OR

Orthopaedics
Frederick Cheng, Chris Farlinger and Caroline Scott, chapter editors Alaina Garbens and Modupe Oyewumi, associate editors Adam Gladwish, EBM editor Dr. Jeremy Hall, Dr. Markb Nousiainen and Dr. Herbert von Schroeder, staff editors
Basic Anatomy Review ................... 2 Differential Diagnosis of Joint Pain . . . . . . . . . 4 Fractures- General Principles . 5 Fracture Description Management of Fractures Fracture Healing General Fracture Complications Orthopaedic Emergencies ................ 7 Trauma Patient Work-Up Open Fractures Septic Joint Osteomyelitis Compartment Syndrome Cauda Equina Syndrome Hip Dislocation Pelvis ................................ 10 Pelvic Fracture Shoulder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1 Shoulder Dislocation Rotator Cuff Disease Acromioclavicular {AC) Joint Pathology Clavicular Fracture Frozen Shoulder Humerus ............................. 15 Proximal Humeral Fracture Humeral Shaft Fracture Elbow ................................ 16 General Principles Supracondylar Fracture Radial Head Fracture Olecranon Fracture Elbow Dislocation E pica ndyl itis Forearm .............................. 18 Radius and Ulna Fracture Monteggia Fracture Nightstick Fracture Galeazzi Fracture Wrist ................................ 19 Calles' Fracture Smith's Fracture Complications of Wrist Fractures Scaphoid Fracture Hand ................................. 21 Evaluation of Hand Complaints Spine ................................ 22 Fractures of the Spine Cervical Spine Thoracolumbar Spine Hip .................................. 26 Hip Fracture Arthritis of the Hip Hip Dislocation after THA Femur ................................. 28 Femoral Diaphysis Fracture Distal Femoral Fracture Knee .................................. 29 Evaluation of Knee Complaints Cruciate Ligament Tears Collateral Ligament Tears Meniscal Tears Quadriceps/Patellar Tendon Rupture Dislocated Knee Patella ................................ 32 Patellar Fracture Patellar Dislocation Patellofemoral Syndrome Tibia .................................. 33 Tibial Plateau Fracture Tibial Shaft Fracture Ankle .................................. 34 Evaluation of Ankle and Foot Complaints Ankle Fracture Ligamentous Injuries Foot .................................. 35 Talar Fracture Calcaneal Fracture Achilles Tendonitis Achilles Tendon Rupture Plantar Fasciitis Bunions (Hallux Valgus) Metatarsal Fracture Pediatric Orthopaedics ................... 38 Fractures in Children Stress Fractures Evaluation of the Limping Child Epiphyseal Injury Slipped Capital Femoral Epiphysis (SCFE) Developmental Dysplasia of the Hip (DOH) Legg-Calve-Perthes Disease (Coxa Plana) Osgood-Schlatter Disease Congenital Talipes Equinovarus (Club Foot) Scoliosis Bone Tumours .......................... 42 Benign Active Bone Tumours Benign Aggressive Bone Tumours Malignant Bone Tumours Articular Cartilage Defects ................ 44 Properties of Articular Cartilage Common Medications ................... 45 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

Toronto Notes 2011

Orthopaedic:a ORI

OR2 Orthopaedics

1'oroDio

2011

Basic Anatomy Review

C5 C6 C7 C6 Tl

DIMI af fanlann

t.llnll cutlniOUI- - - - - 1

Mlllllcutl..au ..,.of... nn
(sensory)

(sensory}

pnrfunU (medi114,5 digit&)

AIIXIlrdijlllftllll

s..,erficillis

f'llmll8fll0ry b111ncha of madim

nM'VI'I

ANTERIOR VIEW
F"IIJIRI 1. Malian, Muac1hatenaG11 allll Ulnar Nama: lnnarvalian of Upper Umll M111cl

'IbroDlo Nota 2011

Buic Anatomy Review

Orthopudla OR3

Axillrf

Circl.l lfi X[

Abduc!Dr

Superficial palmar arch

(senaary)

ANtERIOR VIEW
Figun 2. !Lift) IIDOd SuppiJ tv tile Upp Limb (Rigtd) AdiiJ and Ralial Nem11: lnnarvriDII of the Uppar Limb Tllllla 1. Saaary and Mlltllr Innervation of tile NerYM in dia Upper and Lowar Exlnmitiaa

POStERIOR VIEW

..............
Adary

Dellail'TEII!!! Miner

1..B1Eni Upper Arm (SagiBII's Patch)

L.atn F011111111 L.atn DaiiW11 of tha l*d Meclal Forelnn

llldilll

Triceps EldBn&GII 'Mist AIIXDII llld Allcllctllrs Flaxian ci1he 111 - llijts 'Mist Aex1111llld Adciu:bn Alllian of1he .fh - 5I" Digi11
Artie Plnlr Aaxiln Kn11Raian lftllt Tae Aexion
AJtil Evrnian

....

r.w
111111'

Vlilr 'l'lauRito Rlldiallh ci Ring Filger

S" IJVII

Medial Flnlrm Medial Dolunn Vel of Hand (111111' of Ring and

"lhu.Up": PIN !Radial Nerv11) "OKS9f: AIN (MINIIn Nerve) "Spraad Fingen": Ul111!' NIMI

...."

Dial

Slilaffaot
Danun of Feat
111 W&bSpa

lkl,..ticill'--1 0., l'lra1elll lklrlll

.....u

AJtle Dlniftexian and Inversion Extension

I..BIEni Foot

Anl8ramedial Anlda

OR4 Orthopaedics

Basic Anatomy Reriew/DlfFermtial. Diagnoais of Joint Pain

1'oroDio

2011

ANlERIOR VIEW
Common iliac Brtay - - - f l -+c. e lrrtemal iliac artay Extamlll iliac Brtay fiiHnll_,. - -=i!!".iilll'
Lllllnl CUIIIIIIDUI

POSTERIOR VIEW

niiMI of1ha 1liah niiMI of1ha 1liah

Medial CUIIIIIIDUI

Oblurwbl" narva -!"--!::>"!-!!*--a

Profunda hmoril Brtaly fi!Hnll utery

II 1
,' l'rvfwld1 hmaris 1rt8ry

flllanllltlry

Mil-- - Tibial'*"" Cammon fi!ar (pnnlllll)

niiMI

SaphanaUI narva

IPeronaall nerva

Cammanfitu

IPeranaall narva IPeronaall nerve

O.ep filM

Suplllficial fitu

'I

t:at.leal lmnll plllnla' niMI Medial plantar Madill plllnlllr llt8!y 1.mn11 plllnla' wry

rw

' - - - - l'lln1Br IIIIBry

F"111r1 3. Narvas d Arterias Df l.owlr Limbs

Differential Diagnosis of Joint Pain

Extrinsic neurologic (nerve root compression, herpes zoster, etc.) generalized (fibromyalgia, po1ymya1gia rheumatk:a, siclde cell (ischemic), dermato/polymyositis)
referred pain pain originating from surrounding organs

Intrinsic articular arthritis (degenerative, rheumatoid. crystal-induced, septic, avascular necrosis) neoplastic traumatic (fracture, soft tissue damage, neuropathic arthropathy)
non-articular bursa. tendons, llgaments. muscle (bursitis, tendonitis, myositis)

'IbroDlo Nota 2011

Orthopaedla ORS

Fractures - General Principles

Fracture Description
. -.

--------------------------------

......._ cartiiiQI -......EpPrfAallilll

--l'llriotteum

_Articul.-

1. Integrity of Skin/Soft Tiuua cl.oaed: skin/soft tissue over and near fracture Is intact open: akin/soft tissue over and near fracture is lacerated or abraded, fracture exposed to outside environment. continuous bleeding from puncture sl1e or fat droplets in blood suggest communication with fracture 2. Location (Figure 4} epiphyse&!: end ofbone, forming part of the adjacent joint metaphyBeal: the flared portion of the bone at the ends of the shaft. diaphyseal: the shaft ofa long bone (proximal, middle, distal) physis: growth plate

-CGmpactbn
--MadiJIIry CIVily

3. Ortentatlon/Fracture Pattern (Figure 5) transverse: perpendicular fracture line, direct force, high energy oblique: angular fracture line, angular or rotational force buttmly: slight comminution at the fracture site which looks like a butterfly segmental: a separate segment of bone bordered by fracture lines, high energy spiral: complex, multi-planar fracture line, rotational force, low energy comminutedlmultl-fragmenary: more than 2 fracture fragments intra-articular: fracture line crosses artlcu1ar ca.rtllage and enters joint compression/Impacted: impaction of bone, e.g. vertebrae, proxlmal. tibia torus: a buckle fracture of one cortex. often ln children (Figure 49) green-stick: an incomplete fracture ofone cortex, often in cbildren (Figure 49) pathologic: fracture th.rough bone wakened by disease/tumour

Figure 4. Schamltic Diagram of tha Lang BDna

......

',

2 lidBI = biillenll 2 villwll = AP + IIIIBnll 2 joints - joint allove + bllow 21inll = blllo11 + 1ft. l'llllctico
......

X.IIIJ ..... ., r.

4. Displacement (Figure 5) nondisplaced: fracture fragments are in anatomic alignment displaced: fracture fragments are not in anatomic alignment distracted: fracture fragments are separated by a gap angulated: direction offracture apex. e.g. varus/valgus translated: percentage of overlapping bone at fracture site rotated: fracture fragment rotnted alxrut long axis of bone

',

VI..,_... DIIpllletlll VIm = Apax -.y frvm midlina VI._- Apax1oward midlilll NOTE: dilplllc.ment ref8rl Ia 4hction "' dabll hgmllll

,;-

L .. 1

a. a.....

o..........- eanm.lltad I\ ,,_ \

F. H. Anplllllllll

K.lllpcl8d

J......
C Clllfy VuiDTiee 2D11

Figun 5. Fnctun TYJHII

Management of Fractures
ABCs, primary survey and secondary survey (ATLS protocol) rule out other fractureslinjurles rule out open fracture AMPLE history - Allergies, Medications, Past medical history, Last meal, Events IUlTOunding
injury
lnllclli- fllr llpln llldllltiln

NDCAIT N-nDIHI'Iion

consider pathologic fracture with history of only minor trauma additional himrryfphysical: baseline functional status -handedness (upper extremity) vs. ambulatory ability (lower ertremlty- note distances, stairs, and use of assistlve devices such as canes, walkers, wheelchairs, etc.)

C - n-.Jravuculllr campmmila A - intrwrtia.llw irlcbn I - Saller-Harria 3,4,5 1 - polvtnwma

a - opan fraclln

OR6 Orthopaedics

Fradurel- General

1'oroDio

2011

''..,
..._.For liptlelf
Reduces pain Reduces fur1har dlllliiQII to VBIIIIa, niii'VIS end ski'l Reduces risk of inad'IW18ntly canvatilg cloud ta open fractura Faclitatas petilllll transport

occupation and smoking status mecbanism ofinjury past medical history (note any contraindications to neurovascular status analgesia
imaging

or general anesthetic)

splint extremity 1. obtain the .reduction (refer to Table 22 for appropriate IV sedation) closed reduction apply traction in the long am of the llmb reverse the mechanism that produced the fracture reduce with IV sedation and muscle relaxation (fluoroscopy can be used ifavailable) indications for open reduction - NO CAST (see sidebar, OR5) other indications include failed closed reduction cannot cast or apply traction due to site (e.g. hip fracture)
pathologic fractures

potential fur improved function with open reduction and Internal fiDtl.on (ORIF) potential compUcations of open reductions infection mal-union non-union implant failure new fracture re-check. neurovascular status after .reduction and obtain post-reduction x-ray 2. maintain the reduction mernal stabilization - splints, casts, traction, external fixator internal stabilization -percutaneous pinning, atra.rnedullary fiDtl.on (screws, plates, wires), intramedullary fixation (rods) fullow-up- ewluate bone healing 3. rehabilitate to regajn function and avoid joint stiffness

Fracture Healing
Nann11IH--.
Weelcl (H Hematuma, matn111hiiQIII urvund fnll;tura1ite

Flaura I. HsterotGplc Ollllificatio of Femoral Diaphyllia aftar fHiur fnleblre 11d

Wllllks
Weelcl 6-12

Ostloclasts rllllOW sharp adglls, cellus forms within hematoma

Bone fonm within lhe ellllu., bridging frln"'-

lntrameduiiiY Nailillll

'

Httlrotopic Ollilic:6n The fomullion of bone in abnormal IDC81ions (a.g. in IICCindlry tD pathology.

, .---------------,

Months 6-12
Veers 1-2

Cortical gap ia bridged by bone

Normalarr:lltacbn isacl'iawd tlnugh r1111odalling

Rara 7. Slag of Bone Hllng

x-ray: trabeculae cross fracture site. vlslble callus bridging site on at least 3 of 4 cortices
Evaluation of Healing: Testa of Union cJinical.: no longer tender to palpation or streslling on physk:al eum

"',.---------------, ,

''., .---------------,
F1M:tJn .illtw Flllm!llion of vasidas or bulaelhllt occur on aclnlltousllll:in avellying 1 frlc1lnd bona.

lschanill to bone due to dilrupted blood supply; carrmanly in ba11111 covnd by cartilage.

General Fracture Complications

Table 2. General FI'ICture CompliCiti1111s
Early

Compal1ment ByRtama iliiiY

MallniiHIIIilll
AVBUIII' necllltiis (AVN)

rmction
Fracture blisters

Osteomyelitis ossilicati111 (Ill) Post-trunatic arthriW.Icd: llitrnall

Onnic

pain synd111ma typa 1 (a!PSVReftaK

dystrophy {RSD)
CRPIII'bllu lynplllhlllir; IJplnJphy M 11X1Q01iated raspons1 to an insult in
lhe 8X11'8mitiea; ehanlcblrizacl by iltanse p.m, llmpandUra uynvnllly, IIIIBma IDI m1lladnnsary chlngu.

SIPSis Deep win1tmJiiOiii(DVI) Pulm1111ry amblils !PEl Al:ule raspi'alary dmss synciane {ARDS) llamallhagic shack

Toronto Notes 2011

Orthopaedic Emergendea

Orthopaedics OR7

Orthopaedic Emergencies
Trauma Patient Work-Up
Etiology high energy trauma e.g. motor vehicle accidents, fall from height may be associated with spinal injuries or life-threatening visceral injuries Clinical Presentation local swelling, tenderness, deformity of the limbs and instability ofthe pelvis or spine decreased level of consciousness consider involvement of alcohol or other substances Investigations trauma survey (see Emergency Medicine. Initial Patient Assessment/Management, ER2) x-rays: !at cervical spine, AP chest, abdo x-ray, AP pelvis, AP and lateral of all long bones suspected to be injured other vieWll of pelvis: AP, inlet and outlet; Judet view for acetabular fracture (see Table 15 for classification of pelvic fractures) Treatment ABCDEs and initiate resuscitation to life threatening injuries assess genitourinary injury (rectal exam/vaginal exam mandatory) external or internal fixation of all fractures DVT prophylaxis Complications hemorrhage -life threatening (may produce signs and symptoms of hypovolemic shock) acute respiratory distress syndrome (ARDS) fat embolism syndrome venous thrombosis - DVT and PE bladder/bowel injury neurological damage possible obstetrical difficulties in future persistent sacro-iliac joint pain persistent pain/stiffness/limp/weakness in affected extremities post-traumatic arthritis of joints with intra-articular fractures sepsis if missed open fracture

It'

Orthop...&c Emer.-ils VON CHOP Vascular compromise Open fracture Nlurolovical compromisr/Ceudalquina
5yndrome

Cornpanmentsyndroma
Hip dislocation Ostllomyalilif/SIIplic lll1luilis Unstable Pelvic fnlcture

......

,...----------------. ,

Buck' Tractian A ay&tBrn of wuighll, puUsy1 and ropes 1hat are lttlched 1D the end of a patient'I bed exerting alongiludinll fDn:a on 1h1 distal and of a fnlcbn,
improving its alignment.

Open Fractures
Definition fractured bone in communication with the external environment Emergency Measures removal of obvious foreign material irrigate with normal saline cover wound with sterile dressings IV antibiotics (see Table 3) tetanus status booster splint fracture NPO and prepare for OR (bloodwork, consent, ECG, CXR) operative irrigation and debridement within 6-8 hours to decrease risk of infection traumatic wound often left open to drain but vac dressing may be used re-examine with repeat I&D in 48 hrs

......

,...----------------. ,

33'110 of patilllll$ wi1t1 open fnlc:turvs hav1 mullipla injuries.

OR8 Orthopaedics

Orthopaedic Emergencies
Teble 3. Gustilo Classification of Open Fractures
Gustilo

Toronto Notes 2011

Gl'lde
I

l.englll of Open Wound

Descriptian Mininal contamination and soft tissue injury or mini11111lly conminuted First generation cephalosporin (cefazclinl for 3days

<1em

lraclure
1-10cm
Moderate contamination Soft tissue injury First generation cephalosporin (cefazclinl for 3 days plus Gram.f'legative coverage (gentamicin! for at l1111st 3 days First generation cephalosporin (cefmlinl plus Gram.f'legative coverage (gentamicin! for at least 3 days For soil contamilation, penicillin is added for clostridial coverage

Ill*

>10cm

lilA: Ex11111siw soft tissue injury with ade abiity of soft tissue to cover wound IIIB: Extensive soft tissue injury with pariosteal stJ1lping and bone axposure; inadequlllll soft tissua1D covar woL.Ild IIIC: Vascular injury/compromise

Ant

injury; carminuted filiCIJ.ne, Viat p.

conllrninllian, eliiiiJU8111 mlllorl. ar frlcture more 1liln 8 hcus old is

cllssilied IS

linda Ill

Septic Joint
--------------------------------------------------------

Etiology

....

,..,

Plllm film fblinp in Saptlc Joint

[0-3 days) - usuelty normal. May snow soft-tissue $Welling or joint space widening from loclllizad adama LD [4-6 days) -joint lfiiC8 niiTOWinQ and destruction of cartilage

most commonly caused by Staphylococcus aureus in adults consider coagulase-negative staph in patients with prior joint replacement consider Neisseria gonorrhoeae in sexually active adults most common route of infection is hematogenous

Clinical Presentation
inability/refusal to bear weight, localized joint pain, erythema, warmth, swelling with pain on active and passive ROM, fever

Investigations
x-ray (to r/o fracture, tumour, metabolic bone disease), ESR, CRP, WBC, blood cultures joint aspirate (WBC >80,000 with >90% neutrophils, protein level >4.4 mg/dL, joint blood glucose level, no crystals, positive Gram stain results) rule out heart murmurs

Treatment
IV antibiotics, empiric therapy (based on age and risk factors), adjust pending joint aspirate
C&S

for small joints: needle aspiration, serial if necessary until sterile for major joints such as knee, hip, or shoulder: urgent decompression and surgical drainage

Osteomyelitis
Etiology

....

,,
0......,_.

most common organism is Staphylococcus aureus consider Salmonella typhi in patients with sickle cell disease neonates and immunocompromised patients are susceptible to Gram-negative organisms hematogenous (bacteremia) or exogenous (open fractures, surgery, local infected tissue) spread

Pllin flm findinp of 1. Soft tissueiW&lling

2. Lytic bone destruction 3.1'8riomel r1111dion [funnation of new bone, Blplcially in raspon11 to#)*

Clinical Presentation localized extremity pain fever or swelling 1 to 2 weeks after respiratory infection or infection
at another non-bony site

*G-raDy not sean on plain films until

10-12 days after onset of infection.

Investigations
blood culture, aspirate cultures, ESR, CRP, CBC (leukocytosis) x-ray, bone scan (increased uptake within 24-48 hours after onset in majority of patients), MRI most sensitive/specific

....

,,

Treatment
IV antibiotics, empiric therapy, adjust pending blood and aspirate cultures surgical decortication and drainage local antibiotics (e_g. antibiotic heads) ifMRI suggests an abscess or if patient does not improve after 36 hours on IV antibiotics serial I&D (if required), IV antibiotics eventually changed to PO, splint limb for several weeks followed by protective weight-bearing of the limb

Acute osteomyelitis is medical amarvancy which raquil'lll an allly diagnosis ll1d approprim antimicrobial and surgical traatmant

Toronto Notes 2011

Orthopaedic Emergendea

Orthopaedics OR9

Compartment Syndrome

----------------------------------

Definition increased interstitial pressure in an anatomical "compartment" (forearm. calf) where muscle and tissue are bounded by fascia and bone (fibro-osseous compartment) with little room for expansion interstitial pressure exceeds capillary perfusion pressure leading to muscle necrosis (in 4-6 hrs) and eventually nerve necrosis Etiology intracompartmental: fracture (particularly tibial shaft fractures, pediatric supracondylar fractures, and forearm fractures}, crush injury, revascularization extracompartmental: constrictive dressing (circumferential cast), circumferential bum
lncrllln;ud pr866Ln from blood and intracomparantal swellilg Dacraasad vanous dn1inaga Decrauad lymphdic lhinaga lntncompartmental pressure greater th1111 perfusion pressure

I
into tissue surrounding

Leaky basement

Acidosis ...________ Muscle and - - - - - Musc:leand nerve anoxia nerve necrosis

Figura B. Pathogenesis of Comparbnent Syndrome

Physical Examination pain with passive stretch 5 P's: late sign (see sidebar} Clinical Features pain with active contraction of compartment pain with passive stretch swollen, tense compartment suspicious history Investigations usually not necessary as compartment syndrome is a clinical diagnosis in children or unconscious patients where clinical exam is unreliable, compartment pressure monitoring with catheter AFTER clinical diagnosis is made (normal = 0 mmHg; elevated 0!:30 mmHg or S30 mmHg of diastolic BP) Treatment non-operative remove constrictive dressings (casts, splints}, elevate limb at the level of the heart operative urgent fasciotomy 48-72 hours post-op: wound closure necrotic tissue debridement Specific Complications rhabdomyolysis, renal failure secondary to myoglobinuria Volkmann's ischemic contracture: ischemic necrosis of muscle, followed by secondary fibrosis and finally calcification; especially following supracondylar fracture ofhumerus

5 P" of Compulnlm Syndrome

Pain Out of proportion for inilrf

Not relieved by .,lllgesics lncllliiSed with pBSSive mtl:h rJf compartment musdas {most

11)8Cilicl Pallor: 111111 finding

Pamthesill Pmlysis: late finding Pulsalessnen: 111111 findilg

', ,
MDR impDrlenl aign ill incraasud p11in with passive stretdl. Most important symptom ill pain out of proportion to injwy.

Cauda Equina Syndrome

see Neurosurgery. NS27

', ,
Cauda equina syndrome ill a survical lnlll'glllCY.

ORlO Orthopaeclica

1'oroDio

2011

'' I
Up 1o 50'J. "' palientlll willt lip dillacationa suffar fnlctum aluwhn at 1ht ti11111 of injry.

..

Hip Dislocation
full trauma survey (see see Rmelency Medicine, Initial Patient Assessment/Msmagement, ER2) examine for neurovascular injury PRIOR to open or clo&ed reduction reduce hip dislocations ASAP (ideally within 6 bOUill) to decrease risk of AVN of the femoral head hlp precautions (no extreme hlp flexion, adduction, internal or external rotation) for 6 weeks post-reduction also see Hip Dislocation after THA, OR28

3. Exilmll mtatian 2. lniMIII mtatian- .<L ' .

I
I.
' il l

- --;- t l'

ANTERIOR HIP DISLOCATION

0 Jonll SM Clan 20Q8

F"111111 9. Rachadar Method

, I
llllchallblr Mdloo to llad11:8

mechaniam: posteriorly directed blow to knee with hlp widely abducted clinical features: shortened, abducted. externally rotated limb treatment clo3ed reduction under consdous sedation/GA post-reduction CT to assess joint congruity

Dillacllil11 Patiantlyilg 1141ila wi1h lip ..d lcnaa flexed on injullld tide Surgaan llbnla an pllianl'a injlnd side Surgeon , . _ one arm 111dar pltianl's flarad tnll, IBIIChilg to place111at hind Dn patianl's Dlhlr knee llNl 8Uppclrtmg patient'; irj.Jred legl Willi Dlhar hind, 8UrgBDII tp1p1 Pllillllt' lOde an ililllld ide.
applying 1nldion RIDrction vii. lnll:tion, int. ralldion,

POSTERIOR HIP DISLOCAT10N most frequent type ofhip dislocation mechanism: severe force to knee with hip flexed and adducted e.g. knee into dashboard in motor vehicle accident (MVA) clinical features: shortened, adducted and internally rotated U:mb
treatment

closed reduction under conscious sedation/GA only ifassociated femoral neck fracture ORIF ifunstable, intra-articular fragments or posterior wall fracture
post-reduction CT to assess joint congruity and fractures ifreduction is unstable, put in traction x 4-6 weeks

1htn ut. rotnan once fwmcnl hllld ci11811IIC8!Bilulao- m.

CENTRAL HIP DISLOCATION (rare) traumatk: injury where femoral head la pushed through acetabulum toward pelvic cavity COMPUCAT10NS FOR ALL HIP DISLOCAT10NS post-traumatic art:hriti8 AVN fracture of femoral head. neck. or shaft sclB.tic nerve palsy in 2596 (1096 permanent) heterotopic osslfica.tion (HO) thromboembolism- DVT/PE

Pelvis
Pelvic Fracture
Mechanism young: high energy trauma, either direct or by force transmitted longitudinally through the femur elderly: fall from standing height. low energy trauma

Anbrior

co111m

Clinical Features local swelling. tenderness deformity of lower extremity pelvic instability

Investigations
Figur.1 D. Nvic Calums

x-ray: AP pelvis, inlet and outlet for pelvic fracture Judtt films (obturator and iliac oblique) for acetabular fracture 6 cardinal radiographic Unes of the acetabulum: illoischial Une, iliopectlnealllne, tear drop. roof, posterior rim. anterior rim CT scan useful for evaluating posterior pelvic injury and acetabular fracture

Toronto Notes 2011

Classification Table 4. Tile Classification of Pelvic Fractures (see Figure 11}
Type A Stability Rotationally stable Vertically stable Rotationally unstable Vertically stable Rotationally unstable Vertically unstable Description

Pelvis/Shoulder

Orthopaedics ORll

A1: fracture not involving pelvic ring A2: minimally displaced fracture of pelvic ring {e.g. ramus fracture) 81 : open book 82: lateral compression- ipsilateral 83: lateral compression- contralateral C1: unilateral C2: bilateral C3: associated acetabular fracture Type A Stable Awlsion Fracture

Treatment

ABCs assess genitourinary injury (rectal exam, vaginal exam, hematuria, blood at urethral meatus) if involved, the fracture is considered an open fracture stable fractures - nonoperative treatment, protected weight bearing indications for operative treatment unstable pelvic ring injury disruption of anterior and posterior SI ligament symphysis diastasis >2.5 em vertical instability of the posterior pelvis
Specific Complications (see General Fracture

Complications, OR6)
Type A Unstable Vertical Fracture

hemorrhage (life-threatening) - 1500-3000 ml blood loss injury to rectum or urogenital structures obstetrical difficulties persistent sacroiliac (SI) joint pain post-traumatic arthritis of the hip with acetabular fractures high risk of DVT/PE

Figure 11. Illustration ofthe Tile Classification of Pelvic Fractures

Shoulder
Shoulder Dislocation
the glenohumeral joint is the most commonly dislocated joint in the body since stability is sacrificed for motion
Prognosis

', ,
There are 4 Joints in the Shoulder: glenohumeral, acromioclavicular (AC), sternoclavicular (SC), scapulothoracic.

', ,
Factors Causing Shoulder Instability o Shallow glenoid o loose capsule o ligamentous laxity

recurrence rate depends on age of 1st dislocation: <20 yrs = 65-95%; 20-40 yrs = 60-70%; >40 yrs = 2-4% tuberosity fracture, glenoid rim fracture (Bankart lesion), humeral head impaction (Hill-Sachs lesion) rotator cuff or capsular tear, shoulder stiffness injury to axillary nerve/artery, brachial plexus recurrent/unreduced dislocation (most common complication)

Specific Complications

ANTERIOR SHOULDER DISLOCATION (>90%) Mechanism

abducted and externally rotated arm or blow to posterior shoulder

Clinical Features

pain arm held in slight abduction, external rotation; internal rotation is blocked "squared off" shoulder +ve apprehension test: apprehension with shoulder abduction and external rotation to 90 since humeral head is pushed anteriorly and recreates feeling of anterior dislocation +ve relocation test: a posteriorly directed force applied during the apprehension test relieves apprehension since anterior subluxation is prevented

1. Manubrium 2. Sternoclavicular joint 3. Clavicle 4. Coracoid process 5. Acromioclavicular joint 6. Acromion 7. Humerus 8. Glenohumeral joint 9. Scapula

Figure 12. Shoulder Joints

ORI2 Orthopaeclica

Shoulder

1'oroDio

201 1

+ve sukus sign: presence of subaaomial indentation with distalttacti.on on humerus lndl.cates Inferior shoulder instability neurovascular enm including: uillary nerve (sensory patch over deltoid and deltoid contraction) musculocutaneous nerve (sensory patch on lateral forearm and biceps coutraction)
Tabla 5. AI EBM Parapactin aa Taibi af AIIIBriar sauldar llllblblity
Appnhllllilll
landivq

Rakaliaa
45.83%
54.35%
43.8&r.

52..78%

....
63.89%
98.91!o 98.221

Spacificily

98.91% 97.m
1l.m

PPV NPV

56.26%

77.86!.

Investigations x-rays: AP, trans-sapular, axillary

X-Ray Findings

Silica sign

dislocation uillary view: humeral head is anterior trans-scapular view: humeral head is anterior to the centre of the "Mercedes-Benz sign" Hill-Sachs lesion: divot in posterior humeral head due to forceful impaction of an anteriorly dislocated humeral head against the glenoid rim {Figure 15) bony Banbrt lesion: avulsion of the anterior glenoid labrum (with attached bone from the glenoid rim
Treatment closed reductl.on with IV sedation and muscle rel.uation 2methods traction-countertraction: assistant stabilizes torso with a folded sheet wrapped across the chest: while the MD applies gentle steady traction (see Figure 14) Stimson: whlle patient lies prone with arm hanging over table edge, hang a 5lb weight on wrist fur 15-20 min obtain post-reduction .x-rays check post-reduction neurovascular status (NVS) sling x 3 weeks, followed by shoulder rehabilitation
POSTERIOR SHOULDER DISLOCATION (5%}

PaltlriDr 11111'111....-liga

Figure 13. Apprehlllion Tam

up to 60-8096 are missed on initial presentation due to poor physical cum and radiographs

i
i
f"llllnl 14.

::1
o!! 0

Mechanism adducted, Internally rotated, fleud arm fall on an outstretched hand (FOOSH) 3 E's (epileptic seizure, EtOH, electrocution) blow to 81112rior shoulder Clinical Features
arm is held in adduction and internal rotation; external rotation is blocla:d anterior shoulder flattening, prominent coracoid, palpable mass posterior to shoulder and adduct, internally posterior apprehension ("jerk") test with patient supine, 8eJ: elbow rotate the arm whlle applying a posterior force to the shoulder; patient will "jerk"' back with the

Traction-CaiiiiiBrtractiaa

sensation of subluxation

Investigation
x-rays: AP, trans-scapular, axillary

i
0

X-Ray Findings

Figure 15. AIIIBriar DiiiDCatiaa C.111i1111 Hii-Sachs and Banmt LIISia

dislocation AP view: partial vacancy of glenoid fosaa (vacant glenoid sJgn) and >6 mm space between anterior glenoid rim and humeral head (positive rim sign), humeral head may resemble a Ughtbulb due to internal rotation (Ughtbulb sign) axillary view: humeral head is posterior trans-scapular view: humeral head is posterior to centre of"Mercedes-Benz sign reverse Hill-Sachs lesion (7596 of cases): divot in anterior humeral head reverse bony Bankart lesion: avulsion of the posterior glenoid labrum from the bony glenoid
rim

'IbroDlo Nota 2011

Shoulder

Ortbopaedia OR13

Treatment cloaed reduction: inferior traction on a flexed elbow with presmre on the back ofthe humeral head obtain post-reduction x-rays check post-reduction neurovascular status aUng .1: 3 weeks, fullowed by shoulder rehabilltat!on

Rotator Cuff Disease

rotator cuffam&lsts of 4 muscles that act to stabilize humeral head within the glenoid fossa

......_rCulfiiiUGIII

1111

Supraspinalus

Tillie I. RotaiDr Cliff Muacl81 MuseIa r.\llcloAIId..-s

.......inalu
..,. greallr tub1111Sity af

hl.llleiUS
ScaptAB ..,. grea11!r tuberosity of

.scap.dar IWilMI scap.dar nerve

AxililryiWilMI

NineS-

AbiU:Iian

...........
ExlemBI rablliiJI Exlemlll ratltiiJI
lramal nrtation and adduelion

r..mnur

lrfrupinatus

h1.11181U1
T-Mi1ar . . . . . .ri.
StaptAB

greallr tub1111Sity af
IIISSIII'tullerollily llf

h1.11181U1
StaptAB

humerus

SPECTRUM OF DISEASE: IMPINGEMENT. TENDONITIS, MICRO OR MACRO TQRS Etiology compression of rotator cuff tendons (primarily supraspinatus) and subacromial bursa between the head ofthe humerus and the acromion; leads to bursitis. tendonitis and. ifleft untreated. can Figura 16. Macias Ill' the RatatDr lead to rotBtDr cuffthinning and tear CuH anything that leads to a narrow subacromial space 1. glenohumeral muscle weakness leadiDg to abnormal motion of humeral head 2. scapular muscle weakness leading to abnormal motion ofacromion 3. acromial abnormalities such as congenital narrow space or osteophyte formation
Clinical Features night pain and difficulty sleeping on affi:cted side
pain wone with active motion weakness and loss of range of motion (e.g. trouble with overhead activities) tenderness to palpation over greater tuberosity

Jobe's1811

Tillie 7. RotaiDr Cliff 5Jieclal TIIIB

Tilt
Jalle'alllll

Ellllnilllliln
Supraspinatus - plica tha llhauldar il 90 dagi'IIBS of abcD:tian and Waalinass with IIC!iva ra&istance suggasll 30 daw- of folward flaxiln and in!lmllly ra1B111tla11111 aa lhBI !Bilr 1he 1lum is pointing tuwlld the floor (Fii!IR 171

IJI.oll Tilt

bade agailst IICIIminer resis1Jrlce (Fi!Ju8 171

- iamlly 1'011118 arm aa dcnaiiUrface Dllald 111118 llllbility ta ICiivaly lift 111111 tiNIV !Jan bD Ill klwar bact Patient ins1nl:tad to actively lift 111111 Wft/ from Suggesl$ I &lisclp!Mri& till

l'lllllriDIIGIII
Tilt Nwa Tilt
II_...

and Teres mincr-11111 positioned at patiem's side in Weabess with active resislllnce suggests 90 of llalticn Patient instructad ID llldemlly 1'011118 arm pas1iliar cuff tallr agailst lhi18Sistlnca af1lla mminer (Figura 11)
RalaiDr OM

- passMI aluudar ftaxian (IVJre 181

r.-fr'lilll:

RalaiDr OM -shoulder flexillll ta 90 de!Jees and passivllmlllllralltian(Fp191 patient instructed ID activefv abduct

Pain elic:itad blltwaan 130-170 IUUIJIIIII Pain with internal mbdion suggests Pain with abduction piiB" than 90 degrees IUUIJIIIII tandinopalhy

PlllfU An: 'llllt RalaiDr OM Tend

lhllhrMdll'

Paltaiar cuff 1811

Figura 17. RatatDr Cuff TIIIB Jabe's. l..ift.Oft, Posterior Cliff

ORI4 Orthopaeclica

Shoulder

1'oroDio

201 1

lnvestignions
X-1'11}'!1: AP view may show high riding humerus relative to glenoid, evidence of chronic

tendonitis

MRI: coronallsagittal oblique and axial orientati.Oil8 are useful for assessing full/partial tears and te:ndinopathy, arthrogram: geyser sign (injected dye leaks out ofjoint through rotator cuff
tear) arthrogram: see full thickness tear, difficult to assess partial thl.ckness tears

Treatment and Prognoais mild ("wear") treatment is non-openrt:i.ve (physiotherapy, NSAIDs)

moderate ("tear")

non-operative treatment steroid Injection severe ("repair") impingement that is refractory to 2-3 months physio and 1-2 injecti0118 may require surgical repair, i.e. acromiopl.asty, rotator cuff repair

Acromioclavicular (AC) Joint Pathology

Figure 11. Neer's Test
2 main ligaments attach clavicle to scapula; acromioclavicular (AC) and coracoclavicu1a (CC)

lig8lllents
Mechanism fall onto shoulder with adducted arm (fall onto tip ofshoulder)

Clinical Features
palpate step deformity between distal clavicle and acroml.on (with dislocation) pain with adduction ofshoulder and/or palpation over AC joint limited ROM
Investigations x-rays: AP, Zanca view (10-lSO cephalic tilt), axillary stress views (10 lb weight in patient's
hand)

Figure 11.

....

Tallt

Treatment non-operative (most-common): sling 1-3 weeks, ice, analgesia operative indicati0118: AC and CC ligaments are both tom and/or clavicle displaced posteriorly procedure: excision oflateral clavicle with ACJCC ligament reconstruction

Clavicular Fracture
canllllian

l'naumlllhlnx or

n po111nti., complitations of SIIVTft ecromiociiiViwar joirt ditlocation

J.nddence: pnWmal (5%), middle (80%), or distal (IS%) third ofclavicle common in children (unites :rapidly without complications)

....

',
lnjlrilll wilh

FriCtlnl

CliMe

Mechanism fall on shoulder (8796), direct trauma to clavicle (7%}, FOOSH (696)

Clinical Features
pain and tenting of skin
arm is clasped to chest to splint shoulder and prevent movement

Up to IR of cl11Viw1r fnlctureur& a..oc:iabld with vther fnlcturw (mo.t

CD11111Dnly rib fnlchnsl

Ml.iDrity Df brachial pl1111111

BrB INOCiated with pnlllimal tl*d

fl'lctJna

Treatment evaluate neurovascular status ofentire upper limb proximal and middle third clavicular fractures sling X 1-2 weeks early ROM and strengthening once pain subsides ifends overlap >2 em. consider ORIF
distal third clavi.culn fractures undisplaced (with ligaments intact): sling x 1-2 weeks displaced (CC ligament inJury): ORIF

Speclflc Complications (see General Fmcturt CompUcattcns, OR6) cosmetic bump usually only complication shoulder stiffness, weakne511 with repetitive activity pneumothorax. injuries to brachial plaus and subclavian vessel (all very rare)

'IbroDlo Nota 2011

Shoulder/Humerus

Ortbopaedia ORlS

Frozen Shoulder (Adhesive Capsulitis) - - - - Definition

diamder characterized by progressive pain and lrti1fneas of the shoulder usually resolving spontaneolllly after 18 months

Mechanism primary adhesive capaulit:is idiopathic, usually ast1ociated with diabetes mellitus may resolve spontaneously in 9-18 months secondary adhesive capsulitis due to prolonged immobilization shoulder-hand syndrome -type of chronic regional pain syndrome (reflex sympathetic dystrophy) charact:erlzed by arm and shoulder pain, decreased motion and diffuse swelling following myocardJaliDfarct:lon. stroke, shoulder trauma

....

...--------------.
..

1.....-lnddtncelll.........,. C.,Uilil PrDIQ!Id immobiilll:ion !mOlt

lignilicllllj Femala galdar

Colldltlan5 Alnclltld

AaB>49'!'1111 DiiiiMills meltul {Sx)

Cervical dille dilaua

Clinical Features gradual onset (weeks to months) of diffuse shoulder pain with:
decreased active and passive ROM pain worse at night and often prevents sleeping on affucted side
increased stiffness as pain subsides: continuea for 6-12 months after pain has disappeared

Hyper1hyroidism

0 Streb Myucerdi.. infvl:tian

T11U111 and SLI!iJWV

Investigations
x-nys may be normal, or may show demineralization from disease
Treatment
active and passive ROM (physiotherapy) NSAIDs and steroid injections iflimited by pain MUA (manipulation under aneathesia) and early physiotherapy arthroscopy for debridement/decompression

....

Anldamic nack lractuiBI blood sup!IIY to tha humeral hd 1nd IIIIIIICUar (AVNJ allhlllllmnl

Humerus
Proximal Humeral Fracture
Mechanism o young: high energy trauma (MVA) o older: FOOSH from standing helght in osteoporotic .individuals

haadm.., ....

GIIII!Brtuberolity
....... lubiRIIity

Clinical Futures
pain, swelling, tenderness, painful ROM

Investigations
test a:xillary nerve function (deltoid function and skin over deltoid) o x-.rays: AP, trans-scapular, uill.ary are essential o CT scan: to evaluate for artl.cular involvement and fracture displacement

Classification

Neer classification is based on 4 fracture fragments: head, greatln' tuberosity, lesser tuberosity;

shaft nondisplaced: displacement <1 an andJor angulation <45 displaced: displacement >1 em and/or angulation >45
dlslocatedJsubluxed: humeral head dislocated/aubbw:d from glenoid

Figur. ZD. mGbuBS of tha

Proximal Hu111er

..... ,

.--------------.

Treatment o non-operative sling immobilization (nondlsplaced): begin ROM in 7-10 days to prevent stiffness
closed reduction (minimally displaced) operative ORIF (anatomic neck fractures, displaced. dislocated) hemiarthroplasty may be necessary, especially in elderly

. . . . 0 ... . , . . . , ..._

1. Gl'llllb.-T llJiily ... 2.1.8surTub-ity 3. Humnl Head

4. Shift

TW111111n frmu111: any allhll4 par111 with 1 displacad

displacad fracture neck + dilplaced IPitlr b.tlellJiily or

Spec:Hic Complications (see General Fracture ComplU:mlons, OR6) AVN, u:illary nerve palsy, malunion, post-traumatic arthritis

Fa1111111n fnlclln: diiPIK&d fracture of SLI!iJir:ll neck + biJ1h bilarositias

OR16 Orthopaeclia

Haml:nuiElbow

10ronto Nota 2011

Humeral Shaft Fracture

Mechanism direct blowsJMVA (most common), POOSH, twisting injuries, metastases (in elderly)

'., ..

Clinical Features o pain, swelling, shortening. mot:lon/aepitus at fracture site o must test ra.d1al. nerve function before and after treatment
Investigations x-rays: AP and lateral radiographs ofthe humerus including the shoulder and elbow joints

u.tarntill for Na....-nriM TreltrHnt < 20" anlrlrior..gl.tation < 30" VlllllnngLtllion

Acce,...._

Treatment
in general. humenl shaft fr:actu.res are t:n:ab:d non-opezatively non-operative (most common) redu.c:ti.on- am accept defunnity due m compensatory range of motion ofshoulder hanging cast (wcight of arm in cast provide& traction across fracture site) with sling immobilization x 7-10 days, then Sarmiento functional brace
o

< 3 4:111 ohhorter*lg

operative

Rillk of radial n. and brachial L injury!

indications: open fracture, neurovascular injury, unacceptable fracture alignment, polytrauma. segmental fracture. pathological fracture, "floating elbow" (simultaneoUll unstable humeral and furearm fractures), intra-articular procedure: compression plating (most common), Intramedullary rod Insertion. enemal fixation

Specific Complications (see General Practure Complkations, OR6) o radial nerve Injury: expect spontaneoUll recovery In 3-4 months, otherwise send for

electromyography (BMG) decreased ROM compartment syndrome

Elbow
General Principles
articulation between distal humerus, proximal ulna. proDmal radiUll (humeromdial. hwneroulnar and radioulnar joints} o fractures and disl.ocatl.ons of the elbow are evident on AP, lateral and oblique radiographs

Supracondylar Fracture
most common in pediatric population (peak age -7 years old), rarely seen In adults
o

anterior interosseous nerve (AIN) injury commonly usodated with extension type

Mechanism
>96% are atensl.on injuries via FOOSH (e.g. fall off monkey bars); <496 are flexion Injuries

Clinical Features pain. swelling. point tenderness neurovascular Injury- assess median and radial nerve, radial artery
Rgura 21. X-Ray af Trannana Displacad Supncaadtlar frllctura Df HaiHIWS with ElbGw

Investigations

DialaAtion

x-rays: AP,latc:xal ofelbow; asaess fur fat pad sign

Treatment
non-operative nondisplaced: cast in 900 :flexion for 3 weeks 0 operative Indications: displaced, vascular injury, open fracture requires perc11taneous pinning followed by limb cast with elbow flexed >90" in adults, ORIF is necessary

Specific Complications (see General Fracture Complialtions. OR6) brachial artery injury, median or ulnar nerve injury, compartment syndrome (leads to Volkmann's iachemic contracture), malallgnment cubitus varus (distal fragment tilted into
varus)

'IbroDlo Nota 2011

Ortbopaedia OR17

Radial Head Fracture

a common fracture of the upper limb in young adults
Mechanism FOOSH with elbow extended and forearm pronated

....

r.ntll Trld

, . Radillll"lll&d frac;bn 2. CDI1lllllid fracbn

3. ElbGw dillocation

Clinical Features

marked local tenderness on palpation over radial head (lateral elbow) decreased ROM at elbow, mechanical block to forearm pronation and supination pain on pronation/supination

Investigations .J:-ray: enlarged anterior fat pad (-san sign") or the presence ofa posterior fat pad indicate occult
radial head fractures
Tallie I.
I

end Treatlll..t vf R-.liel He-.! Frec:t.res

Bbow 511b or sq x3-5 days with a.tv ROM

z
3
4

ORFI: ai1\Palilll >30", invalm of joid incongruity exim Cammioolad frlclln Radial bald axcililll plllllhaais Commilded fnlciiR wi1h pos!eliar Radial head excisi111 :!:: plllllhesis lllow cillacalicn

aflh8 radial hlad.

mm

SpecHic Complications (see General Fracture Compltaltions, OR6) myositis ossiftcans recurrent inst8bility (if medial collateral ligament injured and radial head excised)

Olecranon Fracture
Mechanism direct trawna to posterior aspect ofelbow (fall onto the point of the elbow)

Clinical Features
loss of active extension due to avulsion of triceps tendon
Treatment
Du nut WllmobiliZII -'bPW jon > 2.J waaks to IMiid llliffnus.

undisplaced (<2 mm, sbl.ble): cast x 3 weeks (elbow in 45 flexion) then gentle ROM displaced: ORIF (plate and Screwti or tension band wiring) and early ROM ifstable

Elbow Dislocation
third morl common joint dislocation after shoulder and patella most commonly occurs in young people (5-25 yean) in sporting events or high speed MY .As,
dislocation ofulna

9096 are posterior/posterolateral. anterior are rare collateral ligaments disrupted

Mechnism elbow hyperextension via FOOSH or valgus/supination stress during elbow flexion

Clinical Features elbow pain, swelling. defOrmity

fienon contracture absent radial or ulnar pulses Treatment

Rgure Z3. Lateral VIew of Ellow

closed reduction under anesthesia (pori-reduction x-rays required) long-ann splint with forearm in neutral rotation and elbow in 90" flexion early ROM (<2 weeks)

SpecHic Complications (see General Fracture Compltaltions, OR6)

sti1fness (loss of atension), intra-articula.r loose body, neurowscular injury (ulnar nerve, median nerve, bra.chial. artery), radial head fracture

ORIS Orthopaeclica

Elbow/Forearm

ToroDio

2011

Epicondylitis
lateral epicondylitis = "tennis elbow", inflammation of the common extensor tendon as it inserts into the lateral epicondyle medial epicondylitis = "golfer's elbow': inflammation of the common flexor tendon as it inserts into the medial epicondyle repeated or sustained contraction of the forearm muscles
Clinic:el Features
point tenderness over hwneral epicondyle pain upon resisted wrist atension (lateral epicondylitis) or wliBt: flenon (medial epicondylids) generally a self-limited condition. but may take 6-18 months to resolve

Mechanism

Treatment

rest. ice, NSAIDs

use brace/strap

PT, stretching and strengthening corticosteroid injection

BUrgery: percutanOOWi or open release of common tendon from epicondyle (only after 6-12 months ofconservative therapy)

Forearm
Radius and Ulna Fracture
Mechanism
commonly a FOOSH or direct blow
Investigations x-ray: 1) AP and lateral offorearm; 2) AP, lateral, obliqu.e ofelbow and wrist cr if fracture is close to joint
Treatment

goal is anatomic reduction aince imperfect alignment significantly limits fureann pronation and supination ORIF with compresslon plates and screws
Complications (see General Fracture Compliamons. OR6)

Monteggia Fracture
Definition fracture of the proximal ulna with radial head clialoca.tion

Mechanism
direct blow on the po!terlor aspect of the furearm.

hyperpronation

fall on the hypereuended elbow

Clinic:el Features decreased rotation offurearm palpation lump at the radial head ulna angled apex anterior and radial head dislocated anteriorly (mrely the reverie deformity
occurs)

Treatment

Figure 24. MOIIteggla fl'lcblre

....

. ,

ORIF of ulna with indirect radius reduction in 9096 splint and early post-op ROM ifelbow completely stable; otherwise immobilization in plaster with elbow flexed for 6 weeks
Specific Complications (see General Fracture Complications, OR6) compartment syndrome radial/posterior interosseous nerve (PIN) injury decreased ROM

ilollded ulna fladurea, . . _ pnncirnalradiua ID rula out 1 Mon1Bggi1 fnu:lln.

'IbroDlo Nota 2011

ForearmJWrist

Ortbopaedia OR19

Nightstick Fracture
Definition
isolated fracture of ulna

Mechanism
direct blow to forearm (holding arm up to protect face)
Treatment non-displaced: below elbow cast (10 days) followed by forearm brace (-8 weeks) displaced: ORIF if >5096 shaft displacement or >10 angulation

i
\

I i!ii
0

Galeazzi Fracture
Definition fracture ofthe distal radial shaft with disruption ofthe distal radioulnar joint (DRUD most commonly in the distall{3 of radiw; near junction of metaphysis/diaphysis

Mechanism w;ual cause is fall on the hand (mechanical axial loading ofpronated forearm)
lnvestigtltions

x-rays shortening of distal radiw; >5 mm relative to the distal ulna widening of the DRUJ space on AP dislocation of radiWI with respect to ulna on true lateral
Treatment ORIF ofradius ifDRUJ is stable, splint with early ROM ifDRUJ ill unstable, DRUJ pinning and long arm cast in supination x 6 weeks

Fiaare Zfi. &elellli fnlctura

..._,,

For al isollted radiJs frlclu1111 ..... DRW til nil out a Galellli frlclure.

Wrist
Colles Fracture
Definition

transverse distal radius fracture (about 2 an pro:dmal. to the radiocarpal Joint) with dorsal
displacunent ulnar styloid fracture

Epidemiology

most common fractuie In those >40 years, espedal1y in women and those with osteoporotic bone

Mechanism
FOOSH

:;::-...

.....___
.

Clinical Features dinner fork'" deformity swelling, ecchymosis, tenderness

lnveatigations findings on x-ray (Figure 27)

--,:-::>"
.....

APvinr

ii-"*

1. Dol'llltllt 2. Dol'lll diaplac:ement

3. Ullllll' lllytaid fnx:lln

Tnatmant

goal. ill to restore radial height, radial inclination (22), volar tilt (11 ) and articular congruity dosed reduction (think. opposite of the deformity): hemamma block (sterile prep and drape, local anesthetic injection directly into fracture site) or conscious sedation closed reduction -traction with extension (exaggerate injury), then traction with ulnar deviation, pronation, flexion of distal fragment - not a:t wrist) dorsal slab/below elbow cast for 5-6 weeks

4. llldial displacrment 5. Radial tilt

6. Shortaning

I ..
Ill

3
0

Fiaare Zl. Call' fnlctura anlll AssacilbMI Bony Dllfllrmity

x-ray ql week to eD.51lre reduction is maintained obtain post-reduction films immediately; repeat reduction ifnece8sary, consider external fixation or ORIF

OR20 Orthopaedics

Wrist

Toronto Notes 2011

Smith's Fracture
Definition volar displacement of the distal radius (i.e. reverse Colles' fracture) Mechanism fall onto the back of the flexed hand Treatment usually unstable and needs ORIF if patient is poor operative candidate, may attempt non-operative treatment closed reduction with hematoma block (reduction opposite of Colles') long-arm cast in supination x 6 weeks

Complications of Wrist Fractures

most common complications are poor grip strength, stiffness, and radial shortening distal radius fractures in individuals <40 years of age are usually highly comminuted and are likely to require ORIF 80% have normal function in 6-12 months early difficult reduction loss of reduction compartment syndrome extensor pollicis longus (EPL) tendon rupture acute carpal tunnel syndrome finger swelling with venous or lymphatic block late mal-union, radial shortening painful wrist secondary to ulnar prominence frozen shoulder ("shoulder-hand syndrome'') post-traumatic arthritis carpal tunnel syndrome complex regional pain syndrome (reflex sympathetic dystrophy (RSD))

Scaphoid Fracture
Epidemiology common in young men; not common in children or in patients beyond middle age
+---Radius Scaphoid

Mechanism FOOSH resulting most commonly in a transverse fracture through the waist (middle) of the scaphoid Clinical Features pain on wrist movement tenderness in scaphoid region (anatomical "snuffbox") usually undisplaced Investigations x-ray: AP, lateral, scaphoid views with wrist extension and ulnar deviation q2 weeks bone scan CT,MRI Note: a fracture may not be radiologically evident up to 2 weeks after acute injury, so if a patient complains of wrist pain and has anatomical snuffbox tenderness but a negative x-ray, treat as if positive for a scaphoid fracture and repeat x-ray 2 weeks later to rule out a fracture. If x-ray still negative order CT or MRI Treatment non-displaced= long-arm thumb spica cast x 4 weeks then short arm cast until radiographic evidence of healing is seen (2-3 months) displaced = open (or percutaneous) screw fixation Specific Complications (see General Fracture Complications, OR6) AVN of the proximal fragment (since the scaphoid has distal to proximal blood supply, the more proximal the fracture, the greater incidence of AVN) delayed union (recommend surgical fixation) non-union (must use bone graft and fixation to heal)

Metacarpal bones (1-5)

Figure 28. Carpal Bones

Figure 29. ORIF Left Scaphoid

Toronto Notes 2011

Wrist/Hand

Orthopaedic:a OR21

Prognosis fractures of the proximal third of the scaphoid have 70% rate ofnon-union or AVN waist fractures have healing rates of 80-90% distal third fractures have healing rates close to 100%

Hand
see

PUO

Evaluation of Hand Complaints

History hand dominance, AM stiffness, location of pain, swelling, mass, trauma, activity, neurological symptoms, history of arthritis Physical Examination deformities fracture: rotational or angular rheumatoid arthritis: ulnar deviation, swan neck, boutonniere, mallet finger finger position Dupuytren's contracture: flexion contracture of 4th/5th finger swelling/masses Heberden's node: DIP swelling Bouchard's node: PIP swelling rheumatoid arthritis: MCP swelling skin changes nail changes: dubbing, koilonychia, leukonychia, Lindsay's nails, Terry's nails, onycholysis muscle wasting: thenar, hypothenar, intrinsics range of motions, crepitus, joint line tenderness, joint stability all bones, including carpal bones, can be palpated to identify maximum tenderness neurovascular examination Special Tests of the Hand test of flexor digitorum profundus flex DIP while holding MCP in extension if unable to flex DIP, then suggestive of flexor digitorum profundus pathology test of flexor digitorum superfici.alis (sublimes) flex PIP while holding MCP in extension if unable to flex PIP only, then suggestive of flexor digitorum superficialis pathology test ofthumb instability apply a valgus stress to thumb while stabilizing metacarpal; keep MCP flexed slightly while testing ifthere is laxity in thumb, then suggestive of ulnar collateral ligament rupture test of finger instability apply varus and valgus stress to finger while stabilizing PIP ifthere is laxity in PIP, then suggestive of collateral ligament damage Allen's test occlude both ulnar and radial artery; release one at a time to determine patency of each artery Finklestein's test place thumb in palm and cover with all fingers and move wrist into ulnar deviation ifpain is reproduced at radial styloid region, then suggestive of tenosynovitis of 1st compartment (EPB, APL tendons) test of carpal tunnel syndrome see Plastic Sur.gery; PUS

OR22 Orthopaeclica

Spine

1'oroDio

2011

Spine
Spinoua
PIOCIIIJI

lnf8rior ar1icular prociSS

..-ss

Spinous

Su,...ar VI8W
,o!,SpladIran Atlot8'l

Flgara 30. Schematic Diagram of VartaJiral Anltamy 274 - A&D

"*

Fractures of the Spina

see NS34 4 mam types of:fractures (see Table 9)

Tabla 9. Fracture Type aad Calamn lnvolnmaat

Anllrior Burst

Antariot nildla
Midlle, poslerior

Stable lhblbla
lnblllle

Hig!Hnargy IXill laeding + fllllion

WNA (lap belt any) caaing flexi111 and disbaction

(C.ce lrlctu11l

centforce lllPiiad to spine (flexion. axtensian,.

distraction, rotation. shear or axial load)

Cervical Spina
General Princ:iples Cl = atlas: no vertebral body, no spinous process C2 = axis: odontoid= dens 7 cervical vertebrae; 8 cervical nerve roots nerve root exits above vertebra (Le. C4 nerve root exits above C4 vertebra) radl.culopathy = Impingement of nerve root myelopathy = Impingement ofspinal cord Special Testing Compression test pressure on head wonena radicular pain
F"IIJra 31. Bunt. Camprauioll and DillacatiDII Fracblra
Diattaction test: traction on head relieves :radicular symptoms VaJsalva test: Valsalva maneuver lnaeases intrathecal pressure and cauaes ra.dicular pain

Toronto Notes 2011

Spine

Orthopaedic:a OR23

Table 10. Cervical Radiculopatlly/Neuropathy Root C5 C6

Malar Deltoid Biceps Wrist ax11111sion Axillary nerve {patch ovar lat&ral daiiDidl Biceps Biceps Brachioradialis Thlmb and indax. finger Biceps Brachioradialis

Cl
Triceps wrist flexion

ca
Interossei Digillll flexors Ring and little finger

Finger axtansion
Middle finger Triceps

s...ry
Reftp

Fingarjsrk

X-Rays for C-Spine AP spine: alignment AP odontoid: atlantoaxial articulation lateral vertebral alignment: posterior vertebral bodies should be aligned (translation >3.5 mm is abnormal) angulation: between adjacent vertebral bodies {> 11o is abnormal) disc or facet joint widening anterior soft tissue space (at C3 should be S:3 mm; at C4 should be S:8-10 mm) oblique: evaluate pedicles and intervertebral foramen swimmer's view: lateral view with arm abducted 1800 to evaluate C7-T1 junction if lateral view is inadequate (must see C7-T1 in all trauma situations) lateral flexion/extension view: evaluate subluxation of cervical vertebrae Differential Diagnosis of C-Spine Pain trapezial sprain, whiplash, cervical spondylosis, cervical stenosis, rheumatoid arthritis (spondylitis), traumatic injury

Red Flqsfar

BACK PAIN Bowel or bladder dysfunction Anesthesia (Addle) Conritutional symplomf/malillfiiiiiC'( !Chronic di5ease Parllllhuaiu AQa >50
IV drug u.e

ruuromator dllicitl

.......----------------. ,
IGCS = 151 and s11b1e patients wi1t1 -puclud C-$11in8 injury Obtain radiovraphy if: Agu >65
Pamthasia in the extremities Inability Ill rotate neck >45" Dlln!IIIIIUI 1111Chanism of injury (e.g. high speed fall fnlm ei8VIIion > 5ft. etc.)
lletlrmce: CJEM ZOOZ;4(2):84-90 Clllllllliln Capm lm (CCR) Used blguids irTIIIging for alert

C-SPINE INJURY see NS34

Thoracolumbar Spine
General Principles spinal cord terminates at conus medullaris {Ll) individual nerve roots exit below pedicle of vertebra (ie. lA nerve root exits below lA pedicle) Special Tests Straight leg raise (SLR): passive lifting of leg (30-70) reproduces radicular symptoms of pain radiating down post/lat leg to knee, into foot Lasegue maneuver: dorsiflexion offoot during SLR makes symptoms worse or, if leg is less elevated, dorsiflexion will bring on symptoms Femoral stretch test: with patient prone, flexing the knee of the affected side and passively extending the hip results in radicular pain

.......

lmmedillt8 immobilization of C-spile at scene of accident wilh spine board,

C.coU.and sandbags.

Table 11. Lumber Radiculopathy/Neuropatlly

Root
Malar

L4
lkladriceps {knee extension + hip adductionI Tibialis anterior {artie inversion + dorsiflexionI Madialllllllleolus

L5
EHL {extensor hallucis lon!Jlsl Gluteus medius (hip abduction!

S1
Peroneus longus + brevis {artie eversionI Gastrocnemius + soleus {plantar flaxionl

S111111ry
Reftp Test
'lklralilbla

1rt donal webspace and lat&ral l.ataral foot leg

Medial hamstring Straight leg raise Ankle {AchillesI Straight leg raise

Knee {Patellar)
Femanl stretch

OR24 Orthopru:clia

Spine

10ronto Nota 2011

.....

,'

Cui equi111 t'jlldrom and Nptured aartic lllllrflll118111 ca.u af law biiCk pain thllt are conlidencl 11111iCII

emrgenci.

Diffarantial Diagnosis af Bilek Pain 1. mechanical or nerve compression (>9096) degenerative (disc, facet, ligament) peripheral nerve compression (disc herniation) spinal stenosis (congenital. osteophyte, central disc) cauda equJna syndrome 2.others neoplastic (primary. metastatic, multiple myeloma)

infectious (osteomyelitis, TB) metabolic (osteoporosl.s) traumatic fracture (compression, distraction, translation, rotation)
spondyloarthropathies (ankylosing spondylitis) referred (aorta, renal, ureter. paru:reas)
DEGENERATIVE DISC DISEASE l.os8 ofvertebral disc height with age results Jn: bulging and tean ofaDnul.us fibrosus

change in alignment offucet joints

osteophyte formation

can cause back-dominant pain management

nan-operative staying active with modified activity back strengthening NSAIDs do not treat with opioid&; no proven efficacy ofspinal traction or manipulation operative - rarely indicated decompression fusion
Figure 32. Disc H1111illlian

no difference In outcome between non-operative and su.rgk:al management e.t 2 years

Tabl 12.. Typa of Law Back Pam

leg
flaidlll
Extnicn
ExEile, axl8nsilll,

Leg
flaldlll

StandiQ. Willing

WBIDQ, llllndir,)

More llllllclan
Long (weeb.

CGngamal or IC4Ii'ed

Acu181eg back pein Shm AlfM:b lninut.)

Slxntl!r (dlrts, weeb)

Acute or clmic listory

(waab 11111"10Nha)

llalisf of sll'llil. 8K81'Ci&a Relief of linin, axsrcise

of mil. axsrcise

llalisf of sll'llin, ...-ci&e + IUJ'llital decomrnuion if proglllliw or IMr&

dalicit

SPINAL STENOSIS definition: 1liii'l'OWing of spinal canal <10 mm etiology: congenital (idiopathic, osteopetrosis, achondroplaai.a) or acquired (degenerative, iatrogenic- post spinal surgery, ankylosmg spondylosis, Paget's disease, ttauma) clinical features
blle.teral bade and leg pain

neurogenic claudication (see Thble 13) motor weakness normal back flexion; difficulty with back extension investigations: cr1MRI reveals narrowing ofspinal canal, but gold standard = cr myelogram treatment non-operative: vigorous PT (flexion exercises, stretch/strength exmises), NSAIDs, lumbar

epidural. steroids
operative: decompression surgery ifconservative methods failed >6 months

Toronto Notes 2011

Spine

Orthopaedic:a OR25

Table 13. Differentiating Claudication

Yllscullr Wrth standilg tw exercise Walking distance variable Walking set distance Stop walking Relief in -2 min Muscular Clllmping

AIIIViltian

Change in position (usually flexion, sitting, lying downl Relief in -1 0 min Neurogenic neurological deficit

Callltllnt lnflammlllilry Mechanical

Bilek Dominant

Back Pain
I

lntermitlllnt

+
I

Collltllnt Herniation (latsrlll)

Lug Dominant

... ' ,
Intermittent Spi1111l Sbmo1ii

MRI abnormalities are quite common in both qympb)matic lll1d l'fiTIP!omalic individuals and 1111 not necasurily an indiclllion for irt111V811!ion without clinical corrallllion.

Disc Hemilllion (cenlnll)

Facet Joint

Figure 33. Approach to Back Pain

MECHANICAL BACK PAIN definition: back pain NOT due to prolapsed disc or any other clearly defined pathology clinical features dull backache aggravated by activity morning stiffness no neurological signs treatment: symptomatic (analgesics, PT) prognosis: symptoms may resolve in 4-6 weeks, others become chronic LUMBAR DISC HERNIATION definition: tear in annulus fibrosus allows protrusion of nucleus pulposus causing either a central, posterolateral or lateral disc herniation, most commonly at LS-Sl > 14-5 > L3-4 etiology: usually a history of flexion-type injury which tears the annulus fibrosus allowing for protrusion of the nucleus pulposus clinical features back dominant pain {central herniation) or leg dominant pain {lateral herniation) tenderness between spines at affected level muscle spasm loss of normal lumbar lordosis neurological disturbance is segmental and varies with level of central herniation motor weakness (L4, LS, Sl) diminished reflexes (14, Sl) diminished sensation (L4, 15, Sl) +ve straight leg raise +ve Lasegue test bowel or bladder symptoms, decreased rectal tone suggests cauda equina syndrome due to central disc hernation - surgical emergency investigations: MRI treatment symptomatic extension protocol (PT) NSAIDs 90% resolve in 3 months surgical discectomy reserved for progressive neurological deficit, failure of symptoms to resolve within 3 months or cauda equina syndrome due to central disc herniation

OR26 Orthopaedics

Spine/Hip

Toronto Notes 2011

SPONDYLOLYSIS
definition: defect in the pars interarticularis with no movement of the vertebral bodies etiology trauma: gymnasts, weightlifters, backpackers, loggers, labourers clinical features: activity-related back pain investigations oblique x-ray: "collar" break in the "Scottie dog's" neck bone scan CT scan treatment: activity restriction, brace, stretching exercise

SPONDYLOLISTHESIS
definition: defect in pars interarticularis causing a forward slip of one vertebrae on another usually at LS-Sl, less commonly at L4-5 etiology: congenital (children), degenerative (adults), traumatic, pathological, teratogenic clinical features: lower back pain radiating to buttocks

Figure 34. Spondylolysis, Spondylolisthesis

Table 14. Classification and Treatment of Spondylolisthesis Class Percentage of Slip Treatment
0-25%
2
Symptomatic operative fusion only for intractable pain Decompression for spondylolisthesis and spinal fusion

25-50 50-75 75-100 >100

3
4
5

Specific Complications
may present as cauda equina syndrome due to roots being stretched over the edge of LS or sacrum

Hip
Hip Fracture

', ,
X-Ray Features of Subcapital Hip Fractures Disruption of Shenton's line (a radiographic line drawn along the upper margin of the obturator foramen, extending along the inferomedial side of the femoral neck) Altered neck-shaft angle (nonnal is 120-130)

General Features
acute onset of hip pain unable to weight-bear shortened and externally rotated leg painful ROM

'

,,
Normal joint Subcapital fracture Intertrochanteric fracture Subtrochanteric fracture Figure 35. Subcapital. Intertrochanteric, Subtrochanteric Fractures

DVT Prophylaxis in Hip Fractures LMWH (i.e. enoxaparin 40 mg SC bid) on admission, do not give < 12 hrs before surgery.

Toronto Notes 2011

Table 15. Overview of Hip Fractures Fracture Type Femoral Neck (Subcapital) Definition Mechanism

Hip

Orthopaedics OR27

Special Clinical Features

Investigations

Treabnent

Complications DVT, Non-union

lntracapsular Young: MVA, fall from Same as general (See Garden Classification, height Table 16) Eldery: Fall from standing, rotational force Extracapsular fracture Direct or indirect force including the greater and transmitted to the lesser trochanters and intertrochanteric area transitional bone between the neck and shaft Fracture begins at or below the lesser trochanter and involves the proximal femoral shaft

X-ray: AP hip, AP pelvis, cross See Table 16 table lateral hip

Intertrochanteric Fracture Stable: intact posteromedial cortex Unstable: non-intact posteromedial cortex Subtrochanteric Fractures

of upper thigh

Ecchymosis at back X-ray: AP pelvis, AP/Iateral hip Closed reduction under fluoroscopy then dynamic hip screw or IM nail

DVT, varus displacement

of prox. fragment,
malrotation, non-union, failure of fixation device

Young = high energy Eccymosis at back of upper thigh trauma Older = osteopenic bone + fall, pathological fracture

X-ray: AP pelvis, AP/Iateral hip Closed reduction Malalignment, non-union, under fluoroscopy wound infection then plate fixation or 1M nail

Table 16. Garden Classification of Femoral Neck Fractures Type I

II

Displacement None None Some Complete

Extent Incomplete Complete Complete Complete

Alignment Valgus Neutral Varus Varus

Trabeculae Malaligned Aligned Malaligned Aligned

Treatment Internal fixation to prevent displacement Internal fixation to prevent displacement Elderly: Hemi-/total hip arthroplasty Young: ORIF Elderly: Hem-/total hip arthroplasty Young: ORIF

.....

,,

Ill
IV

AVN of Femoral Head Distal to proximal blood supply along femoral neck to head (medial femoral circumflex artery) Susceptible to AVN if blood supply disrupted Etiology: femoral neck fracture, chronic systemic steroid use

Type I

Type II

Type Ill

Type IV

Figure 36. Garden Classification of Femoral Neck Fractures

Arthritis of the Hip

Etiology

osteoarthritis (OA), inflammatory arthritis, post-traumatic arthritis, late effects of congenital hip disorders or septic arthritis
Clinical Features

pain (groin, medial thigh) and stiffness aggravated by activity morning stiffness, multiple joint swelling, hand nodules (RA) decreased ROM (internal rotation is lost first) crepitus fixed flexion contracture leading to apparent limb shortening (Thomas test) Trendelenberg sign

.....

,}-------------------.

DVT Prophylaxis in Elective THA (continue 2-3 weeks post-op) low molecular weight heparin or coumadin.

Investigations

x-ray OA: joint space narrowing, subchondral sclerosis, subchondral cysts, osteophytes RA: osteopenia, joint space narrowing, subchondral cysts bloodwork: ANA, RF

OR28 Orthopaedics

Hip/Femur

Toronto Notes 2011

Treatment conservative: weight reduction, activity modification, PT, analgesics, walking aids operative: realign = osteotomy; replace = arthroplasty; fuse = arthrodesis complications with arthroplasty: component loosening, dislocation, heterotopic bone formation, thromboembolus, infection, neurovascular injury arthroplasty is standard of care in most patients with hip arthritis

Hip Dislocation after THA

Etiology total hip arthroplasty (THA) that is unstable when hip is flexed, adducted and internally rotated or extended and externally rotated (avoid flexing hip >90 degrees or crossing legs for approximately 6 weeks after surgery) Epidemiology occurs in 1-4% of primary THA and 10-16% of revision THAs risk factors: neurological impairment, post-traumatic arthritis, revision surgery, substance abuse Treatment external abduction splint to prevent hip adduction constrained acetabular component for recurrent dislocation if no issue with position of acetabular/femoral implants Complications sciatic nerve palsy in 25% (10% permanent) heterotopic ossification (HO)

Femur
Femoral Diaphysis Fracture
Mechanism high energy trauma (MVA, fall from height, gunshot wound) in children, can result from low energy trauma (spiral fracture) Clinical Features shortened, externally rotated leg (if fracture displaced) inability to weight-bear often open injury, always a Gustilo III Investigations AP pelvis, AP/lateral hip, femur, knee Specific Complications hemorrhage requiring transfusion fat embolism leading to ARDS extensive soft tissue damage ipsilateral hip dislocation/fracture nerve injury Treatment stabilize patient immobilize leg ORIF with intramedullary nail, external fixator, or plate and screws within 24 hours early mobilization and strengthening

c!J liS
Supracondylar Condylar Intercondylar Figure 37. Distal Femoral Fractures

Distal Femoral Fracture

Mechanism direct high energy force or axial loading three types (Figure 37)

'IbroDlo Nota 2011

Femur/Knee

Ortbopaedia OR29

Futures

direct high energy force or axial loading

extreme pain knee effilsion (hemarthrosis) shortened. externally rotated leg if displaced

Treatment
ORIF early mobilization and strengthening

Complications (see General Fracture Complications, OR6) femoral artery tear nerve injury eDensl.ve soft tissue injury

angulation deformities

Knee
Evaluation of Knee Complaints
History general orthopaedic history also inquin: about common knee symptmns locking: mechanical block to atension
torn meniscuslloose body in joint pseudo-locking: limited ROM without mechanical block effusion, muscle spasm after injury, arthritis painful clicking (audible) torn meniscus giving way: instability cruciate ligament or meniscal tear, patcllar dislocation
1. I'Ditlriar ham of 111111111 meniKus 1. Anl8rior ham of menilc:ul
1. I'Ditlrior cn.:iatllligamant Anl8rior cruciat81ig1ment If 5. I'Ditlriar ham of medial menia:111 li. Anl8rior hom of mllllilll o

l!i til :;

Rgure 38. Diagram uf 'lfle Rig.. Tibial Plata

.I

8 .,.._of Freldl11 of tllllllee 1. and ext. 2. Ext. end inL I'Gtalion 3. VIrus and Yllgua 4. Ant. and poll glile 6. Compression 111d disb8ction
5. Mad. nllllllhift

Physical Examination

general orthopaedic physical exam (do not forget to evaluate hip) Special Tests of the Knee Anterior and Polter.lor drawer testa (see Figure 39) demonstrate tom ACI. and PCI., respectively knee flexed at 900, foot immobilized, hamstrings released
Lacbmano tat

111811 Hflltary
CUPS
Cli:kilg

if able to sublux tibia anteriorly, then ACL may be torn if able to sublux tibia posteriorly, then PCL may be torn

Lacking
Nblbility ,... (lacatian) lw161g

demonstrates torn ACL

hold knee in 10-20" fleJ:ion, stabilizing the femur try to sublux tibia anteriorly on femur similar to anterior drawer test, more reliable due to less muscular stabilization Polter.lor aag lip demonstrates tom PCI. may give a false positive anterior draw sign flex: knees and hips to 90", hold ankles and knees view from the lateral. aspect if one tibia sags posteriorly compared to the other, its PCL Is tom Pivot lh1ft lipl demonstrates torn ACL start with the knee in atension internally rotate foot, slowly flex knee while palpeting and applying a valgus force normal knee will flex: smoothly ifincompetent ACL, tibia willsublux anteriorly on femur at 5tart of maneuver. During flex:lon, the tibia will reduce and extemally rotate about the femur (the "pivot"') reverse pivot 5hlft (start in flmon, mernally rotate, apply valgus and mend knee) suggests tomPCI. Collateral Upment stre88 felt palpate ligament for opening" ofjoint space while testing with knee in full extension, apply valgus force to test MCL, apply VllrWI force to test LCL repeat tcst5 with knee in 20" flexion to relax joint caprule opening only in 200 fiWon due to MCL damage only opening in :zoo of:flenon and full a1eD&ion Is due to MCL, crudate, and Joint capsule damage

.....
diflic!Jt i-1 acute

knee injuri11. lmmllllililllleg and r-.eamine in one west.

--

Antariar D..- Tast

Figera 311. Antarior 111d Pestarior Drawer Tall

OR30 Orthopaeclica
1Cstl for men!KJd tear

Knee

1'oroDio

2011

Crouch compression test joint line pain when squatting (anterior pain suggests patellofemoral pathology) McMurray's test useful collaborative information (see Figure 40) with knee in flexion, palpate joint line for painful "pop/click" intemally robrte foot. varus stress, and extend knee to test lateral menisCUll externally rotate root, valgus stress, and extend knee to test medial menisCUll

,..,..AJ

61. ; /

,f,l

.. -r - .-- - -- -1
T"'_ _.. - - ..)
L

iS

X-Rays AP standing. lateral skyline - tangential view with knees flexed at 45 to see patelklfemoral jolnt 3-foot standing view - useful in evaluating leg length and varusfva1gus alignment see Ottawa Knee Rules (Emer,pncy Medicine, ERl7)

b..mlnllllan far l.ltll'll

M iscBITar ..

I o

Cruciate Ligament Tears

ACL tear much more common than PCL tear

Tabla17.

af ACL and PCL ljuria

Sudden decelendi111 Sudden posl2rior dispiiiCI!ment a! tibia wl1m kn!e is llyperaxienlian end inllmll rotatiln af ttlill on iem!J' flaxad ar hyperaxtanded (daiNialrd MVA qury)

lillary

kmlediate SWilling Jnee ilivilg Wfl(

nbility ID activity

kmlediate SWilling Fain with push alf Camot descend stairs

Bfusion (hemertlrallis) Anllmnadial jainllina lllldarnass Pasilive p0118riar-.. Reverse liwl iHt Other liQII18IIWI.. bonr i1juriaa

Bfusion (hemerthrallis) PalllarDiatanll pnl h tandemass Pasilive antm diiiWS Positive lBclmm Pivot fit Tat for MCI., meniscal

F"1111ra 41. T1 MRI of Ta.. ACL

Stable lcnaa with nilirnal functional imtabimtian Z-4 weaks wilh early ROM and
llrq1henilg

-innant

UnsliMe llnee or yamg parsJrVhigll-damand lifaslyla: ligarnanl: IICGnslrucliiiJ Posterior sag

Collateral Ligament Tears

MCL tear more common than LCL tear

Mechanism valgus force to knee =medial collateral ligament varus force to knee =lab:ral collateral ligament

....

Clinical Features
swelllngleffusion tenderness above and below joint line medially (MCL) or laterally (LCL) joint laxity with varus or valgus force to knee lamy with endpoint suggests partial tear lamy with no endpoint suggests a complete tear test for other injuries (e.g. O'Donahue's triad), common peroneal nerve injury
Treatment partial tear: immobilization x 2-4 weeks with early ROM and strengthening complete tear or multiple ligamentous inJuries: surgtcal repair ofligamenta- not for MCL or LCL on thdr own

PartialligamentoUI '-" n mora panullh.. camplallliga11111111DLII'hlln.

..... ,
l i - Sourca far ACL

Maniacal Tears
medial tear much more common than lateral tear

llllciiii!NI:tian
I.Hallllb'ing

2. Middla 1/3 pallllllr tandan

3. AIDgmt (e.g. ead11111r)

(bon&1111J11r-bona)

Mechanism twisting furce on knee when it is partially fl.eud (e.g. stepping down and turning) requires moderate trauma in young person but only mild trauma in dderly due to degeneration

Toronto Notes 2011

Knee

Orthopaedic:a OR31

Clinical Features
immediate pain, difficulty weight-bearing. instability and clicking increased pain with squatting and/or twisting effusion (hemarthrosis) with insidious onset (24-48 hrs after injury) joint line tenderness medially or laterally locking of knee (if portion of meniscus mechanically obstructing extension)

Investigations MRI, arthroscopy Treatment if not locked: ROM and strengthening if locked or failed above: arthroscopic repair/partial meniscectomy

Quadriceps/Patellar Tendon Rupture

Mechanism sudden forceful contraction of quadriceps during an attempt to stop more common in obese patients and those with pre-existing degenerative changes in tendon DM, SLE, RA, steroid use, renal failure on dialysis

Clinical Features
inability to extend knee or weight-bear possible audible "pop" patella in lower or higher position with palpable gap above or below patella respectively may have an effusion

Investigations ask patient to straight leg raise knee x-rayto rule out patellar fracture lateral view: patella alta with patella tendon rupture, patella baja with quadriceps tendon rupture Treatment nonoperative treatment for incomplete tears with preserved extension of knee surgical repair of tendon indicated for complete ruptures

Dislocated Knee
Mechanism high energy trauma by definition, caused by tears of multiple ligaments

Clinical Features
classified by relation of tibia with respect to femur anterior, posterior, lateral, medial, rotary knee instability effusion pain ischemic limb
Investigations x-rays: AP, lateral, skyline associated radiographic findings include tibial plateau fracture dislocations, proximal fibular fractures and avulsion of fibular head ankle brachial index (abnormal ifless than 0.9) arteriogram if abnormal vascular exam Treatment urgent closed reduction complicated by interposed soft tissue assessment of peroneal nerve, tibial artery; and ligamentous injuries repair of associated injuries; also may need decompressive fasciotomy especially if vascular repair undertaken fasciotomy knee immobilization x 6-8 weeks

OR32 Orthopaedics

Knee/Patella
Specific Complications high incidence of associated injuries popliteal artery tear peroneal nerve injury capsular tear chronic: instability, stiffness, post-traumatic arthritis

Toronto Notes 2011

Patella
Patellar Fracture
Mechanism direct blow to the patella indirect trauma by sudden flexion of knee against contracted quadriceps
Undisplaced Vertical

Lower/Upper Pole Comminuted Displaced

Clinical Features marked tenderness inability to extend knee or straight leg raise proximal displacement of patella patellar deformity effusion Investigations x-rays: AP, lateral, skyline consider bipartite patella: congenitally unfused ossification centres with smooth margins on x-ray Treatment non-displaced (<2 mm) straight leg immobilization 6-8 weeks PT: quadriceps strengthening displaced: ORIF (>2 mm) comminuted: ORIF; may require partial/complete patellectomy

Osteochondral
Julio Saunders 2003

Figure 42. Types of Patellar Fractures

Patellar Dislocation
Mechanism lateral displacement of patella after contraction of quadriceps against a flexed knee Risk Factors young, female obesity high-riding patella (patella alta) knock-knees (genu valgum) Q-angle (quadriceps angle) increased shallow intercondylar groove weak vastus medialis tight lateral retinaculum Clinical Features knee catches or gives way with walking severe pain, tenderness anteromedially from rupture of capsule weak knee extension or inability to extend leg unless patella reduced +ve patellar apprehension test patient apprehensive when examiner laterally displaces patella often recurrent, self-reducing Investigations x-rays: AP, lateral, skyline view of patella check for fracture of medial patella and lateral femoral condyle Treatment non-operative first knee immobilization x 4-6 weeks progressive weight bearing and isometric quadriceps strengthening if recurrent surgical tightening of medial capsule and release oflateral retinaculum, possible tibial tuberosity transfer, or proximal tibial osteotomy

Figure 43. Q-Angle

Toronto Notes 2011

Patellati'ibia

Orthopaedic:a OR33

Patellofemoral Syndrome
Mechanism

(Chondromalacia Patellae)

softening, erosion and fragmentation of articular cartilage, predominantly medial aspect of patella commonly seen in active young females

predisposing factors
malalignment causing patellar maltracking (patellofemoral syndrome) post-trauma deformity of patella or femoral groove recurrent patellar dislocation, ligamentous laxity excessive knee strain (athletes)

Clinical Features
deep, aching anterior knee pain exacerbated by prolonged sitting (theatre sign), strenuous athletic activities, stair climbing, squatting sensation of instability, pseudolocking tenderness to palpation of underside of medially displaced patella pain with extension against resistance through terminal30-400 swelling rare, minimal if present

....

,,

Pain with firm camprusion of pliiEIII. iniD medial femlnl groove is pathognomonic of chondromalacia paldlle.

Investigations x-rays: AP, lateral, skyline Treatment

non-operative continue non-impact activities NSAIDs PT: quadriceps strengthening surgical with refractory patients tibial tubercle elevation arthroscopic shaving/debridement lateral release of retinaculum

Tibia
Tibial Plateau Fracture
Mechanism
axial loading (e.g. fall from height) femoral condyles driven into proximal tibia can result from minor trauma in osteoporotics

....

Clinical Features
lateral fractures more common than medial

,,
Ducriptian Involvement of lirteral plateau &plit hcturu lnvolvemllll of lateral plateau: &plit depression

Classification
Schatzker classification (see sidebar)

Typ1

Investigations x-rays: AP, lateral, skyline

Ill

Treatment if depression on x-ray is <3 mm

straight leg immobilization x 4-6 weeks with progressive ROM weight bearing if depression is >3 mm ORIF often requiring bone grafting to elevate depressed fragment

lnvolvemlllll of lllta111l plateau: pul'll deprNSion fnlc1ul'll Medial plateau fractun pllltaau fracturu 8il:andyl11r with meblphy5saV

IV

v
VI

diaphyseal involvement

Specific Complications (see General Fracture Complications, OR6)

ligamentous injuries meniscallesions

AVN
infection

OR34 Orthopaeclica

TihWADkle

1'oroDio

2011

.... ,
1ibi1lllhllfthcturu hlwaliltl ilcidanca of ccmpartment syndrome and .-e oft8n QIIOC:iabld with wfttiAue

Tibial Shaft Fracture

Mechanism nwneroua, including MVA, falls, sporting injuries

iljuriaa.

Clinical Features open vs. closed amount of dJsplacement neurovascular status most commonly fractured long bone most common open fracture Investigations x-rays: AP,lateral. skyline
Treatment

closed minimally displaced: straight leg cast x 4-6 weeks with early weight bearing
diapla.ced: ORIF with reamed IM nail. plate and screws, or external fimtor

open

atc:mal fixation or IM nail

vascularized coverage ofsoft tissue defects (often heal poorly)

Flgare U. lllllal &aft Frachlre Treated wlllllnti1Hiedulary Nail dlcrawa

Specific Complications (see General Fmcture Com.pllcatkms, OR6) high incidence of neurovascular injury and compartment syndrome poor soft tissue awerage

Ankle
Evaluation of Ankle and Foot Complaints

.... ,
.,...... ........... Enmn;y

Spec:ial Tests
Bllterior drawer: examiner attempta to displace the foot Bllteriorly against a fixed tibia talar tilt: foot is stressed in inversion and Bllgle of tala.r rotation is evaluated by x-ray

llldU& ERill
Q

X-Ray
AP, lateral

Di"lr l'llqUillld 1:

P'ain in lh maiiiiOI zone AND bony bnlamau _.lha podarior of lhe medial or lld811111111111101ua OR inability10 weiclttt bear both ilmllldiablly lifter and in lhe E.R.

mortise view: ankle at 15 of internal rotation gives true view of ankle joint joint space should be symmetric with no talar tilt Otn!.wa Ankle Rules should guide use ofx-my (see sideba.r) cr to better characterize fractures

Ankle Fracture
Mechanism pattern of fracture depends on the position of the ankle when trauma occurs generally involves

lpsll.ateralligamentous tears or transverse bony avulsion contnlateml shear fractures (oblique or spiral) classification systems Danis-Weber (see below) Lauge-Hansen: based on foot's position and motion relative to leg

Danls-Webar Classification (F.igure 45)

based on level offibular fracture relative to syndesmosis Type A (infra-syndesmotic) pure inversion injury avulsion of lateral malleolus below plafond or tom calcaneofibular ligament shear fracture of medial malleolus Type B (trans-syndesmotic) external rotation and eversion (most common) avulsion of medial malleolus or rupture of deltoid Ugament spiral fracture ofla.teral ma.lleolus starting at plafond

'IbroDlo Nota 2011

Ankle/Foot

Ortbopaedia OR35

Type C (supra-syndesmotic) pure eztemal rotation avulsion of medial malleolus or tom deltoid ligament p08terior malleolus may be avulsed with p08terior tibio-fibular ligament fibular fracture is above plafond (called Maisonneuve fracture if at proximal fibule) frequently telll'!l synde.mmsis
Treatment undisplaced: non-weight bearing below knee cast indications for ORIF all fracture-dislocations most of type B, and all of type C trimalleolar (medial, posteriru; Imeral) fractures talar tilt >10 medial clear space on XR greater than superior clear space open fracture/open joint injury high inc.l.dence of post-traumatic arthritis

Ligamentous Injuries
Medial Ugament Complex (deltoid ligament) evenl.on lnjury

usually avulses m.edlal or posterior malleolus and strains syndesmosis

Lateral Ligament Complex (ATF, CF. PTF) invenri.on injury ATF most severely injured if ankle is plantar flexed swelling and tenderness anterior to lateral malleolus ++ ecchymoses

+w ankle anterior drawer

Treatment

may have significant medial talar tilt on inversion stress x-ray

microscopic tear (Grade I) rest. ice, compression, elevation (RICE) macroscopic tear (Grade In strap ankle In dorsi1leDon and eversion x 4--6 weeks PT: strengthening and proprioceptive retraining

Figura 45. Ring Priadpla af tha Aalda and DMII..Wibar Cllalllcatlon

complete tear (Grade DI) below knee walking cast 4-6 weeks PT: strengthening and proprioceptive retraining surgical intervention may be required ifchronic symptomatic instability develops

Foot
Talar Fracture
Mechanism axial loading or hyperdorsiftcdon (MVA, fall from a height) 60% oftalU5 covered by articular cartilage tenuous blood supply runs distal to proDma1 along taiar neck. high risk of AVN with displaced fractures

PIT

TC
ATT

Investigations
x-rays: AP, lateral cr to better characterize fracture MRI can clearly define extent ofAVN
Treatment undisplaced: non-welght bearing below knee cast x 20-24 weeks displaced: ORIF (high rate of nonunion, AVN)
Figura 4&. Anld1 Lig.....t CGIIIpiiXII

....

',

With a hiltury af1nllmll frDm axial loading of loww limb always consider pinlll injuriA. femo111l nlldt. 1ilial

tlllar/cah:anllll hcbnl.

OR36 Orthopaedica

Foot

Toronto Notes 2011

Calcaneal Fracture
Mechanism axial loading: fall from a height onto heels
...._, I

..

10% of fractures associated with compression fractures of thoracic or lumbar spine 5% are bilateral

Physical Examination
swelling, bruising on heel/sole wider, shortened, flatter heel when viewed from behind

C.lcannl lftcture TI'Mtmlllt

Princ:iplp

1. Avoid wound compliclllions 2. Restore articular congruity 3. Rastora normal calcaneal width end 1\eight 4. Maximum functional r&eOV81'f may tag langtr then 12 months

Investigations
x-rays: AP, lateral, oblique (Broden's view) loss of Bohler's angle CT - assess intraarticular extension

Treatment
closed vs. open reduction is controversial non-weight bearing cast approximately 3 months with early ROM and strengthening

Achilles Tendonitis
Mechanism
chronic inflammation from activity or poor-fitting footwear

may also develop heel bumps (retrocalcaneobursitis)

Physical Examination
pain, stiffness and crepitus with ROM thickened tendon, palpable bump

Treatment
rest, NSAIDs gentle stretching, deep tissue calf massage orthotics, open back shoes DO NOT inject steroids (risk of tendon rupture)

Achilles Tendon Rupture

Mechanism
...._, I

...----------------,

loading activity, stop-and-go sports (e.g. squash, tennis, basketball) secondary to chronic tendonitis, steroid injection

Clinical Features
audible pop, sudden pain with push off movement sensation of being kicked in heel when trying to plantar flex palpable gap apprehensive toe off when walking weak plantar flexion, +ve Thompson test: with patient prone, squeezing the calf muscles should passively plantar flex the foot to demonstrate intact Achilles tendon +ve test = no passive plantar flexion = ruptured tendon

The mast common site of Achilles tendon rupture is 2-6 em from its insertion where the blood supply is the

poorest.

Treatment
low demand or elderly: cast foot in plantar flexion (to relax tendon) x 8-12 weeks

high demand: surgical repair, then cast as above x 6-8 weeks

Plantar Fasciitis (Heal Spur Syndrome)

Mechanism
repetitive strain injury causing microtears and inflammation of plantar fascia female:male = 2:1 common in athletes (especially runners) also associated with obesity, DM, seronegative and seropositive arthritis

'IbroDlo Nota 2011

Foot

Ortbopaedia OR37

morning pam and stiffness intense pain when walking from rest that subsides aa patient continues to walk swelling, tenderness over sole greatest at medial calc:aneal tubercle and 1-2 em distal along plantar fa.K:I.a pain with toe dorsiflexion (stretches fascia)

Futures

Investigations

plain radiographs m rule aut fractures often see exostoses (heel spurs) at insertion offilsda into medial calcaneal tubercle (see Figure 47) spur is reactive to inflammation. not the cause ofpain

Figu111 47. X-Ray of Banr Hl Spur

Treatment rest, ice, NSAIDs, steroid injection PT: stretcbing, ultrasound orthotics with heel cup

m counteract pronation and disperse heel strike forces endoscopic surgical release of:lUcia in refractory cases spur removal is not required

Bunions (Hallux Valgus)

Machanlam

---------------------------Nonnalangle <15" Hallux Valgus ar9& > 15'

valgus alignment on 1st MTP (hallux valgus) causes eccentric pull of extensor and lntrlnslc muscles reactive exostosis forms with thickening of the skin creating a bunion most often associated with poor-fitting fuotwar but can be hereditary lOx more frequent in women
Features pamful bursa over medial eminence of 1st metatarsal head pronation (rotation inward) ofgreat toe numbness over medial aspect of great toe
Treatment
cosmetic and to relieve pam properly frtted shoes Oow heel) and toe spacer surgical osteotomy with realignment of 1st MTP joint

non-operative first

Figu111 41. Hallu: Valgus

Metatarsal Fracture
as with the hand, 1st, 4th. 5th metatarsals (M'l1 are relatively moblle, whlle the 2nd and 3rd are

fixed (Table 18)

use Ottawa Foot Rules to determine need fur x-nry (see sl.debar)

Tillie 1I. Types of M81Btarul Fracturas

frldu..
Mdllllm

Cllll:ll
Tendllr bad 5th MT

Awbsian of basa af 5th MT

(Jclles lracbnl

Suddlln invnion fulluMd by

camction of pernneus brevis

Raq.Jiras ORIF if li&ji!CIId

"NWB BK cast x 6wkll OIIIF ifalllleta

.... , !
DIMnfottWH Xrays only ,..quired if: 1'8in in lha milfuDI: mna AND bcmy llndemns owr the nwicul or bas. Ill the liflh melltllul OR inability ID
waight -.. bDih immadhrtllly .rtar

Midllhaft:5thMT

Pllinfulllhllt of 5th MT Pllinfulllhllt of 2111 II" 3111 MT

TIIIIDII

2nd, 3rd MT (March frac1unl) 1stMT

Painful 1st MT

OIIIF if displaced otherwile NWB Blcast x3 wb thlll walicDII CISt X2\\b

inj..y and in tha ER.

Tlna-MT fnu:lln- clslacatilll Fal CdO !EnterfliiiC8d foal II" diad CIIISh injiJY

SlialtSned farafocn prominent OilIF ba (l.islnrle frac:lu11)

OR38 Orthopaeclica

Pediatric Orthopaedia

1'oroDio

2011

Pediatric Orthopaedics
....,,

..

Fractures in Children
typeoffracture

mact

Gr.1111ick lractmlllara aay tD raduca but can radisplaca i'l cast u 1o

' Praxinal RlldUI

Praxinal RlldUI

f"IIGII8 49. Graaraslick (1..., 11111 Tarus (rigllt) Fnc:tures

usually greenstick or buckle because periosteum is thicker and stronger adults fracture through both cortices epiphyseal growth plate plate often mistaken for fractu.n: and vice versa x-ray opposite limb for comparison meche.nism which causes ligamentous injury in adults canses growth plate injury in children intra-articular fractures have worse consequences in children because they usually involve the growth plate anatomic reduction gold standard with adults may cause limb length discrepancy in children (overgrowth) accept greater angular deformity in clilldren {remodeling minimizes deformity) time to heal shorter in children always be aware of the possibility ofchild abuse make sure mecbanlsm compatible with injury high J.nda ofsuspicion. look for other signs, including x-ray evidence of healing fractures at other sites

Stress Fractures
Mechanism

Type I

insufficiency fracture stress applied to a weak or structu.rally deficient bone fatigue fracture repetitive. excessive force applied to normal bone most common in adole&eent athletes tibia is most common site
Diagnosis and Treatment localized pain and tenderness aver. the involved bone plain films may not show fracture for 2 weeb bone scan +ve in 12-15 days treatment is rest from strenuous activities to allow remodeling (can take several months)

Type II

Evaluation of the Limping Child

Type Ill

see Pediatrics. P95

Epiphyseal Injury
Type IV

Tabla 19. Sllltar-llania Claailil:ltian af Epiphpallllnjury

SALT(EIR-&ril Type
through;
hile)

Tllllnlant
Closed reiB:Iian and cast imlmlimlian heals ckl nat lllfect IJDWih 95'1

II (Above)
Type

Through mllaphysis Through plate

plate

ll(l.aw)

ta plata Md IIana growth Anatomic reduction by ORF1c prmnt IJQWih e1T81t

Sid 11181Bphysis
of
H1 incidiiiC8 af pMh aiT86t; no specific tJaalmant

i
f"IIGII8 50. Sllltar-llarril Classification

&

IV {llmdJ 101 tlmQI) Through

V!Ram)

Crusll

Toronto Notes 2011

Pediatric Orthopaedic.

Orthopaedia OR39

Slipped Capital Femoral Epiphysis (SCFE) - - - type I Salter-Harris epiphyseal injury most common adolescent hip disorder, peak at pubertal growth spurt risk factors: male, obese, hypothyroid Etiology multifactorial genetic: autosomal dominant, blacks > caucasians cartilaginous physis thickens rapidly under growth honnone (GH) effects sex honnone secretion, which stabilizes physis, has not yet begun overweight: mechanical stress trauma: causes acute slip

Clinical Features
acute: sudden, severe pain with limp chronic: limp with medial knee or anterior thigh pain tender over joint capsule restricted internal rotation, abduction, flexion Whitman's sign: with flexion there is an obligate external rotation of the hip pain at extremes of ROM

Investigations x-rays: AP, frog-leg, lateral radiographs posterior and medial slip if mild slip, AP view may be normal or show slightly widened growth plate compared with opposite side Treatment and Complications mild/moderate slip: stabilize physis with pins in current position severe slip: ORIF or pin physis without reduction and osteotomy after epiphyseal fusion complications: AVN (most common), chondrolysis, pin penetration, premature OA, loss of ROM
""' I
In alipped capital hmo..IIPiphysis, bilirte11l inwlvement occurs in llbout

25%.

Developmental Dysplasia of the Hip (DOH)

formerly called congenital dysplasia of the hip (CDH) due to ligamentous laxity, muscular underdevelopment, and abnormal shallow slope of acetabular roof spectrum of conditions that lead to hip subluxation and dislocation dislocated femoral head completely out of acetabulum dislocatable head in socket head subluxates out of joint when provoked dysplastic acetabulum, more shallow and more vertical than normal painless (if painful suspect septic dislocation) Physical Examination diagnosis is clinical limited abduction ofthe flexed hip (<50-600) affected leg shortening results in asymmetry in skin folds and gluteal muscles, wide perineum Barlow's test (for dislocatable hip) flex hips and knees to 90 and grasp thigh fully adduct hips, push posteriorly to try to dislocate hips Ortolani's test (for dislocated hip) initial position as above but try to reduce hip with fingertips during abduction positive test: palpable clunk is felt (not heard) ifhip is reduced Galeazzi's Sign knees at unequal heights when hips and knees flexed dislocated hip on side oflower knee difficult test if child <1 year false positive if congenital short femur Trendelenburg test and gait useful if older (>2 years) Investigations U/S in first few months to view cartilage follow up radiograph after 3 months

....

'

5 F's1Ut l'nldispue 1D Dftlllapmental Dpplnia af IIIII Hip F.,ily hiltory Female Frank bnlech Firstborn Left hip

OR40 Orthopaedica

Pediatric Orthopaedica

Toronto Notes 2011

Treatment and Complications 0-6 months: reduce hip using Pavlik harness to maintain abduction and flexion 6-18 months: reduction under GA, hip spica cast x 2-3 months (if Pavlik harness fails) >18 months: open reduction; pelvic and/or femoral osteotomy complications redislocation, inadequate reduction, stiffness AVN offemoral head

Legg-Calva-Perthes Disease (Coxa Plana)

self-limited AVN of femoral head. presents at 4-10 years of age etiology unknown, 20% bilateral, males> females, 1/10,000 associations family history low birth weight abnormal pregnancy/delivery history of trauma to affected hip key features AVN of proximal femoral epiphysis, abnormal growth of the physis, and eventual remodelling of regenerated bone

Clinical Features child with hip pain and limp tender over anterior thigh 1lexion contracture: decreased internal rotation, abduction ofhip Investigations x-rays may be negative early eventually, characteristic collapse of femoral head (diagnostic) subchondral fracture metaphyseal cyst Treatment goal is to preserve ROM and preserve femoral head in acetabulum PT: ROM exercises brace in flexion and abduction x 2-3 years femoral or pelvic osteotomy prognosis better in males <5 years old. <50% of femoral head involved, abduction >30 50% of involved hips do well with conservative treatment complicated by early onset osteoarthritis and decreased ROM

Osgood-Schlatter Disease
Mechanism repetitive tensile stress on insertion of patellar tendon over the tibial tuberosity causes minor avulsion at the site and subsequent inflammatory reaction (tibial tubercle apophysitis) most common in adolescent athletes, especially jumping sports Clinical Features tender lump over tibial tuberosity pain on resisted leg extension anterior knee pain exacerbated by jumping or kneeling, relieved by rest Investigations x-rays: fragmentation of the tibial tubercle, ossicles in patellar tendon Treatment benign, self-limited condition may restrict activities such as basketball or cycling flexibility, strengthening exercises

'IbroDlo Nota 2011

Pediatric Orthopaecll.a

Ortbopaedia OR41

Congenital Talipes Equinovarus (Club Foot)

fixed deformity 3 partB to defonnity talipes: talus is inverted and internally rotated eq_uinus: ankle is plantar flexed varus: heel and forefoot are In varus (supillated) may be idiopathic, neurogenic, or syndrome-associated 1-211,000 newborns, 5096 bilateral, occurrence M>P, severity P>M

Physical Examination
ex:amine hips fur associated DDH examine knees for deformity examine back for dysrapbiam (unfused vertebral bodies)

Treatment

correct deformities In the following order (Ponseti Technique): Fllre 51. The Club Foot furefoot adduction, ankle inversion, equinus Depicting tha GnJU 11d BaQ change strapping/C81it ql-2 wecb hfDnnity surgical release in refractory case (50%) delayed until 3-4 months of age 3 year recurrence rate = S-10% mild recurrence common; affected foot is permanently smaller/stiffer than normal foot with calf muscle atrophy

Scoliosis
Definition lateral cu.rvature of spine with ftl'tebral rotation Epidemiology age: 10-14 years more frequent and more severe in females Etiology idiopathic: most colDllWn (90%) congenital: vertebrae fail to form or segment neuromuscular: UMN or LMN lesion, myopathy other: osteochondrodystrophies, neoplastic, traumatic portural: leg length discrepancy, muscle spum Clinical Features 0 back. pain o 1o where several vertebrae affected 2 above and below fixed 1o to try and maintain normal posltlon ofhead and pelvis asymmetric shoulder height when bent forward
o Adam's test: rib hump when bent forward prominent scapulae, creued flank, asymmetric pelvis aaaodated posterior midline skin leslons in non-idiopathic scoUoses cafe-au-lait spots, dimples, neuro1ibromas Wllary freckling. hemangiomas, hair patches o aaaodated pes c:avus or leg atrophy apparent leg length discrepancy

Flaure sz. CoiJb Allgla - 1181d to monilllr lila proarauio af lila ICOiiatic Cllr8

....

X-Raya 3-foot standing measure curvature - Cobb Angle (Figure 52) may have associated kyphoala
Treatment

In lllruclul'lll or mr.t acalilnlia. ._ndilg foMads makas th1 CUM 1110111 Gbvioul.

based on degree ofcurva.ture <20": observe for changes >20" or progressiw: bracing (many types) that halt/slow curve progression but do NOT

IW!ullll tcllio em by comcting 1111 undallying probla11.

>40", cosmetlcally unacceptable or respiiatory problems: sw-glcal correction (spillal fusion)

reverse deformity

OR42 Orthopaeclica

Bone Tum.oun

1'oroDio

2011

Bone Tumours
Ralflllgll

primary bone tumours are rare after 3rd decade metastases to bone are rela.tively common after 3rd decade

ParsisiBnt skllrtll pain LIICIIized Ulnd81118M Sponmn1111111 fnctura Enlqing mast/soft tiss1111swelling

Diagnosis rarely regional adenopathy routine x-ray location (which bone, diaphysis, metaphysis, epiphysis)
pain, swclling.

size

lytic/lucent vs. scluotic ilivolvement (cortex, medulla, soft tissue) matrix (radiolucent, radiodense or calcified) periosteal reaction margin (geographic n. permeative) any pathologic:al fra.cture soft tissue swelling malignancy is suggested by rapid growth, warmth, tenderness, lack ofsharp definition staging should include bloodwork Including liver enzymes CTchest bone scan bone biopsy should be referred to specialized centre prior to biopsy classified into benign, benign aggressive. and malignant MRl of affected bone

53. Codml.-s Triangla Daifiad isliftad off th1 CDrtax by DIDplastic tiuu1

a radiographic llndlnl In malignaacy, wllara lila

Benign Active Bone Tumours

1. Ostaold Osteoma

peak incidence In 2nd and 3rd decades, M:F = 3:1 small, round radiolucent nidus ( <1 an) surrounded by dense bone tibia and femur most common produces severe intermittent pain. mostly at night (diurnal prostaglandin production) characteristically relieved by NSAIDs not known to metutasize
2. Ostaochondroma

2nd and 3rd decades, M:F = 1.8:1 4596 ofall benign bone tumours metaphysis oflong bone (distal ends offemurlproximal ends of humerus) cartilage-capped bony spur on mrface of bone ('"mushroom" on x-ray) may be multiple (hereditary, autosomal dominant form) - higher risk of malignant chELDge generally very slow growing and asymptomatic unless impinging on neurovascular structure malignant degeneration occurs in 1-296 (becomes painful or rapidly grows)
3. Enchondroma (Figure 54)

Figure 54. T1 MRI of Femoral

2nd and 3rd decades 5096 occur in the small tubular bones ofthe hand and foot; others in femur, humerus, ribs benign c:artilagenous growth. develops in medullary cavity singlelm.ultlple enlarged rarefied areas in tubular bones lytic lesion with sharp margination and central caldficatl.on malignant degeneratl.on occurs in 1-296 (pain in absence of pathologic fracture is an important
not known to metastasize

clue)

4. Cystic Lesions includes unicameral/solitary bone cyst (most common), fibrous cortical defect children and young adults local pain. pathological fracture (5096 presentations) or incldental detection lytic translucent area on metaphyseal side of growth plate cortex thinned/expanded; well defined lesion
aspiration cystic fluid: grecnlyellow colour with high ALP

treatment of unicameral bone cyst with steroid injections bone graft

Treatment

treatment only necessary ifsymptomatic osteochondroma: resection cystic lesions: currettage and bone graft

'IbroDlo Nota 2011

Bone Tumoura

Ortbopaedia OR43

Benign Aggressive Bona Tumours

Giant Cell Tumours/Aneurysmal Bone Cyst/Osteoblastoma (Figure 55) affects patientll ofskeletal maturity, peak 3rd decade fuund in the distal femur, proximal tibia, distal radius, sacrum, tarsal bones, spinal
(osteoblastoma)

cortex appears thinned. expanded; well-demarcated sclerotic margin; T2 MRI enhances fluid

within lesion (hyper-intense signal) local tenderness and swelling 15% recur within 2 years of surgery giant cell tumour occasionally met:astasizes (1-2%)

Tnabnent
intralesional curettage + bone graft or cement wide local adsion of ezpendable bones

Malignant Bone Tumours

Tallie 20. Mast Cammon Maliaaiiii:Tumaar Types fur Age
<1 1-10
3().4()

Nalllileltoml

Ewilg's af tubullr bcxiiiS

Figura 55. X.aay of Anearpmal Bane Cyst_ Nota tha aggrassive

dastructian of bona

Ostaoslrcarna. Ewing's afllat banas

>40

lleliaJUn cell SIII'CIIliB,. fboslmJma. periosteal asleoslmJma. 011lignant giant eel Unaur, iyn'flhama Meblsbltic c:arciiiRII, nr.dtiple myelDRII, chandi'CISIIrcDRII

1. Osteo5an:oma (Figure 56) most frequently diagnosed in 2nd decade of life (60%) history of Paget's disease radiation predilection fur distal femur (45%), proximal tibia (20%) and proximal hwnerus (15%) invasive, variable histology; frequent metastases without treatment Oung most common) painful. poorly defined swelling. decreased ROM

Hay shows Codma.ns triangle (Figure 53) characteristic periosteal elevation and spicule formation representing tumour extension into
periosteum

Fllare 51. X-Ray of Olte0111rcama of Dlml

destructive lesion in metaphysis may cross epiphyseal plate treatment: complete resection (limb salvage, rarely amputation), neo-adjuvant cbemo
survival- 70%

2. Chondrosarcoma (Figure 57) primary (213 cases)

previous normal bone, patient over 40; expands into cortex to give pain, pathological fracture. flecks ofcalcification secondary (1/3 cases) malignant degeneration of pre-existing cartilage tumour such as enchondroma or osteochondroma, younger age group and better prognosis than primary chondrosarcoma most commonly occurs in pelvis, fennu; ribs, scapula, humerus (with metastasis to the hmg) unresponsive to chemotherapy, treat with aggressive surgical resection+ reconstruction

3. Ewing's Sarcoma most occur between 5-20 years old

ft.orid periosteal reaction in diaphysis oflong bone
moth-eaten appearance with perioneallamellated pattern (onion-&dnning) present with mild fever, anemia, leukocytosis and increased ESRJLDH metastases frequent without treatment treatment - resection, chemotherapy, radiation

survival- 70%
4. Multiple Myeloma most common primary malignant tumour of bone in adults
90% occur in people >40 yelll'll old present with anemia, anorexia, renal failure, nephritis, increased ESR, bone pain (cardinal early

Figura 57. X-lay af Femanll Cllondroaarcoma

symptom), compression fractures, hypercalcemia bigb J.ncJ.denc:e of lnfections (e.g. pyelonephrttlslpneumonia)

OR44 Orthopaedica

Bone Tumours/Articular Cartilage Defects

Toronto Notes 2011

diagnosis Cf-guided biopsy of lytic lesions at multiple: bony sites serum/urine protein electrophoresis treatment chemotherapy, radiation, surgery for symptomatic lesions or impending fractures see Hematolog)'> H47
Breast
lung Breast lung

Kidllll'(

Kidney

5. Bone Metastases 2/3 from breast or prostate; also consider thyroid, lung, kidney usually osteolytic; prostate occasionally osteoblastic bone scan for MSK involvement, MRI for spinal involvement may be helpful stabilization of impending fractures internal fixation, IM rods bone cement

liLT wllh a lasher Pickle llrlllst

Thyroid
Kidney

Articular Cartilage Defects

Properties of Articular Cartilage
lacks blood supply and does not have innervation or lymphatic drainage varies in thickness from 2 mm to 4 mm and is thickest at periphery of concave surfaces and central portions of convex surfaces composed of type 2 collagen, water, proteoglycans, and chondrocytes collagen provides resistance against tensile stresses and transmits vertical loads water and proteoglycans provide turgor and elasticity and help to limit friction chondrocytes synthesize the cartilage matrix and control matrix turnover rate Etiology overt trauma or repeated minor trauma; most commonly from sports injuries early stage osteoarthritis genetic degenerative diseases such as osteochondritis dissecans Clinical Features very similar to symptoms of osteoarthritis (joint line pain with possible effusion, etc.) often have predisposing factors such as ligament injury, malalignment of the joint (varus/ valgus), obesity, bone deficiency (avascular necrosis, osteochondritis dissecans, ganglion bone cysts), inflammatory arthropathy, and familial osteoarthropathy may have symptoms oflocking or catching related to the torn/displaced cartilage Investigations arthroscopy to visualize focal pathology and guide treatment strategy MRI may also be used to visualize the defect
Table 21. Outerbridge Classilicl1ion of Chondral Detects
Gl'lde

Promrte

I
II

Chandl'll 011111111 Softening and swellng of cartilage

Fragmentation and fissuring < 1/2 ilch in diameter Fragmentation and fissuring > 1/2 ilch in diameter
Erosion of cartilage down to bone

Ill
IV

Treatment arthroscopic lavage and debridement ofthe joint marrow stimulation techniques (microfracture, drilling, abrasion arthroplasty) involves creating a site of bleeding where new growth/healing can take place osteochondral grafts; also known as the OATS procedure or mosaicplasty involves transferring osteochondral fragments from non-weightbearing surface to area of defect autologous chondrocyte: implantation (ACI) currently only available in the U.S. and Europe involves harvesting patient's cartilage, growing it in culture: medium outside of the patient, then reinserting the newly cultured chondrocytes back to fill the chondral defect osteochondral allograft; only used in limited circumstances when defect is very large

Toronto Notes 2011

Common Medications

Orthopaedic:a OR45

Common Medications
Table 22. Common Medications
Dnlg Nama cefamlin (Arx:eftl heparin Dosing Sclu1dulll 1-2 g rl q8h 51XXJIU SC q12h lniiCIIIions PnlphylBCtically bsfore trlhopaedic surgery To IR\'efll venous thcrdiosis !lld pulmonary emboli DVT iJ'Ophylaxis asp. i1 hip 111d knee surgery Conscious sedation lor short iJ'Ocedures Conscious sedation lor short procedures Suspension (injected into inflllll8d joint or bursa)
Calllllllllls

Fi11t genllrlllion ceph&l011p0rin; do not use with penicillin allergy Moniter pllllelets, follow P1T which should rise 1.5-2x Fixed dose, no improved bioavaiability, increased bleeding rates Medications used tDgether during fracture reduction- monitDr lor respiat!lry depression Short acting anesthetic used i1 conjunction with midazolam (Versedillll

dalteparin (Fragmin11111 enaxaparin (lovenox<ll fondaparinux (Arixtnl11111 midazolam (Versedillll

l.MWH

5000 IU SCOD 30-40 mg SC bid 2.5mgSCOD 0.02 mgilqj IV

fentanyl (Sublimazel

O.S-3 fliVkll IV

triamcinolone (Aristocortl- an injectable steroid

0.5-1 ml of 25 mglml

Potent anti-inflammatory effect Increased pain lor 24 hours,1'11'81y causes fat necrosis and skin depigmentation
NSAID, may cause gastric erosion and bleeding Use with indomethacin Use with misoiJ'OslOI NSAID, may cause gastric erosion and bleeding Short acting llleslhetic often used in conjunction with f&ntanyl (Sublimaze1111 )

naproxen misoiJ'OslOI (Cytotec1111) indomethacin (lndocicPI ibuprofen (Advir, Motrin1111 ) propofol {Diprivan1111 )

25G-500 mg bid 200 flQqid 25 mg PO tid 200-400 mg tid 1-2 m!Vkg IV

Pain due to inflammation, soft tissue Prophylaxis of heterotopic ossification after THA Prophylaxis of heterotopic ossification after THA Pain {including post-op), inflammation {including arthitis) Conscious sedation for short iJ'Ocadures

OR46 Orthopaedica

References

Toronto Notes 2011

References
Tatboolai Admi JC, Hamblen DL Outline olfrlctum: incUiing joint injllies. 11th ed. Torunto ([WI: Cliurdiill LNilgstone. 1999. Blllckbouma Ul. racall. 3rd ad. Ul Bllckbaurn1. Phi-hia (PA): Lippincott Williams & 2002. Brinker MA.IIeview or orthopaedc tniUilll. TOICIIID (ON): W.B. Saunde11 CompiiiY, 2001.

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