cause
unacceptable loss of function)
bone, describes multiple small
endosteal lucent lesions or
holes, often with poorly defined
margins, with sparing of the
cortex.)
- Periosteal reaction : “Onion
skin”/”sunburst”
MRI : Soft tissue involvement
CT Chest : Pulmonary mets
Bone scan : very hot
Neoadjuvant chemotherapy (8- Extensive curettage and
12w) -> Surgical resection -> reconstruction
Maintenance chemotherapy (6-
12m) (Bone grating or
prosthetic replacement as
needed)
Condition CONGENITAL TALIPES EQUINOVARUS (CTEV)
Deformity 1. In general, the Heel is in equinus (downwards),
the entire hindfoot in varus (inwards) and mid-foot
and forefoot adducted and supinated
PES PLANUS (FLEXIBLE FLAT FOOT)
Physiologic variant consisting of :
- Decrease in the medial longitudinal arch
- Valgus hindfoot
- Forefoot abduction with weightbearing
‘Flexible’: Foot flat ONLY on weightbearing
Resolved spontaneously
PES CAVUS (HIGH ARCHED FOOT)
A foot deformity characterized by an
elevated longitudinal arch
Caused by Muscle imbalance :
- Strong Peroneus longus
- Weak tibialis anterior
This lead to contracted plantar fascia ->
fixed plantar flexion of the forefoot -> High
arch foot

2. Muscles contractures lead to the characteristic

deformity that includes (CAVE)
- Midfoot Cavus (tight intrinsics, FHL, FDL)
- Forefoot Adductus (tight tibialis posterior) Must rule out other neuromuscular disease
- Hindfoot Varus (tight tendoachilles, tibialis :
posterior, tibialis anterior) - Freidreich's ataxia
- Hindfoot Equinus (tight tendoachilles) Differential diagnosis for rigid flat foot - Cerebral palsy
- Tarsal coalition - Charcot-Marie-Tooth
3. Bony deformity consists of - Inflammatory joint disorder - Polio
- Talar neck is medially and plantarly deviated - Neurological disorder - Spinal cord lesions
- Calcaneus is in varus and rotated medially around - Congenital Vertical Talus
talus
- Navicular and cuboid are displaced medially

Epidemiology Most common defect 20 – 25% in adults - May be seen in both pediatric and adult
M>F populations
 50% Bilateral Usually bilateral
- 2/3 of patients have associated neurologic
Causes : Can be associated with generalized condition
- Idiopathic ligamentous laxity - When bilateral, often hereditary
- Defect during fetal development
- Neurological disorder and neural tube defect (
myelomeningocele, spinal dysraphism)
- Associated with arthrogryposis, tibial deficiency
and constriction rings.
- Postural deformity caused by tight packing in
overcrowded uterus (oligohydramnios)

Clinical Deformity can be seen obvious at birth Hx : Usually asymptomatic, may have arch Hx : 8-10 y/o , Ankle pain (painful calluses
Features - small calf pain/pretibial pain during activity under head of 1st metatarsal, 5th
- shortened tibia metatarsal, and medial heel due to plantar
- medial and posterior foot skin creases PE : flexed first ray)
- foot deformities - Foot flat on weight bearing (reconstitutes
• hindfoot in equinus and varus with toe walking, hallux dorsiflexion, or foot PE : Toe walking, Tight heel cord,
(differentiated from more common positional foot hanging) decreased ankle dorsiflexion
deformities by rigid equinus and resistance to - Valgus hindfoot deformity
passive correction) - Forefoot abduction
• midfoot in cavus
• forefoot in adduction

Associated disorders such as DDH and spina bifida

must always be examined !
Investigation X ray : X Ray : X ray : AP/Lateral of foot
I) Anteroposterior (AP) view : taken with the foot
30° plantarflexed. Indicated if painful flexible flatfoot to rule MRI Spine and EMG : Rule out
- Line is drawn through long axis of talus parallel to out other mimicking conditions : neuromuscular disease
its medial border and through calcaneum parallel to • Tarsal coalition
its lateral border. • Accessory navicular
- Kite’s angle (Talocalcaneal angle) : <20 deg Required views : weightbearing AP, lateral
(normally 20-40°) and oblique
 Finding : Meary’s angle will be apex plantar
• Angle subtended from a line
drawn through axis of talus
and axis of 1st ray.

II) Lateral – Dorsiflexion lateral (Turcon View)

- Talocalcaneal angle <35 deg (Normal > 35 deg)

III) AP/Lateral : Hindfoot parallelism between talus

and calcaneous

Management Non-operative (Asymptomatic pt) : Non-operative : Orthotics

 GENU VALGUS
Serial manipulation and casting (Ponseti method)
Goal : Rotate foot laterally around a fixed talus
1-4m -> Serial weekly casting (Correct cavus with
forefoot supinated, correct adduction and heel
varus by rotating calcaneus and forefoot into
forefoot abduction)
Week 8 -> Tendoachilles lengthening
4 – 8m -> Foot abduction orthosis (Denis-Brown Bar
in external rotation)
2-4y/o -> Tibialis Anterior Tendon transfer
GENU VARUM (Infantile Blount’s Dz)
- observation, stretching (tight heel cord), Operative :
shoewear modification, orthotics - plantar fascia release, posterior tibial
tendon transfer
Operative (Refractory pain) : - tendoachilles lengthening (TAL), and +/-
1st metatarsal dorsiflexion osteotomy
- Achilles tendon or gastrocnemius fascia
lengthening
- Calcaneal lengthening osteotomy(with
Deformity and Deformity that displaces the distal end of lower limbs away from midline Bowed leg
Classification Aka knock knees
Intermalleolar distance >8cm Considered pathological if :
- Intercondylar distance > 6cm
Classification according to etiology: - Deformity is unilateral
- Asymmetrical
I) Bilateral Genu Varum : - In child over age of 3

• Physiological Common causes :

• Renal osteodystrophy (renal rickets) - Blount’s disease
• Skeletal dysplasia - Metabolic ( ricket)
❑ Morquio syndrome - Post infection
❑ Spondyloepiphyseal dysplasia - Skeletal dysplasia (osteochondroplasia)
 ❑ Chondroctodermal dysplasia
Blount’s Disease :
II) Unilateral Genu Valgum : developmental disorder of tibia characterized by disordered
growth of the medial aspect of the proximal tibial physis
• Physeal injury from trauma, infection, or vascular insult resulting in progressive lower limb deformity:
• Proximal metaphyseal tibia fracture ✓ varus
• Benign tumors ✓ procurvatum
• Fibrous dysplasia ✓ internal rotation of the tibia
• Osteochondromas
• Ollier's disease Proximal media tibia physis -> genu varus, flexion and internal
rotation + compensatory distal femoral valgus

Epidemiology Location : distal femur is the most common location of primary Age : 2-5 years
pathologic genu valgum but can arise from tibia
Risk factor :
✓ overweight children
✓ early walkers (< 1 year)
✓ Hispanic and black

Basic Pathophysiology :
- Early walker / Obese kid -> Physis of tibia bear > weight and
pressure -> compressed -> growth inhibited -> At the same
time, fibula continue to grow => Uneven growth
Investigation AP hip and knee AP/Lateral Knee :
- lateral deviation of the axis or deviation toward or beyond the joint - Marked distortion of tibial epiphysis
margin. - Abnormal flattening or sloping of medial half of
epiphysis
- Metaphyseo-diaphyseal (drennan) angle. If it exceed
11°, suggestive of Blount’s disease.

Langenskiod classification
o Type I thru IV : increasing medial metaphyseal beaking
and sloping
o type V and VI : epiphyseal-metaphyseal bony
 bridge (congenital bar across physis)

Management I) Non Operative : Conservative

- Observation ❑ If < 2 years old, the best treatment is
observation. It could be physiologic and will
II) Operative : correct itself over 1 year.
- Hemiepiphysiodesis or physeal tethering (staples, screws, or ❑ If the bowing worsen, or in a child age 2-4 years
plate/screws) of medial side. old, is usually treated with KAFO, Knee Ankle
Foot Orthotic.
- Distal femoral varus osteotomy Operative
❑ If severe bowing, operative correction,
osteotomy is needed
DEVELOPMENTAL DYSPLASIA OF HIP (DDH)
SLIPPED UPPER FEMORAL EPIPHYSIS (SCFE)
PERTHES DISEASE
______________________________________________________________________________________________________________________

“Don't walk behind me; I may not lead.

Don't walk in front of me; I may not follow.
Just walk beside me and be my friend”
- Bittaufiq wannajah semua ☺