LMCC Orthopedic Review Lecture

Back to Basics
April, 2012

Dr. P.R. Thurston

LMCC Orthopedic Review Lecture

There are 10 basic topics about which questions may be
framed for medical student examinations in Orthopedics.

1)
2)
3)
4)
5)
6)
7)
8)
9)
10)

Fractures.
Low Back Pain.
Child, Painless Limp.
Pulmonary Fat Embolus.
Compartment Syndrome.
Metabolic Bone Disease.
Metastatic Disease.
Septic Hip / Osteomyelitis Children.
Dislocations.
Trivia.

Definitions
Fracture:A discontinuity in the structural
integrity of a bone.
Infraction:-

An incomplete fracture.

Dislocation:Complete loss of contact of the

articular surfaces of a
Subluxation:-

Non-concentric joint surfaces.

Reduction:Returning a fracture or dislocation to an

anatomical alignment.
Comminution:-

Multiple fragments.

joint.

Fractures
Definition :-

A discontinuity in the structural

integrity of a bone.

A fracture occurs because the force applied

exceeds the breaking strength of the bone so that the
Load can no longer be transferred across that zone
of the bone.

Fractures
Mechanical Properties of Bone
Bone is a two-phase material :Calcium HydroxyApatite
Osteoid

Ca10(PO4)6(OH)2

Collagen type I and II

= mineral

= fibrous

Calcium is strong in compression, but weak in tension.

Osteoid is strong in tension, but weak in compression.

Fractures
(for adult bone)

BUT :-

Calcium is stronger in compression

than Osteoid is in tension

And therefore :-

Bone always fails first in tension

Fractures
A bone consists of three
areas :-

Each region has its own

fracture characteristics.

the Diaphysis

the Metaphysis

the Epiphysis.

Fractures
Diaphyseal

Bending
Torque

Oblique
Spiral

Direct

Metaphyseal

Traction

Transverse

Compression

Epiphyseal

Intra-articular
Pediatric

Mixed

Fracture Description

This fracture is angulated

laterally, since it points
laterally.
The distal fragment is tilted
medially

Fracture Description
1) The distal fragment is always described with
relation to the proximal segment.
2) Displacement = Translation of bone ends.
3) Angulation

= Orientation of bone ends.

4) Angulation identifies to where the fracture points.

5) For clarity, the tilt of the distal fragment is often
used to describe angulation.

Fractures
A fracture can occur in :Growing Bone.
=

Pediatric Deformities.

Normal bone subject to abnormal forces.

= Traumatic Fractures.
Abnormal bone subject to normal forces.
= Pathologic Fractures.
Normal bone subject to cyclic forces.
= Fatigue or Stress Fractures.

Fractures
I

IV

Salter-Harris Classification
II

III

Fractures
Salter-Harris Classification
1) Fractures interfering with growing bones.
2) Worse prognosis with increasing number.
3) Probability of surgery increases with
number.

Stress or Fatigue Fractures

Repeated loading below acute
failure threshold.
Eventual fatigue failure.
Military recruits, runners, aerobics.
Tibia, metatarsals, femoral neck.
Initial x-ray can be negative.
Bone tenderness Bone scan.

Pathologic Fractures
Failure through abnormally
weakened bone
Minimal trauma BEWARE
Osteoporosis
Metastasis
Tumours:- Benign,
Malignant
(Multiple Myeloma).
Metabolic Bone Disease

Pathologic Fractures
Metastases:
Lytic

Sclerotic

Lung

Colon

Thyroid

Renal

Breast

Prostate

Pathologic Fractures
Metastases:
- require fixation to prevent fracture if they are > 1/3.
- produce pain on weight bearing in the lower limb.
- survival > 3 months.
- cannot be managed by medical therapy.
- radiotherapy after fixation (2 weeks)
(radiotherapy induced osteonecrotic fractures)

Pathologic Fractures

Osteitis Deformans / Pagets Disease

4% of pop. Over 40
yrs.
accelerated bone
turnover
often assymptomatic
monostotic >
polyostotic
loss of stature
AV shunting
pathologic bone

Gout
Urate crystalopathic arthritis
Crystals in periarticular tissues
Inconsistant elevated serum urate
Allopurinol and colchicine
Tophi in periarticular soft tissues
Deposits in non-articular cartilage
Juxta-articular erosions

Indications for Closed Reduction

There is significant displacement.
Reduction is possible.
The reduction, if gained, can be held.
The fracture has not been produced by a traction
force.

Indications for Open Reduction

1)
2)
3)
4)
5)
6)
7)
8)

There is a significant Displacement.

Open Fractures.
Intra-articular Fractures.
Un-reducible Fractures
Reductions that cannot be maintained in a cast.
Comminuted or Segmental Fractures.
Floating Joints.
Fractures with Neurovascular damage.

Open Fractures
Classification :1. < 1 cm., inside-out, little soft tissue damage.
= low potential for infection.
2. 1 cm. 10 cms., outside-in, requires debridement, but
no flap or skin graft.
= moderate potential for infection.
3. > 10 cms., outside-in, high energy, devitalized muscle,
comminution or bone loss, soft tissue loss.

Open Fractures
Classification :3A.

No loss of soft tissue cover, no flap required.

3B.

Flap required due to soft tissue stripping.

3C.

Associated vascular injury.

Type 1. Open Fracture = 6 mm, extend & debride

Degloving Mechanism

Degloving Mechanism

Type III C Injuries Vascular Injury

Note pallor of the ankle

No pulses

Fracture Complications
1. Pulmonary Fat Emboli
2. Compartment Syndromes

Pulmonary Fat Emboli :-

A.R.D.S.

- Long bone fractures, burns, contusions.

- Interstitial pneumonitis due to free fatty acids
- S.O.B. & confusion in young adults.
- Axillary & Subconjunctival Petechiae.
- Serum lipase elevated.
- pAO2 reduced if < 50 20% mortality.
- Ventillatory support
- Dexamethazone.
- 5 day course.

Pulmonary Fat Emboli :-

A.R.D.S.

Since Pulmonary Fat Emboli occur as an on-going

process, involving either repeated showers of emboli or
an evolution of insults, the most effective treatment is:-

Early Fracture Fixation

for both prevention and management.

Compartment Syndromes
- increased interstitial tissue pressure.
- fractures, burns, tight dressings.
- normal pressure < 25 mm. Hg.
- when the tissue pressure > venous capillary pressure, but less
than the arteriolar pressure.
- 6 Ps
- pain.
- pallor.
- pulselessness.
- paresthesias.
- paralysis.
- poikylothermia.

Compartment Syndrome
Symptom: Pain out of proportion to that
expected for the injury.
Signs: 1. Loss of function of muscle due to
ischemia within the compartment.
2. Pain with passive stretch
3. Numbness etc. are LATE findings!
4. If neuro symptoms present, potential
for full neuro recovery is only 10 %.

Rx Compartment Syndrome
Release all compressive
dressings / plaster.
Elevate extremity to
heart level.
Fasciotomies.

4compartment
fasciotomy

Compartment Syndrome

Careful monitoring.
Recognise it - 5 Ps
Call Orthopaedic
Surgeon
Pressure measurements

Back Pain

Classification of MechanicalBack
Pain
Postural syndrome (MacKenzie)
normal tissues become painful by the application of
prolonged stresses (sitting, bending etc)
Dysfunction syndrome
soft tissues are shortened and stiff. Usually >30 year
old, poor posture, under exercised, reduced mobility
Derangement syndrome
Disc derangement (tears and herniation)

Causes and Classification of Back Pain: McNab

Spondylogenic

Viscerogenic
Vasculogenic
Neurogenic
Psychogenic
Spondylogenic

Osseus:
Trauma
Infection
Neoplasms
Inflammatory
Metabolic (eg.Pagets)
Deformities
Soft tissues:
Muscles
SI joints
Disc
Facets

Anatomy

Extension

Flexion

Three joint complex (Kirkaldy Willis)

R e c u r r e n t r o t a t io n a l s t r a in
S y n o v ia l r e a c t io n fa c e t jo in t

D is c c ir c u m fe r e n c ia l t e a r s

C a r t ila g e d e s t r u c t io n
O s t e o p h y t e fo r m a t io n

r a d ia l t e a r
D is c h e r n ia t io n

C a p s u la r la x it y

Instability

I n t e r n a l d is c d is r u p t io n

S u b lu x a t io n

Lateral N. Ent

d e c r e a s e d is c h e ig h t

E n la r g e m e n t o f a r t ic u la r p r o c e s s

Central Stenosis

o s te o p h y te s

Non operative Treatment of Back Pain

Do nothing
Activity modification
Medications
Exercise and physiotherapy
Braces
Manipulation
Massage therapy
Traction/inversion therapy
Vitamins/Supplements/Diets
Weight control
Every Suzanne Summers sponsored abs
exerciser

Disc herniation

Ms J.H. 25 y.o. female presented with cauda equina syndrome

Cauda Equina Syndrome

Sciatica associated with bowel or bladder dysfunction.
Perineal numbness.
Low or Sequestrated Lumbar Disc.
Pressure on S1, S2 and/or S3 nerve roots.

Requires immediate Decompression to

avoid permanent disability.

Spinal stenosis
Symptoms:
unilateral radicular pain
bilateral claudication
better with forward flexion of trunk
better walking uphill
rare bowel/bladder involvement

Signs:
usually no neuro signs
look for pulses
stress test

Investigations:
XR
CT
Myelo-CT
MRI

Developmental Dysplasia of the Hip

An in utero Anterior Subluxation of the hip.
Growth in this position produces excessive Anteversion /
Adduction.
Classification:
Positional
2/1000
Hereditary 2 x more likely if
mother
Teratologic Arthrogryphosis
50% bilateral, F > M 8:1
Test ALL newborns at birth
Conservative Rx at birth Pavlik, D.diaper
Surgical Rx if resistant

Legg-Perthes Disease
Osteochondrosis (avascular necrosis)
Proximal Femoral Epiphysis
Necrosis, revascularization, fragmentation, healing
3 11 yrs., M > F 4:1, 15% bilat.
Subluxation laterally, Coxa plana, Coxa magna
Osteoarthritis 50 yrs.

Slipped Capital Femoral Epiphysis

Weakness of the physis of the femoral head allows
medial and inferior slip during the last phase of
growth.
Shortening of the leg, adduction, painless limp and
external rotation contracture.
Observation if mild, fixation if severe
Surgery risks Avascular Necrosis of femoral head

Ages for Hip Disease

D.D.H.
Septic Hip
Legg-Perthes
Transient Synovitis
S.C.F.E.

Birth
Birth 11
3 11
3 11
11 - 16

Osteomyelitis
Acute infection, metaphyseal
90% Staph., 20% mortality
100% growth abnormality
Periosteal elevation, osteolysis
Sequestrum, Involucrum

Dislocations
The articular surfaces are no longer in contact.

Commonly affects Shoulders > PIP joints > Elbows > Ankles.
Often associated with fractures.
Occasionally associated with neurologic injuries

Shoulder Dislocations
95 % anterior
1 % posterior

Luxatio erecta
Medial

Axillary nerve injury

Rapid reduction

Shoulder Dislocations
Conscious sedation.
Traction reduction.
Immobilization.
Recurrent.
Voluntary
Habitual.
Multiaxial instability.

Elbow Dislocation
Posterolateral.

Median nerve injury.

Ulnar nerve injury.

Rapid reduction.

Early mobilization.

Time for a 10 minute break!

1.

Talipes Equinovarus is the proper name for :-

a.
b.
c.
d.
e.

Flat feet
In-toeing
Club feet
Knock knees
Wry neck

Pes Planus
Metatarsus Adductus
Genu Valgus
Torticolis

Talipes Equinovarus
congenital deformity of the foot
Equinus, Inversion, Adduction, Supination
2 per 1000 live births
50% bilateral
M >F 2:1
Serial corrective casts at birth
Surgery if resistant
EARLY TREATMENT IS ESSENTIAL

2.

A Trendelenburg sign refers to :-

a.
b.
c.
d.
e.
f.

Leg length discrepancy

Gait abnormality
Knee recurvatum
Scoliosis
Hip Contracture
Abductor weakness

Trendelenberg Gait

3.

All of these are signs of D.D.H.

except :a.
b.
c.
d.
e.

Limited Abduction
Ortolani Sign
Asymmetric Skin Folds
Galeazzis Sign
McMurray Sign
Knee Meniscal Tear

Ortolani, Barlow & Galeazzi Signs

4. The most common congenital

spinal abnormality is :a.
b.
c.
d.
e.

Scoliosis
Spina Bifida
Torticolis
Klippel Feil Syndrome
Multiple Hereditary Osteochondroma

Spinal Bifida
defect of neural tube closure
Lumbar spine, commonly low
2 per 1000
myelodysplasia
Mild to complete paraplegia
Occulta, meningocoele, Myelomeningocoele
Bowel and bladder dysfunction

5.

5.

Polydactyly

6.

6.

Syndactyly

7.

7.

Sprengels Deformity

Omovertebral Bone

8. A 6 year old boy with delayed physical

development, convulsions, tetany,
weakness, blue sclera and bony deformities
is most likely suffering from :a.
b.
c.
d.
e.

Physical Abuse
Ehlers Danlos Syndrome
Osteogenesis Imperfecta
Multiple Hereditary Exostoses
Myositis Ossificans

9. A 6 year old boy with delayed physical

development, a rachitic rosary, weakness
and bony deformities is most likely
suffering from :a.
b.
c.
d.
e.

Physical Abuse
Rickets
Scurvy
Osteitis Deformans
Myositis Ossificans

9.

Rachitic Rosary

9.

Delayed Ossification

10. This is :a.

Osteomyelitis

b.

Osteomalacia

c.

Osteoporosis

d.

Osteitis Deformans

e.

Leprosy

11. A child with knee pain has a ____

problem until proven otherwise.
a.
b.
c.
d.
e.

Knee
Femoral
Tibial
Hip
Patella

12. All of the following are part of the

differential of hip pain in a 6 year old,
except :a.
b.
c.
d.
e.

Femoral Osteomyelitis
Septic Hip
Transient Synovitis
Legg-Perthes Osteochondritis
Slipped Capital Femoral Epiphysis

13. Osteomyelitis in children is

produced by what route of infection?
a.
b.
c.
d.
e.

Direct extension from another focus

Hematogenous spread
Perforating wounds
Lymphatic spread
Septic hip

14.

Paronychia

An infection of the base

of the nail plate

15.

Felon
A pulp space infection

16.

a.
b.
c.
d.
e.

All of these are findings of a

herniated L5-S1 disc, except :Absent Achilles reflex
Lateral foot numbness
S1 Nerve Root
Sciatica
Low back pain
Extensor Hallucis Longus weakness
L5 nerve root

17. Avascular necrosis of the femoral

head is associated with all of the
following except :a.
b.
c.
d.
e.

Steroid use
Alcohol
Deep sea diving
Lipid storage disease
Diabetes

18.
8 year old boy
What is the
Diagnosis?

Legg Perthes
Osteochondosis

19.

Diagnosis?

Gout

20. What is this deformity?

A Diner Fork Deformity

21.

Probable Diagnosis?

A Colles Fracture

21. Colles
Fracture

21.

Colles Fracture

distal radial fracture

FOOSH
occurs at all ages
commonly 60 yrs. +
osteoporosis
intra-articular

CR & K-Wires

External vs Internal Fixation

22. Diagnosis? :-

22. Diagnosis? :- A Scaphoid Fracture

23. The common complication

of this fracture is :-

23. Proximal pole Avascular Necrosis

due to a Scaphoid Fracture

24. This is a :-

a. Buckle Fracture
b. Greenstick Fracture
c. Stress Fracture
d. Pathologic Fracture
e. Growth Arrest line

24.
This is a :a. Buckle Fracture
b. Greenstick Fracture
c. Stress Fracture
d. Pathologic Fracture
e. Growth Arrest line

25. Is this fracture treated by Closed or

Open Reduction?

25.

ORIF

25. Fractures of Necessity

26. What is the Diagnosis?

26. Posterolateral Dislocation of the Elbow

26. Reduction by traction.

TRACTION

27. What is the Diagnosis?

27. Anterior Dislocation of the Shoulder

27. Reduction by traction

Traction

28.
This is a :a. Supracondylar #
b. Olecranon #
c. Dislocation
d. Forearm #
e. Radial Head #

28. Supracondylar Fracture

29. The complications of a

Supracondylar fracture in children
include all of the following except :a. Malunion
b. Volkmanns Ischemic Contracture
c. Compartment Syndrome
d. Cubitus Varus
e. Peripheral Nerve Injuries
f. Pulmonary Fat Embolus

30. The only sign of a Compartment

Syndrome that is always present
is :a. Pain
b. Pallor
c. Pulselessness
d. Paresthesias
e. Paralysis

31. Compartment pressures

indicating the need for fasciotomy :-

a. 0 15 mms. Hg
b. 15 25 mms. Hg
c. > 25 mms. Hg
d. > 50 mms. Hg
e. > 75 mms. Hg

32. A 20 yr. old male with a fractured

femur has findings of confusion,
tachypnea and conjunctival petechia.
The most likely diagnosis is :a. Pneumonia
b. Pulmonary Fat Emboli
c. Cerebral Contusion
d. Cardiac Contusion
e. Transient Stress Reaction

35. What fracture is this?

A Fracture of the Humerus

35. The commonest complication of this

fracture is :-

35. A Radial Nerve Palsy

36. Does this fracture require surgery?

Yes, it is a Traction
Injury and cannot be
reduced and held
closed.

37. This patient

most likely has a
fracture of the
.?
Right Hip Fracture
External rotation
Shortening
Flexion

A Sub-capital Hip Fracture

38. All of the following are complications

of this fracture except :a. Malunion
b. Avascular
necrosis
c. Fat emboli
d. Non-union
e. Thrombophlebitis

38. Blood Supply of Femoral Head

38. Save Head versus Replacement

38. Subcapital Hip Fractures

Properties
1. Avascular Necrosis - 30%
2. Malunion - 30%
3. Non-union - 30%
4. Surgery required
5. Older population
6. Pathologic - Osteoporotic

Garden Classification

39. Whats the Diagnosis?

39.

Intertrochanteric Hip Fracture

39. Intertrochanteric Fractures

Properties

1. Varus deformity
2. Well - Healing
3. Traumatic + Osteoporosis
4. Surgery required
5. Mid-range Age population

40.
Surgery
or not?
Yes, Subluxation of
the Talus due to
rupture of the Distal
Tibio-fibular
Syndesmosis.

41.

Surgery or not?

Yes, Unstable
Bimalleolar
Ankle Fracture

42. What is the approach to this fracture?

23 y.o. male
Basketball injury
Open fracture
Numbness
dorsum of toes

42.
Reduce dislocation
Sterile dressing
Splint extremity
Re-check NV status
IV Antibiotics
Tetanus
Surgery

43.
A 45 yr. old male, who was previously in good
health, has sudden onset of transverse low back pain
and right sided sciatica to his foot, after chopping
wood at the cottage. Upon arising the following morning,
he notices
numbness on the outer border of his
right foot and some weakness in the right leg. He
has no bowel or bladder problems.
The most likely diagnosis would be:a.

Lumbar Muscular Strain.

b.

Herniated Lumbar Disc.

c.

Herniated Lumbosacral Disc.

d.

Cauda Equina Syndrome.

e.

Spinal Stenosis.

44. Your initial approach to this problem

would include some or all of the following:a.

Bedrest.

b.

Anti-inflammatories.

c.

Muscle Relaxants.

d.

Spinal X-rays.

e.

Physiotherapy.

f.

Orthopedic/Neurosurgical referral.

g.

CT-Myelogram or MRI

h.

Discectomy

45. During the work-up for this problem, the

patient complains that he has unaccountably soiled
his underwear, without knowing it. Your response to
this would be to:a.

Reassure the patient that this is not serious

b.

Order an urgent MRI

c.

Get an urgent referral to Neuro/Orthopedics

d.

Place the patient on immediate bedrest.

46. Which of the following signs and

symptoms are consistent with a torn
medial meniscus of the knee:a.

Inability to squat

b.

Pain on descending stairs

c.

Locking

d.

Recurrent effusions

e.

All of the above.

47.
A 35 yr. old male falls jogging and sustains an
undisplaced lateral malleolar fracture of the ankle. He is
treated in a Below-knee Walking cast, but returns to the
ER 24 hrs. later complaining of increased, persistent, burning
pain at the ankle.
Your initial response to this situation would be :-

a.

Re-X-ray the ankle.

b.

Remove the cast.

c.

Measure the compartment pressures.

d.

Instruct the patient to elevate the limb and prescribe an

anti-inflamatory.

48. The most common dislocations of

the shoulder are:-

a.

Medial.

b.

Posterior.

c.

Luxatio Erecta.

d.

Anterior.

49.

Metastatic lesions to bone, of

the following tumours, usually
produce lytic defects except:a.

Thyroid.

b.

Pancreas.

c.

Prostate.

d.

Kidney.

e.

Lung.

Th - Tha Thats all folks!