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TABLE OF CONTENTS
NO.
1
TITLE
INTRODUCTION TO ORTHOPAEDICS
History-Taking
Analgesics Ladder (by WHO)
Post-Op Management (fever/oliguria/dyspnoea/shock)
Plaster Techniques
FRACTURES GENERAL PRINCIPLES***
Definitive treatment
Open Fractures
Emergency Care
Irrigation & Debridement
Stabilisation of Fracture
Wound Coverage
Delayed Union & Non-Union
Management of Bone Loss
Fracture Healing
Compartment Syndrome
Avascular Necrosis
TipBits for Fractures
SHOULDERS
Approach to Shoulder Problems
Rotator Cuff Impingement
Calcification of the Rotator Cuff
Biceps Tendonitis
Rupture of Biceps Tendon
Frozen Shoulder***
Shoulder Joint Instability & Dislocations
Other Disorders of the GH Joint
Disorders of the Scapula
Fractures of the Clavicle
Fractures of the Scapula
AC Subluxation/Dislocations
SC Dislocations
ARM
Fractures of the Proximal Humerus
Fractures of the Shaft of Humerus
Fractures Around the Elbow in Children
Fractures & Dislocations Around the Elbow in Adults
PAGE
4
17
29
36
39
HIP
10
51
Pelvic Fractures
Approach to Hip Pain
Congenital Dislocation of the Hip (CDH) /
Developmental Dysplasia of the Hip (DDH)
Hip Dislocation
Perthes Disease (Coxa Plana)
Slipped Capital Femoral Epiphysis (SCFE)
Pyogenic Arthritis
Transient Synovitis
TB Hip
RA Hip
OA Hip
AVN of the Hip***
Proximal Femoral Fractures Summary
KNEE
Knee DDx
Common Knee Symptoms
Meniscal Tears
Meniscal Cysts
Chronic Ligamentous Instability
Osgood-Schlatter Disease
Osteochondritis Dessecans
Patellar Fracture
Recurrent Dislocation of the Patella
Patellar/Quadriceps Tendon Rupture
Dislocated Knee
Chondromalacia Patellae
OA Knees***
RA
Bakers Cyst (Popliteal Cyst)
Housemaids Knee (Prepatellar Bursitis)
Clergymans Knee (Infrapatellar Bursitis)
Semimembranous Bursa
Charcots Joint
TIBIA
Tibial Plateau Fracture
Tibial Diaphysis Fracture
ANKLE
Evaluation of Ankle Complaints
11
64
12
72
74
13
14
15
16
FOOT
SPINE
77
82
93
98
104
108
17
18
19
20
21
22
23
24
111
113
117
118
120
124
139
142
INTRODUCTION TO ORTHOPAEDICS
HISTORY TAKING
PRESENTING COMPLAINT
Pain
- SOCRATES
- For timing/frequency
o Early morning pain hallmark of inflammation
o Relieved at night often mechanical in nature
o Night pain indicates severity of pain, ?underlying malignancy
- For relieving factors: include analgesics & TCM
For upper limb
Activity
- Hand dominance
Loss of function for lower limb
- Washing, dressing, combing,
- Going to shops
feeding, writing
- Use of walking aids (community ambulant?)
- Use of chopsticks (assess fine
o Any lift landing?
motor skills)
- Walking distance
- Use of stairs
Also assess pre-morbid ADL status (dressing, eating, ambulating, toileting, hygiene)
Specific to lumbar spine
- History of injury
- Radiation of pain (look for dermatomal distribution)
- Associated neurological symptoms (numbness/paresthesia) & their distribution
- Any sphincter disturbance (bladder & bowel symptoms secondary to cauda equina
syndrome)
Mild pain:
Step 1: Simple analgesics (non-opioid)
o Initiate topical and/or simple oral non-opioid analgesics (e.g. paracetamol,
NSAIDs)
o + adjuvant e.g. tricyclic antidepressants, anticonvulsants (pregabalin or
gabapentin) for neuropathic pain.
Moderate pain:
Step 2: Weak opioid
o Weak opioid (e.g. tramadol, codeine phosphate or dextropropoxyphene)
o + adjuvant e.g. tricyclic antidepressants, anticonvulsants
Severe pain:
Step 3: Strong opioid
o Opioids (e.g. morphine, oxycodone)
o + adjuvant e.g. tricyclics, anticonvulsants
POST-OPERATIVE MANAGEMENT
1.
2.
3.
4.
5.
6.
7.
then reabsorbed, with collapse of the supplied lung segments, usually the basal lobes.
The collapsed lung may become secondarily infected by inhaled organisms.
Post-Op Fever
Days 0-2
mild pyrexia
o tissue damage and necrosis
At the site of the operation
o haematoma
higher persistent pyrexia
o postoperative atelectasis
o specific infections related to the surgery
Note that fever due to blood transfusion may occur in this initial post-op period.
Postoperative atelectasis generally occurs within 48 hours.
It is an extremely common post-operative complication with some degree of
pulmonary collapse occurring after almost every abdominal or trans-thoracic
procedure.
Mucus is retained in the bronchial tree, blocking the finer bronchi; the alveolar air is
Predisposing factors
obesity
smoking
wound pain
pregnancy
muscular weakness
nasogastric tube
abdominal distension
bronchopneumonia
patients who have some other type of indwelling prosthesis, for example
total hip replacement
As a general rule prophylactic antibiotics should be given in the perioperative period
and then discontinued. It is best if the first dose can be given on induction of
anaesthesia. Prolonged administration of antibiotics is accompanied by undesirable
side effects, such as the emergence of antibiotic resistant organisms, or the
development of pseudomembranous colitis; it is for this reason that duration of therapy
should be stated.
Postoperative wound infection
Postoperative wound infection is a potentially hazardous complication of surgery. It is
important to consider the risk of it occurring, and to give prophylaxis if appropriate.
Risk factors
- senility, diabetes, ischaemia, malnutrition, vit C & Zn deficiency
- steroids and cytotoxic drugs, radiotherapy
- long preoperative hospital admission
- shaving the operative site the night prior to surgery
- rough handling of the tissue
- poor blood supply, for example sutures too tight
Wound irrigation
moistening of tissue
Days 5-7
>7 days
physiological saline; its low osmolarity may aid in free tumour cell lysis
topical antiseptic, e.g. chlorhexidine and iodine; both may cause undesirable
cell death of host tissue. Alternatives include spraying dry povidone-iodine
spray onto the wound - this has been shown to reduce infection rates - or
local injection of antibiotic peroperatively.
causes related to specific ops, e.g. failure of bowel anastomosis with fistula
formation & leakage
Causes are less likely to be directly related to the specific operation undertaken.
Causes include:
wound sepsis
thrombotic disease
postoperative atelectasis
postoperative pneumonia
wound infection
intravenous phlebitis
prostitis
gout
parotitis
drug reaction
transfusion reaction
o non-haemolytic transfusion reactions
o febrile transfusion reactions
IN SUMMARY
wind -- atelectasis within 48 hrs, aspiration, pneumonia
water -- UTI's, especially if catheterized
wound -- check for wound infection.
veins -- (OK, it's a "V") DVT, phlebitis from IV's
drugs -- drug reactions (uncommon)
Fever within 48 hours is usually atelectasis. After 48 hours, atelectasis is less likely.
After 5 days:
wound infection
intraabdominal abscess (CT abdo and pelvis)
DVT
Post-op Dyspnoea
1. Atelectasis -- usually within 48 hours, more likely in elderly, COPD, smokers, obese
patients, and those with upper abdominal incisions. Treatment is to mobilize,
encourage deep breathing and coughing, chest physiotherapy
2. Aspiration -- risk factors include GERD, food in the stomach, intestinal obstruction,
and pregnancy (delayed gastric emptying). Prevent via preoperative fasting in elective
patients, 'rapid sequence" induction in emergency patients, and those at high risk.
3. Pneumonia -- atelectasis, aspiration and copious secretions are predisposing factors.
Often gram-negative, and or polymicrobial.
4. Heart failure -- caused by fluid overload in patients with limited myocardial reserve,
post op MI, or dysrhythmias (most commonly a fib).
5. Pulmonary embolus -- most clinically significant pulmonary emboli arise from the iliac
and femoral veins.
Post-Op Oliguria
Pre-renal -- COMMONEST CAUSE OF LOW URINE OUTPUT
o external fluid loss (hemorrhage, dehydration, diarrhea)
o internal, third space loss -- bowel obstruction, pancreatitis
Renal -- nephrotoxic medications
o Untreated pre-renal causes leading to acute tubular necrosis
Post renal -- prostatic hypertrophy, blocked foley, stone in solitary kidney
Post-Op Shock
Basic haemodynamics: CO = SV x HR
Recognising shock
o Easy signs to find:
Urine output
The best CVP is if you see pee
Think Foley
Blood pressure
Skin temperature
Mental status
Drain saturation
o Lab investigations
FBC
Serial FBC for any patient with bleeding risk
Lactate
BUN / Cr
Coagulation profile
Electrolytes (specifically bicarb)
Resuscitation fluids
o No evidence to show that one type of fluid is superior to another in
resuscitation
o Ensure that you use enough crystalloid.
General principles
o Resuscitation with appropriate and
enough fluids
o Give blood if bleeding or evidence of
oxygen delivery problem
o Pressors to mitigate hypotension
o Stress dose steroids if indicated
o Intensive insulin
o Normothermia
Hypovolaemic shock
o Bleeding
Think about the surgery and everything that could go wrong
Surgical bleeding vs. postoperative oozing
Support with fluids and blood products.
Treat hypothermia
Inadequate resuscitation
Patients are NPO for several hours prior to surgery
Patients with intraabdominal processes (especially infection and SBO)
have tremendous fluid losses.
The best prevention of postoperative resuscitation problems is
preoperative resuscitation.
Post-op septic shock
o Utilize Rivers goal directed protocols (N Engl J Med 2001; 345:1368-1377,
Nov 8, 2001 )
CVP 8-12
Urine output > 0.5 cc/kg/hr
SvO2 > 70
Hgb to 10, Dobutamine
MAP>65
Norepinephrine or Dopamine
Post-op cardiogenic shock
o Patient may not complain of chest pain although there may be clues on exam.
o EKG/Echo/Swan/enzymes, etc.
o Must weigh risk of bleeding (ASA, thrombolytics, cath) vs. benefit
Usually benefit of treating heart outweighs risk
o Inotropic support
Abdominal compartment syndrome
o Post op laparotomy patients can be at risk for this as well as cirrhotics
o EASY to measure. Basically stick a foley catheter to a CVP monitor
o Abnormal is over 20 cm water. Dangerous over 30.
o Treatment is decompression
o You only find it if you THINK about it.
Summary
o Resuscitation, resuscitation.
o Think about hypovolemia
o Think about bleeding.
o Think about sepsis.
o Think about abdominal compartment syndrome
o Get an EKG in high risk patients.
o And remember The best treatment is PREVENTION
o
PLASTER TECHNIQUES
Basic Principles
1. One joint above and below the fracture
2. Cast is well molded with no pressure points
3. Always place a backslab/U slab even if patient is just admitted for pain control.
4. All hand fractures have a standard functional hand position cast
Indications
Fractures that can reduced and be stably maintained
No major soft tissue injury
No suspicion of compartment syndrome
No vascular compromise
Types of Plaster Casting
Forearm U slab: Forearm fractures
Shoulder U and O slab: Proximal and midshaft humerus fractures
Intrinsic plus hand slab: Hand fractures
Above knee cylinder slab: Knee injuries
Above knee slab: Tibia/Fibula fractures
Below knee slab: Ankle fractures
FRACTURESGENERAL PRINCIPLES
Mechanism: remember the process leading to the fracture
Traumatic
Pathologic remember O M I T: osteopenia/osteoporosis, metabolic bone
disease (hyperparathyroidism, hyperthyroidism, osteogenesis imperfecta,
rickets), infection, tumour
Stress repetitive mechanical loading, periprosthetic
CLINICAL FEATURES OF FRACTURES
Pain and tenderness
Loss of function
Deformity
Abnormal mobility and crepitus (avoid)
Altered neurovascular status (important to document)
INITIAL MANAGEMENT
ABCDEs
Limb - attend to neurovascular status (above and below)
Rule out other fractures/injuries (especially joint above and below)
Rule out open fracture
Take an AMPLE history - A llergies, M edications, P ast medical history, L ast
meal, E vents surrounding injury
Analgesia
Splint fracture - makes patient more comfortable, decreases progression of soft tissue
injury, decreases blood loss
Imaging
RADIOGRAPHIC DESCRIPTION OF FRACTURES
Rule of 2s
2 sides: bilateral
2 views: AP and lateral
2 joints: above and below the site of injury
2 times: before and after reduction
Identify view + date + patient identification (This is an AP X-ray view of the knee
joint taken on 1/12/10 for Mdm. Gee)
Anatomy
Which bone
If diaphyseal decribe by thirds : proximal/middle/distal
Type
spiral # - rotational force, low energy (# line > 2x bone width)
oblique # - angular and rotational force
transverse # - direct force, high energy
comminuted # (> 2 pieces) - direct force, high energy
compression #
avulsion # - strong muscle inserting into small bone e.g. quads to
patella, triceps to olecranon, peroneus tertius to 5th metatarsal head
butterfly # - 2 lines break out obliquely from point of contact of blow
producing a free-floating butterfly fragment
Articulation
Extra-articular: diaphysis/metaphysis
Intra-articular salter-harris classification (for children)
Apposition (% displacement) any shortening? [i.e. bayonet #]
Angulation
Apex
Associated structures (aka soft tissue): calcification, gas, foreign bodies
8
DEFINITIVE MANAGEMENT
Goals Obtain and Maintain Reduction
reduce
stabilize
rehabilitate
Attempt closed reduction
if successful
Then stabilize
if unsuccessful
Open reduction
Then stabilize-- usually internal fixation
Rehabilitate
Reduction
Is reduction necessary?
may not be for clavicle, fibula, vertebral compression fractures
reduce when amount of displacement is unacceptable
imperfect apposition may be acceptable while imperfect alignment is rarely
acceptable
Closed when possible
Closed reduction
Minimise damage to blood supply
Rely on soft tissue attachments
Rarely adequate for intraarticular #
Difficult in babies whose bones cannot see in X-ray
Open reduction: indications remember NO CAST
N - N on-union
O - O pen fracture
C - neurovascular C ompromise
A - intra- A rticular fractures (require anatomic reduction)
S - S alter-Harris III, IV, V and/or special situations depending on site
T - poly T rauma
Others
failure to reduce using closed reduction
cannot cast or apply traction due to site (e.g. hip fracture)
pathologic fractures
fractures in paraplegics for nursing access
potential for improved function with ORIF
infection
new fracture through screw holes
implant failure
Stabilization
Stabilize the fracture site but do not completely immobilize the limb if possible
External stabilization
1. splints/tape
2. casts
3. traction
4. external fixator
Rigid fixation
Internal fixation
immediate loading but
1. percutaneous pinning (Kirschner or K-wires)
does not stimulate
callus formation
2. extramedullary fixation (screws, plates, wires)
3. intramedullary fixation (rods) - biomechanically advantageous
Rehabilitation
To avoid joint stiffness
Isometric exercises to avoid muscle atrophy
Range of motion (ROM) for adjacent joints
Continuous Passive Motion (CPM) following rigid fixation of fracture allows joint
motion to prevent stiffness for intra-articular fractures
After cast/splint removed and fracture healed resistive muscle strengthening
Evaluate bone healing (clinical, x-ray)
OPEN FRACTURES
EMERGENCY!
Definition: A fracture or its haematoma that communicates with the environment.
Gustilo-Anderson Classification of Open Fractures*****
Superficial to deep
Laceration
<1cm long
Soft tissue
Little damage,
no crush
II
1-10cm
IIIa
>10cm
Moderate
crushing, no
flap/avulsion
Extensive
damage to skin,
muscle, neurovasculature
Fracture
Usually
transverse,
short oblique,
little
comminution
Moderate
comminution
Contamination
Clean puncture
(compound
from within)
Comments
Simple #
[5% chance of amputation]
Moderate
contamination
Butterfly #
[10% chance]
Extensive
comminution
& instability
Severe
contamination
Gr
I
10
EMERGENCY CARE
Sterile scrub: use scrubbing brush and scrub the site to debride all necrotic
tissues (dead muscle/fat/other tissues) --- how to tell if muscle is dead or not?
4Cs
Dead
Live muscle
muscle
Consistency
Mushy
Turgid
Colour
Pale pink
Pink/bright
red
Contraction (most important)
Absent
Present
Capillary
No bleed
Bleeding
Approx. 30% of patients with open fractures are polytrauma patients who have suffered
damage to 2 or more systems. Manage according to ATLS. Only manage the fracture
when the patient is stable. [In grey: for open #s]
1. ABCDE
2. Neurovascular status of the limbs (above & below)
Control any haemorrhage with direct pressure. Set IV line & start IV fluids.
Dont reduce any # unless there is apparent neurovascular compromise from
position of #.
Dressings & splints that might have been put on at the accident site should be
removed partially to assess soft tissue conditions and neuromuscular function.
All sterile wound dressings should be left in place because redressing wounds
in the emergency room increases the infection rate
3. Any other #/injuries (above & below) remove gross debris, i.e. turf, rocks
4. Rule out open #
5. Take an AMPLE Hx
6. Analgesia 75mg I/M pethidine
7. Start IV antibiotics [after wound c/s samples are taken] in all open # during the first
3-5 days (empirical NOT prophylactic!) Use broad spectrum antibiotic (e.g. 1st
generation cephalosporins); in grade 3 #, add gentamicin +/- metronidazole, and
monitor for toxicity.
8. Tetanus toxoid booster (TTB) 0.5mL
Human anti-tetanus immunoglobulin (HATI) 250 units
Simple wound
Tetanus-prone
wound
Full course + booster within
TTB
10y
Full course + booster 10y ago
TTB
TTB + HATI
Non-immunised / unknown
TTB
TTB + HATI
9. Splint to decrease pain, progression of soft tissue injury, blood loss
10. Imaging (X-rays)
11. NBM and prepare for EOT
Must get into OT within 6h (golden hours) since risk of infection increases
after this time
Done under LA/GA
11
Complications of open #s
Bone
Osteomyelitis
Mal-union (NB. healing will always take place, its only a matter of how
good the healing is)
Non-union (healing has ceased, both pieces not united by 6 months)
Certain bones are prone, e.g. tibia (due to poor muscle coverage),
scaphoid, NOF (due to poor blood supply)
Also depends on severity of injury
Types
Hypertrophic: insecure fixation / premature wt bearing
Atrophic: poor blood supply, ends osteoporotic (e.g. in
DM, vasculopathy, infection, sig tissue damage) --- Mx:
open decortications & cancellous bone graft
AVN
Arthritis
Regional
Neurovascular injury
Soft tissue blisters
Types: haemorrhagic and non-haemorrhagic
Mechanisms of injury: shearing of skin (may become infected if
operated on), ischaemia (can be due to compartment syndrome!)
Compartment syndrome*****
Complex regional pain syndrome 1
Heterotopic ossification
Joint stiffness
Systemic
Hypovolaemic shock
Fat embolism
Venous thrombo-embolism (DVT/PE) from immobility
Multi-organ dysfunction syndrome
ARDS (especially in polytrauma patients)
Local
System
-ic
Hemorrhagic shock
Sepsis
Fat embolism
DVT / PE
ARDS
Late
Malunion
Nonunion
AVN
Post-traumatic arthritis
Osteomyelitis
Heterotopic ossification
Growth disturbance in children
Joint instability
Joint stiffness
Nerve compression /entrapment
Reflex sympathetic dystrophy (RSD)
Multi-organ failure
Renal failure
Shocked lung
PTSD, depression
Early
Neurovascular injury
Swelling
Compartment syndrome
Infection
Implant failure
Soft tissue blisters (infection)
Meticulous removal and resection of all foreign and dead material from the wound.
All non-viable, mutilated or macerated skin removed. Dead, frayed skin edges
are excised. Skin colour is a good determinant of viability of skin. When a cut
skin edge does not bleed then it is dead.
Fasciae are expendable so it can be safely removed without fear of functional
deficit.
Difference between dead & live muscle (see emergency care)
Free fragments of bone are removed. Fractured bone ends must be exposed so
that they can be cleaned with brushes or removed.
Exposed tendon will not survive for long. Early skin coverage, skin grafting or a
muscle/skin flap may be necessary to preserve its viability.
Wound cultures should be taken at the end of the procedure.
STABILISATION OF FRACTURE
Immobilisation of the fracture is crucial for the healing of soft tissue and bone.
Stabilisation prevents further injury to the surrounding soft tissue, limits
intensity and duration of inflammatory response, diminishes spread of bacteria,
facilitates tissue perfusion and encourages early wound repair.
Should still provide free wound access for repeated debridement and placement
of local or distant flaps and bone grafts.
Should not interfere with blood supply of fracture segments and should be
sufficiently rigid to allow early joint motion and at least partial weight bearing.
Slings, splints, casts and traction may be used as definite care of simple grade I and
grade II injuries and as temporary methods for more complex fractures.
Slings can be used in fractures of humeral shaft or to provide additional support for
internally or externally stabilized forearm lesions. Splints can provide initial
stabilization of fractures below the elbow and knee.
Circular castshave no place in early Mx as they cannot accommodate swelling.
May prevent the detection of further soft tissue damage, circulatory impairment
and/or increase in compartment pressures.
Casts can be used as subsequent care of stable grade 1 and 2 tibial fractures after the
wound is closed and swelling subsided.
Can also be used as a secondary method of immobilization after removal of an
external fixator.
Traction may be indicated for pelvic fractures, acetabular lesions and femoral
fractures. But rarely used in the upper extremity.
External fixation is indicated for most contaminated grade 3b and c fractures.
WOUND COVERAGE
Skin grafts are transplanted completely by detaching a portion of skin from a donor
site and transferring it to a raw bed-- has to achieve a new blood supply within 2-3
days to ensure viability.
Often used as in intermediary measure before a flap.
There are 2 kinds of skin grafts.
Partial/split-thickness skin graft consists of epidermis and part of the dermis.
Can tolerate less ideal conditions and less vascularity than full thickness skin
graft. The donor site must be able to heal spontaneously by epithelialisation and
if necessary, more grafts may be taken from the same place. Good for covering
large skin defects overlying viable tissue such as muscle, for large size wounds
or those of questionable circulation. Grafts contract, have poor growth in
children and have abnormal pigmentation. Partial thickness skin grafts are
taken from inner thigh or lateral buttock.
Full thickness is composed of the full thickness of the skin. Generally used for
fresh, non-contaminated wounds of small size. Full thickness skin grafts are
taken from groin or postauricular area, supraclavicular area.
Flaps contain a pedicle attachment to the body receiving its sustenance via a
network of blood vessels.
Because of their own blood supply, they can be used to reconstruct skin and
soft tissue defects irrespective of their vascularity.
Choice of flap coverage must take into account patients age & needs, location,
size & condition of the defect, likelihood of subsequent reconstructive surgery
& associated zone of injury, tissues available for the flap.
Flaps can be classified as skin, fasciocutaneous, muscle and musculocutaneous.
Used for defects with poor vascular beds such as wounds overlying the tibia,
exposed metal plates, bare bones and tendons, bone defects and open joints.
Delayed bone or soft tissue reconstruction is proposed, especially if bone graft
or tendon transfer is being planned.
An example of a local flap is the gastrocnemius. Used around the knee and
proximal third of the tibia, one of the 2 heads of the gastocnemius is used and
there must be a functional soleus. The soleus is sometimes used for mid-tibial
defects or sometimes even the distal third of the tibia
Free microvascular flap is used for large defect.
Helps prevent multiple reoperations. Provide durable coverage of the fracture
site, diminishes the infection rate and shortens the healing time. E.g. latissimus
dorsi and vertical rectus abdominis.
Bone injury occurs during initial injury or from subsequent repeated debridement.
Any bone replacement methods should only be done after adequate soft tissue
coverage and revascularization.
Bone grafts
Work via 3 mechanisms: osteoconduction, osteoinduction and osteogenesis.
Osteoconduction is the process whereby transferred bone acts as a scaffold for new
bone to grow. (+ neovascularisation)
Osteoinduction occurs when undeveloped tissue is transformed to bone by one or
more inducing agents.
Osteogenesis is new bone formed from live osteoblasts in the transplanted autograft.
Bone transport
Used for large gaps (Ilizarovs principle of distraction osteogenesis: induction of
new bone between bone surfaces that are pulled apart in a gradual, controlled
manner. Distraction gives rise to neovascularisation hence stimulating new bone
formation.)
A segment of bone is created by corticotomy or osteotomy through normal bone in
one of the fragments of the fracture. This segment is transported by wires and new
bone forms in the gap by gradual distraction. The segment is moved by 1mm a day.
This technique of callostasis allows simultaneous restoration of a bony defect,
correction of limb length and deformity, improvement in the condition of local soft
tissues and the treatment of infection.
14
0h
Within 8h
3-6 wks
6-12 wks
4
5
6-12 mths
1-2 yrs
Hematoma formation.
Inflammatory reaction with proliferation of the cells under
periosteum and within the medullary cana. Macrophages,
undifferentiated stem cells and platelets surround fracture site.
Osteoclasts remove sharp edges (thus # more visible on
radiographs), Callus forms within hematoma
Bone forms within the callus, bridging fragments. Forming
woven bone.
Consolidationwoven bone is replaced by lamellar bone
Normal architecture is achieved through Remodelling
Venous obstruction
Increased venous pressure
Constrictive dressing, cast, splint
Diagnosis
Tibial compartments (common) and forearm flexor compartment
may lead to Volkmanns ischemic contracture
Clinical signs and symptoms
Early
Pain out of proportion to injury & not relieved by analgesics**
Increases with Passive stretch of compartment muscles
Paresthesias
Pallor
Palpable tense, swollen compartment
Late
Paralysis (inability to move limb - late)
Pulses are usually still present (CRT normal)
Definition
Condition where pressure within an enclosed anatomical compartment rises
sufficientto occlude the microvascular circulation causing tissue ischaemia and, if
untreated, tissue necrosis.
Intracompartmental pressures over 30 mm Hg or over diastolic pressure requires
intervention
Etiology
Fracture, dislocation
Soft tissue damage & muscle swelling
Crush injury
Arterial compromise
Muscle anoxia
Treatment
Remove constrictive dressings
Bivalve casts down to skin and spread open
Place limb at level of heart
Emergency fasciotomy if difference between diastolic BP and compartment
pressure is greater than 30 mmHg (treat within 4-6h of onset symptoms)
15
AVASCULAR NECROSIS
TIPBITS FOR #S
Aetiology
Steroid use --- NOT dose related idiosyncratic
Alcohol
Post-traumatic fracture/dislocation
Septic arthritis
Sickle cell disease
Gauchers disease
Caissons disease deep sea diving/the bends
Perthes disease
Idiopathic
AVN Classification
Stage Clinical Features
X-ray Features
1
Preclinical phase of No plain x-ray abnormality; may be detectable on MRI
ischemia and
necrosis; no pain
2
Painful
Early radiographic changes i.e. fragment appears dense,
normal bone contour
3
4
Painful
Very painful
Mechanism
Occurs following disruption of blood supply to bone
Occurs especially in those bones extensively covered in cartilage which rely on
intra-osseous blood supply and distal to proximal blood supply, e.g. head of femur,
proximal pole of scaphoid, body of talus
Results in ischemia
Pathologic changes include resorption, subchondral fractures and loss of cartilage
16
Tendinitis
Rupture
Frozen shoulder
Joint disorders
Glenohumeral arthritis
Acromioclavicular arthritis
Any preceding trauma (frozen shoulder and rotator cuff tear often follow minor
precending injury).
Referred pain
Neck pain shoulder pain may be due to cervical pathology; shoulder pain is
typically located over the deltoid insertion and tip of shoulder, not along the
trapezius or neck.
Cervical spondylosis
Cardiac ischaemia
Mediastinal pathology
Instability
Dislocation
Subluxation
Bone lesions
Infection
Neoplasm
Nerve lesions
INVESTIGATIONS:
No blood investigations are required usually; shoulder X-ray is the most useful invx
Important features to look out for on shoulder X-ray:
- Narrowing of subacromial space
- Bony spur on inferior aspect of acromion or acromioclavicular joint
- Calcification of supraspinatus tendon (acute calcific tendinitis)
- Narrowing of joint spaces esp. glenohumeral joint
- Osseous lesion(s) if any
17
Instability
AC joint injuries
Impingement syndrome
Frozen shoulder (women) primary cause
Rotator cuff tears
Degenerative arthritis
Frozen shoulder primary/secondary cause
Middle-aged
Old
Rotator cuff
Elderly gentleman
S: shoulder +/- lateral aspect of
arm (confused w radiculopathy)
O: insidious/sudden after freq use
C:
R: none
A:
T: worse at night
E: cannot lie on affected arm
S:
Stem
Pain
Functional assessment
Frozen shoulder
Old gentleman / middle-aged lady
S: shoulder
O: <18months ago
C:
R: none
A:
T:
E: lying on shoulder while sleeping / night
pain because Im not conscious of where
my hands & arms go when Im asleep
S:
Shoulder instability
Young gentleman
S: shoulder
O:
C:
R: none
A:
T:
E:
S:
LOOK
FEEL
MOVE
SPECIAL TESTS
Frozen shoulder
Shoulder instability
Describe what you mean by impingement syndrome / frozen shoulder / shoulder instability.
Definition
Impingement syndrome
impingement
position
where
the
glenohumeral joint is in abduction, slight
flexion and internal rotation
-
Frozen shoulder
Known also as adhesive capsulitis, it is a
well-defined disorder characterised by
progressive pain and stiffness which
usually resolves spontaneously after 18
months.
Shoulder instability
Shallowness of the
glenoid fossa of the
scapula & lack of support
provided by weak lig (3
GH ligamentsMedial,
Inferior, Superior;
transverse humeral lig;
coracohumeral lig) make
the GH joint unstable
strength mainly depends
on the rotator cuff
muscles
Investigations:
X-ray
Management
Pathogenesis
SECONDARY ADHESIVE CAPSULITIS
Friction leads to localised oedema and
Intrinsic causes
Anterior instability
For acute dislocations:
Manipulation and
reduction followed by
immobilisation in a
bandage or sling for
several wks
Recurrent dislocations:
Indications for surgery
include frequent painful
dislocation and recurrent
subluxation
Posterior instability
M. strengthening
exercises
Surgery considered when
condition is disabling &
there is no gross joint
laxity
Anterior dislocation
M & R with sedation /
GA
Hippocratic method:
increasing traction
applied to the arm with
the shoulder in slight
abduction while an
assistant applies firm
counter traction to the
19
Posterior dislocation
M & R by pulling on the
arm with shoulder in
adduction followed by
lateral rotation while
humeral head is pushed
forwards.
Immobilisation in a sling
20
The greatest amount of wear occurs in the impingement position where the
glenohumeral joint is in abduction, slight flexion and internal rotation
PATHOPHYSIOLOGY
- Pathological processes can be summed up into wear, tear and repair
- Friction leads to localised oedema and swelling (tendinitis) wear
- Tendinitis is usually self-limiting but with prolonged or repetitive impingement
minute tears can occur, especially in elderly tear
- Tears can be complicated by scarring, fibrocartilaginous metaplasia or calcification
in the tendon
- Healing is accompanied by a vascular reaction and local congestion which is
painful, and this may contribute to further impingement
- Healing is more rapid in younger patients (but also more painful) and less vigorous
in the elderly (less pain, chronic tendinitis that doesnt heal completely).
- Deposits of calcium hydroxyapatite appear in the supraspinatus tendon in acute
(calcific) tendinitis. Although these calcifications are not painful, the florid vascular
reaction which produces swelling and tension causes severe symptoms. The
calcium usually resorbs quickly and disappears in a few months.
HISTORY
(SUB)ACUTE TENDINITIS
- Patient <40 years old
CHRONIC TENDINITIS
- Patient 40-50 years old
- Patient has a history of recurrent attacks of subacute tendinitis
- Pain settles with medications (NSAIDs) or rest but recurs when doing more
demanding activities
- Pain characteristically worse at night, and patient cannot lie on affected side
- Pain and stiffness restrict daily activities
CUFF TEAR
- Partial or full thickness tear occurs with progressive fibrosis & disruption of the
rotator cuff
- Usually >45yo with refractory shoulder pain with increasing stiffness and weakness
- Partial tears are hard to detect as they present with painful arc but still normal
motion of the shoulder. Patient can abduct the shoulder upon giving LA because
pain is the limiting factor usually. Intact tendon fibres provide continuity for
vascular ingrowth and repair.
- Complete tears occur spontaneously after a sprain or jerking injury of the shoulder,
and the patient complains of acute pain and inability to abduct the arm. To
distinguish from partial tear: No abduction despite LA. There is little or no reaction
and no repair; proxial fibres may retract and become stuck down.
PHYSICAL EXAMINATION
SIGNS OF SUPRASPINATUS TENDINITIS
- Pain at the point of insertion of the supraspinatus along the anterior border of the
acromion, best felt with the arm held in extension
- Painful arc: Pain on active abduction between 60 and 120 degrees of motion, with
disruption of scapulohumeral rhythm.
- Impingement sign: Pain elicited when affected arm is passively flexed, abducted
and internally rotated (the greater tuberosity is brought under the coracoacromial
arch impinging the supraspinatus)
- Impingement test: Pain on doing the above procedure is reduced after injection of
H&L into the subacromial space
SUPRASPINATUS TEAR
- Difficulty in initiating abduction
Ability to actively abduct the arm after passively abducting it above 90 degrees
the abduction paradox, as supraspinatus initiates abduction but deltoid can abduct
the shoulder the rest of the way
Drop sign: the abducted arm suddenly drops to the side when it is lowered past a
certain angle of abduction
INVESTIGATIONS
TEAR
Conservative
Surgical
1. X-ray
3. MRI
2. Ultrasound
(ii)
MANAGEMENT
TENDINITIS
BICEPS TENDONITIS
- Impingement syndrome.
- Pain and tenderness sharply localised to the bicipital groove.
- Rest, local heat and deep transverse frictions. Consider a local corticosteroid
Conservative:
Surgical
Treatment:
- No treatment in the elderly if isolated lesion.
- If part of a rotator cuff lesion esp if patient is young, may need anterior
acromioplasty with reattachment of the tendon (splint the arm with the elbow
flexed for 4 wks)
Biceps:
Origin - long head from the supraglenoid tubercle and lies in the bicipital groove, short head is from
the tip of the coracoid process of the scapula;
Insertion - posterior part of the tuberosity of the radius and deep fascia on medial aspect of forearm
via bicipital aponeurosis
Action- supinator of the forearm, flexor of the elbow jt and weak flexor of the shoulder jt]
INVESTIGATIONS
- X-rays usually normal useful in excluding other causes of painful shoulder, such
as infection, post-traumatic stiffness, diffuse stiffness and reflex sympathetic
dystrophy when patient 1st presents
MANAGEMENT
Conservative
AETIOLOGY
The term frozen shoulder should be reserved for a well-defined disorder characterised
by progressive pain and stiffness which usually resolves spontaneously after 18 months.
PRIMARY ADHESIVE CAPSULITIS
- Idiopathic in cause
- Associated with DM, Dupuytrens contracture, hyperlipidaemia, hyperthyroidism,
cardiac disease
- Global contracture of the shoulder joint, but maximally in the rotator interval area
and around the coracohumeral ligament
SECONDARY ADHESIVE CAPSULITIS
-
Intrinsic causes
Extrinsic causes
CLINICAL FEATURES
- Patient aged 40-60 years
- Aching in the arms and shoulder after trauma, often trivial
- Pain gradually increases in severity and prevents sleeping on the affected side
- Subsides after several months with increasing stiffness that continues for 6-12mths
- Movement is regained gradually but may not return to normal
Physical findings: shoulder appears normal with no wasting; most marked feature is
decreased active and passive movement in all directions
Aim of conservative treatment is to relieve pain and prevent further stiffening while
waiting for recovery (since natural course is recovery in 12-18 months)
Analgesia (NSAIDs), corticosteroid injections, local heat.
Physiotherapy:
o Repeated circular movement of shoulder
o Assisted abduction use towel or rope, loop it over an overhead bar like a
pulley system, and hold on to each end with one hand. Patient uses downward
pull of normal arm to passively abduct painful arm overhead.
o Assisted internal rotation both hands gripping either end of a towel slung
across the patients back diagonally; the hand on the painful side holds the
lower end while the hand on the normal side holds the end above the shoulder.
Patient uses hand on normal side to pull upwards on towel, passively
internally rotating the painful shoulder.
o Wall-crawling patient uses fingers to crawl up a wall slowly, increasing
flexion movement.
Surgical
Poorly defined role, only for patients who fail conservative management
Manipulation under anaesthesia (least invasive) passive stretching of the capsule
while patient is under anaesthesia, but be careful of causing fractures especially in
the elderly.
Distend the joint by injecting a large volume of sterile saline under pressure
Fibrolysis/ division (open or arthroscopic) of the supraspinatus and infraspinatus
may dramatically improve ROM. Must be followed by aggressive physiotherapy
post-op.
PROGNOSIS
- Better in younger patients with post-traumatic frozen shoulder; the idiopathic frozen
shoulders that occur in diabetics tend to recur and not improve.
23
X-RAY FEATURES
ANTERIOR SHOULDER DISLOCATION TYPES OF X-RAY VIEWS
Y-SCAPULAR (LATERAL
AP VIEW
AXILLARY VIEW
SCAPULAR) VIEW
AP-overlapping shadows of the humeral head and glenoid fossa with the head lying
below and medial to the socket. Look out for Hill-sachs lesion which may indicate
recurrent anterior dislocations
Normal shoulder jt
COMPLICATIONS
Early
(i)
Rotator cuff tear: occurs usu in older people, difficulty in abducting the arm
after reduction
(ii)
Axillary nerve injury: patient unable to contract the deltoid (can inititate
abduction but difficulty in abduction beyond a certain angle) and small patch of
anaesthesia over the muscle (regimental badge area); usu a neuropraxia
[course of axillary n.: arises from posterior cord of the brachial plexus (C5,6) in
the axilla, passes through quadrangular space then comes into close relationship
with the inf aspect of the capsule of the shoulder jt and medial side of the
surgical neck of the humerus] Radial n., median n., ulnar n, musculocutaneous
n. may be injured sometimes
(iii)
Axillary artery injury: examine for ischaemia before and after reduction
(iv)
Fracture-dislocation: associated fracture of the humerus-ORIF. Greater
tuberosity may be sheared off
Late
(i)
(ii)
(iii)
Shoulder stiffness
Unreduced dislocation: closed reduction can be attempted up to 6wks after
injury
Recurrent dislocation: common if the glenoid labrum is detached or the
capsule is stripped off the front of the neck of the glenoid; more common in
younger patients 90%, 50% in older patients
TREATMENT
M & R with sedation or sometimes GA
(i)
Kochers method: not recommended due to risk of nerve, vessel & bone injury
(ii)
Stimsons technique: patient lies prone with arm hanging over side of bed;
(iii)
2.
-
ANTERIOR INSTABILITY
most common type, accounts for 95% of instability
Mechanism of injury: arm is forced into abduction, external rotation and extension
In recurrent dislocations: labrum and capsule often detached from the anterior rim
of the glenoid(Bankart lesion) and there is the presence of an indentation on the
posterolateral aspect of the humeral head (Hill-Sachs lesion)
CLINICAL FEATURES
- Patient may describe his shoulder as coming out after a sporting event in an acute
dislocation
- Complain that shoulder dislocates with relatively trivial actions and often he/she
can reduce the dislocation himself
- In recurrent subluxation: patient may describe a catching sensation followed by
numbness or weakness
- ROM full btw episodes of dislocation
- Apprehension test: examiner lifts the arm into abduction, external rotation and
then extension, patients body tautens in apprehension when he senses that the
humeral head is abt to slip anteriorly. Repeat test by applying pressure to the front
of the shoulder at the same time, patient will feel more secure now
- Drawer test: scapula is stabilised with one hand while examiner grasps the upper
arm with the other hand to manipulate the head of the humerus forwards and
backwards with the patient supine
25
Fulcrum test: patient lies supine and examiner places one hand behind the patients
shoulder to lever the humeral head forward by extending and laterally rotating the
arm, patient becomes apprehensive.
INVESTIGATIONS
- X-ray shoulder jt: AP, lateral and axillary views:
Hill Sachs lesion best shown on AP with arm internally rotated
X-RAY FEATURES
- AP view humeral head looks abnormal in shape as it is medially rotated(light bulb
sign); humeral head stands somewhat away from the glenoid fossa (empty glenoid
sign)
AP view
transcapular view
axillary view
Lat view- posterior subluxation, dislocation and sometimes deep indentation on the ant
aspect of humeral head, may have accompanying fractures of the humeral neck,
posterior glenoid rim or lesser tuberosity
-
CT shoulder
Arthroscopy
Examination under anaesthesia (EUA) to determine direction of instability
TREATMENT
- For acute dislocations: Manipulation and reduction followed by immobilisation in a
bandage or sling for several wks
- Recurrent dislocations: Indications for surgery include frequent painful dislocation
and recurrent subluxation
COMPLICATIONS
(i)
unreduced dislocations
(ii)
recurrent dislocations
TREATMENT
- M & R by pulling on the arm with shoulder in adduction followed by lateral
rotation while humeral head is pushed forwards.
- Immobilisation in a sling
4. POSTERIOR INSTABILITY
- Recurrent instability almost always a posterior subluxation with the humeral head
riding back on the posterior lip of the glenoid
- Subluxation when the arm is in flexion and internal rotation
- Posterior drawer test positive: humeral head pushed backwards while the scapular
spine and coracoid process are held by the other hand
- Posterior apprehension test positive: forward flexion and internal rotation of the
shoulder with a posterior force on the elbow
- Treatment: muscle strengthening exercises, surgery considered when condition is
disabling and there is no gross joint laxity
26
5.
-
Tuberculosis
- Uncommon
- Starts as osteitis, rarely diagnosed till arthritis supervenes.
- May proceed to abscess and sinus formation, and possibly fibrosis ankylosis.
- X-ray shows generalized rarefraction of bone in early stages with erosion of
joint surfaces. Late cases may have cystic destruction of the joint.
- Treatment: Anti-TB meds and rest the joint until acute symptoms settle.
Rheumatoid Arthritis
- AC joint, shoulder joint and various synovial pouches usually involved.
- X-ray shows progressive loss of articular space and peri-articular erosions
- Treatment: Methylprednisolone may be injected into joint & subacromial bursa.
Osteoarthritis
- Usually secondary to other fairly obvious disorders: congenital dysplasia, local
trauma, long-standing rotator cuff lesions, RA or AVN of head of humerus.
- X-rays show characteristic OA picture.
Milwaukee Shoulder
Patient presents with swelling of the shoulder and x-rays show a bizarrely
destructive form of arthritis. Similar conditions are encountered in other joints.
Largely crystal-induced rapidly progressive arthropathy; sometimes associated
with massive rotator cuff tears.
No satisfactory treatment
Most commonly involve the middle 1/3 of the clavicle, outer fragment will
be pulled down by the weight of the arm while inner half held up by SCM
Early
1. Pneumothorax
2. Damage to subclavian vessels
3. Brachial plexus injury
Late
1. Non-union, esp displaced outer 1/3 fractures
2. Malunion (healed #leaves a lump, most common Cx)
3. Shoulder stiffness
Treatment:
Mechanism of injury: body is fractured by a crushing force, a/w rib fractures, lung
contusion and haemo/pneumothorax, neck is fractured due to a blow or a fall on the
shoulder
Fractures of the scapula (high energy fracture) can be a/w injuries to the chest,
brachial plexus, spine, abdomen and head
Treatment:
Malunion (+ crepitus)
X-ray:
Complications:
(i)
Supraspinatus tendinitis
(ii)
Unreduced dislocation
(iii)
Ossification of the ligaments
(iv)
secondary OA
Treatment:
AC dislocation: fixation with a screw for 8wks, rest the arm for 2 wks
followed by physio; considered only for young and active patients
STERNOCLAVICULAR DISLOCATIONS
-
ACROMIOCLAVICULAR SUBLUXATION/DISLOCATIONS
-
Definitions
Posterior dislocations
1. Closed reduction (sedate patient first, then pull at the shoulder)
2. If unreduced ORIF or acceptance of some degree of permanent
instability (depending on patient characteristics and functionality)
28
One part
Two part
Epidemiology: occurs after middle age. Most common in osteoporotic postmenopausal women
Mechanism of injury: fall on the outstretched arm (causes # in older patients,
dislocation in younger patients)
Clinical features: large bruise on upper part of arm, may have associated axillary n.
and brachial plexus injury
X- ray:
Three
part
Four part
2 fragments are
displaced, usu head (#
along surgical neck) and
greater tuberosity
All the major parts are
displaced
- Complications:
One part fracture involving surgical neck
1. Vascular and nerve injuries esp axillary nerve
2. Stiffness of the shoulder maximal at the outset
3. Malunion with loss of rotation
4. Avascular necrosis of the head of humerus: 10% of 3-part fractures, 20% of 4-part
fractures
-
Treatment
29
Fall on the elbow with the arm abducted causes a oblique or transverse #
Complications:
Early
1. Brachial artery injury (dx with arteriography)
2. Radial nerve injury- patient presents with wrist drop and
paralysis of the MCP extensors; common with oblique #s
at the junction of the middle and distal 1/3 of bones
Late
1. Delayed union, malunion and non-union (common in
conservatively managed patients)
2. Joint stiffness
Treatment:
- U slab Cast Brace, or
- ORIF
- Most heal readily; weight of arm with external cast enough to pull fragments
together. Hanging cast is applied from shoulder to wrist with elbow flexed and
forearm is suspended by a sling around patients neck
- Spiral fractures unite in about 6wks while other fractures take 4-6wks longer
- Cx rate after IF of humerus high (compression plate, screws, intramedullary nail,
external fixation)
Indications for surgery:
Radial n palsy
Segmental #
Open #
Pathological #
Intra-articular extension
Floating elbow (humeral + forearm #)
Non-union
30
31
Complications:
Early
1. Brachial artery injury, can cause Volkmans ischaemia
2. Compartment syndrome pain + 1 positive sign [pain on passive extension of the
fingers, tnese and tender forearn, pulseness, blunted sensation, increased capillary refill
time], KIV angiography, vessel graft, forearm fasciotomy
3. Median n., esp anterior interosseous branch, recovery usu in 6-8wks
4. Ulnar n. damaged by careless pinning
Late
1. Malunion, causing varus deformity of the elbowgunstock deformity, rarely
valgus(may cause late ulnar n. palsy), may need correction by supracondylar osteotomy
2. Elbow stiffness
3. Myositis ossificans
Treatment
Type I
Undisplaced fracture
Type II
Type IIa
Type IIb
Type III
Treatment:
Displacement <30deg- collar and cuff
Displacement>30 deg- closed or open reduction. IF not necessary
Never remove radial head as it interferes with growth of the radius
Late
1. Stiffness of the elbow
2. Late ulnar n. palsy due to friction in roughened bony
groove
Treatment:
Undisplaced-splint and repeat x-ray
Displaced- closed reduction with percutaneous pinning or ORIF
4. PULLED ELBOW
Mechanism of injury: pull on the arm with forearm pronated, causing subluxation of
annular ligament over head of radius into radiocapitellar joint.
- Usually affects a child between 2-3yo
No x-ray findings
Type A
Extra-articular
supracondylar #
- rare in adults
- usu displaced
and unstable
ORIF
Type B
Type C
Intra-articular bicondylar# with
Intra-articular unicondylar #
varying degrees of comminution
- high energy # with soft tissue damage
- examine for vascular or nerve injury
Undisplaced #
Posterior slab with elbow flexed almost 90 deg
Check x-rays 1/52 after injury
Displaced#
ORIF, elbow held at 90 deg with arm in a sling, healing occurs
by 12wks
Skeletal traction may be considered for severely comminuted #
Elbow replacement in the elderly
Complications
Early
1.Vascular injury
2.Median n. or ulnar n. damage
Late
1. Elbow stiffness
2. Heterotopic ossification
Treatment: Supinate then flex the elbow, ligament pops back in place
5. FRACTURED NECK OF RADIUS
Mechanism of injury: Fall on outstretched hand, forcing elbow into valgus and
pushing radial head against capitulum; same injury in adult usu causes radial head #
Clinical features: pain on rotating forearm
X-ray: may have a Salter Harris II injury; proximal fragment is tilted distally, forwards
and outwards
33
Complications:
1. Joint stiffness of the elbow and radioulnar jt
2. Myositis ossificans
3. Recurrent instability of the elbow if injury to the medial collateral lig and if there
is excision of the radial head
Mason classification
Type I
Vertical split in the
radial head
LA injection and
aspiration of
haematoma
Collar and cuff for
3/52
X-ray: lateral view needed, check position of radial head as it may be dislocated
Complications:
1. Stiffness
2. Non-union
Treatment:
- Comminuted # with triceps intacttreat as a bruise and rest in sling for 1/52 as
immobilization can lead to stiffness in the elderly; obtain check x-ray
- Undisplaced transverse# immoblise at 60 deg in a cast for 2-3/52
- Displaced transverse # ORIF with tension band wiring
Type II
Single fragment of lateral
portion of the head broken off
and usu displaced distally
Reduction and fixation with a
small screw
Type III
Head is comminuted
Excision of radial head
4.
-
Mechanism of injury:
- FOOSH with elbow in extension causes posterior dislocation
- Side swipe injury (driver with elbow out of the window) causes forward
dislocations usu a/w # and severe soft tissue damage
Complications:
Early
1. Brachial artery injury
2. Median or ulnar n. injury
Late
1. Stiffness
2. Heterotopic ossification, myositis ossificans; if bone mass restricts elbow function,
excise when mature
3. Unreduced dislocation
4. Recurrent dislocation if there is a large coronoid# or radial head #
5. Secondary OA
Line drawn down the long axis of the radius does not intersect the capitulum,
indicating radial head dislocation
Treatment:
Uncomplicated dislocation: reduce under anaesthesia
Slight flexion of elbow and traction on forearm correct lateral displacement further
flexion of elbow while pushing olecranon forwards check nerves and circulation +
check x-raycollar and cuff for 3/52 with elbow flexed>90deg
Dislocation with associated #: fix the #
Side swipe injuries repair vascular damage, skeletal stabilization
Persistent instability temporary external fixation
5.
-
35
Cause: minor trauma to origin of wrist extensors / fibrosis of extensor carpi radialis
brevis (ECRB) e.g. painting, carpenter
CUBITUS VALGUS
Cause: non-union of # lateral condyle (a/w bony knob on medial elbow)
Mx:
Undisplaced backslab
Moderate displacement closed reduction and backslab
Unstable K-wire and cast
Rotated Open reduction and K-wire
Cx: Tardy ulnar nerve palsy manage by transposing ulnar nerve anterior to elbow
RHEUMATOID ARTHRITIS
Features: pain, tenderness, swelling, stiffness, usually bilateral
X-ray: bone erosion, radial head destruction, widened trochlear notch of the ulna
Rx: splint, radial head resection, partial synovectomy, arthroplasty
OSTEOARTHRITIS
Cause: intraarticular #s, loose bodies, crystal deposition dz
Features: pain, stiffness, ROM, ulnar n palsy
X-ray: Jt space, bone sclerosis, osteophytes, loose bodies
OLECRANON BURSITIS
Causes: pressure, friction, infxn, gout (a/w tophi), RA (a/w polyarthritis & subcutaneous
nodules over the olecranon)
Features:
o Lateral epicondylar pain, aggravated by shaking hands & opening doors.
o Pain on active wrist extension with a straight elbow. Normal ROM.
o Pain reproduced by extending wrist against resistance or by passively flexing in
thus extending the tendons
Rx: rest, lifestyle modification, H&L injection, extra-corporal shockwave, excision of
fibrous mass, lengthen tendon (ECRB)
36
SUPRACONDYLAR FRACTURES
Fractures in distal 1/3 of humerus proximal to the trochlea & capitulum
Epidemiology: common childhood #. Adults: More proximal, commonly with
comminution, spiraling & angulation
Mechanism of injury: FOOSH
Features: pain over elbow, swelling, deformity
Important complication: Volkmanns ischaemic contracture df: irreversible
contracture of flexor muscles of the hand due to ischaemic processes in the forearm
DDx: dislocation of elbow (equilateral by epicondyles & olecranon is disrupted)
Support
Cx:
1. Arterial obstruction: Brachial arterial kinking by proximal fragment. Arterial wall
damage results in Volkmanns ischaemic contracture. Symptoms = Pain, Pallor,
Paraesthesia, Paralysis, Perishing cold, swelling & bruising)
2. Median nerve injury
3. Malunion cubitus varus (may cause ulnar tunnel syndrome)
ELBOW DISLOCATIONS
Mx:
Indications for
reduction
Manipulation
technique
Fixation
X-rays
Remanipulation
if reduction is
poor
Observation
Arterial obstruction
# displacement &/or angulation
<50% bony contact
Backward tilt 15%
Medial or lat tilting of 10% (may cause tardy ulnar n palsy)
Severe torsional deformity
Manipulation under GA
1. Disimpaction: Traction applied at 20o flexion with
countertraction applied to arm
2. Reduce post tilt/displacement: Flex elbow to 80o while
maintaining traction
3. Correct lat displacement/torsional deformity: manipulate
epiphyseal complex
Fix with elbow at greatest angle of flexion possible w/o
compromising circulation (check radial pulse)
Never apply a complete plaster due to risk of swelling
AP & lateral
No more than 2 remanipulations due to risk of swelling.
Employ continuous traction instead (e.g. Dunlop traction)
K-wires & plaster backslab may be used for unstable #
Overnight, esp for complications of vascular compromise
37
Monteggia
Hairline
Undisplaced (marginal
or segmental)
Displaced (marginal or
segmental)
Comminuted
Rx
Mx:
o
o
o
Cx:
o
o
o
o
o
o
Minimal tilting
o
Monteggia
Galeazzi
NIGHTSTICK INJURY
FOREARM FRACTURE-DISLOCATIONS
TYPES OF CASES
Ganglion
Pigmented villonodular synovitis (PVNS)
Implantation dermoid cyst
OA Heberdens & Bouchards nodes
Haemangiomas
Pseudoaneurysms
SCC
Glomus tumours
Joint
RA hands
OA hands
Vascular
Nerve
Haemangiomas
Ulnar n palsy
Median n palsy
Radial n palsy
Carpal tunnel syndrome
Lumps
Muscle /
tendon
Bones
Joint
Periarticular
Radiculopathies
Erbs palsy (C5-6)
Klumpke palsy (C8-T1)
de Quervains dz
Tenosynovitis
RA Swan neck & Boutonniere
deformities, tendon rupture
Trigger finger
Dupuytrens contracture
Mallet finger
Colles #
Smiths #
Scaphoid #
Bennetts #
Boxers #
Gamekeepers thumb
Scaphoid dislocation
Lunate dislocation
RA
OA
Infection
De Quervain
Tenosynovitis
Instability
Painful Hand
Neck
Shoulder
Mediastinum
RA
OA
Carpal tunnel
Tenosynovitis
Infection
NB. CTS, De Quervains disease and trigger finger are all tenosynovitis (i.e. same Mx)
I. HANDS
ACUTE INFECTIONS
GENERAL
-
PATHOLOGIES
1. Trauma
2. Tumour
3. Infection
4. Inflammation
5. Degeneration
Painful Wrist
Cervical spondylosis
SPECIFIC TYPES
PARONYCHIA
Infection under nailfold.
39
DUPUYTRENS CONTRACTURE
Definition: nodular hypertrophy & contracture of palmar aponeurosis.
Pathogenesis: local microvessel ischaemia increased xanthine oxidase activity
superoxide free radical production stimulate myofibroblast proliferation &
type III collagen formation. Specific platelet-derived and fibroblast growth factors
also play a role in the aetiology.
o Allopurinol may help to reduce symptoms (XO inhibitor)
o The process of chronic inflammation is thought to be essential to the
subsequent fibrosis
Features: Middle-aged man.
LOOK
o Appearance of any visible cords, any pitting/tethering of skin on
palmar aspect of hand
o Scars from previous surgery
o Flexion deformities at MCPJ and PIPJ of the involved fingers
o Involvement of thumb & 1st web space (a sign of more aggressive dz)
o Garrods pads at PIPJs on dorsum of hand (thickening of s/c tissues)
FEEL
o Palpate swelling, note fixation to skin
o Compare with other palm!
MOVE
o ROM of involved fingers
o Passively move the joints with fixed deformities
OFFER
o To enquire about causes & associations
o Assess patients function, e.g. writing & dressing
o Look for other features of diffuse fibromatosis
DDx:
o Skin contracture (look for scar from previous wound)
o Tendon contracture (thickened area or cord moves on passive flexion of
involved finger)
o Congenital contracture of little finger (affects PIPJ)
o Ulnar nerve palsy (claw hand deformity)
Conditions associated with Dupuytrens contracture (DEAFEST PAIL)
o DM
o Epilepsy
o Age
o Family history (AD) / fibromatoses
o Epileptic medication (e.g. phenobarbitone)
o Smoking
o Trauma & heavy manual labour
40
Bone (avulsion #)
Extra-articular or involving <2/3 of joint
conservative Rx
Intra-articular or involving 2/3 of joint
surgical reduction
MUSCLE CONTRACTURE
Forearm
Intrinsic
muscles
MALLET FINGER
Muscle (imbalance)
Treat with mallet splint (conservative)
DROPPED FINGER
BOUTONNIERE
Flexion deformity of PIP joint due to interruption of central slip of extensor tendon
Lateral slips separate and head of proximal phalanx pops up in between
Rx: post traumatic usually repairable. Chronic deformity (in RA) usually cannot be
repaired
LOOK
FEEL
MOVE
Pathology:
Most often due to formation of nodule in FDS tendon where it glides under the
A1 pulley in the region of the metacarpal head.
Flexor tendon trapped at entrance of tendon sheath; forced extension causes
opening snap. Tender nodule may be felt in front of sheath at the MCPJ
DDx:
RA
Septic arthritis
Suppurative tenosynovitis
Tumour of tendon sheath
Dislocation
Dupuytrens contracture
Pre-triggering
Triggering
Triggering &
Locking
Contracture
Features
Hx of triggering not demonstratable on PE; tenderness
Demonstrable catching, but patient can actively extend the digit
Demonstrable locking, requiring passive extension (IIIa) or inability
to actively flex (IIIb)
Fixed flexion contracture of PIP joint
Mx:
Splinting (MCP joint flexed 15; not that efficacious)
Activity modification (i.e. reduce local trauma)
H&L into tendon sheath: high rate of success in female patients, with short
duration of symptoms (<4mths), for discrete palpable nodule, single digit
involvement, no associated conditions (e.g. RA, DM)
Surgical release
o If injection therapy failed or if patient has other pathologies (e.g. RA)
which is suspected to cause triggering & cannot be treated conservatively
Divide entire A1 pulley (tendon sheath) in the midline under vision, then
ask patient to actively move the digit to confirm full release (motion
encouraged immediately following the procedure)
Complications: incising too distally cut the A2 pulley bowstringing
LUMPS
PIGMENTED VILLONODULAR SYNOVITIS (PVNS)
Definition: benign proliferative disorder of synovial lining of joint, bursa & tendon
sheaths. Produces localised/diffused nodular thickening of the synovial membrane.
2 types (+ sites)
i) Diffuse form
o Affects entire synovial lining of a joint, bursa or tendon sheath; affects
large joints
o More commonly in the knee, followed by the hip; ankle; shoulder joints
ii) Localized/nodular form
o Appears in the form of a localized nodule or mass in a synovium, and the
surrounding synovium is generally normal
o Affects tendon sheaths around small jts of hands & feet (termed nodular
tenosynovitis)
Presentation: solitary, well circumscribed, tan colored, and sometimes has pale
X-ray: joint swelling, periarticular erosions, joint space narrowing, sub chondral
cyst, osteophytes formation (secondary OA changes)
yellow regions of lipid deposition. Insidious onset, dull aching jt pain, nodular or
diffused jt swelling, ROM, locking of joint.
recurrence (>50%) If refractory to repeated surgery, may be managed with lowdose radiotherapy
ENCHONDROMA
Commonest primary bone tumor of hand
Hard, irregular, fixed swelling
MALIGNANT MELANOMA
NEUROMA
NEUROFIBROMA
Localised to digit and part of hand
4-5cm, irregular and wrinkled skin, soft, mobile with skin, a/w cafe au lait spots
GLOMUS TUMOURS
VASCULAR TUMOURS
May have thrills and bruits
PYOGENIC GRANULOMA
Relatively common benign vascular lesion of skin and mucosa. Exact cause
unknown
Usually occurs in children and young adults as a solitary, glistening, friable,
polypoid bright red papule or nodule. Prone to bleeding and ulceration.
Ranges from few mm to several cm in size.
Regressing lesions: Appear as soft fibroma. Normally occurs at head & neck, and
distal extremities.
Typically evolves rapidly over a period of a few weeks.
Usually Hx of trauma preceding the onset of lesion may be elicited
Untreated lesions eventually atrophy, fibrose and slowly regress.
OSTEOCHONDROMA
II. WRISTS
Carpal Bones (lateral to medial):
Some Lovers Try Positions That They Cannot Handle
Scaphoid, Lunate, Triquetrium, Pisiform, Trapezium,
Trapezoid, Capitate and Hamate
Alignment in Gilulas Arc (Carpal Arc)
JOINT DISORDERS
CHRONIC CARPAL INSTABILITY
Causes:
Injury
Arthritis
Kienbcks disease (patchy lunate AVN after trauma)
Features:
Pain
Weakness
Clicking on movement
Commonest type: Scapholunate dissociation X-ray shows
Terry Thomas sign (abnormal gap between scaphoid & lunate)
43
Rx:
3. Occult
4. Interosseous
Treatment:
KIENBOCKS DISEASE
MUSCLE / TENDON
TENOSYNOVITIS/TENOVAGINITIS
-
LUMPS
GANGLION
Definition:
Entrapment tendinitis of the tendons contained within the first dorsal compartment at
the wrist (MCQs: APL & EPB); causing pain with tendon movement
Pathology
Features:
Types:
1. Simple
2. Compound chronic inflammation distends tendon sheath above & below the
flexor retinaculum ( a/w TB, RA)
Inflammation causes thickening & stenosis of synovial sheath of the 1st dorsal
compartment containing the EPB & APL
Cause: wringing out clothes, pruning roses, cutting with scissors, cradling baby
Women 30-50 YO
Pain over radial styloid process, swelling & palpable thickening of fibrous sheath
along course of tendons
Finkelsteins test +ve (exquisite pain in region of radial styloid on forced ulnar
deviation of wrist with thumb in fist); NB. This test may also be positive in CMC
degenerative joint disease, e.g. OA
44
DDx:
Aetiology
o
o
If diagnosis is still in doubt, obtain Roberts view in order to profile CMC joint
Treatment
Conservative
NSAIDs
Cold compression
H&L injection: inject in sheath
AND/OR
Thumb spica splint for 1 month
Surgical
Decompression of 1st compartment sheath
(tendon sheath release)
- Determine if there is any instability of
the wrist joint & correct it if present
Pathophysiology
Infection
Radial n palsy (+ve Tinels)
Snapping of extensor tendon (due to extreme radial release of extensor retinaculum)
APL & EPB tendon adherence (will limit thumb movements)
NERVES
CARPAL TUNNEL SYNDROME
Features
Symptoms may present at night or with certain activities e.g. driving, reading
newspaper. Pain, paraesthesia numbness over lateral 3.5 fingers. Burning pain &
paraesthesia over median n distribution. Usually occurs at night, waking the patient
up, relieved by shaking arm and/or hanging arm over side of bed.
Late symptoms: Wasting of thenar eminence, weak thumb abduction (autonomic
innervations by median n.), decreased sensation of lateral 3.5 fingers
Tinels & Phalens tests positive
DDx:
o
o
o
Definition
40-50YO
Women > men
Investigations
Anatomical boundaries
45
Treatment
Non-surgical
NSAIDs
Splinting of wrist in a neutral position (especially at night)
H&L injections just proximal to the carpal tunnel
Surgical
Carpal tunnel decompression (division of flexor retinaculum under tourniquet
control) either as open or endoscopic procedure
Potential complications to be explained to patient
o Scar formation (keloid/hypertrophic scars)
o Scar tenderness post-op
o Failure to relieve symptoms due to incomplete division of flexor retinaculum
o Nerve injury palmar cutaneous n. (lies supf to flexor retinaculum) and
motor branch of thenar muscles (usually leaves the radial side of median n.
towards distal extent of the standard incision) risk of n. injury can be
decreased by making the skin incision on the ulnar side of the palmar crease
TRUE [MCQ]
S/S: wrist pain & tenderness over distal radius, characteristic deformity
o
o
o
o
o
o
46
Normal: 11mm
If #: <11mm
Volar tilt
Normal: 22
If #: <20
Reduction
method
Backslab
External
fixation
Post
reduction
Normal: 11
If #: <11
Management:
Manipulation
Radial Inclination
sweaty skin
Mx: physioRx, rest & splintage for pain,
chemical sympathetic blockade if severe
Most common complication
Of the extensor pollicis longus.
Mx: tendon transfer
TFCC tear
Shoulders & fingers
SCAPHOID FRACTURE
Accounts for 75% of wrist #
Mechanism of injury: FOOSH with wrist extended. Combination of dorsiflexion &
radial deviation
Blood supply of scaphoid diminishes proximally [supply by dorsal and volar
branches of radial artery]
NB. Rare in the elderly osteoporotic patient [MCQ]
Complications
Sudecks atrophy
Clinical Features:
o
o
o
X-ray: often hard to see, 4 views required (AP, lat & 2 oblique), repeat in 14 days if
unsure (# may not be seen in first few days). Usually # is through narrowest part of
bone (i.e. waist); other potential # sites include tubercle and proximal pole #.
Type a
Type b
Type c
Mx:
Initial Mx
Cx:
Most common complications are poor grip strength, stiffness and radial shortening
80% have normal function in 6-12 months
Early Cx:
O Difficult reduction +/- Loss of reduction
O Compartment syndrome
O EPL tendon rupture
O Acute carpal tunnel syndrome
O Finger swelling with venous or lymphatic block
Late Cx:
O Malunion, radial shortening
O Painful wrist secondary to ulnar prominence
O Frozen shoulder (shoulder-hand syndrome; aetiology unknown)
O Post-traumatic arthritis
O Carpal Tunnel Syndrome
O Reflex sympathetic dystrophy
LUNATE DISLOCATION
Rotation & anterior displacement of lunate
X-ray: crescent moon shape of bone becomes obvious on AP view
Cx: median n. palsy, Sudecks atrophy, AVN (& secondary OA)
Rx: closed reduction under GA + plaster fixation, open reduction if closed
reduction fails
PERILUNATE DISLOCATION
More common than Lunate dislocation
Rest of Carpus displaced backwards
Lunate vs. perilunate dislocation
The key to differentiation between both is what is
centered over the radius. If the capitate is centered over
the radius and the lunate is tilted out, it is a lunate
dislocation (left). If however the lunate centers over
the distal radius and the capitate is dorsal, we are
dealing with a perilunate dislocation (right).
Radiology Assistant, Wrist Carpal Instability
48
SCAPHOID DISLOCATION
Displacement is usually anterior
Rx: closed reduction + plaster fixation in stable position. If instability is present, fix
with K-wires
BENNETTS FRACTURE
Fracture of 1st metacarpal bone with fracture line
extending to the CMC joint
Small medial fragment of bone seen on X-ray. Proximal
& lateral subluxation of 1st metacarpal present.
Rx: closed reduction & plaster fixation
GAMEKEEPERS THUMB
Rupture of ulnar collateral ligament. Also equals to skiiers thumb
Mechanism: forced abduction of thumb (FOOSH, killing of game animals by
breaking their neck in between thumb and finger)
Progressive MCPJ subluxation and impaired grasp results, with tenderness over
medial side of MCPJ. May be a/w avulsion fracture
Rx: Scaphoid cast for 6 wks if minimally displaced. Internal fixation, Sx repair,
MCPJ fusion depending on severity of displacement / tear.
BOXERS FRACTURE
At 5th metacarpal (picture on the right)
60 degree flexion at fracture site acceptable. Dropped
knuckle deformity permanent.
METACARPAL SHAFT FRACTURE
Mostly stable and undisplaced.
If displaced, need ORIF with plates or K-wire. Make sure
that there is no rotational deformity. Otherwise will have
scissoring of fingers on flexion.
RUGGER JERSEY FINGER
Results from forceful hyperextension of DIPJ with FDP in
maximal contraction (e.g. player grasping the jersey of his
opponent during tackling) opposite MOI from mallet finger
Tendon may rupture directly from its insertion into the
bone, or it may avulse bone fragment from the base of
distal phalanx
Acronym: ReaCTeD
H & L INJECTIONS
Common hand indications: Trigger finger, De Quervains tendosynovitis, CTS, RA
Up to 2 injections on the same digit (interval of at least 3 months)
Complications: tendon rupture
BRACHIAL PLEXUS LESIONS
Types
Lesions in continuity more than half of plexus injuries. Traction commonest
cause. Nerve roots affected postganglionic. Treatment is expectant.
Lesions with ruptured nerve roots only surgical intervention can offer any hope of
recovery
Complete avulsion lesions nerve avulsed from cord (both dorsal n ventral roots
ruptured) as opposed to brachial plexus injuries where dorsal roots are spared.
Partial avulsion dorsal roots spared thus muscle paralysis with preservation of
sensation
Long standing plexus lesions
Erbss palsy (C5 C6, sometimes c7) overweight babies with shoulder dystocia at
delivery (upper obstetrical palsy); waiters tip deformity shoulder internally
rotated, elbow extended, wrist flexed n pronated. N to rhomboids and long thoracic
N spared.
Klumpkes palsy (C8, T1) lower obstetrical palsy; intrinsic muscles wasted,
clawhand, sensory loss on medial side of forearm n wrist, commonly a/w Horners
syndrome because T1 is affected.
T1 root only wasted intrinsic muscles, sensory loss on medial side of hand,
(incomplete lower obstetrical palsy, cervical spondylosis, neurofibromatosis, CA)
Acute traumatic lesions commonest mechanisms - depression of shoulder with lat
flexion of the neck to opposite side or traction of arm will find bruise on lateral
jaw, inferior jaw and on shoulder.
o Might have subclavian artery trauma
49
SEDDONS CLASSIFICATION
1.
2.
3.
Axonotmesis: loss of the relative continuity of the axon and its covering of
myelin, but preservation of the connective tissue framework of the nerve
Loss in both motor and sensory fnx is more complete with axonotmesis
than with neuropraxia,
Neurotmesis:
SUNDERLAND SYSTEM
Temporary loss of function reversible within hours to months of the injury (the
average is 6-8 weeks). (not the 1mm/day rule).
Nerve
Thus, when the axons regenerate, they may enter an incorrect nerve sheath,
resulting in abnormal regeneration.
Site of Entrapment
Provocative Test
Supra/infraclavicular
Arm elevation
Pressure between the scalene muscles
Radial nerve
Distal forearm
Ulnar nerve
Median nerve
Cubital tunnel
Guyon's canal
Proximal forearm
Carpal tunnel
Accompanying the loss of the nerve sheath is intraneural scarring, which further
obstructs axonal regrowth through the site of injury.
50
PELVIC FRACTURES
Most common fracture involves pubic rami, followed by ilial, ischial, acetabular,
Tile Classification
Type A
Type B
Type C
Type A: stable, minimally displaced, includes avulsion fractures and fractures not
involving pelvic ring, e.g. rami fracture
Type B: partially unstable, rotationally unstable, but vertically stable, e.g. open
book fracture from external rotational force to pelvis
Type C: unstable, rotationally and vertically unstable, associated with rupture of
ipsilateral ligaments, e.g. vertical shear fracture
Treatment
ABCs
Assess genitourinary injury (rectal
exam/vaginal exam mandatory)
Type A - bedrest and mobilization
w walking aids
Type B/C - external or internal
fixation
Complications
Hemorrhage - life threatening
Fat embolism
Bladder/bowel injuries
Neurological damage
Obstetrical difficulties
Persistent sacro-iliac (SI) joint pain
Post-traumatic arthritis of the hip with acetabular fractures
[MCQ] Trendelenburg test is a test of stability of pelvis on femur
Diagnosis
History of injury, high energy trauma
Examination reveals local swelling, tenderness; if
unstable, may have
Deformity of the hips and instability of pelvis with
palpation
X-rays (i.e. AP, inlet, and outlet views) judet view
for acetabular fractures
1. Site of pathology
Referred pain
Joint disorders
Periarticular
disorders
Discogenic dz
Infection Perthes dz
OA
Osteonecrosis
RA
Hernia
Tendinitis
2. Cause of pathology
Vascular:
Infection:
Trauma:
Autoimmune:
M
I
51
- N
- Congenital:
SCFE, CDH
Medial gap the greater the gap, the greater the possibility of dislocation
Neck/shaft angle (normal 120-135; <120 coxa varus, >135 coxa valgus)
4. Other neighbouring structures
Acetabular margins
Sacroiliac joint
Joint space
Ischium
CDH
Transient synovitis (commonest cause of hip pain in child)
Septic arthritis
Perthes disease
Juvenile Chronic Arthritis
SCFE
OA, AVN, RA
GAIT ANALYSIS
Normal Gait
1. Stance phase = heel strike + mid stance + push off
2. Swing phase = acceleration + initial swing + midswing + deceleration
Type of gait
Antalgic
Trendelenburg
Notes
Short stance phase
Sound side sags
Short leg
Ipsilateral hip
drops when weight
is on short leg
Adductor lurch
Toe to heel
High steppage
Broad based
Parkinsonian /
festinant
Spastic
(scissoring)
Causes
Pain (infxn, inflammation, transient synovitis)
Contralateral abductor weakness, hip
dislocation/ subluxation, short NOF, hip pain
Previous # or congenital shortening
Hip dysplasia, CP
CP, club foot, idiopathic
Proprioception loss, foot drop (damage to L5;
common peroneal n. palsy)
Ataxia (cerebellar lesions)
Parkinsons disease
UMN lesion e.g. cord compression, multiple
sclerosis or CP
52
CONGENITAL DISLOCATION OF
DYSPLASIA OF THE HIP (DDH)
THE
Features
U/S not done at birth because laxity of hip joint, may get spurious reading
at birth (in order for baby to come out of birth canal) hence earliest U/S
is at 6 weeks
When to do U/S
For high-risk cases (e.g. positive family history / extended breech delivery)
/ hip laxity / hip clicks
To ensure concentric stable reduction after treatment
Weekly after with splint to ensure reduction and correct
application of splints
Every 6 weeks after once hip reduced
Most effective <3 months old (3 months onwards: X-rays; must
ensure concentric reduction with good acetabular cover, if not
mechanical forces of hip not evenly distributed may get OA)
Mx
1. Watch
Possible causes:
Intrauterine malposition
(a/w breech presentatn)
Tight iliopsoas
Shallow acetabulum
(acetabular dysplasia)
Fibrous tissue in
acetabulum
Physical examination:
Assymetrical skin creases, short limb, internally rotated, hip abduction ROM
Ortolanis test (tests reducibility) impeded hip abduction + clunk as dislocation
reduces
Barlows test (tests dislocatability) dislocate the hip by flexing the hip joint and
adducting it followed by posterior force in the line of the shaft of femur.
Trendelenburgs test positive
Ix
U/S Hip
X-ray
Diagnosis is CLINICAL
U/S or X-rays can be used but both are NOT used to diagnose at birth
X-ray: radiation + hip is not ossified
Observe if
Hip laxity only
Hip clicks
2. Abduction
splint /
Pavlik
harness
3. Close
reduction
& hip
spica
0 to 6 months
If unable to achieve stable reduction with splints then closed
reduction and hip spica attempted
BEFORE
4. Open
reduction
& hip
spica
AFTER
6 to 12 months
Closed reduction can still be attempted but more difficult to
achieve stability
Open reduction then done
12 to 18 months
Child is already weight bearing
Open reduction usually involves femoral derotation and
shortening
Acceptable is thought to remodel accordingly
Above 18 months
Potential for acetabular remodeling is less
Both acetabular and proximal femoral surgery will be required.
Prognosis
Pyogenic arthritis
X-ray
Management
Muscle imbalance
Trauma
Myositis ossificans
Knee injury
Coxa magna (occurs in up to 50% of children after a hip dislocation)
Posture
Treatment
X-ray:
Clinical features:
Small dense
capital epiphysis
Catterall grading
Severity
Prognosis
Revascularisation may be
complete w/o bone collapse
55
Mx:
Initial
Definitive
Good prognosis:
Onset <6YO
Partial fem head involvement
No metaphyseal rarefaction
Normal fem head shape
No Rx needed
Poor prognosis:
Onset >6YO
Complete fem head involvement
Severe metaphyseal rarefaction
Lateral fem head displacement
AVN
Coxa vara Rx: osteotomy to prevent secondary OA
Secondary OA
Bilat SCFE: 1/3 of cases
Mx
Manipulation is contraindicated!!!
Displacement <1/3 of
epiphyseal width
Accept position
Epiphyseal fixation with pins
Displacement >half of
epiphyseal width
X-ray:
PYOGENIC/SEPTIC ARTHRITIS
Epidemiology:
Children <2yo, usually Staph by haematogenous or local spread (from femoral OM)
*** True clinical emergency; if undiagnosed, may result in complications such as
complete destruction of the articular cartilage and the underlying epiphysis, loss of the
adjacent growth plate, and dislocation of the joint ***
Investigations:
Management:
Medical
o IV antibiotics (penicillin for strep; and cloxacillin for staph)
o ESR and CRP levels are valuable indicators of clinical response. The CRP is
generally more sensitive than the ESR, and antibiotics should be continued at
least until this measure has normalized.
o Switching to oral antibiotics is also acceptable, provided that adequate blood
levels of the antibiotic are demonstrated, the patients parents are reliable, and
the antibiotic does not cause a gastrointestinal disturbance that would interfere
with its absorption.
Surgical
o Consider septic joint to be a closed abscess :. Dont expect ABx alone to work
56
TB HIP
Groin / thigh pain, limp, muscle wasting, limb shortening, hip deformity, ROM
X-ray:
General rarefaction
Femoral epiphyseal enlargement
Bone abscess
Articular destruction
Healing by fibrous ankylosis
Management:
Anti-TB drugs
Skin traction
Evacuate abscess, joint debridement
Arthrodesis or joint replacement if joint is destroyed
RA HIP
Multiple joint involvement, groin pain, limp, & painful movement
X-ray:
TRANSIENT SYNOVITIS
Epidemiology: boys 2x more than girls, 3-10yo; commonest cause of irritable hip
History
o Unilateral groin/hip pain
o Very young children: no other symptoms except crying at night
o Recent Hx of URTI, pharyngitis, bronchitis or otitis media (in >50% of cases)
o No definitive cause known
Physical examination
o Antalgic gait
o Tenderness during palpation even during passive movement
o Mild restriction of motion (in 2/3 of patients)
o Log roll (most sensitive test): detect involuntary muscle guarding of one side
compared to the other
Treatment
o Apply heat & massage
o Bed rest for 7-10 days in a position of comfort
o Medications: NSAIDs (naproxen/ibuprofen)
Osteoporosis
Decreased joint space
Periarticular erosion and bone destruction
Management:
OA HIP
Causes:
Young adults
Congenital subluxation
Perthes disease
SCFE Coxa vara,
Acetabular deformities / injury
Older adults
RA,
AVN,
Pagets dz,
Primary OA
57
Clinical features:
More common in Caucasians (in Caucasians, OA hip > OA knee; in Asians, OA knee
> OA hip)
Groin pain radiation to knee
Joint stiffness due to synovial hypertrophy & capsular fibrosis
Limp, Trendelenburg positive
Fixed flexion deformity
Leg in ext rotation & adduction posture
Decreased ROM
X-ray:
Management:
Analgesics
Physiotherapy
Walking aids
Surgery: Osteotomy, arthroplasty
Transplant surgery
Others
Antiphospholipid antibodies
Gaucher disease (hereditary, autosomal recessive disease of
glucocerebroside metabolism, results in accumulation of cerebrosidefilled cells in bone marrow)
Decompression disease (Caisson disease) nitrogen bubbles
Sickle cell disease
PATHOGENESIS
Multifactorial, involving
(a) Metabolic factors
(b) Local factors affecting blood supply to bone
- Vascular damage
- Increased intraosseous pressure
- Mechanical stresses
Summary of various pathogenetic mechanisms
1) Arterial supply interruption:
- Fracture
- Dislocation
- Infection
2) Arterial occlusion:
(intra-vascular occlusion / venous stasis & regrograde arteriolar stoppage)
- Sickle cell disease
- Vasculitis
- Caisson disease
3) Capillary compression: (by marrow swelling)
- Steroids
- Gauchers disease
Begins with interruption of blood supply hyperaemia of surrounding area
demineralisation, trabecular thinning collapse of bone with mild stress
CLINICAL FEATURES
Usually affects anterolateral femoral head
Other bones that can be affected: humeral head, femoral condyles, proximal tibia,
vertebrae, small bones of hands and feet scaphoid, talus
Commonly presents with pain
- Weight-bearing and motion-induced pain in most cases
- Rest pain occurs in two-thirds of patients, and night pain in one-third
58
Surgery
IMAGING
(a) Plain films
Earliest findings are mild density changes (plain XR may be normal for months
after symptoms begin)
Sclerosis, cysts in subsequent part of disease
Pathognomonic crescent sign subchondral lucency (evidence of subchondral
collapse)
Later stages: Loss of sphericity or collapse of femoral head
Ultimately joint space narrowing, degenerative changes in the acetabulum result
(b) MRI
DIAGNOSIS
Clinical, based on typical symptoms with compatible findings on imaging
Rule out other causes of pain and bony abnormalities
FICAT-ARLET STAGING
Stage 0
Stage 1
Stage 2
Stage 3
Stage 4
Hip-at-risk
CT scan and XR normal
Positive findings on MRI or biopsy
XR changes seen but no collapse
Early flattening of dome crescent sign
Flattening of femoral head with joint space narrowing
Signs of early OA
TREATMENT
Conservative (ineffective at halting progression)
Bed rest
Partial weightbearing with crutches
NSAIDs or other analgesics
Bisphosphanates slows resorption of necrotic bone
Extent of dz:
A: <15%
B: 15-30%
C: >30%
PREDISPOSING FACTORS
Nonmodifiable
Old Age
Early menopause
Female Sex
Nulliparity
Caucasian
Family/Personal History of fractures
59
Modifiable
HISTORY
Fall
What happened
before fall
[hazards at home]
Predisposing
factors to fracture
Modifiable
Non-modifiable
Comorbidities
Premorbid functional status
Osetoporotic Risk Factors
Radiological
Preop
Analgesia
Antibiotics if infection suspected
Pre-op traction for pain relief and to ensure union takes place in a good position
Thromboembolism prophylaxis (SC heparin 5000 units BD)
NOF
Other
Extracapsular
INVESTIGATIONS
Confirm diagnosis, determine severity
Pre-operative investigations
Subcapital
Transcervical
Basal
Intertrochanteric
Pertrochanteric
Involves the trochanter(s) which are themselves
fractured
PHYSICAL EXAMINATION
Shortened
Externally rotated
[MCQ] # of proximal half: flexion & abduction
Bruising (suggest extra capsular #)
Tenderness over femoral neck
Painful limited hip movements
INITIAL MANAGEMENT
2
3
Displaced
MANAGEMENT
-
For NOF #:
<60yo
>60yo
Gardens 1, 2
Gardens 3, 4
Cancellous bone screw [PRESERVE HEAD]
Cancellous bone screw (~65yo)
Hemiarthroplasty
Hemiarthroplasty (uni/bipolar) (~90yo)
Total hip replacement
Ultimately depends on patients pre-morbid ADL status & his/her aims, probability of
successful op & risks of requiring a 2nd operation
-
Sample of questionnaire:
Internal fixation with a dynamic hip screw will suffice usually. Unless it is a
reverse oblique fracture.
[MCQ] If treated conservatively, will result in MALUNION
61
NOTE: Total Hip Replacement involves replacement of the acetabulum also, usually
reserved for patients with OA, pathological fracture, revision of implant will see on
X-ray that acetabulum is metal as well, with screws going into hip bone
Physiotherapy
DHS Plate
and Screw
Austin Moore
(has 2 holes, no neck,
doesnt need cement)
Moores has a short neck, thus used for subcapital and mid-neck fractures; Thompson
has longer neck, used for fractures near base of NOF
Thompson better for osteoporotic patients
Lifespan: about 10 yrs [must explain to patients before and after op that lifespan varies
between patients if you have no symptoms past 10 years, you need not replace it
immediately]
Material: ultra high molecular wt polyethylene and surgical grade stainless steel
HIP ARTHROPLASTY
Hip Arthoplasty
Hemi arthroplasty
(Only femoral component)
Total Hip replacement (THR)
(Femoral & acetabular component)
Bipolar arthroplasty
Unipolar arthroplasty
(Moores & Thompson)
AFTER-CARE:
Weight
bearing
Implant
Try and get pt to sit up by 24h, walk by 72h
Internal fixation
Sit up by 24h
Encourage mobility with non-wtbearing (wheelchair)by 72h
Do not weight bear until healing of # occurs, if not high risk of
cutout
Late
(>30 days)
POST-OP MANAGEMENT
Use GS principles
Ask about relevant social history & family support
Management of post-op DVT
62
o
o
o
SUBTRONCHANTERIC FRACTURES
least common hip fracture, seen in younger population with high energy injuries
highly unstable
transverse, spiral or oblique fracture passes below lesser trochanter
x-rays show flexed and abducted proximal fragment, from pull of iliopsoas on lesser
trochanter, gluteus medius and minimus on greater trochanter
Treatment
a. obtain a good closed reduction under fluoroscopy on the fracture table
b. internal fixation with intramedullary nail
FEMORAL DIAPHYSIS FRACTURES
high energy (MVA, fall from height, gunshot wounds)
low energy (spiral fracture in children)
high morbidity/mortality (hemorrhage, fat embolism, ARDS, MODS)
blood replacement often required
frequently comminuted with soft tissue trauma
Clinical
a. leg is shortened, externally rotated
b. unable to weight bear
c. assess neurovascular status
d. r/o: open fracture, soft tissue compromise
e. r/o: child abuse with spiral fractures in children
Treatment
o ABCs of trauma are essential
o
o
o
o
63
Pain
Generalised
OA
RA
Deformity
Instability
Anterior
Posterior
Lateral
Osgood-Schlatter dz
Bakers cyst
Meniscal cyst
Housemaids knee
Popliteal cyst
Clergymans knee
Popliteal aneurysm
Chondromalacia
Meniscal tear
patellae (CMP)
(med & lat)
Patellofemoral OA
Osteochondritis
dissecans (OCD)
Meniscal disorders
Tendinitis
Bursitis
Osgood-Schlatters dz
RA
TB
Recurrent dislocation of patella
Genu varum / valgum
Charcot jt: DM, perineuropathy, tertiary syphilis, tabes dorsalis,
syringomyelia, myelomeningocele
Ligamentous instability (ACL, PCL, med & lat collateral ligs)
Recurrent dislocation of patella
Osteochondritis dissecans
RA
Pathology
Lipoma
Sebaceous cyst
Artery
Popliteal artery
aneurysm
PE & Comments
- Soft to firm; smooth/lobulated surface
- If large & soft elicit fluctuation
- slip sign
- Elicit which layer lipoma is in e.g. S/C or I/M
(in the latter, the lipoma disappears on m.
contraction)
- Soft to firm; smooth surface
- +/- punctum (present in 50%)
- Attached to the skin, hence does not move
independently from the skin
- 50% bilateral; expansile pulsation
- Comment on diameter (2cm diameter)
- Palpate all LL pulses (distal pulses may not be
palpable if aneurysm is thrombosed)
Vein
Nerve
Enlarged bursae
Cysts
Saphena varix (@
saphenopopliteal
junction)
DVT
Neuroma
Bakers cyst
Popliteal cyst
History
- ligamentous injuries require high energy force
- meniscal injury in young & old person requires moderate & mild force respectively
64
Cx:
Recurrent synovial effusion & articular cartilage damage due to loose meniscal tag
swelling, OA
MENISCAL CYSTS
Tender & tense swelling arising from outer part of meniscus along the joint line
(usu lateral)
Hx of joint injury may be present
Rx: if symptomatic, arthroscopic decompression or removal
CHRONIC LIGAMENTOUS INSTABILITY
Chronic instability sense of joint wanting to or actually giving way
pain & recurrent swelling
ODonahues triad (aka unhappy triad): ACL tear + med meniscus tear + med
collateral lig tear
ACL injury more common than PCL injury
History
PE
Rx
Post-op physio
impt in all cases
ACL Tear
PCL Tear
o indirect varus blow to knee
o fall onto flexed knee
o hyperextended knee + internal rotation
with plantar flexed foot
o hit anterior tibia on
o audible pop, knee instability
o giving way
dashboard in MVA
o immediate swelling
(dashboard injury)
o hyperflexion
or
o inability to continue activity
o patients with greater Q-angle got
hyperextension
with
greater chance of ACL tear
anterior tibial force
Anterior drawer +
Sag sign +
Lachmans + (falsely +ve in PCL tears)
Posterior drawer +
Apleys distraction test +
Apleys distraction test +
Conservative hamstring & quadriceps ex., physio, external brace
Stabilization / Reconstruction
o Reattachment (tightening of loose lig / capsule),
o Reinforcement (diversion of healthy muscles or tendons to
strengthen weak structures), using hamstrings, patellar,
quadriceps
o Replacement (rerouting living structures or inserting synthetic
material)
65
History
PE
MCL Tear
o valgus force to knee
o +/ "pop" heard
o severe pain with partial tears
o complete tear may be painless
Rx
LCL Tear
o varus force to knee
o similar history to MCL
o rule out common peroneal n.
injury (difficult dorsiflexion
and decreased sensation at the
top of the foot)
swelling
tender above and below medial joint line
Medial & Lateral collateral ligament tears: Valgus & Varus stress
tests + respectively
assess joint space opening with valgus force
o pain
o Laxity with end point - partial tear
o absence of end point - complete tear
o rule out ACL and medial meniscus tear
minor
o immobilize briefly, early ROM and strengthening
moderate
o knee immobilizer or cast (NB. Ligaments take 3/52 to heal)
o early physiotherapy with ROM and strengthening
severe or combined
o surgical repair of associated injuries
o surgical repair of isolated MCL/LCL tear is controversial
OSGOOD-SCHLATTER DISEASE
Traction injury of apophysis which patellar ligament inserts into (partial avulsion of
tibial tuberosity cos of unequal growth rate between patellar ligament and bone)
Tender lump over tibial tuberosity
Pain after activity, usually on active knee extension
Usually young adolescent
X-ray: fragmentation/displacement of tibial apophysis
Rx: Restrict activities especially sports. Spontaneous recovery.
[MCQ] patient doesnt present with loose bodies in knee joint because it is extraarticular!
OSTEOCHONDRITIS DESSECANS
Separation of small osteocartilaginous fragment of condyle articular
usually a/w hx of trauma
PATELLAR FRACTURE
History
Direct - blow to patella (Usually comminuted)
Indirect - sudden strong contraction of the quadriceps femoris against resistance
(Usually a transverse #)
Immediate pain
Physical
Swelling & bruising of knee joint +/- abrasions
Marked tenderness at knee joint
Patellar deformity (+/- palpable gap)
Inability to extend knee
Proximal displacement of patella
X-Ray
AP, lateral (need to exclude bipartite patella - common congenital fragmentation of
the patella)
Treatment
Isolated vertical fractures - non-operative treatment - plaster cast 6/52, early ROM
Transverse displaced fracture ORIF with wires.
Comminuted fracture - ORIF; may require complete or partial patellectomy
Indications for surgical tx
o sig articular step-off > 2mm
o loss of extensor mechanism with displacement > 3mm
o open #
RECURRENT DISLOCATION OF THE PATELLA
surface,
66
Mx
Reduction & backslab
Quadriceps strengthening exercise
Operation: repair of torn medial structures / soft-tissue realignment / transposing
patellar ligament medially (realignment procedure)
PATELLAR/QUADRICEPS TENDON RUPTURE
Low energy injury, sudden forceful contraction during attempt to stop fall
Partial or complete
More common in patients with DM, SLE, RA, steroid use
History
o fall onto flexed knee
o inability to extend knee
Physical
o palpable gap between patella and quadriceps
o may have hemarthrosis / effusion of knee
Investigations
o knee radiographs to rule out patellar fracture
o joint aspirate may show hemarthrosis
Treatment
o surgical repair of tendon
DISLOCATED KNEE
CHONDROMALACIA PATELLAE
Anterior knee pain in adolescent girls worse on climbing stairs
Retropatellar tenderness, friction test +, effusion
Chronic / recurrent overload of patellar articular surface due to malcongruence of
patellofemoral surfaces OR abnormal tracking of patella during flexion/extension.
A/w development of OA
Ix: skyline views of patella, CT, arthroscopy
Rx:
Conservative: analgesics, reduce activities, physioRx, quadriceps-strengthening
exercises
Operative: shaving of articular cartilage, arthroscopy lavage, realignment of patella,
patellectomy
RHEUMATOID ARTHRITIS
Stage 1 (synovitis) pain, chronic swelling, large effusion, thickened synovium
Stage 2 (articular erosion) joint instability, ROM. X-ray: loss of jt space &
marginal erosion, but lack of osteophytes c.f. OA
Stage 3 (deformity) pain, deformity, instability & disability. X-ray: bone
destruction
Rx:
Conservative splintage, intraarticular steroid injection
Operative osteotomy, TKR
BAKERS CYST
Definition
o Posterior herniation of knee joint capsule
o Leading to escape of synovial fluid into the posterior bursae, stiffness &
knee swelling (fluid distention of the gastrocnemio-semimembranous bursa)
o Common in children, occurring more often in boys
o Often a/w OA and Charcots joints
o Important to rule out DVT, but the two can co-exist
Diagnosis
o PE: swelling usually below the joint
Fluctuant
Transillumination possible
Non-tender
Positive slip sign it is a deep structure.
67
Reducible only if connected to knee joints which not all bakers cysts
are especially in children.
o U/S: fluid between semimenbranosus & medial gastronemius tendons in
communication with posterior knee cyst (100% accuracy)
Because of their anatomic location, Bakers cysts can increase risk of DVT
o Most commonly, the Baker cyst is located between tendons of the medial
head of the gastrocnemius and the semimembranous bursa. Occasionally,
the Baker cyst can be found between the heads of the gastrocnemius
muscles. This can result in a lateral deviation of the popliteal vein, and a
compression of the popliteal vein-predisposing to venous stasis and DVT
Treatment
o In children, surgical excision of popliteal cysts is rarely indicated
Usually spontaneous resolution of cysts in 10-20 months;
A prolonged period of observation is strongly recommended before
surgical excision is considered.
In protracted cases, cysts may respond to aspiration and steroid
injection, (note that unlike adults, the cyst may not be intra-articular
and therefore may respond to aspiration
o In adults: reoccurrence is common, even following surgical removal, and
therefore treatment is directed toward intra-articular pathology;
POPLITEAL CYST
Definition
o Cyst located on the medial side of popliteal fossa, just distal to flexion
crease of the knee, under medial head of gastrocnemius
Epidemiology
o Found in children & young adults
o 2x more common in boys
o Usually unilateral
Diagnosis
o More prominent during knee extension & vice versa
o If cyst is not found in medial part of popliteal fossa or has a solid
component (on U/S), rule out tumour with CT/MRI scan
Treatment
o Asymptomatic ones can be treated non-surgically with good results
o Though spontaneous remission is not to be expected in all cases
Osteoarthritis (Knees)
Secondary
Trauma acute or chronic
Rheumato RA
Infections Syphilis
Metabolic Hyper PTH
Joints affected:
PIPJs of hands (Bouchards nodes)
DIPJs of hands (Heberdens nodes)
Thumb joints
MTPJ of big toe
Cervical and lumbar spine
Hip
Knee
* frequency of OA: Asians: knees > hips; Caucasians: hip > kness
OA of knees and hands F>M ; OA hip- M> F
Other risk factors
Hereditary
Obesity
Competitive contact sport
Deformities e..g genu valgus/varum
Recreational running is NOT a risk factor
Vascular AVN
Traumatic
69
o
o
o
Physical Examination
Genu varum/valgus predisposes to OA usually genu varum
Fixed flexion deformity
Externally rotated
If joint swelling, is MILD
Joint line tenderness
Crepitus
Decreased ROM
Patellofemoral OA (5%)
Examine other joints as well
Note absence of rheumatoid nodules / tophi / rashes / Sjogrens
Examine HIP, BACK
Neuro exam SMART sensory, motor, autonomic, reflexes, trophic changes
Investigations
To confirm diagnosis and exclude differentials
To look for causes (not applicable usually)
To look for complications (not applicable usually)
Radiological
AP weight bearing (so that even small degrees of articular cartilage thinning can be seen)
Lateral
Skyline (tangential) view
Long film (to see degree of varus/valgus)
L-O-S-S findings
Loss of joint space
Loose bodies
Osteophytes
Subchondral sclerosis
Subchondral cyst
Management
Nonpharmacological
Physiotherapy
Preservation and improvement of joint mobility
Exercise
Range of motion and muscle strengthening exercises
Load reduction
Body weight reduction if obese
Use of walking aids
Avoid kneeling and squatting.
Pharmacological
Paracetamol
NSAIDs
70
High tibial
osteotomy
Knee replacement
Only in certain cases e.g. unicompartmental involvement. Osteotomy permits redistribution of weight
Contraindications
Inflammatory arthritis
Severe flexion deformity >15o
Varus/ valgus >15o
>5mm loss of subchondral bone
lateral thrust while walking
When symptoms are severe
Try to avoid doing in patients <60 as TKRs usu last only ~10y
Types
o Unicompartmental
o Total +/- preservation of PCL; PCL preservation preserves proprioception function but wear of prosthesis
For PFOA
Complications
Intraop GA, # of tibia or femur
Immediate vascular injury to superficial femoral, popliteal and genicular vessel
Early DVT/PE, fat embolism, infection, peroneal nerve palsy (1%)
Late loosening, patellar instability, #, disruptn of extensor mechanism, periprosthetic #, wear of polythene surfaces
Arthroscopy to confirm diagnosis
Rx
- Realignment procedures
- Cartilage transplantation (still under research)
- Patellectomy (problems a/w it include loss of normal knee power and function, quadriceps weakness, and failure to
resolve anterior knee pain, may eventually require total knee arthroplasty for knee arthritis)
- Patellofemoral arthroplasty
- Total knee arthroplasty
Approach to OA knee
1) Confirm Dx of OA knee: pain and its characteristics
2) Exclude other sites of pathology
a) back pain, PU claudication
b) hip
c) ischaemic pain or neuropathic pain
Ischaemic pain
Neuropathic pain
Fixed claudication distance
Variable claudication distance
Better walking downslope
Better walking upslope
Recovers quickly with rest
Recovers slowly with rest
Pain present at night
Pt usu sleep in kyphosed
position with no pain
3) Exclude DDx
a) malignancy other bone pain, LOW, LOA etc.
b) septic arthritis fever, tenderness, swelling, trauma, intraarticular injectn
c) RA other jts, morning stiffness, pain
d) gout precipitant, inflammation
71
2. Fractures that do not result in joint instability or deformity and can therefore be
treated with nonoperative modalities.
TIBIAL DIAPHYSIS FRACTURE
Most common long bone #.
Commonly open #
High intensity injury
o associated with crush injuries and MVAs
Soft tissue, nerve and vessel injury common
o assess neurovascular status
o rule out open fracture
Displacement is difficult to control
Good reduction is required
o minimal shortening and angulation
Healing time: 16 weeks on average
Treatment
ATLS principles first
Conservative managemenet
o For closed injuries (= closed reduction)
o Long leg cast x 4-6/52
o Followed by below-knee cast until healed
Surgical management
o For open injuries
ORIF with external fixator
wounds on anterior surface heal poorly and may necrose
o For unstable injuries or failed closed reduction require IM nail
o For patients with high risk of compartment syndrome
Delayed indications
73
neurovascular status
look, feel, move (dorsiflexion, plantarflexion)
assess for tenderness at knee (Maisonneuve), lateral and medial malleoli
special test: anterior draw (for ankle), talar tilt, squeeze test, Thompson test
X-ray
views
o AP, Lateral and Mortise (15 degrees internal rotation)
o Mortise gives true view of talus in tibiotalar joint
o space between talus > tibia and talus > fibula
o space should be symmetric and < 4 mm with no talar tilt
o disrupted space signifies ligamentous or bony injury
When to x-ray - Ottawa ankle rules
Ankle x-ray is only required with
o pain in malleolar zone AND
o bony tenderness over posterior aspect of the distal 6 cm of medial or lateral
malleolus OR inability to weight bear both immediately and in E.R.
Foot x-ray series is only required with
o pain in midfoot zone AND
o bony tenderness over navicular or base of fifth metatarsal OR inability to
weight bear both immediately and in E.R.
Ring Principle of the Ankle
The ankle can be thought of as a ring comprising of
a: lateral malleolus
d: deltoid ligament
b: medial malleolus
e: syndesmotic ligament
c: posterior (medial) malleolus
(syndesmosis)
f: calcaneofibular ligament
Fractures of the ankle involve
ipsilateral ligamentous tears or bony avulsion
contralateral shear fractures
Pattern of fracture
determined by mechanism of injury
74
In Summary...
Corresponds to Danis Weber type...
A
B
C
Supination-Adduction (Weber A)
sequence of injury:
1. supination force may rupture portions of lateral collateral ligaments or may
avulse distal fibula, resulting in transverse fracture below the level of intact
syndesmosis;
2. adduction forces talus against the medial side of the joint, resulting in vertical
fracture of the medial malleolus
Treatment
Undisplaced fractures: NWB BK cast
Displaced fractures: reduce ASAP
Indications for ORlF
all fracture-dislocations
all type C fractures
trimalleolar (lateral, medial, posterior) fractures
talar shift or tilt
failure to achieve or maintain closed reduction
Prognosis dependent upon anatomic reduction
high incidence of post-traumatic arthritis
2
Maisonneuve fracture: spiral fracture of the proximal third of the fibula associated with a tear of the
distal tibiofibular syndesmosis and the interosseous membrane
75
LIGAMENTOUS INJURIES
Medial Ligament Complex (deltoid ligament)
Responsible for medial stability
Usually avulses medial or posterior malleolus
usually a/w syndesmotic or lateral ankle sprain
Lateral Ligament Complex (ATFL, CFL, PTFL)
Responsible for lateral stability
Makes up for >90% of ankle ligament injuries
Clinical: swelling and discoloration, pop sound,
giving way
Diagnosis: stress x-rays and mortise view
o talar inversion produces joint separation exceeding the unaffected side by
six degrees (talar tilt test)
Frequncy of injury: ATFL > CFL > PTFL
Anterior Talofibular Ligament (ATFL)
Most common ligamentous ankle injury
Sprained by inversion and while ankle is in plantar flexion
Swelling and tenderness anterior to lateral malleolus, ++ ecchymoses
Anterior draw test for ankle positive with Grade III ATFL injury
attempt to sublux talus anteriorly
if positive then stress other lateral ligaments
Talar tilt test for integrity of other ligaments
Grading and Treatment of Ligamentous Ankle Injuries
Initial treatment of all sprains follows the RICE protocol (Rest, Ice, Compression,
Elevation). Protective weight-bearing is instituted with crutches. This is continued until
normal gait is restored.
Aetiology
ligamentous laxity
Joint (loss of normal proprioception)
internal derangement of anatomy
intra-articular loose body
Treatment depends on cause
Strengthening and balance training for neuropathic joint
ligament reconstruction for lateral laxity and talar tilt
Physical
X-rays
LOOK
FEEL
MOVE
OFFER
Non-surg Rx
Surgical Rx
Hammer toe
Mallet toe
Claw toe
More common in Females, Elderly, with RA
Imbalance between intrinsic (lumbricals & interossei) and extrinsic (long
flexors & extensors) muscles of the lesser toes
For claw toe: may be 2 to neurological disorders e.g. peripheral
neuropathy (Charcot-Marie-Tooth disease, DM), LMN disease (polio),
UMN disease (CP, stroke, multiple sclerosis)
Affects lesser toes, most commonly 2nd toe
Usu all 4 lesser toes
involved; may be B/L
Flexion deformity at Flexion deformity
Flexion deformity
PIPJ
at DIPJ
at PIPJ and DIPJ
+/- DIPJ extension
NO
MTPJ/PIPJ + hyperextension of
+/- MTPJ extension
involvement
MTPJ
Any callosities
Any tenderness
Is the deformity fixed or mobile
Watch the patient walk
Examine patients shoes
Ask questions to assess effect of the condition on his/her life
Appropriate footwear (usually unhelpful for mallet toe)
Mobile deformity
Mobile deformity
Mobile deformity
Flexor-to-extensor
Flexor digitorum
Flexor-to-extensor
tendon transfer
longus tenotomy
tendon transfer
Fixed deformity
Resection of
proximal phalangeal
H&N +/- flexor &
extensor release
Proximal
phalangectomy
PIPJ arthrodesis
Fixed deformity
Resection of
middle phalangeal
H&N +/- flexor
tenotomy
DIPJ arthrodesis
Amputation of
distal of distal
Fixed deformity
Resection of
proximal
phalangeal H&N
+/- flexor &
extensor release
Extensor tenotomy
for MTPJ
phalanx (to
include nail &
matrix)
contractures
Resection of
metatarsal heads
of the lesser toes
Hammer toe
Mallet toe
HAMMER/MALLET/CLAW TOE
Epidemiology
Aetiology
Painful callosities:
Terminal
phalangectomy
Claw toe
HALLUX VALGUS
Definition: valgus angulation of 1st metatarsal (i.e. lateral angulation of big toe)
Epidemiology: most common disorder involving the 1st MTP joint
Causes: idiopathic; hereditary, loss of muscle tone, RA; increased incidence in those
who wear enclosed footwear
Associated deformities: inflamed bunion, hammer toe, metatarsalgia, secondary OA
of 1st MTP jt
Ix: do a plain weight-bearing X-ray to assess
1) degree of valgus deformity
2) presence of OA of the first MTPJ
Rx:
- Non-surgical: appropriate footwear & physiotherapy
- Surgical: depending on patients wishes, level of activity & state of peripheral
vascular system
Bunionectomy
1st metatarsal realignment osteotomy
Excision arthroplasty (Kellers procedure) essentially a proximal
hemiphalangectomy
Fusion for degenerative joint disease
77
HALLUX RIDGDUS
Definition: literally means stiff great toe; however, limited ROM is only one of
the symptoms that constitute this diagnosis
Epidemiology: second most common disorder involving the 1st MTP joint (the first
being hallux valgus). Seen in adolescents & in adults.
Causes: Primary OA of MPJ of great toe.
Diagnosis
Symptoms: pain on top of great toe +/- diffuse, lateral forefoot pain
resulting from increased weight-bearing on lateral foot to offload the hallux.
Pain is worse with certain activities and with certain footwear.
Signs: tender dorsal osteophyte at 1st MTP joint (usually confirms this dx);
slightly antalgic gait; limited plantarflexion & dorsiflexion a/w pain
especially at the end of ROM
Treatment
Conservative
- Activity modification: use of in-sole orthotics, avoid extreme DF of
great toe (e.g. kneeling/squatting with toes in great extension)
- Pharmacological: paracetamol, NSAIDs
Surgical
- Cheilectomy: excision of all irregular bony spurs that limit motion
- MT osteotomy: based on the premise that metatarsus elevatus or a
long first MT are the underlying causes of hallux rigidus
- Joint arthroplasty (commonly known as Keller technique): involves
the excision of the base of the proximal phalanx; indicated in
moderate to severe cases of hallux rigidus in individuals with low
functional demands who desire the maintenance of joint motion;
however, complications are common such as hallux weakness,
elevation, floppiness, a short hallux, and development of transfer
lesions under the second MTP joint
- Arthrodesis: salvage procedure should other surgical interventions fail
& hallux rigidius is severe enough
= flat foot
Condition whereby the arch of the foot collapses with the entire sole of
the foot coming into complete / near complete contact with the ground.
Aetiology:
Young
Flexible
Functional
Hypermobile lig laxity
Tibialis post tendon dysfunction
Rigid
Tarsal coalition
Inflammatory jt dz
Neurogenic disorders
Adult
Acquired
Diagnosis:
Physical Examination (see picture)
o Abducted forefoot
o Valgus hindfoot
o Flexible flatfoot: arch appears when patient dorsiflexes (not a true
collapsed arch because medial longitudinal arch is still present)
Treatment:
When to treat: (1) if patient has rigid flatfeet, (2) if there is associated foot or
lower leg pain, or if the condition affects the knees or the lower back
Use of orthotics (arch support to be used for the rest of patients life;
exercises recommended by podiatrist)
Surgery as last resort (usually time-consuming & costly)
78
FOOTBALLERS ANKLE
Anterior ankle impingement syndrome
- Definition of ankle impingement syndrome: painful mechanical limitation of full
ankle ROM secondary to an osseous or soft-tissue abnormality
Repeated forced dorsiflexion tearing of anterior capsule of ankle joint subsequent
bone spur formation (osteophytes) aka anterior exostoses of the tibia subsequent pain
+ limited ROM
Treatment:
Acute phase
Conservative: NSAIDs, physiotherapy, orthotics, bracing
Surgical: arthroscopic excision & debridement
Recovery phase
Posterior splinting for 1/52 with supportive brace & compression stocking
Physiotherapy for 2/52 for strengthening, ROM, proprioception and sportsspecific rehabilitation
CALCANEAL FRACTURE
ACHILLES TENDONITIS
-
Diagnosis
pain, aggravated by passive stretching
tenderness, swelling
crepitus on plantar flexion
Treatment
rest, gentle stretching, NSAIDs
proper footwear +/- orthotics
do NOT inject steroids (prone to rupture)
TALAR FRACTURE (RARE)
79
PLANTAR FASCIITIS
BUNIONS
intrinsics
secondary exostosis forms with bursa and thick skin creating the bunion
Treatment: (1) cosmetic reasons, (2) for pain with shoes
Conservative: properly fitted shoes and toe spacer
Surgical: removal of bunion with realignment of 1st MTP joint
METATARSAL FRACTURE
As with the hand, 1st, 4th, 5th metatarsals (MT) are relatively mobile, while the 2nd and
3rd are fixed
Types of Metatarsal #s
Fracture
Avulsion of base of
5th MT
Jones Fracture midshaft 5th MT
Mechanism
Sudden inversion
followed by
contraction of peroneus
brevis
Stress injury
Stress injury
Clinical
Treatment
Tenderness at base of
5th MT
X-ray foot
Requires ORIF if
displaced
Symptomatic
80
1st MT Fracture
Trauma
Painful 1st MT
Lisfranc Fracture
2nd Tarso-MT
fracture- dislocation
Shortened forefoot
prominent base
ORIF if displaced
otherwise NWB BK
cast x 3 weeks then
walking cast x 2 weeks
ORIF
81
Axial
Diagnosis
Hx
Tx
Facet
Spondylosis (OA)
Epidemiology
Pain
dominance
Worse with
Onset
Duration
Old
Back
Other aspects
of history
PE
Normal
Ix
Conservative
MRI
NSAIDs
Activity modification
Exercise/physiotherapy
Lumbar corset
Surgical
(all under GA)
Fuse
Extension
Short (days to weeks)
Leg Pain
Radicular
PID (commonly L5, S1 S1
affected)
Young
Old
Leg
Leg
Claudication
Spinal stenosis
Flexion
Extension
Congenital/acquired
Short episode attacks (minutes)
Acute or
chronic (weeks to months)
Symptoms of radiculopathy
Neurogenic claudication
Sciatica (+/- cross sciatica)
Pain, weakness and/or
numbness in the legs
Shooting pain down calf
while walking (ask for
a/w m. weakness, tingling /
segmental sensory
numbness
deficits)
Cough impulse positive
Rule out cauda equina syndrome Variable claudication
distance
(impt complication)
Pain even on standing
Urinary retention
Park bench to park
Saddle anaesthesia (loss of
bench relieved with
sensation over the buttocks
flexion
& the perineum)
No pain at night (patient
LL weakness
sleeps on lateral
decubitus foetal
position)
Rule out vascular claudn
1. Listing (to relieve n. root
Same as radicular
compression), paravertebral
(+) 4. Pulses
m. spasm, restricted ROM
2. SLR, Bowstringing,
Laseague tests +ve
3. Tone, Reflex, Power
4. Sensation
X-ray (to exclude bone disease) & MRI
NSAIDs
Back care education
Bed rest
Epidural steroid injection
Physiotherapy
Back care education
Discectomy
Nerve decompression
Indication: failure of 3
months of conservative mx,
cauda equina syndrome
Usually only alleviate
symptoms of radiculopathy,
not of LBP
& fuse
(Transforaminal Lumbar Interbody Fusion, or TLIF)
Caveats
Sciatica (df): leg pain localised in the distribution of one/more lumbosacral nerve roots, typically L4-S2, with or
without neurological deficit. [when the dermatomal distribution is unclear, please describe it as non-specific
radicular pattern]
Both spondylosis and degenerative disc disease may occur at the same time (chicken & egg phenomenon)
Can have 2 or more concurrent pathologies, e.g. lumbar spondylosis with spinal stenosis (spinal stenosis increases
with age but the symptoms may be exacerbated by further compression due to spondylosis)
Causes of spinal stenosis can also cause radiculopathy as well
Give the other as differential, e.g. PID ddx spinal stenosis
82
Other differentials
Cauda Equina syndrome
Neoplastic (primary, metastatic)
Trauma - fracture (compression, distraction, translation, rotation)
Spondyloarthropathies (e.g. ankylosing spondylitis)
Referred pain - aorta, renal, ureter, pancreas
Important Red flags (rule out malignancy, infection, trauma)
- Age (<20 or >50 increased risk of conditions listed above)
- LOW, LOA
- Hx of malignancy
- Night pain
- Fever, chills, rigors
- Hx of trauma
- Any bladder/bowel symptoms
X-Ray
Oblique views: look for "Scottie Dog" sign (= spondylolysis)
S superior facet
N transverse process
I inferior facet
P pars interarticularis
83
Surgical
SCOLIOSIS
Causes
Nonstructural
Structural
Signs
posteromedial
knee reflex
limitation of femoral stretch
L5
ankle dorsiflexion, great toe
extensor, hip abductor
lateral calf or 1st web space
hamstring reflex
limitation of SLR
Complications:
S1
ankle plantar flexion
lateral aspect of foot
ankle reflex
limitation bowstring
- Cauda equina syndrome urinary retention, saddle anaesthesia, lower limb weakness
Investigations:
Conservative
Bed rest
NSAID
Epidural steroid injection
Physiotherapy
Back care education
- full length AP spine X-ray (measure Cobbs angle sup & inf
extent of scoliosis is where both sides of the intervertebral
space is of equal height)
- lateral flexion X-rays,
- X-ray pelvis (look for Risser sign)
84
Pulmonary TLC & FVC due to thoracic lordosis deformity (Cobbs angle >70o)
Cardiac Right heart dz causing pulm HPT. ( Cobbs angle >80o)
Listing
Limb length discrepancy
Backache
Radiculopathies
Mx:
Age
Prepubertal/
Pubertal
Postpubertal
Cobbs
Angle
<20
20-40o
>40o
>50o
S/S
Mx
Neurogenic claudication
LUMBAR SPONDYLOSIS
Definition:
Flattening of disc & displacement of posterior facet joints, due to 2o OA facet joint
Vascular claudication
Invx: lat X-ray, CT myelogram (waisting of dye column, posterior indentation, partial
or complete block)
Epidemiology:
Mx:
Conservative
Surgical
Decompression
SPONDYLOLISTHESIS
Forward translation of upper vertebral body over the lower vertebral body, usually at
L4/5 or L5/S1 level
Causes
1.
2.
3.
4.
5.
6.
Spondylolytic
Pathological
Operative
Trauma
Elderly
Dysplastic
S/S
I
II
III
IV
0-25
25-50
50-75
75-100
Mx
Definition
Cauda equina syndrome (CES) has been defined as low back pain, unilateral or usually
bilateral sciatica, saddle sensory disturbances, bladder and bowel dysfunction, and
variable lower extremity motor and sensory loss usually due to mechanical compression
of the cauda equina.
Aetiology
V
Spinal epidural hematoma
Spinal anaesthesia
IVC thrombosis
I
Abscess
T
Traumatic injury
A
M
I
Idiopathic
N
Tumour (primary/metastatic)
Lymphoma
Others
Spinal anaesthesia
Lumbar disk herniation
Late-stage ankylosing spondylitis
History
Low back pain - This pain may have some characteristic that suggests something
different from the far more common lumbar strain. Patients may report severity or a
trigger, such as head turning that seem unusual.
Radiating pain
o Acute or chronic
Unilateral or bilateral lower extremity motor and/or sensory abnormality
Bowel and/or bladder dysfunction
o Initial presentation may be of difficulty starting or stopping a stream of
urine that may be followed by frank incontinence first of urine then of
stool. Urinary incontinence is on the basis of overflow.
o Usually with associated saddle (perineal) anaesthesia (Examiner can ask if
toilet paper feels different when wiping.)
86
Physical Examination
Local tenderness to palpation over the lower back
Pain radiating to the legs
Loss or decreased reflexes
o Hyperactive reflexes may signal cord involvement, hence ruling out CES
o Similarly, Babinski sign / other signs of UMN involvement rule out CES
Sensory loss/abnormality in perineal area or lower extremities
o Test light touch
o Anaesthetic areas may show skin breakdown
Muscle weakness
o +/- muscle wasting (if chronic)
Alteration in bladder function may be assessed empirically by obtaining urine via
catheterization. A significant volume with little or no urge to void, or as a post-void
residual, may indicate bladder dysfunction. Bedside ultrasonography may be also
used to estimate or measure post-void residual bladder volume.
Management
Investigations
Imaging
o Plain radiography - Unlikely to be helpful in cauda equina syndrome but
may be performed in cases of traumatic injury or in search of destructive
changes, disk-space narrowing, or spondylolysis
o CT with and/or without contrast - Lumbar myelogram followed by CT
o MRI - Superiority of MRI over CT only suggested by case reports (Early
consultation with the appropriate subspecialty is encouraged to guide
imaging studies.)7
o Ultrasonography may be used to estimate or measure post-void residual
volume.
Other Tests
o Catheterization for residual urine volume may reveal urinary retention
suggesting a neurogenic bladder.
Prehospital care should focus on associated symptoms related to the pain (ie, what
besides the pain is different).
Stabilize acute life-threatening conditions.
Immobilize the spine if traumatic.
Emergency Department Care
No proven medical treatment exists, and therapy generally is directed at the
underlying cause of cauda equina syndrome (CES).
For mechanical compression of the cauda due to disk herniation, surgical
intervention may be indicated.
Admit patients to appropriate service (usually neurology, neurosurgery, or
orthopedic surgery) with frequent neurologic checks.
Complications: Residual weakness, incontinence, impotence, and/or sensory
abnormalities are potential problems if therapy is delayed
Middle Column
Post longitudinal ligament
Post annulus fibrosis
Post 1/2 of vertebral body
Posterior Column
Post body elements
Supra- & intraspinous lig.
Facet joints
Ligamentum flavum
87
Relieved by
Neuro
symptoms
Inspection
Straight leg
raise
Neurological
signs
Younger
- Increase in abdominal pressure
(laughing, coughing, lifting,
straining)
- Spine flexion, prolonged sitting
Listing to 1 side
Pain, numbness, paraesthesia,
weakness
Listing, scoliosis, loss of lumbar
lordosis, paravertebral spasm
- SLR elicits nerve root
compression (i.e.
radiculopathy)
- SLR, SNST, Bowstring and
cross SLR positive
Radiculopathy (usu L5 &/or S1)
CERVICAL MYELOPATHY
Patient age
LBP
aggravating
factors
Spinal stenosis
Causes of compression
Spine flexion
Symptoms
Signs
- "Finger escape sign" (the patient is asked to hold out their hand with fingers
extended and the medial fingers drift into flexion)
- Urinary retention (rare)
Investigations
Exclude tumour!
Plain X-rays
CT (bony spurs & ligament ossification)
MRI (disc prolapse & cord compression)
Pavlov's Ratio: ratio of the distance from the
posterior aspect of the vertebral body to the
anterior aspect of the lamina (i.e. space allowed
for the cord at the same level) to the AP width of
the vertebral body. Normal: 1 Abnormal:
0.85
Management
CERVICAL SPONDYLOSIS
(ORTHOPAEDIC DEGENERATIVE DISEASE OF THE C-SPINE)
Features
- IV disc degenerate & flatten + bony spurs on ant & post margins of vertebral bodies
- Posterior spurs may encroach upon the IV foramina compressing nerve roots
- >40YO, male > female, usually C5/6
DDx
- Thoracic outlet syndrome (look for signs of limb ischaemia; perform Roos test and
Adsons manoeuvre) (a/w ulnar n. palsy)
- Carpal tunnel syndrome
- Rotator cuff lesions (abnormal shoulder movements, no neurological signs)
- Cervical tumour (symptoms are constant)
Risk factors
- Smoking
- Drinking
- Excessive driving
Investigations
Conservative:
- Heat & massage, NSAIDs, cervical collar, physioRx
Surgical:
- Discectomy anterior fusion
- Corpectomy (removing part of vertebral body; latin corpus vertebrae)
- Laminoplasty
- Laminectomy foraminectomy.
- Indications: progressive neurological deficits, multiple levels of cord compression
CERVICAL LESIONS
TORTICOLLIS
Causes
Acquired
Acute - muscular damage caused by inflammatory diseases, such as myositis,
lymphadenitis, or tuberculosis (TB); from cervical spinal injuries that produce scar
tissue contracture; and, less commonly, from tumor or medication
Spasmodic - organic central nervous system disorder, probably due to irritation of
the nerve root by arthritis or osteomyelitis. Benign paroxysmal torticollis might
be migraine variant.
Ocular torticollis - compensatory mechanism enacted by patients with trochlear
nerve palsy or superior oblique muscle weakness
Hysterical
Presentation
Congenital
Traumatic infants after difficult delivery - breech presentation (delivery buttocks
first instead of heads first)
Skeletal anomalies, atlantoaxial instability
Klippel-Feil syndrome
The presence of craniofacial asymmetry (e.g. hypoplasia of the face including the small
left eye) indicates congenital or long-standing torticollis.
Management
1. Lower trunk of brachial plexus n subclavian artery pass btw the ant n middle
scalene muscles and over the 1st rib.
2. Compression maybe due to cervical rib (rare), fibrous bands or abnormalities of
scalene attachments, or by a pancoast tumour
3. Symptoms increase with increasing age as shoulders sag
4. Typically woman in her 30s complains of pain n paraesthesia extending down from
her shoulder down the ulnar aspect of her arm to the medial two fingers
5. Worse at night, agg by bracing shoulders or raising arms above shoulder height
N root pain, paraesthesia in one / both (rare) arms. Radiating to outer elbow,
dorsum of wrist, middle n index finger. Weakness is rare. Prolapse usually
above/below C6 vertebrae so C6 & C7 N roots commonly affected
Acute torticollis may be present
X-ray shows disc space. MRI to confirm.
Ddx
o Soft tissue sprain neurological S&S absent.
o Neurological amyotrophy (acute brachial neuritis) sudden, severe pain @
back or shoulder. Multiple neurological sites affected & might have winging
of scapula. Pain followed by flaccid paralysis a few days later.
o Cervical spine infection unrelenting & local spasm with severe pain. X-ray:
erosion of bone
o Cervical tumors neurological signs progressive. X-ray/MRI shows bone
destruction. Primary tumors rare, secondary more common. Of primary,
sarcoma & multiple myeloma most common.
Treatment
o Heat, analgesics
o Rest with collar (in 75% of patients symptoms will resolve with non-operative
measures)
o Reduce: traction intermittently placed for 30 mins @ a time. Up to 8kg
o Remove: anterior approach discectomy fuse affected area / maintain height
using bone grafts.
o
1)
2)
3)
4)
91
Odontoid view
Shows C1 burst fractures, C1-2 alignment, Dens fractures
C1 Ring Fracture Classification - Posterior Arch - 28%, Jefferson Burst Fx,
Anterior Arch Blow Out, Lateral Mass Fx, Transverse Process Fx
Jefferson Fracture - Axial loading. Open Mouth View - Lateral Mass Spreading, >
6.9 mm = Transverse Lig Avulsion.
C1 Burst Fracture Treatment
1. Stable (Intact Transverse Ligament) - Rx - Halo 10 - 12 wks.
2. Unstable - Traction Reduction, Halo 12 - 16 wks,
Late Instability: C1-2 Fusion
Odontoid Fracture Classification
1. Type 1 - Tip Avulsion, Type 2 Waist (worst),
Type 3 Body
2. Type 2 Unstable, Easily Missed, 10% Spinal
Cord Injury due to translation, Poor Prognosis,
Assoc Fx 20 - 30%
3. Type 3 - Good prognosis, Reduction, Brace (halo
device) vs fixation, heals easily
AP view
Spinous processes should line up and have equal gaps
sagital plane fractures
lateral mass fractures
facet fractures / dislocations (below)
92
DM FOOT (ORTHO)
EPIDEMIOLOGY
- Prevalence of DM is 8.2% (28.4% in 60-69 age group)
- 5% of all Diabetics develop foot ulcers
- In Spore, 2 amputations done daily
o Foot ulcers commonly become infected gangrene result in Major Lower
Limb Amputation
- Mortality: 10% at time of amputation, 30% within a year, 70% within 5 years
HISTORY:
PATIENT PROFILE (include OCCUPATION! nature of job)
2. VASCULOPATHY:
o Microangiopathy:
terminal arterioles
thickening of basement membrance of endothelium
o Atherosclerosis: middle-sized and large arteries
When did you sustain the injury? How was it sustained? What were you doing at
that time?
When did you discover it? How did you realize it?
3. IMMUNOPATHY
o Defects in leukocyte function (phagocytosis, chemotaxis, adherence,
neutrophil dysfxn)
PAIN:
SOCRATES
Localised to toe/heel?
PATHOGENESIS OF DM FOOT
1. NEUROPATHY (20-40% of all diabetics)
o Sensory
o Motor
o Autonomic
Vascular claudication
1) Pain in muscle (usu described as cramp)
2) Only on exercise (ask abt claudication distance: quantify in eg. no. of bus stops)
3) Disappears on rest
Followed by Gram negative rods (eg. Pseudomonas (rotten fruit smell, green
discharge), Proteus, E. coli) and anaerobes eg. Bacteroides (faecal smell)
MODES OF PRESENTATION:
Cellulitis
Abscess (supf/deep)
Ulcer (decubitus / vascular / neuropathic)
93
ULCER:
Site:
Plantar (sole) neuropathic
Heel/toes vascular (ischaemic)
Size
Pain?
Recent trauma / foreign body penetration eg. rusty nail (even seemingly
insignificant)
Acute onset
Pain
Erythematous, warmth
Dry/ wet?
Monitoring of DM: hypocount, HbA1c; what are the usual values? How often
follow-up? Did doctor say good control?
Previous hospitalizations for DM, any surgery done? DKA, HHNK, abscess, ulcer,
gangrene etc
Complications:
o Microvascular
Neurogenic
- painless
- deformed joints
- loss of sensation (vibration,
proprioception)
PHYSICAL EXAMINATION:
GENERAL:
VITALS
Skin:
o Scars, Sinus, Healed wounds
Signs of PVD (chronic ischaemia):
Shiny
Loss of hair
Pigmented skin
Sensory:
Joint deformity (charcots jt, claw toe, hammer toe)
Motor:
Muscle wasting
Autonomic:
Dry skin, Fissuring, Callosity
Ulcer:
o Site interdigital web space, dorsum, sole, heel
o Size
o Shape
o Floor: pus, slough, necrotic tissue, granulation tissue
o Edge: punched-out vascular; irregular
o Any foreign body in ulcer?
o Surrounding skin : erythematous, necrotic, warm, tender
Swelling
Cellulitis
Gangrene dry / wet?
Popliteal pulse
Femoral pulse
o NB: Vasculopathy assessment: (prognostic significance for distal amputation)
0 pulses NO chance
Ulcer:
o Tenderness, bogginess around ulcer
o Squeeze surrounding skin for discharge quantity, colour, odour
Tenderness of each individual metatarsal bone / joint (OM, SA):
o dorsal surface
o deep palpation of SOLE (pus tends to be dependent)
Sensation:
o Semmes-Weinstein monofilament (5.07 gauge applies 10g of force test 9
points on sole and 1 point in 1st web space if pt cannot feel means high risk!!!
o Vibration
o Propioception
o Pin prick
o Light touch
Motor (usually not required): test ankle reflexes.
Test upper limb for glove and stocking distribution too!
Move:
Palpation:
INVESTIGATIONS:
BLOODS
FBC anaemia, TWC with differential count for infx ( leukocytosis, polymorphic
neutrophils)
U/E/Cr nephropathy
CULTURES
Wound swab of ulcer take pus and from deepest possible part to increase yield
o Gram stain
o C/s (aerobic and anaerobic)
IMAGING
MANAGEMENT:
WAGNER CLASSIFICATION of DM foot ulcers: This determines management. In
general, lower grades respond to ABs and debridement. Higher grades (2-5) require
amputation.
Grade
Description
Treatment
Patient education
Accommodative footwear
Regular clinical, podiatry exam
Offloading with total contact cast
Walking brace/special footwear
Surgical debridement
Wound care
Offloading
Culture-specific Antibiotics
Debridement or partial amputation
96
Offloading
Culture-specific antibiotics
Lower extremity amputation
Vascular consultation
Major extremity amputation
Vascular consultation
o
KINGS CLASSIFICATION
Clinical Condition
Normal
High-risk
Ulcerated
Cellulitic
Necrotic
Major Amputation
Stage
1
2
3
4
5
6
General measures:
Surgery:
Dry gangrene:
Multidisciplinary approach
POLYTRAUMA
Definition of polytrauma
Injury to several (>1) physical regions or organ systems where at least 1 injury or a
combination of several injuries is life threatening
Important to break the figure down into its components, such as E3V3M5 = GCS 11.
A Coma Score of 13 or higher correlates with a mild brain injury, 9 to 12 is a moderate
injury and 8 or less a severe brain injury.
Abbreviated Injury Scale
An anatomical scoring system.
Injuries are ranked on a scale of 1 to 6, with 1 being minor, 5 severe and 6 an
unsurvivable injury.
98
Example
Region
Injury Description
AIS
Chest
Cerebral Contusion
No Injury
Face
Flail Chest
16
Abdomen
2
5
25
Extremity
Fractured femur
External
No Injury
Injury severity
o
50
sympathetic activation
Renin-angiotensin-aldosterone activation
Classification of shock
(% of blood
Class I
loss)
<15%
Pulse pressure
Resp Rate
14-20
Urine outpt
>30
Mental status -
Class II
15-30%
20-30
20-30
Mild anxiety
Class III
30-40%
(SPB)
30-35
5-15
Confused
Class IV
>40%
>35
Neg
Lethargic/
obtunded
Early hyperglycaemia
Plasma cortisol increases in proportion to injury with corresponding sympathoadrenal response (until adrenal perfusion fails)
Early hyperglycaemia occurs with increased sympatho-adrenal activity
Peripheral insulin resistance & depressed insulin secretion with high circulating
catecholamines & glucagon release
Skeletal glycogenolysis
100
Risk is higher w/ non-operative therapy but is also higher w/ overzealous reaming of femoral canal
Multiple trauma w/ major visceral injuries and blood loss (incidence may
be as high as 5-10%)
- Cause of death on 3rd day after pelvic fracture is due to fat embolism
- NB. Complications of skeletal traction do not include fat embolism
- Clinical manifestations
Symptoms usually begin 24-48 hours after injury
Major criteria
Hypoxia
Altered mental status
Petechial rash
Minor criteria
Tachycardia (>110/min)
Tachypnoea
Hypotention
Fever (>38.5 C)
Retinal changes of fat globules or petechiae
Renal dysfunction
Jaundice
Acute drop in hemoglobin and/or platelets
Elevated ESR
1 major and 4 minor criteria, plus fat microglobulinemia, must be
present to formally diagnose fat embolism syndrome
- Treat the hypoxaemia
4. Thromboembolism (DVT)
- develops 5-7 days later, worried about pulmonary embolism
5. Tetanus
- develops 7 days later
- administer tetanus toxoid as prophylaxis, especially with lacerations, abrasions,
dirty wounds and open fractures
Circulation
1. Posterior dislocation of sternoclavicular joint
2. Abdominal injuries: liver injuries and splenic rupture
3. Pelvic ring fracture
4. Hip injuries: may sustain internal bleeding and neuropathies as well. Usually
caused by dislocations and fractures.
5. Femoral shaft fractures: femoral artery involved
101
Mangled Extremity
- High energy transfer or crush resulting in some combination of injuries to
arteries, bones, tendons, nerves and/or soft tissue
- Scored using MESS (Mangled Extremity Severity Score)
A) Skeletal/ Soft Tissue Injury
Low energy (stab: simple fracture; pistol/ gunshot wound)
Medium energy (open or multiple fractures; dislocation)
High energy (high speed MVA or rifle GSW)
Very high energy (high speed trauma + gross contamination)
B) Limb Ischemia
Pulse reduced or absent but perfusion normal
Pulseless; paresthesia, diminished capillary refill
Cool, paralysed, insensate, numb
C) Shock
Systolic BP always > 90mmHg
Hypotensive transiently
Persistent hypotension
D) Age (years)
<30
30-50
>50
* Score doubled for ischaemia > 6hrs
- Acutely differentiates salvageable and unsalvageable limbs
- MESS 7 carries a 100% predictive value for amputation
Acute Compartment Syndrome
- pressure within a closed muscle compartment exceeds the perfusion
pressure
- tissue pressure exceeds venous pressure and impairs blood outflow
1
2
3
4
1*
2
3*
0
1
2
0
1
2
lack of oxygenated blood and lack of waste product removal results in pain
and decreased peripheral sensation secondary to nerve irritation
caused by either external restriction of compartment (eg. tight splints, casts,
dressings) or internal increase in compartment volume (eg. haemorrhage,
post-ischaemic swelling)
5Ps: Pain, paresthesia, pallor, paralysis, pulselessness
Complications: muscle necrosis, Volkmann contracture
Treatment: Fasciotomy
Necrotizing Fasciitis
- insidious soft tissue infection characterized by tissue necrosis
- organisms spread from subcutaneous tissue along superficial and deep
tissue planes, of which the latter causes vascular occlusion, ischaemia and
tissue necrosis.
- less seen in multiple trauma
- 3 types of NF: Type 1 Polymicrobial NF
Type 2 Grp A Strep NF (Flesh-eating bacterial infection)
Type 3 Gas gangrene
- presents with fever, chills, erythema and painless bullae formation
- treatment: antibiotics and surgical debridement
Gas Gangrene
- onset: 12-24hrs after injury
- commonly Clostridial infection, but may be caused by other organisms
- decreased oxidation reduction potential promotes advance of a highly
lethal condition
- less seen in multiple trauma
- present with intense pain and swelling around the wound
- associated with a brownish discharge and bronze discolouration of wound
- gas (with a musty odour) formation usually not marked
- important to distinguish from anaerobic cellulitis, which presents with
abundant gas formation that is foul smelling in nature
- distinction between the 2 made by doing a Gram stain of the exudate
- management: fluid & electrolyte replacement, antibiotics, multiple
incisions & fasciotomy, hyperbaric oxygen
Osteomyelitis
- infection of bone and bone marrow
- difficult to treat, can be life threatening as well due to septicaemia
- routes of spread: haematogenous, contiguous from a focus of infection
- bacteria can be inoculated at the time of trauma
102
Primary survey
Tertiary period
Secondary survey
Optimal timing of long bone # stabilization in trauma patients in the primary period
divided into 3 groups of patients:
* Early stabilisation (within 48h) does not improve
Polytrauma
survival but it will benefit some patients, e.g. reduces
without brain
the number of days of mechanical ventilation
and chest injury
(? Improves morbidity)
* Hence it is preferable to perform long bone
stabilisation in polytrauma patients
* No evidence that early stabilisation (within 48h)
Brain injury
improves survival compared to late stabilisation
Chest injury
0B
1B
2B
Acute period
articular congruity
stable fixation
axial alignment with the rest of the extremity
restoration of full range of motion
Limb salvage v.s. amputation (many scoring systems i.e. mangled extremity
scores/Hannover fracture scale)
Special considerations
Pelvis
Spine
103
Long bones
Pelvic #
Ensure that theres no need for general surgical intervention e.g. intra-abdominal
or retroperitoneal haemorrhage
Haemorrhage control with pelvic packing and temporary stabilisation with external
fixators and pelvic clamps
Spine #
Long bones #
Pts with # shaft of femur can lose up to 1L of blood. Femoral shaft fractures
should undergo immediate stabilization of the fracture within 24h of injury
FRACTURES
General Mx of #
ABCDE
- Assess neurovascular status, beware of compartment syndrome
- If hypovolaemic IV fluids, packed cells, whole blood
Analgesics
Preliminary skin traction to relieve pain, minimize further displacement
How to determine if # is displaced or not: compare continuity of trabeculae lines
Traction: things to note
Traction can be skin or skeletal
Skeletal traction can be with Thomass splint or pulley frame or both
Traction care
Ring pressure (Thomass splint)
Pressure sores: Buttocks, Tendo Achilles, under heel
Common peroneal palsy weakness of dorsi flexion
Loosening of Steinmann pin
Upper limb fractures dislocations by Lee Yizhi
Fracture
Clavicle
Method
Remarks
Malunion in adults
Excellent remodeling in
children
Sling 3/52
Scapula body:
Scapula neck:
Physio
ORIF if # dislocat
n
AC subluxat :
n
AC dislocat :
Anterior: conservative
Posterior: ORIF
Reduction under GA
Hippocrates/Kochers
104
Sling 3/52
dislocation
Pulled elbow
ORIF (plates/screws/rods)
Long arm cast 6/52, check x-ray at 2/52
Physio
Posterior
n
dislocat :
Prox humerus:
Shaft of humerus
Supracondylar
Lateral condyle
Proximal radius
in adults:
In children:
Olecranon
Elbow dislocation
Radial head
Commonly missed!
4% of shoulder dislocatns
Usually seen in osteoporotic
pple >50yrs
Try to conserve head in
young pts even with Neers
3/4
Suspect mets in elderly!
Galeazzis:
Cx: Shortening, angular
deformity (gunstock),
decreased ROM
Acute: Brachial A inj,
compartment sx, volkmanns
ischaemia
Myositis ossificans
Cubitus valgus, tardy ulnar
palsy: corrective osteotomy
Both in children:
Colles
Smiths (reverse
Colles)
Bartons
Radial styloid/
Chauffeurs
Undisplaced
scaphoid
Displaced
scaphoid
Trans-scaphoid
perilunate
dislocation
Peri-lunate
dislocation
Metacarpal
Median n compression
Lunate AVN leading to OA
Rotational malunion,
stiffness
105
Mallet finger
Game-keepers
thumb
Impt Hip & Lower Limb #s and Ds (plus impt tendon ruptures)
Type
Acetabulum, #
Hip, post. D
-- Hip is flexed, add & int rot
Hip, ant. D
-- Hip is abd, ext rot
Treatment
o minimal displc/ highly frag
Traction, Hamilton-Russell
o main part intact, fem head displc
ORIF w cancellous screws &
plates
o Muscle relaxant + Reduce, flex
knee, hip 900, correct add & int
rot, lift fem head into
acetabulum
o OR if irreducible
o ORIF if a/w #s elsewhere
o Muscle relaxant + Reduce, flex
knee, hip 900, correct abd & ext
rot, push down, convert to post.
D, lift fem head into acetabulum
o IF w screws + Manipulate if slip
> 30% + epiphyseal closure
o Subtroch Osteotomy if
epiphysis closed (chronic)
o Undisplc --> CRIF
o Displc --> Arthroplasty
o unfit for multiple Sx or badly
displc, typ 4, avn & non-union
likely --> Hemiarthroplasty/
Total hip replacement w/o
tryring CRIF
displc
o Typ 4: complete #, totally
displc
Neck of fem, basal (extracap) #
-- shortened, ext rot
Intertroch #
-- shortened, ext rot
Types:
1) # line thru mass of Great
Troch,
2) (1) + separation of Less
Troch,
3) separation of Great & Less
Troch,
4) 4. w a spiral # down prox
fem shaft
Fem shaft #
-- leg is shortened, ext rot, abd
due to pull of quds & hams
o AVN
o Involvement of Other Hip
Tx principles
o Young (< 50 y.o.) CRIF
o Elderly --> arthroplasty
Cxs
o AVN disruption of
arterial ring @ base of neck
o Non-union typ 3 & 4,
bone graft (young),
arthroplasty (elderly)
Patellar D
Cxs
o AVN & non-union NOT
common
Cxs
o Failure of fixation (cutting
out of fixation device)
coxa vara*
*if early, bedrest & skeletal
traction
Cxs
o Hypovolemic shock
o Fat embolism
o Delayed Union, Non-union
esp. conservative
o Mal-union lat. Angulation
Tx = osteotomy
o Limb Shortening
o Knee stiffness due to
quads tethering, knee jt
invovlement or prolonged
immobilisation
o Infection
Remarks
106
Patellar #
Cxs
o Compartment syndrome
o Valgus deformity
o Joint stiffness
Cxs
o Infection
o Vascular injury (prox #
damage pop artery)
o Compartment Syndrome
o Delayed, Non-union -->
Intramed Nail + bone graft
indicated
o Malunion --> angulated -->
osteotomy
Calcaneum #
o fall from height
o calcaneum driven up against
talus
o flattened Bohlers angle
o check hip, pelvis, spine for #
o extra-art --> involve posterior
part, calcaneal processes
o intra-art --> oblique # line, run
to superior articular surface
Cxs
o Adhesions
o Recurrent subluxation
Tx principles
o reduce to restore shape of
mortise
o plaster x 8/52
Cxs
o Joint stiffness
o OA (not common)
Cxs
o Mal-union (valgus)
o Asymmetrical growth (# thru
epiphysis may cause fusion
of physis)
o Shortening of leg
Tx principles
o elevate leg + ice packs -->
decrease swelling
o x-rays, CT scans (better
views)
Cxs
o Broadening of foot
o Talocalcaneal stiffness -->
subtalar arthrodesis or triple
arthrodesis
107
Types:
Clinical features
1.
2.
3.
4.
5.
6.
Investigations
Waldvagel Classification:
A haematological spread
B a/w wound
C contiguous spread from local infection
1) type of organism
2) site of infection
3) host response (immunocompromised?)
Principles of treatment
A = sound bone
B = new bone
C = involucrum
D = cloaca
E = sequestrum
Site:
X-ray: normal in first 10 days. Later, rarefaction of metaphysis & periosteal new
bone formation. Sclerosis when healing occurs
FBC: leukocytosis
ESR
Blood C/S
Bone scan (usu. technetium or gallium radioisotopes used): turns + before x-ray
changes appear. For doubtful cases.
Complications
3 things to consider:
5.
6.
7.
8.
Management
Pathology
Risk factors: DM, old age, immunosuppressed, steroid Rx, chronic disease, obese,
Opley classification:
A
Early 1 mth
B
Intermediate 1mth to 1 yr
C
Late >1 yr
multiple ops at same site, difficult / long ops, haematoma formation, tight dressings,
wound tension
Management:
CHRONIC OSTEOMYELITIS
Investigations:
Management:
Investigations
Blood C/S
Joint aspiration, pus microscopy & C/S
X-ray: widened joint space & soft tissue swelling; subarticular bone destruction if
late stage
U/S: joint effusion
Complications:
Dislocation
Epiphyseal destruction & pseudoarthrosis
Growth disturbance shortening or deformity if physis is damaged
Ankylosis if articular cartilage is eroded
Sepsis 25% if untreated
Management:
Joint aspiration
Systemic antibiotics
Splintage
Drainage and joint washout
Rehab: increasing movement when joint is not inflamed. If cartilage has been
destroyed, keep immobile to allow ankylosis to occur
TUBERCULOSIS
Main TB entities in orthopaedics
TB spondylitis
TB osteomyelitis
TB arthritis
TB tenosynovitis
TB myositis
Pathology
Common organisms:
Clinical features
Clinical features
Spine (50%)
Hip
Knees
Investigations:
X-ray: soft tissue swelling, rarefaction of bone, joint space narrowing &
irregularities w bone erosion on both sides of joint, periarticular osteoperosis
Synovial biopsy
ESR , Mantoux test +
Management:
110
OSTEOPOROSIS
If both Z & T-scores are abnormal, it means patient has secondary osteoporosis
DEFINITION
A bone disease characterized by
cortical and 25% for trabecular bone. [bone loss occurs within 2wks; bone formation
takes 3 mths]
Bone size increases from childhood to adolescence and peaks at ard 35 yrs. From then
on, decrease at 0.3%/yr for men and 0.5%/yr for women till 50 yrs old. Menopause
for women (50-60 yr old) causes decrease at 3%/year due to decrease in oestrogen; it
subsequently normalises again at 0.5%/yr.
Wolffs law - Bone is deposited and resorbed in accordance with the stresses placed
upon it.
RISK FACTORS
Osteoporosis Selfassessment Tool
for Asians (OSTA)
Nonmodifiable
Modifiable
Definition
Normal
Osteopaenia
Osteoporosis
Severe osteoporosis
T-score is the number of s.d. below the average for a young adult at peak bone
density (based on BMD of 25yo Caucasian females)
Z-score is the number of s.d. below an average person of the same age.
If Z-score is normal but T-score is not, it means patient has primary osteoporosis
(i.e. senile or post-menopausal osteoporosis)
INVESTIGATIONS
X-Ray if applicable
Vertical trabeculae bears the most weight of stress hence disappear last.
Osteoporosis got prominent vertical trabeculae but no horizontal.
o Picture-framing of vertebrae accentuation of cortical outline
o Codfish appearnace of vertebrae due to concave end-plates
o Pathologic fractures vertebral compression fracture (ant height of vertebrae is
80% or less of the posterior height) if multiple of spine -> Dowagers hump
o Singhs index for trabeculae at hip jnt grade I (only one present) to grade VI
(all present)
Ca/ PO4 to exclude osteomalacia (normal in osteoporosis, low in osteomalacia)
o
111
TFT; LFT; tumor markers and myeloma screen (FBC, ESR, bone marrow
aspiration, urine electrophoresis, skull X-ray)
Measurement of BMD
o Dual energy X Ray absorptiometry (DEXA) of hip for diagnosis, spine for
monitoring of treatment is the investigation of choice
Rationale for dual energy: to take X-ray of soft tissues and of bone at
different penetrance levels
o Other rarely done investigations include U/S heel/ tibia, quantitative CT scan
o
Selective Estrogen
Receptor
Modulators (SERMs)
Synthetic Steroid
Others
Raloxifene
(EVista)
MANAGEMENT:
BMD T-score
>+1
1 to -1
-1 to -2.5
< -2.5 + fragility fracture
Action
Re-BMD in 5y
Re-BMD in 2y
Medical prevention, F/U BMD @ >1yr
Medical treatment, F/U BMD @ >1yr
Medications available
HRT
Bisphosphonates
Aledronate
(Fosamax)
112
RHEUMATOID ARTHRITIS
DEFINITION
PATHOLOGY
Prevalence:
Gender:
Age of onset:
Morbidity:
Mortality:
PATHOGENESIS
-
- Erosion of articular
cartilage and
subarticular bone
o Direct invasion by
pannus
o Degradative
enzymes secreted by
neutrophils
o osteoclastic
activity in
underlying bone
- Tendons, ligaments, jt
capsule also destroyed
Cause unknown
Postulated to be response of a genetically susceptible host to an infectious agent
CLINICAL PRESENTATION
SYMPTOMS / HISTORY TAKING
- HLA-DR4, HLA-DR1
- Twin studies
o Monozygotic twins: 30%
concordance rate
o Dizygotic twins: 3%
1. Joint involvement: typically affects PIP, MCP, wrist, elbow, shoulders, knees,
ankles, feet
- Pain
- Stiffness:
- Swelling
- Deformity
- ROM
Insidious onset
Early morning stiffness at jt, last for >1hr before improvement
Symmetrical, Red inflamed, warm to touch
Progressive in nature
Fever
Fatigue, malaise
Weight Loss
113
4. Associated with
Sjogrens Syndrome:
Feltys Syndrome:
Palm
Palmar erythema
Dorsum
Wasting of the interossei, best
seen in 1st dorsal web space
5. Loss of function
FEEL
MOVE
7. Family history
8. Social History
OFFER
Occupation
Family setup
Caregiver
PHYSICAL EXAMINATION
LOOK
Wrist
-
Volar subluxation
Radial deviation
Piano key sign subluxation of DRUJ causing head of ulna to
pop up on dorsum of the wrist where it can be jogged up & down
Thumb
Z-thumb deformity (flexion of IPJ and hyperextension of MCPJ)
Fingers
Ulnar deviation of the fingers, involving the more lateral digits in
the more advanced cases
Volar subluxation at MCPJ, most commonly over index & middle
fingers
Swelling of PIPJ
Swan-neck deformity (flexion of DIPJ, hyperextension of PIPJ)
Boutonniere deformity (hyperextension of DIPJ, flexion of PIPJ)
Extra-articular manifestations:
Ophthalmic
Sleritis
Episcleritis
Keroconjunctivitis sicca
Respiratory
Pulmonary effusion
Pulmonary fibrosis
Cardiac
Pericarditis
Vascular
Vasculitis
Reticulo-endothelial
Lymphadenopathy
Splenomegaly
Feltys syndrome
Neurological
Multifocal neuropathies
Carpal tunnel syndrome
114
First 4 must be
present
continuously
for 6 weeks
INVESTIGATIONS
BLOODS
1. FBC
2. U/E/Cr
3. LFT
5. RF
6. ANA
JOINT ASPIRATION
1. Analysis of synovial fluid: Straw coloured, cloudy, flecks of fibrin
IMAGING
X-rays: disease monitoring, treatment response
MANAGEMENT
Goals:
CONSERVATIVE MANAGEMENT
1. Non-pharmacological:
Rest
Patient education
Physiotherapy
Occupational therapy
factors)
NSAIDs: Indomethacin, Diclofenac, Naproxen
o Symptomatic treatment: anti-inflammatory, analgesia
o Does not alter disease progression
o ADRs: PUD
o Contraindication: Renal impairment
Steroids: Prednisolone
o Symptomatic treatment: anti-inflammatory
o May help slow disease progression/joint damage
Disease modifying anti-rheumatic drugs (DMARDs): Methotrexate, Gold,
Hydroxychloroquine (See Table)
o Slow down disease progression of bone & cartilage destruction
o Take 1-6 months to be effective
o Monotherapy/Combination
Anti-TNF :
Etanercept, Abcliximab, Infliximab
SURGICAL MANAGEMENT
1. Surgical Release for nerve entrapment syndromes (eg. Trigger finger, CTS, De
Quervains)
2. Synovectomy
For persistent synovitis > 6 mths
115
Methotrexate
Pharmacology
- Recommended as initial
DMARD
- Rapid onset of action (12mths)
- Retards progression of
radiological erosions
Hydroxychloroquine
Toxicity
Investigations
- Rash
- Abdominal cramps
- Diarrhoea
- Retinal pigmentation
- Eye
examination (612 mthly)
- N+V
- Mucosal ulcers
- Liver cirrhosis, LFTs
- Interstitial pneumonitis
- Severe BM suppression
- Baseline FBCs,
U/E/Cr
- LFTs, Hep B/C
status
- CXR
Sulfasalazine
- N+V
- Headache
- Rash
- BM suppression
- FBC, LFTs
Gold
- Rash
- Ulceration, mucositis
- Nephrotic syndrome
- Pancytopenia
- FBC
- UFEME,
U/E/Cr (at
every injection)
Leflunomide
- Alternative to MTX
- Slows radiographic
progression
- Diarrhoea
- Alopecia
- Headache
- Immunosuppression
- LFTs
- FBC, U/E/Cr
116
ANKYLOSING SPONDYLITIS
Definition: chronic, multi-systemic inflammatory disorder of the sacroiliac joints and
axial skeleton (characterised as a seronegative spondyloarthropathy)
Predilection for SI joints & spine progressive stiffening & fusion of axial skeleton
EPIDEMIOLOGY
15-25 YO
Male : Female = 4:1
Mnemonic: P-A-I-R
HLA-B27
First degree relatives at risk of psoriatic arthritis, IBD & Reiters syndrome
PATHOLOGY
Enthesitis: subchondral granulation tissue that erodes the joint & is replaced
gradually by fibrocartilage and then ossification (occurs in ligamentous capsular
attachment sites to bone)
In the spine, this occurs at junction between vertebral bodies and annulus fibrosus
of IV discs. Outer fibres of the discs eventually undergo ossification
syndesmophyte is formed progresses to the characteristic bamboo spine
SIGNS
Decreased lumbar lordosis
Kyphosis
Restricted lumbar spine movement in all planes
Restricted chest expansion : <5cm at 4th intercostal space
Extra-articular manifestations Iritis, uveitis, myelopathy, AR, arrhythmia,
pulmonary fibrosis
SYMPTOMS
Recurrent lower back pain
o Insiduous onset
o For >3 months
o Often begins unilaterally & intermittently
As the disease persists, it becomes more persistent & bilateral &
progresses more proximally
o Dull character
o Poorly localised to the buttock/thighs
o Symptoms worse in the morning & after periods of inactivity, relieved with
exercise
2C
Spinal
cord
6A
Heart
Aortic regurgitation
Cardiac conduction defects
Lung
Anterior uveitis
Atlantoaxial subluxation
Aortic regurgitation
Apical lung fibrosis
Amyloidosis
Archilles tendonitis
Systemic
Amyloidosis
Osteoporosis
INVESTIGATIONS
ESR
Rh factor
FBC
ECG
Raised
Negative
Normochromic anaemia
Conduction defects
Synovial fluid
complement
X-ray
Bone scan
Squaring of vertebrae
Vertebral fusion
Romanus lesion: shiny corners of vertebrae due to sclerosis
Bamboo spine due to syndesmophyte formation
Erosion & sclerosis at anterior corners of vertebrae
Facet joint fusion
Atlantoaxial dislocation
SI joint bony erosion, marginal sclerosis, +/- fusion
Whiskering calcification of tendons attached to ischial tuberosity
Osteoporosis / OA changes ( jt space, sclerosis, ossified bone
cysts)
Apical lung fibrosis
Costovertebral jt involvement
Sacroilitis & spinal involvement
117
GOUT
GRADES OF SACROILITIS
I
II
III
IV
Widening of joint
Joint erosion
Sclerosis on both sides
Ankylosis
Rome criteria
NY criteria
MANAGEMENT
Aims:
CONSERVATIVE
Lifestyle modification
Pharmacotherapy
- NSAIDs (usually
indomethacin)
- Sulphasalazine
Radiotherapy
Local corticosteroid injection
Systemic steroids
SURGICAL
Hip stiffness
Spine flexion deformity
118
Imaging
o Punched out lesions / rat-bitten / lytic areas with overhanging edges(after 1st
year of disease)
o Erosion with joint space preservation is typical.
119
c.
Intra-compartmental
Wide excision
(w/o exposing tumour)
Extra-compartmental
- Radical incision
- +/- bone graft OR prosthetic
replacement
- Radical
incision
and
prosthetic replacement OR
amputation
- +/- chemo to risk of mets
120
Renal
*Most are osteolytic
Breasts
4. Chondrosarcoma
Prostate
except prostatic (blastic)
Lungs
5. Ewings sarcoma
Testes
& breast (blastic & lytic)
Others
Fibrous tissue
Marrow
Benign
Osteoid osteoma
Chondroma
Osteochondroma
Fibroma
Eosinophilic granuloma
Children/Adolescents (<20YO)
Vascular
Uncertain
Haemangioma
Giant-cell tumour
Chondrosarcoma
Multiple myeloma
Osteosarcoma (~50YO)
Metastatic tumours
Spine
Hands / feet
Malignant
Osteosarcoma
Chondrosarcoma
Fibrosarcoma
Ewings sarcoma
Myeloma
Angiosarcoma
Malignant giant-cell tumour
Osteochondroma
Simple bone cyst
Aneurysmal bone cyst
Giant cell tumour (proximal tibia, distal radius,
distal femur)
Non-ossifying fibroma (cortex)
Osteosarcoma (esp knee & proximal humerus)
Chondrosarcoma
Diaphysis
Ewings tumour
Non-specific
Osteoid osteoma
Chondroma
Metastatic
Aneurysmal bone cyst
Giant cell tumours
Multiple myeloma
Metastatic
Chondroma
Giant cell tumours (calcaneum)
Metastatic
Multiple myeloma
Metastatic
Chondrosarcoma
121
Bone tumour
X-ray findings
Site
Age
Others
Osteoid osteoma
Femur, tibia
<30
Adolescence
Arises at puberty,
presents ~30YO.
Need to rule out
chondrosarc if >30y/o
Children up to puberty
Young adults
Child
No Rx unless #ed.
20-40YO
Sunray appearance
Bone areas of rarefaction in medulla
Subperiosteal new bone formation
Codmans triangle = lifting of periosteum prox to tumor @
the edge of the sunray
Central medullary type: initially appears like a chondroma.
Destructive medullary tumour with flecks of calcification
Bimodal distribution:
10-20YO; ~50YO
(a/w Pagets dz)
>40YO
Hx of patho #
High rate of recurrence if not completely
excised
Curette & fill with bone chips
Excision & bone graft/ prosthetic
replacement
Metastasize readily esp to lungs
ALP by 3-4X
Biopsy to confirm dx
ChemoRx RT
Resection / amputation
Tend to metastasize late
Osteochondroma
Chondroma
(enchondroma)
Simple (solitary)
bone cyst
Aneurysmal bone
cyst
Non-ossifying
fibroma (fibrous
cortical defect)
Giant cell tumour
Osteosarcoma
Chondrosarcoma
122
malignant change in
cartilage cap of
osteochondroma
Diaphysis of long bone
Multiple
myeloma (single
tumor =
plasmacytoma)
Metastatic
tumours
Ewings tumour
(primitive neuroectodermal
tumour, PNET)
Enneking Classification
Grade
G0
Benign
(surgical)
G1
Low grade malignant
G2
High grade malignant
Site
T0
Benign Intracapsular &
intracompartmental
T1 (A) Intracompartmental
T2 (B)
Extracompartmental
Metastasis M0
No regional / distant mets
M1
Regional / distant mets
10-20YO
45-65YO
50-70YO
M0
M0
M0 or 1 (giant cell tumour)
123
ORTHOPAEDIATRICS
FRACTURES
Prevalence in Singapore
Bimodal distribution
Modal peaks:
7 and 11 years old
Median age: 7.64 0.05 years old
By Gender
Male modal peaks: 7 yrs & 11 yrs
Female modal peaks: 5 yrs & 10 yrs
Type
I
II
III
IV
Basic Principles
Presence of growth plate which gets injured before ligaments ( avulsion #s)
Presence of secondary ossification centers CRITOE
Potential for remodeling in those less than 10 years of age
Less likely for joint stiffness due to casting
Treatment is usually non surgical
Greenstick and Buckle #s
Plastic deformation
Pathological fractures
Non-accidental Injuries
Growth plate
Example
Distal fibula #
Distal radius #
Tillaux #
If surgery is required...
Minimal dissection to ensure no damage to growth plate
Usually smooth pins used instead of plate and screws as smooth pins produce
minimal growth plate damage and periosteum
Usually combined with casting postoperative for added stability to fixation
Pins inserted percutanoeusly where possible.
Remodelling
- Remodelling occurs 75% at the physis, 25% at the fracture site
- Physeal remodelling
Once physis is aligned, it resumes symmetrical growth
- Diaphyseal remodelling
Follows Wolffs law form follows function.
- The closer the fracture to an active physis, the greater the remodelling potential
124
vi.
vii.
iii. Grade IIB (with rotation component to the #) closed reduction &
percutaneous pinning (CRPP)
iv. Grade III M & R and CRPP
Brachial artery & median nerve may kink (not rupture)
Presents as pulseless hand
Ulnar n. usually not affected (if affected, usually iatrogenic)
Management closed reduction (right)
Complications
i. Cubitus varus (increased extension but reduced flexion)
6. Proximal humeral #s
i.
Has great potential remodeling due to the fact that the shoulder is one most
mobile joint in the body.
ii.
Usually treated with collar and cuff OR an O slab.
7. Supracondylar #s
iii.
In Singapore, the typical child who has a supracondylar fracture is a
7yo boy falling off a monkey bar with his non dominant hand
iv.
Most common fracture in KKH requiring surgery
v.
Classification
i. Grade I (posterior fat pad sign seen) Cast Immobilisation
ii. Grade IIA (Baumann angle = 75, anterior humeral line bisects
capitulum) M & R
c.
126
6. Tillaux #s
a. Growth plate not completely closed yet and lig > bone :. Tillauxs fracture
Refer early
Brachial Plexus Injuries
Clavicle fracture
No intervention
Reassure family
If the infant initially demonstrates discomfort with the fracture, the long arm
sleeve of the infant's shirt can be pinned to the shirt for 7 to 10 days to provide
adequate immobilization.
Humerus fracture
Life-threatening condition
127
1
1
1
1
1
Clinical Features
Childs tilts or looks to the sides opposite to the tight SCM
Facial asymmetry on the side of the torticollis
Limited lateral rotation on the same side of torticollis
Limited lateral flexion on the opp side of torticollis
Points
1
1
Management
Exclude secondary causes
If under 1 year can be treated effectively with stretching (physio)
Surgery usually needed for those above 1 year old.
Release of the SCM is done with or without a reconstruction of the sternal head
Post op aggressive physiotherapy with use of custom made cervical collar for
immediate post op period.
1
1
128
3yo to
schoolgoing
Painful
Most commonly due to infection
Trauma (exclude NAI)
Toddlers # (1-4yo): distal tibial #
Transient synovitis
DX OF EXCLUSION
Inability to bear weight
a/w excessive running
May be related to upper respiratory
infection
Gets better with rest
Growing pain
Diagnosis of exclusion
Usually between 4-5yo and during
puberty
Bone growth rate faster than rate of
increase in length of muscle &
tendon
Pain occurs usually at the end of the
day, often relieved with massage /
after a good nights rest
Leukaemia (4-10yo)
Schoolgoing
through
adolescence
Painless
Limb length discrepancies
Bone: femur versus tibia
shortening
Joint: commonly DDH
Generalised
o Muscle hypertrophy on
one side; causes: nerves
(NF), vessels
(haemangiomas)
o Polio infection
Physiological
o Metatarsal adductors
o Tibial torsion
o Femoral anteversion
o Flat foot
Biggest concern: undiagnosed
dislocated hip ( DDH)
Significant limb length
discrepancy
Asymmetrical thigh crease
Hip clicks
Limited/asymmetrical
abduction
Adolescents
Transient synovitis
Commonest cause of irritable hip
Epidemiology: boys 2x more than
girls, 3-10yo
History
o Unilateral groin/hip pain
o Antalgic limp
o Very young children: no other
symptoms except crying at
night
o Recent Hx of URTI,
pharyngitis, bronchitis or otitis
media (in >50% of cases)
o No definitive cause known
Slipped Upper Femoral Epiphysis
(~15yo)
Thought to be due to excessive
weight on a predisposed hip
Maybe due to an endocrine
abnormalities (Pituitary, growth,
thyroid and parathyroids, gonadal
hormones)
Diagnosis delayed because they can
present with knee pain
Always need surgery to stop
progression
Growing pain (see above)
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DDH
Incidence
1:1000 live births
Common enough for the condition to be screened by the neonatologists
Risk factors
1st female child
Family history
Breech
Condition predisposing to crowding of uterus (multiple pregnancies,
oligohydramnios, fibroids, baby too big, mother too small)
Diagnosis:
Diagnosis is CLINICAL
Barlow maneuver test of dislocatability
see if hip can come out or not, test positive when it goes
back in on the way
Ortolani maneuver test of reducibility
pushing a hip that is already out; clunk only when it
moves over labrum
U/S or X-rays can be used but not to diagnose at birth
X-ray: radiation PLUS hip is not ossified
U/S not done at birth because laxity of hip joint, may get spurious
reading at birth (in order for baby to come out of birth canal)
hence earliest U/S is at 6 weeks
When to do U/S
For high-risk cases (e.g. breech) / hip laxity / hip clicks
To ensure concentric stable reduction after treatment
Weekly after with splint to ensure reduction and correct
application of splints
Every 6 weeks after once hip reduced
Most effect <3 months old (3 months onwards :X-rays; must
ensure concentric reduction with good acetabular cover, if not
mechanical forces of hip not evenly distributed may get OA)
When to do X-rays
3 months onwards
Management
Goals
130
Hindfoot equinovarus
Forefoot supination
Forefoot adduction
Cavus
131
Management
I) Ponseti casting
- Serial casting and manipulations soon after birth.
- Foot corrected distal to proximal
o Weekly for 4 weeks
o Fortnightly for 4 weeks until external rotation of 60 achieved
o Then assess need for TA tenotomy if hindfoot still uncorrected.
#1
#2
#5
SUMMARY:
External rotation: tilt toe and turn out
60deg in relation to the knee
Principle: serial casting & manipulation
FOREFOOT: casting (forefoot corrected
first then hindfoot!)
HINDFOOT: cut the tendon (if force into
casting, will cause vertical talus)
Then BOOTS & BARS
#4
Classification
Two diagnostic groups
Dynamic
Due to generalised ligamentous laxity
All children have this till about 7yo
Ask patient to tip toe tightening of plantar fascia
arches indicative of ligamental problems
Jacks Test (reverse of tip-toe; pull toe up arch appears)
Due to tight TA
Growth spurts creates muscle tightness esp TA due
to imbalance of muscle and bone growth
Due to collagen tissue disorders, e.g. Marfans
Fixed Flatfeet
Neuromuscular e.g. CP
Idiopathic
Tarsal coalition with/without peroneal spasm
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Calcaneo Navicular
9 to 12 years
Do an oblique x-ray
Talo - calcaneum
12 to 15 years; 50% bilateral
Do a CT
Management
Dynamic with no tight TA
Dynamic with tight TA
Fixed
- Tarsal coalition
SCOLIOSIS
Classification
- Idiopathic
- Neuromuscular
CP
SMA
Myelomeningocoele
Muscular dystrophies
- Congenital
Hemivertebrae
Block vertebrae
- Syndromic
Ehler-Danlos
Marfans
Neurofibromatosis
VACTERL
133
Clinical Assessment
- General assessment + height
- Back examination
Scoliometer (in clinic)
Spinal balance: plumbline
Screening test: Adams Forward Bending Test
Why positive?
Neurological examination
Cobbs angle (X-ray)
Time of diagnosis
Severity of first X-ray
Any previous treatment
Associated symptoms
Back Pain
Neurological: clumsiness/weakness, bowel/bladder function
Physical Examination
- Foot deformity, particularly unilateral
- A lack of rotational deformity on Adams forward bending test
- Hyperkyphosis
- Tight hamstrings (popliteal angle > 5060 deg)
- Abnormal curve pattern : Not R thoracic and/or L lumbar
- Unequal or abnormal reflexes
X-rays
- Widened pedicles
- Kyphosis
- Atypical curve pattern
- Lack of vertebral rotation
- Rapid curve progression (>1 degree / month)
- Absent pedicles (`winking owl)
- Limb length discrepancy
MRI
When to order
o Neurologic abnormalities on physical exam (dont forget the feet)
o Structural (congential) abnormalities on plain film
o Excessive kyphosis
o Apex left thoracic or thoracolumbar curves
o Early onset scoliosis
o Syndromic features present
What to look for
Syringomyelia
Chiari malformations
Tethered cord
Diastematomyelia
Treatment
CEREBRAL PALSY
Definition
Non progressive insult on a developing brain
The brain lesion is permanent and non progressive, but the natural history of
cerebral palsy is not static.
If non-progressive insult on a developed brain = stroke
Aetiology
About 10 to 15% of patients documented perinatal hypoxia.
Cerebral palsy is not solely the result of prematurity because 60 to 65% of
afflicted children were born at full term
Although only approximately 10% of cerebral palsy patients weigh less than
1,500 grams at birth, in this low birth weight group the risk of having cerebral
palsy is 90 per 1,000, compared with 3 per 1,000 if weighing more than 2,500
grams and appropriate for gestational age
Low birth weight for gestational age & prematurity are commonly
associated with the development of spastic diplegia
Types
Neuropathic Types***
Spastic
Overactive Golgi
apparatus
The only one in which
Ortho team can intervene
Ataxic
Athetoid
Hypotonic
Mixed
Anatomic Patterns***
Hemiplegic
Diplegic
Quadriplegic
Total body
Others
Triplegic
Monoplegic
135
Diplegic
Quadriplegic
Walker
Efficient Walking
Supple Hamstrings
Supple TA
Upper Limb is the best position for function
Efficient walking
No crouch/jump gait
No tiptoeing
No scissoring
Dietary control (optimal BMI; too heavy, patient cannot bear weight)
All should walk !! (if not, could be due to poor parental support, laziness
[rehab into society would be even more difficult])
Non Walker
Investigate reason
Painless seating
Seating Clinic
No pelvic tilt
136
Botulinum A Toxin
intramuscular injection of a neurotoxin produced by Clostridia bacteria.
It is delivered into or near sites of nerve arborization, and blocks the release of
acetylcholine from presynaptic vesicles at the myoneural junction.
Recovery of tone results from the sprouting of new nerve terminals, which
peaks at about 60 days
The agent is injected using a 23- or 25-gauge needle, usually without local or
general anesthesia
The muscles are located by palpation.
To reach muscles that are deep or difficult to localize, electromyographic
guidance and electrical stimulation have been used
BTX diffuses readily, so the injection should be placed in the muscle belly
Hamstring release
In those with very severe crouch gait and popliteal angles usually
exceeding 45o
Release of semitendinosus
Fractional lengthening of semimembranosus and biceps femoris
Adductor release
Done for significant scissoring in walker
Uncorrectable tight adductor in non- walker such that perineal hygiene
is compromised
Painful subluxed hips
Tendon Transfers
Split Posterior Tibialis Tendon Transfer
Triple Arthrodesis
Salvage procedure
138
Comminuted
Hairline
Greenstick
Compression
Avulsion
Impacted
Transverse (<30o)
Oblique (>30o)
Spiral
Spiral wedge torsional forces
Bending wedge characteristic butterfly fragment
Comminuted wedge bending wedge # with fragmented butterfly
fragment
Complex spiral >1 spiral fragments
Complex segmental double #
Complex irregular bone lying btw main elements is fragmented
If not detected on XR initially:
Do oblique XR
Repeat film after 7-10 days
Children
Elastic spring of periosteum may cause recurrence of angulation, hence
plaster fixation must be well done.
Rapid healing
Common sites
Vertebral bodies
Heels
Common sites
Base of 5th metatarsal (peroneus brevis)
Tibial tuberosity (quadriceps) (Osgood-Schlatters disease)
Lower pole of patella (Johansson-Larsens disease)
Upper pole of patella (quadriceps)
Lesser trochanters (iliopsoas)
One fragment driven into another
DESCRIBING FRACTURES
1. Level
Anatomical epiphysis, epiphyseal plate, metaphysic, diaphysis
OR
Thirds proximal, middle, distal
2. Displacement
Direction of displacement in terms of movt of distal fragment
Degree of displacement in % of # surfaces in contact
3. Angulation
Described in terms of the direction the point of # angulation is
pointing towards (eg anterior angulation in Colles #)
4. Axial rotation Easily missed, examine the joints above & below the #
5. Open / Close
Open
Gustilo Classification
Open from within or without latter has risk of infxn,
hemorrhage & injury to muscles, nerves or bld vessles. Also
usually comminuted & more difficult to manage.
2-3L
3-5L
3-5L
Smiths #
Galeazzi #dislocation
Monteggia #dislocation
Features
Pain, no trigger
Correctable by active extension
Correctable by passive extension
Fixed flexion deformity
Mx
NSAIDs
H&L
H&L, Sx sheath
incision
Sx release
10
Fixation by:
Cannulated screws /
pins
DHS
>65YO
hemiarthroplasty.
o
Unipolar (Moores
or Thompsons)
o
Bipolar for
younger PTs
<65YO attempt joint
salvage
20
Risk of AVN (%)
TRIGGER FINGER
Stage
Pre-triggering
Triggering
Triggering &
Lock
Contracture
30
40
140
Potts Classification
First degree
# of a single malleolus (medial or lateral)
Second degree
# of both medial & lateral malleoli
Third degree
# of medial, lateral & posterior malleoli
SCOLIOSIS
List of Causes
Non
structural
Structural
SPONDYLOLISTHESIS
Causes
1. Dysplasia congenital lumbosacral facet jt dysplasia
2. Isthmic (spondylolytic) break in the pars interarticularis
3. Elderly (degenerative) OA degeneration of facet joints
4. Trauma
5. Suspicious (pathological) neoplasm
6. Post-op due to laminectomy for decompression
Meyerding classification
Grade % translation of
VB
I
0-25
II
25-50
III
50-75
IV
75-100
BONE TUMOURS
Ennekings Classification
Grade
G0
Benign
(surgical)
G1
Low grade malignant
G2
High grade malignant
Site
T0
Benign Intracapsular & intracompartmental
T1 (A)
Intracompartmental
T2 (B)
Extracompartmental
Metastasis
M0
No regional / distant mets
M1
Regional / distant mets
Staging for Malignant Neoplasia
IA
G1
T1 M0
IB
G1
T2 M0
IIA
G2
T1 M0
IIB
G2
T2 M0
IIIA
G1 or 2 T1 M1
IIIB
G1 or 2 T2 M1
Staging for Benign Neoplasia
1
Latent
G0 T0
2
Active
G0 T0
3
Aggressi
G0 T1 or 2
ve
OSTEOPOROSIS
BMD T-score
>-1
-1 to -2.5
<-2.5
<-2.5 + fragility
fracture
M0
M0
M0 or 1 (giant cell
tumour)
Definition
Normal
Oteopenia
Osteoporosis
Severe osteoporosis
RHEUMATOID ARTHRITIS
Stage 1 (synovitis) pain, chronic swelling, large effusion, thickened synovium
Stage 2 (articular erosion) joint instability, ROM. X-ray: loss of jt space & marginal
erosion, but lack of osteophytes c.f. OA
Stage 3 (deformity) pain, deformity, instability & disability. X-ray: bone destruction
141
DISEASES MNEOMONICS
10. Can H&L (hydrocortisone and lignocaine) everything except plantar fascitis and
archilles tendonitis
142