ORTHOPEDICS

Dr. H. von Schroeder

Paul Kuzyk, Mark Shekhman and Adam Sidky, chapter editors
Anna Kulidjian, associate editor
AN APPROACH TO ORTHOPEDICS ......... 2 FEMUR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
History Femoral Diaphysis Fractures
Physical Examination Supracondylar Femoral Fracture
Investigations
KNEE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
FRACTURES - GENERAL PRINCIPLES ...... 3 Common Knee Symptoms
Clinical Features of Fractures Evaluation of Knee Complaints
Initial Management Ligamentous Injuries of the Knee
Radiographic Description of Fractures Anterior Cruciate Ligament (ACL) Tear
Definitive Management Posterior Cruciate Ligament (PCL) Tear
Open Fractures Medial Collateral Ligament (MCL) Tear
Fracture Healing Lateral Collateral Ligament Tear
Complications of Fractures Meniscal Tear
Compartment Syndrome Patella/Quadriceps Tendon Rupture
Avascular Necrosis (AVN)
Dislocated Knee
SHOULDER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
General Principles PATELLA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Acromioclavicular Joint Sprain Patella Dislocation
Clavicular Fracture Chondromalacia Patellae
Anterior Shoulder Dislocation Patellar Fracture
Posterior Shoulder Dislocation TIBIA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Rotator Cuff Lesions Tibial Plateau Fracture
Impingement Syndrome Tibial Diaphysis Fracture
Frozen Shoulder
ANKLE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
HUMERUS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Evalution of Ankle Complaints
Humeral Shaft Fracture Ankle Fractures
Proximal Humeral Fracture Ligamentous Injuries
Recurrent Ankle Subluxation
ELBOW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Supracondylar Fracture FOOT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Radial Head Fracture Evaluation of Foot Complaints
Olecranon Fracture Talar Fracture
Elbow Dislocation Calcaneal Fracture
FOREARM FRACTURES . . . . . . . . . . . . . . . . . . . . 13 Achilles Tendonitis
General Principles Achilles Tendon Rupture
Nightstick Fracture Plantar Fasciitis
Galeazzi Fracture Bunions
Metatarsal Fracture
Monteggia Fracture
Complications of Forearm Fractures ORTHOPEDIC INFECTIONS . . . . . . . . . . . . . . . 34
WRIST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Osteomyelitis
Scaphoid Fracture Septic Arthritis
Colles’ Fracture PEDIATRIC ORTHOPEDICS . . . . . . . . . . . . . . . . 36
Smith’s Fracture Fractures in Children
Barton’s Fracture Evaluation of the Limping Child
Complications of Wrist Fractures Epiphyseal Injury
SPINE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Pulled Elbow
Differential Diagnosis of Back Pain Developmental Dysplasia of the Hip
Degenerative Back Pain Legg-Calve-Perthes Disease
Cauda Equina Syndrome Slipped Capital Femoral Epiphysis
Trauma Congenital Talipes Equinovarus (CTEV)
Thoracic and Lumbar Spine Scoliosis
HIP ................................... 20 BONE TUMOURS . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Differential Diagnosis of Hip Pain Benign Bone Tumours
Pelvic Fractures Benign Aggressive Bone Tumours
Hip Dislocation Malignant Bone Tumours
Hip Fracture
Arthritis of the Hip SURGICAL PROCEDURES . . . . . . . . . . . . . . . . . . 41
Avascular Necrosis (AVN) of the Femoral Head REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
MCCQE 2006 Review Notes Orthopedics – OR1
 AN APPROACH TO ORTHOPEDICS
HISTORY
Identification
identifying data
• include: occupation, hobbies, hand dominance
chief complaint
past orthopedic history
• injuries, past non-surgical treatment, past surgery
• investigations: Xray, CT scan, MRI, etc.
other medical history
• past surgery, medical illnesses, allergies, medications
History of Present Illness
important to obtain details regarding onset and progression of symptoms
pain
• OPQRST (Onset, P rovoking / Alleviating factors,Quality, Radiation, Site, Timing)
• muscular, bony, or joint pain ?
• number of joints involved and symmetry of involvement
inflammatory symptoms
• morning stiffness (> 30 min), tenderness, swelling, redness, warmth
mechanical/degenerative symptoms
• increased with activity, decreased with rest
• locking, giving way, instability
weakness, deformity, stiffness, crepitus
neoplastic and infectious symptoms
• constant pain, night pain
• fever, night sweats
• anorexia, fatigue, weakness, weight loss
• mets from ( PT B arnum Loves Kids): P rostate, Thyroid, Breast, Lungs, Kidney
activities of daily living
• getting up, sitting down, using bathroom, combing hair, transferring
referred symptoms
• shoulder pain from the heart or diaphragm
• arm pain from the neck
• leg pain from back
• back pain from the kidney, aortic aneurysm, duodenal ulcer, pancreatitis
PHYSICAL EXAMINATION
Look, Feel, Move
always examine the joint above and below
look - skin, shape, position - compare sides
• SEADS: S welling, Erythema, Atrophy, Deformity, Skin changes
feel - palpate soft tissue, bone, joint line
• assess: tenderness, temperature, effusion, deformity
move the affected joint(s)
• active and passive range of motion (ROM), crepitus present?, instability?
• passive ROM > active ROM suggests soft tissue inflammation or muscle weakness
neurovascular tests
• pulse, reflexes, power (grade with MRC scale), sensation
(most accurate method of eliciting sensory deficits is by ‘two-point discrimination’)
special tests depend on joint
observe gait: walking, heel-to-toe, on heels, on toes
INVESTIGATIONS
Diagnostic Imaging
plain X-rays: 2 views taken at 90º to each other
CT/myelography, MRI, EMG (electromyelography) / NCS (nerve conduction study)
99Tc (Technetium) bone scan
• reflects osteoblastic activity or inflammatory reaction
• positive with fractures, tumours, local reaction
gallium scan
• positive when uptake on gallium is greater than on 99Tc
• reflects hypervascularity, taken up by leukocytes
• positive with infection
Blood Tests for Painful, Swollen Joint
CBC, ESR, Rheumatoid Factor (RF), ANA, C-reactive protein (CRP)

OR2 – Orthopedics MCCQE 2006 Review Notes

 FRACTURES - GENERAL PRINCIPLES
mechanism: remember the process leading to the fracture
• traumatic
• pathologic - tumour, metabolic bone disease, infection, osteopenia
• stress - repetitive mechanical loading
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 - Allergies, Medications, Past medical history, Last meal,
Events 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
patient identification
identify views
open or closed (gas in soft tissue = open)
site
• which bone
• if diaphyseal decribe by thirds : proximal/middle/distal
• extra-articular: diaphysis/metaphysis
• intra-articular
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
soft tissue
• calcification, gas, foreign bodies
displacement (position of distal fragment with respect to proximal)
• apposition/translation - describes what percentage of surfaces remain in contact
• angulation - describes which way the apex is facing
• rotation - distal fragment compared to proximal fragment
• shortened - due to overlap or impaction
DEFINITIVE MANAGEMENT
goals – “Obtain and Maintain Reduction”
• reduce
• stabilize
• rehabilitate

attempt closed reduction

successful unsuccessful

stabilization open reduction

• cast
• external fixation
• traction stabilization
• internal fixation
rehabilitate

Figure 1. Fracture Management

MCCQE 2006 Review Notes Orthopedics – OR3

 FRACTURES - GENERAL PRINCIPLES. . . CONT.
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
indications for open reduction - remember NO CAST
• N - Non-union
• O - Open fracture
• C - neurovascular Compromise
• A - intra-Articular fractures (require anatomic reduction)
• S - S alter-Harris III, IV, V and/or special situations depending on site
• T - polyT rauma
• others
• failure to reduce closed
• 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 open reduction with internal fixation (ORIF)
• complicatoins
• infection
• non-union
• 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
internal fixation
1. percutaneous pinning
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
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!
fracture communicates with skin surface
examine fracture carefully to classify (Table 1)

Table 1. Classification of Open Fractures

Size Soft Tissue Injury Antibiotics
Type 1 < 1 cm Minimal Ancef
Type 2 >1cm Moderate; no dead soft tissue Ancef
Type 3 >1cm Extensive muscle damage; Ancef,
includes gunshot wounds, Gentamycin,
major vascular injury Flagyl
barnyard injury
initial management
1. do not reduce open fractures unless there is neurovascular compromise from position of fracture
2. remove gross debris i.e. turf, rocks
3. all open fractures are contaminated, therefore obtain culture and cover wound with sterile dressing
4. administer tetanus vaccine/booster (Table 2)
5 start antibiotics
6. splint
7. NPO and prepare for O.R.
ONCE IN O.R.:
8. irrigation and debridement,
9. reduction and stabilization after I&D
OR4 – Orthopedics MCCQE 2006 Review Notes
 FRACTURES - GENERAL PRINCIPLES. . . CONT.
must get to O.R. within 6 hours, since risk of infection increases after this time
wound usually left open to drain
re-examine, with possible repeat I&D in 48 hours and closure if appropriate

Table 2. Indications for Tetanus Vaccination

Tetanus History Clean Wound Dirty Wound

Td TIG Td TIG
unknown or <3 Td
doses Y N Y Y

>3 Td doses N* N N** N

* Y if >10 years since last dose

** Y if >5 years since last dose
Td=0.5 mL adsorbed tetanus toxoid
TIG=250 units tetanus immune globulin

Complications of Open Fractures

osteomyelitis
soft tissue damage
neurovascular injury
blood loss
nonunion

FRACTURE HEALING
Normal Healing
weeks 0-3 hematoma, macrophages surround fracture site
weeks 3-6 osteoclasts remove sharp edges, callus forms within hematoma
weeks 6-12 bone forms within the callus, bridging fragments
months 6-12 cortical gap is bridged by bone
years 1-2 normal architecture is achieved through remodelling

Figure 2. Stages of Bone Healing

Evaluation of Healing - Tests of Union

clinical - no longer tender to palpation or angulation stress
x-ray - trabeculae cross fracture site, visible callus bridging site

COMPLICATIONS OF FRACTURES
Table 3. Complications of Fractures
Early Late
Local Neurovascular injury Malunion
Infection Nonunion
Compartment syndrome Osteonecrosis
Implant failure Osteomyelitis
Fracture blisters Heterotopic ossification
Post-traumatic arthritis
Reflex sympathetic dystrophy (RSD)
Systemic Sepsis
Deep vein thrombosis (DVT) / pulmonary embolus (PE)
Fat embolus
Acute respiratory distress syndrome (ARDS)
Hemorrhagic shock

MCCQE 2006 Review Notes Orthopedics – OR5

 FRACTURES - GENERAL PRINCIPLES. . . CONT.
COMPARTMENT SYNDROME(see Figure 3)
in anatomical "compartments" where muscle and tissue bounded by fascia and bone
(fibro-osseous compartment) with little room for expansion (i.e. forearm, calf)
increased interstitial pressure in compartment exceeds capillary perfusion
pressure which leads to muscle necrosis and eventually nerve necrosis
intracompartmental pressures over 30 mm Hg usually require intervention
Etiology
fracture, dislocation
soft tissue damage and muscle swelling
crush injury
arterial compromise
muscle anoxia
venous obstruction
increased venous pressure
constrictive dressing, cast, splint
Diagnosis
classically the tibial compartments
also in forearm flexor compartment
• may lead to Volkmann’s ischemic
contracture Figure 3. Pathogenesis of Compartment Syndrome
clinical signs and symptoms
• early
• pain
• greater than expected for injury
• not relieved by analgesics
• increase with passive stretch of compartment muscles
• pallor
• palpable tense, swollen copmparment
• late
• paralysis (inability to move limb - late)
• pulses are usually still present
• paresthesias
• NOT pulslessness
• most important feature found on physical exam is PAIN out of
proportion to injury (the other signs are ‘late signs’)
compartment pressure monitoring
• in unresponsive or unreliable patients
• normal tissue pressure is about 0 mm Hg
• pressure increases markedly in compartment syndromes.
• when intra-compartmental pressure rises to within 10 to 30 mm Hg of patient's
diastolic blood pressure inadequate perfusion and/or ischemia results
• fasciotomy usually is indicated when the tissue pressure rises to 40-45 mm Hg in a patient
who has any signs or symptoms of a compartment syndrome-even if distal pulses still present

Table 4. Signs of Compartment Syndrome in Anterior Leg and Forearm

Anterior leg Volar forearm

Fracture Type Tibial fracture Supracondylar (humerus)

Weakness Toe, foot extension Finger, wrist flexion
Pain Toe, foot flexion Finger, wrist extension
Sensory 1st dorsal web space Volar aspect of fingers

Treatment
remove constrictive dressings
bivalve casts down to skin and spread open
place limb at level of heart
emergency fasciotomy to release compartments if difference between diastolic blood pressure
and compartment pressure is less than 30 mmHg (treat within 4-6 hours of onset symptoms)

OR6 – Orthopedics MCCQE 2006 Review Notes

 FRACTURES - GENERAL PRINCIPLES. . . CONT.
AVASCULAR NECROSIS (AVN)
Causes
steroid use (inflammatory arthritis, inflammatory bowel disease (IBD), allergies, renal disease, asthma);
NOT dose related - idiosyncratic
alcohol
post-traumatic fracture/dislocation
septic arthritis
sickle cell disease
Gaucher’s disease
Caisson’s disease - deep sea diving/the bends
idiopathic

Table 5. AVN Classification

Stage Clinical Features X-ray Features
1 Preclinical phase of ischemia No plain x-ray abnormality;
and necrosis; no pain may be detectable on MRI
2 Painful Early radiographic changes i.e.
fragment appears dense,
normal bone contour
3 Painful Radiographic changes obvious,
abnormal bone contour
4 Very painful Collapse of articular surface and signs
of arthritis on both sides of the joint

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

SHOULDER
GENERAL PRINCIPLES
shoulder is a complex 4 part joint
• glenohumeral joint
• acromioclavicular (AC) joint
• scapulothoracic joint
• sternoclavicular joint
examination should involve each of the joints in isolation
the joint is highly mobile therefore decreased stability
dislocations and subluxations following trauma are common
rotator cuff and tendon degeneration are more common than osteoarthritis (OA)
may be referred pain from C-spine
Physical Examination of the Shoulder
LOOK - inspect both shoulders anteriorly and posteriorly, clavicle, deltoids, scapula (SEADS)
FEEL - for tenderness, swelling, temperature changes, muscle characteristics (include all joints and bones)
MOVE - Active/Passive
Active ROM
• forward flexion and abduction
• external rotation (elbows at side and flexed 90 degrees, move arms away from midline)
• internal rotation (hand behind the back, measure wrt. level of the spine)
Passive ROM
• abduction – 180 degrees
• adduction – 45 degrees
• flexion – 180 degrees
• extension – 45 degrees
• internal rotation – level of T4
• external rotation – 40 - 45 degrees

MCCQE 2006 Review Notes Orthopedics – OR7

 SHOULDER . . . CONT.
X-Ray
radiographic views of the shoulder should include
• AP, trans-scapular, and axillary views (at least)
• stress views of the acromioclavicular joint where indicated
look for the Mercedes Benz sign (see Figure 4)
• in the trans-scapular radiograph to look for dislocation
• humeral head should occupy the circle and be overlapping glenoid

Figure 4. Mercedes Benz Sign

Adapted with permission from McRae, Clinical Orthopedic Examination, 3rd ed. Churchill Livingstone, New York, 1994.

ACROMIOCLAVICULAR (AC) JOINT SPRAIN

AC joint is usually injured after fall onto shoulder with adducted arm
2 main ligaments which attach clavicle to scapula
• acromioclavicular (AC) ligament
• coracoclavicular (CC) ligament
acromioclavicular sprains
• Type I: partial injury, no instability, no displacement (sprain of AC ligament) CC-intact
• Type II: disrupted AC ligament, sprain of CC ligament
• Type III: disrupted AC and CC ligaments with superior clavicle displacement
(shoulder displaced inferiorly)
• Type IV: clavicle displaces superiorly and posteriorly through trapezius
• Type V: clavicle displaced inferior to acromion or coracoid (beware brachial plexus injury!)
physical examination
• palpable step between distal clavicle and acromion
• pain with adduction (touch opposite shoulder)
radiographically apparent on stress view (hold weights in hand)
treat type I or II with ice, immobilization, early ROM and strengthening
treat type III the same or repair if skin compromise imminent
operative repair of type IV and V
• excision of lateral clavicle with reconstruction of CC and AC ligament

CLAVICULAR FRACTURE
fall on shoulder or onto outstretched hand
presents as pain and tenting of skin
cosmetically poor but not disabling
brachial plexus and arterial injuries in 10%
classified by proximal, middle (most common), or distal third of clavicle
treatment of proximal and middle third clavicular fractures
• closed reduction with figure-of-eight brace or sling x 1-2 weeks
• early ROM and strengthening
distal third clavicular fractures are unstable and may require ORIF

ANTERIOR SHOULDER DISLOCATION

over 90% of all shoulder dislocations, usually traumatic
may be of two general types:
• involuntary: traumatic, unidirectional, Bankart lesion, responds to surgery
• voluntary: atraumatic, multidirectional, bilateral, rehab, surgery is last resort
occurs when abducted arm is externally rotated or hyperextended
recurrence rate depends on age of first dislocation
• at age 20: 80%; at age 21-40: 60-70%; at age 40-60: 40-60%; at age > 60: < 10%
associated with Hill-Sachs lesion
• indentation of humeral head after impaction on glenoid rim
OR8 – Orthopedics MCCQE 2006 Review Notes
 SHOULDER . . . CONT.
also associated with Bankart lesion
• avulsion of capsule when shoulder dislocates
• associated bony avulsion called "Bony Bankart Lesion"
• occurs in 85% of all anterior dislocations
axillary nerve and musculocutaneous nerve at risk
some associated injuries more common in elderly
• vascular injury and fracture of greater tuberosity
Physical Examination
“squared off” shoulder
humeral head can be palpated anteriorly
arm held in slight abduction and external rotation
loss of internal rotation with anterioinferior humeral head
axillary nerve may be damaged, therefore check sensation and contraction over lateral deltoid;
for musculocutaneous nerve check sensation of lateral forearm and contraction of biceps
apprehension test: for recurrent shoulder instability
• with patient supine, gently abduct and externally rotate patient’s arm to a position where it may
easily dislocate; if shoulder is dislocatable, patient will have a look of apprehension on face
X-Rays
humeral head anterior (to Mercedes Benz sign) in trans-scapular view
axillary view is diagnostic
AP view may show Hill-Sachs lesion if recurrent
rule out associated humeral neck fracture
Treatment
intravenous sedation and muscle relaxation
gentle longitudinal traction and countertraction
+/– alternating internal and external rotation
Hippocratic Method - foot used in axilla for countertraction (not recommended - risk of nerve damage)
Stimsons’s method - patient prone with arm hanging over edge of table, weight hung on wrist
(typically 5 lbs for 15-20 mins)
X-Ray to verify reduction and check neurologic status
sling x 3 weeks with movement of elbow, wrist, fingers
• rehabilitation aimed at strengthening dynamic stabilizers and avoiding the unstable position
(i.e. external rotation and abduction)
recurrent instability and dislocations may require surgery

POSTERIOR SHOULDER DISLOCATION

5% of all shoulder dislocations
caused by force applied along the axis of the arm
• shoulder is adducted, internally rotated and flexed
the four Es which cause posterior dislocation are:
• Epileptic seizure
• Ethanol intoxication
• Electricity (ECT, Electrocution)
• Encephalitis
often missed due to poor physical exam and radiographs
if caused by seizure, often bilateral shoulder dislocations
Physical Examination
anterior shoulder flattening, prominent coracoid
blocked external rotation, limited abduction
X-Rays
humeral head posterior in trans-scapular view
Treatment
inferior traction on flexed elbow + pressure on back of humeral head
may require reduction under general anesthetic
splint for 3 weeks following reduction

ROTATOR CUFF LESIONS

the rotator cuff is a sheet of conjoined tendons
• SITS : S upraspinatus, Infraspinatus, Teres minor, Subscapularis
stabilizes the head of the humerus in the glenoid, when arm extended or abducted
about 80% of 80 year olds have rotator cuff lesions

MCCQE 2006 Review Notes Orthopedics – OR9

 SHOULDER . . . CONT.

supraspinatus

infraspinatus

subscapularis
teres minor
joint capsule

Figure 5. Muscles of the Rotator Cuff and Position at the Glenoid

Illustration by Kevin Millar

IMPINGEMENT SYNDROME
also called "Painful Arc Syndrome"
describes impingement of supraspinatus tendon between
• humeral head/greater tuberosity and anatomic arch between anterior edge
and undersurface of acromion, AC joint and CA ligament
Physical Examination
painful arc between 90-130 degrees of abduction
pain on palpation of rotator cuff
impingement test
• place patient’s hand on opposite shoulder and lift elbow off chest - reproduces pain
• may have associated osteophytes under acromion or AC joint
Types of Impingement Syndrome
mild (“wear”)
• inflamed rotator cuff
• aching, reversible, +/– weakness
• treatment is non-operative (physiotherapy, NSAIDs)
moderate ("tear")
• tendon is thick and fibrotic, microtears
• night pain and shoulder weakness prominent
• non-operative treatment +/– steroid injection
severe ("repair")
• tear of rotator cuff, cannot start abduction
• may require surgical repair

FROZEN SHOULDER
process which involves adhesive capsulitis
Primary Adhesive Capsulitis
idiopathic, usually associated with diabetes mellitus
may resolve spontaneously in 9-18 months
Secondary Adhesive Capsulitis
due to prolonged immobilization
• "Shoulder-Hand Syndrome" - hand in cast, immobilized shoulder
• following myocardial infarction, stroke, shoulder trauma
Treatment
active and passive ROM (physiotherapy)
NSAIDs and steroid injections if limited by pain
MUA (manipulation under anesthesia) or arthroscopy for debridement/decompression
diabetics usually have poor outcomes

OR10 – Orthopedics MCCQE 2006 Review Notes

 HUMERUS
HUMERAL SHAFT FRACTURE
from falls on outstretched hand, MVAs or direct load applied to arm
generally treated non-surgically
complications include radial nerve injury and nonunion
Treatment
undisplaced fracture +/– radial nerve palsy
• collar and cuff x 4-6 weeks, then active exercises for shoulder, wrist and hand if fracture united
• radial nerve palsy usually improves spontaneously over 3-6 months; if no improvement at
3 months then EMG
displaced fracture
• apply collar and cuff or sugar-tong plaster splint cast and reassess radial nerve
• immobilize 2-3 weeks then go to frontal brace and begin active upper limb exercises
• ORIF indicated if:
1) poor closed reduction,
2) polytrauma,
3) segmental fracture,
4) pathologic fracture,
5) neurovascular compromise,
6) associated fracture of proximal ulna “floating elbow”

PROXIMAL HUMERAL FRACTURE

especially common fracture in osteoporotic person
fall on o uts tretched h and ( FOOSH)
pain, swelling and tenderness around the shoulder (especially around greater tuberosity)
fracture involves
• proximal humeral diaphysis (surgical neck)
• +/– greater tuberosity
• +/– lesser tuberosity
classify into 2, 3, and 4 part fractures
Treatment
if needed, treat for osteoporosis
undisplaced
• stable/impacted, use Velpeau sling x 1 week then active ROM
• unstable (unusual), use Velpeau sling x 3 weeks then gentle ROM
displaced > 1 cm or angulated > 45º
• attempt closed reduction, Velpeau sling x 2 weeks, gentle ROM
• ORIF if unsatisfactory reduction
fracture with dislocation of glenohumeral joint
• high incidence of neurovascular injury and osteonecrosis
• ORIF; hemiarthroplasty may be necessary

Fractures in this region may involve

the anatomical neck (rare) (1),
the surgical neck (2),
the greater tuberosity(3),
or the lesser tuberosity (4)

Combinations of these injuries

are common and may involve
two-part (5),
three-part (6), and
four-part fractures (7)

Figure 6. Fractures of the Proximal Humerus

Reproduced with permission from McRae, Practical Fracture Treatment, 2nd ed. Churchill Livingstone, New York, 1989.

MCCQE 2006 Review Notes Orthopedics – OR11

 ELBOW

Figure 8. Displaced Supracondylar

Figure 7. Anatomy of the Elbow Fracture of Humerus
SUPRACONDYLAR FRACTURE
usually in children
fall on outstretched hand
Treatment
children
• closed reduction +/– percutaneous pinning in O.R. with fluoroscopy
• cast in flexion x 3 weeks
adult
• undisplaced fracture, may be treated in cast
• displaced fracture, ORIF since closed reduction usually inadequate
Complications
stiffnes most common
see Complications of Fractures section
RADIAL HEAD FRACTURE
mechanism: fall on out s tretched h and ( FOOSH)
clinically: progressive pain due to hemarthrosis with loss of ROM and pain on lateral side of elbow
aggravated by forearm pronation or supination
careful, may not be seen radiographically
look for “sail sign” of anterior fat pad or the prescence of a posterior fat pad on x-ray to detect occult
radial head fractures
Mason Classification
Type 1: undisplaced segmental fracture, usually normal ROM
Type 2: displaced segmental fracture, ROM compromised
Type 3: comminuted fracture
Type 4: Type 3 with posterior dislocation
Treatment
Type 1: elbow slab, sling 3-5 days, early ROM
Type 2: ORIF radial head
Type 3/4: excision of radial head +/– prosthesis
OLECRANON FRACTURE
fall on point of elbow with avulsion by triceps or fall on outstretched arm
active extension absent
gross displacement can not be reduced closed because of pull of triceps
Treatment
undisplaced: above elbow cast 2 weeks, early ROM
displaced: ORIF, above elbow slab x 1 week, early ROM
ELBOW DISLOCATION
usually young people in sporting events or high speed MVA
> 90% are posterior or posterior-lateral
fall on outstretched hand
rule out concurrent radial head or coracoid process fractures
Treatment of Posterior Dislocation
closed reduction: traction then flexion
above elbow backslab with elbow 90 degrees and wrist pronated
open reduction if unstable or loose body (unusual)
Complications
stiffness
intra-articular loose body
• usually from joint surface cartilage
• not obvious on x-ray
• occasionally medial epicondyle is pulled into joint, especially in children
heterotopic ossification (bone formation)
• prevented by indomethacin immediately following surgery
recurrent dislocation is extremely rare
OR12 – Orthopedics MCCQE 2006 Review Notes
 FOREARM FRACTURES
GENERAL PRINCIPLES OF FOREARM FRACTURES
more commonly fracture of both bones, usually displaced
if only one bone fractured look for dislocation of other
displaced fractures of radius or ulna mostly treated by ORIF, as non-surgical
methods often result in limitation of pronation/supination
forearm fractures in children are usually of the greenstick type, in which only one cortex is involved
COMPLICATIONS SPECIFIC TO FOREARM FRACTURES
cross union - radius malunites to ulna
loss of pronation/supination
loss of extension of elbow
difficult to reduce and maintain closed
• accurate reduction is essential, usually requires ORIF
shoulder-hand syndrome (frozen shoulder)
NIGHTSTICK FRACTURE(see Figure 9)
isolated fracture of ulna, with minimal displacement
mechanism: from holding arm up to protect face from blow
rule out fracture clinically and radiographically
treatment: below elbow cast 6 weeks for distal 1/3 fractures
if angulation of proximal 2/3 severe; consider ORIF
GALEAZZI FRACTURE(see Figure 10)
fracture of distal radius
dislocation of distal radio-ulnar joint (DRUJ) at wrist
treatment: immobilize in supination to reduce DRUJ, ORIF

Figure 9. Nightstick Fracture Figure 10. Galeazzi Fracture

Illustration by Chesley Sheppard Reproduced with permission from McRae, Practical Fracture Treatment,
2nd ed. Churchill Livingstone, New York, 1989.

MONTEGGIA FRACTURE(see Figure 11)

fracture of ulna with associated dislocation of radial head
treatment: ORIF is recommended- open reduction of the ulna is usually followed by
indirect reduction of the radius

Figure 11. Monteggia Fracture Showing Anterior

and Posterior Dislocation of Radial Head
Adapted with permission from McRae, Practical Fracture Treatment, 2nd ed. Churchill Livingstone, New York, 1989.

MCCQE 2006 Review Notes Orthopedics – OR13

 WRIST
SCAPHOID FRACTURE (see Figure 12)
Etiology
second most common carpal fracture, common in young adults
maintain a high index of suspicion with falls o n outs tretched
h and (FOOSH )
blood supply is from distal to proximal poles of scaphoid
- risk of avascular necrosis (AVN)
Diagnosis
clinical
• pain on wrist movement i.e positive scaphoid test
• tenderness elicited in anatomical snuff box and
over scaphoid tubercle
x-ray Figure 12. Scaphoid Fracture
• AP/lateral/scaphoid views required
• x-ray alone may not reveal scaphoid fracture Reproduced with permission from McRae, Practical
• +/– bone scan and/or CT scan Fracture Treatment, 2nd ed. Churchill Livingstone,
New York, 1989.
Treatment
Suspected Scaphoid Fracture

undisplaced displaced

–ve x-ray +ve ORIF

cast 2 weeks cast 8 weeks

(thumb spica) (check weekly x 3)

repeat x-ray

–ve +ve cast off

fracture healed
clinical exam yes no

–ve +ve

STOP bone scan STOP cast +/– OR

Figure 13. Scaphoid Fracture Algorithm

Complications
nonunion +/– AVN
highest incidence of AVN (30%) is with fracture of proximal 1/3
high incidence of nonunion and AVN with significant displacement
COLLES' FRACTURE(see Figure 14)

Figure 14. Colles' Fracture and Associated Bony Deformity

Adapted with permission from McRae, Practical Fracture Treatment, 2nd ed. Churchill Livingstone, New York, 1989.

OR14 – Orthopedics MCCQE 2006 Review Notes

 WRIST . . . CONT.
Etiology
most common wrist fracture
fall on o uts tretched h and ( FOOSH)
most common in osteoporotic bone
Diagnosis
clinical
• swelling, ecchymosis, tenderness
• “dinner fork” deformity (Figure 14)
• assess neurovascular status (carpal tunnel syndrome)
X-ray: distal fragment is
1. dorsally displaced with dorsal comminution
2. dorsally tilted fragment with apex of fracture volar
3. supinated
4. radially deviated
5. shortened (radial styloid normally 1cm distal to ulna) +/– fracture of ulnar styloid
Treatment
nondisplaced
• short arm cast applied to wrist under gentle traction
• neutral wrist position
displaced
1. anesthesia - hematoma block commonly used
2. disimpaction - axial traction with increasing force over 2 minutes
(pull on thumb and ring finger, with countertraction at the elbow)
3. reduce by pulling hand into
• slight flexion
• full pronation
• full ulnar deviation
4. maintain reduction with direct pressure to fracture site, apply well moulded dorsal-radial slab (splint)
5. post-reduction x-ray (AP/lateral), goal to correct dorsal angulation and regain radial length
6. check arm after 24 hours for swelling, neurovascular status
7. circular cast after 1-2 weeks; check cast at 1, 2, 6 weeks; cast off after 6 weeks, physiotherapy
(ROM, grip strength)
if inadequate reduction at any time
• try closed reduction under GA
• ORIF
SMITH’S FRACTURE(see Figure 15)

Type a Type b Type c

Figure 15. Smith’s Fracture
Illustration by Marc Dryer

Diagnosis
clinical presentation and radiographic evidence
fracture similar to Colles’ but volar displacement
of distal radius
Treatment
hematoma block
closed reduction in supination and slight flexion
splint
ORIF if unstable reduction
BARTON’S FRACTURE(see Figure 16)
Diagnosis
clinical presentation and radiographic evidence
intra-articular fracture of distal radius resulting
from shearing force Dorsal Ventral
classified as dorsal or volar depending upon
location of fragment Figure 16. Barton’s Fracture
Illustration by Marc Dryer
MCCQE 2006 Review Notes Orthopedics – OR15
 WRIST . . . CONT.
Treatment
attempt closed reduction although rarely adequate
dorsal: slight extension, pronation, splint
volar: slight flexion, supination, splint
usually requires ORIF if unstable reduction

COMPLICATIONS OF WRIST FRACTURES

most common complications are poor grip strength, stiffness, and radial shortening
80% have normal function in 6-12 months
early
• difficult reduction +/– loss of reduction
• compartment syndrome
• extensor pollicis longus (EPL) tendon rupture
• acute carpal tunnel syndrome
• finger swelling with venous or lymphatic block
late
• malunion, radial shortening
• painful wrist secondary to ulnar prominence
• frozen shoulder ("shoulder hand syndrome")
• post-traumatic arthritis
• carpal tunnel syndrome
• reflex sympathetic dystrophy (RSD)

SPINE
DIFFERENTIAL DIAGNOSIS OF BACK PAIN
degenerative (90% of all back pain)
• mechanical (degenerative, facet)
• spinal stenosis (congenital, osteophyte, central disc)
• peripheral nerve compression (disc herniation)
cauda equina syndrome
neoplastic
• primary, metastatic
trauma
• fracture (compression, distraction, translation, rotation)
spondyloarthropathies
• e.g. ankylosing spondylitis
referred
• aorta, renal, ureter, pancreas
Epidemiology
common problem
L4-5 and L5-S1 most common sites
10% nerve root compression
less than 2% results from tumour, trauma, other diseases
DEGENERATIVE BACK PAIN
Pathogenesis
loss of vertebral disc height with age results in
• bulging and tears of annulus fibrosus
• change in alignment of facet joints
• osteophyte formation
pain sensation is transmitted by branches of adjacent nerve root,
which innervates disc and facet joints
• results in both localized pain and referred pain down adjacent spinal nerve
• radiating pain typically occurs in buttocks and down legs
pain may originate from disc +/– facet joints
disc herniations are most commonly posterolateral or lateral (see Colour Atlas NS20)
• posterolateral herniations (most common) affect the nerve root below the disc
(i.e. the L4-L5 disc compresses L5 root)
natural history: 90% improve with non-operative treatment within 3 months
non-operative
• modified activity
• back strengthening
• NSAIDs
surgical
• decompression +/– fusion
• no difference in outcome between non-operative and surgical management in 2 years
OR16 – Orthopedics MCCQE 2006 Review Notes
 SPINE . . . CONT.

Table 6. Types of Low Back Pain

Mechanical Back Pain Direct Nerve Root Compression
Disc Origin Facet Origin Spinal Stenosis Root Compression
Pain Back Back Leg Leg
Dominance
Aggravation Flexion Extension Exercise, extension Flexion
standing, walking walking, standing
Onset Gradual More sudden Congenital or Acute leg ±
acquired back pain
Duration Long Shorter Acute or Short episode
(wks, months) (days, wks) chronic history attacks
(weeks to months) (minutes)
Treatment Relief of strain, Relief of strain, Relief of strain, Relief of strain,
exercise exercise exercise exercise + surgical
decompression if
progressive or severe
deficit
spinal stenosis
• acquired stenosis best thought of as a progression or end stage degenerative disc disease,
in which osteophytic growth results in a narrowed spinal canal

Table 7. Differentiating Claudication

Neurogenic Vascular
Aggravation With standing or extension Walking set distance
walking distance variable
Alleviation Change in position (usually Stopping walking
flexion, sitting, lying down)
Time Relief in 10 minutes Relief in 2 minutes
Character Neurogenic ± neurological deficit Muscular cramping

X-Rays
AP, lateral, obliques
indicated for new onset back pain (i.e. r/o tumour, congenital deformities)
• look for "Winking Owl sign” ––> signifies tumour invasion of pedicle
CT scan/myelography, MRI
• for spinal stenosis, cauda equina syndrome, disc herniation
x-rays not very helpful for chronic degenerative back pain
• radiographic degeneration does not correlate well with back pain
CAUDA EQUINA SYNDROME
most frequent cause is large central disc herniation
progressive neurological deficit presenting with
• saddle anesthesia
• decreased anal tone and reflex
• fecal incontinence
• urinary retention
• SURGICAL EMERGENCY! will cause permanent urinary/bowel incontinence if untreated

Table 8. Lumbar Radiculopathy/Neuropathy

Root L4 L5 S1
motor quadriceps ankle dorsiflexion ankle plantar flexion
tibialis anterior great toe extensor
hip abductor
sensory posteromedial lateral calf or lateral aspect of foot
1st web space
reflex knee reflex hamstring reflex ankle reflex
test limitation of limitation of limitation bowstring
femoral stretch straight leg raise

MCCQE 2006 Review Notes Orthopedics – OR17

 SPINE . . . CONT.

Figure 17. Dermatomes of the Figure 18. Alignment of Cervical Spine

Upper and Lower Limbs Adapted with permission from McRae, Clinical Orthopedic
Examination, 3rd ed. Churchill Livingstone, New York, 1994.

TRAUMA
C-Spine X-rays
can you see C1 to superior portion of T1? - if not, film is INADEQUATE
should have Swimmers view (one arm above head and one arm below head)
for adequate visualization of C7-T1
open mouth odontoid view for adequate visualization of atlanto-axial joint
identify
1) alignment (on lateral films - see Figure 18)
• anterior body (1)
• posterior body (2) should curve to anterior foramen magnum
• facet joints (3)
• laminar fusion line (4) should curve proximally and point to posterior base of foramen magnum
2) vertebral bodies
• height and width
3) cartilage
4) soft tissues
• prevertebral soft tissue: C3=3-5 mm, C7=7-10 mm
Clearing C-spine X-rays
x-ray (AP/lat/odontoid)

abN N

uncons cons

neck pain

yes no

CT abN flex/ext x-ray

N cleared

Figure 19. Algorithm for Clearing C-spine X-rays

OR18 – Orthopedics MCCQE 2006 Review Notes

 SPINE . . . CONT.

Table 9. Cervical Radiculopathy/Neuropathy

Root C5 C6 C7 C8
Motor Deltoid Biceps Triceps Digital flexors
supraspinatus Brachioradialis intrinsic
Biceps

Sensory Axillary nerve Thumb and Middle Ring and

(middle deltoid) index finger finger little finger

Reflex Biceps Brachioradialis Triceps Finger jerk

Middle deltoid reflex reflex

THORACIC AND LUMBAR SPINE

Table 10. Elements of 3 Column Spine
Anterior Column Middle Column Posterior Column
Anterior longitudinal ligament Posterior longitudinal ligament Posterior body elements
Anterior annulus fibrosis Posterior annulus fibrosis Supraspinous, intraspinous ligaments
Anterior 1/2 of vertebral body Posterior 1/2 of vertebral body acet joints ligamentum flavum

Table 11. Basic Types of Spine Fractures and their Mechanisms

Type Mechanism
1. Compression Flexion
• Anterior Anterior flexion
• Lateral Lateral flexion
2. Burst Axial load +/- flexion/rotation
3. Distraction Flexion, distraction, common in lap-belted MVC (Chance)
4. Fracture dislocation Flexion-Rotation, Shear, Flexion Distraction

Chance Fracture of the Spine

failure of anterior, middle, and posterior columns caused by high tensile force;
most commonly seen in MVC lap-belted passenger
CT scan to assist with diagnosis
X-Ray (see Figure 20)
oblique views show "Scottie Dog"
look for disruption of "Scottie Dog" to identify spondylolysis

S - superior facet
N - transverse process
P - pars interarticularis
I - inferior facet

Adapted with permission from McRae, Clinical

Orthopedic Examination, 3rd ed. Churchill
Figure 20. Scottie Dog Livingstone, New York, 1994.

Treatment
compression
• wedge: conservative if < 50% compression
• burst: may push material into spinal canal therefore surgical
correction (distraction and IF for stabilization)
distraction
• Chance: if part-bony, part-soft tissue, conservative management with hyperextension orthosis
• surgical stabilization required with extensive soft tissue, ligamentous injury
rotation
• burst type: inherently unstable therefore internal stabilization
MCCQE 2006 Review Notes Orthopedics – OR19
 HIP
DIFFERENTIAL DIAGNOSIS OF HIP PAIN IN THE ADULT
traumatic
• fracture (femur or pelvis), dislocation, labral tear
arthritic
• septic, osteoarthritis, inflammatory (see Rheumatology Chapter)
vascular
• AVN of femoral head
trochanteric bursitis and gluteal tendonitis
neoplastic
referred
• hip pain is felt in the groin area and anterior thigh
• spine usually involves buttock and posterior thigh
• knee, abdominal viscera, vascular (intermittent claudication)
X-Ray Diagnosis
views: AP, lateral, Judet (oblique) views

Table 12. Radiological Diagnosis of Hip Pathology

Finding Osteoarthritis (OA) AVN Hip Fracture
Loss of joint space Localized None None
Subchondral +++ ++ None
Sclerosis Acetabulum and head Head only
Osteophytes +++ None None
Erosions None None None
Leg shortening +/– None +++ if displaced

Note: AVN becomes same as OA later in disease process, and hip fracture may have preexisting OA
PELVIC FRACTURES
most common fracture involves pubic rami, followed by ilial, ischial, acetabular, coccygeal and sacral bones
Tile Classification (see Figure 21)
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

Type A Type B Type C

Stable Avulsion Fracture Open Book Unstable Vertical Fracture
Figure 21. Illustration of the Tile Classification of Pelvis Fractures
Illustration by Seline McNamee

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)
Treatment
ABCs
assess genitourinary injury (rectal exam/vaginal exam mandatory)
Type A - bedrest and mobilization with walking aids
Type B/C - external or internal fixation
OR20 – Orthopedics MCCQE 2006 Review Notes
 HIP . . . CONT.

Complications
hemorrhage - life threatening
bladder/bowel injuries
neurological damage
obstetrical difficulties
persistent sacro-iliac (SI) joint pain
post-traumatic arthritis of the hip with acetabular fractures
HIP DISLOCATION
mainly seen with artificial hips
1. Anterior (rare)
blow to knee with hip widely abducted
clinically: limb fixed, externally rotated and abducted
femoral head tends to migrate superiorly
attempt closed reduction under GA
then CT of hip to assess joint congruity
2. Posterior
severe forces to knee with hip flexed and adducted (e.g. knee into dashboard in MVA)
clinically: limb shortened, internally rotated and adducted
femoral head tends to migrate inferiorly/medially
+/– fracture of posterior lip of acetabulum or intra-articular fracture
sciatic nerve injury common especially with associated acetabular fracture
assess knee, femoral shaft for other injuries/fractures
+/– fracture of posterior lip of acetabulum or intra-articular fracture
attempt closed reduction under GA +/– image intensifier
then CT to assess congruity and acetabular integrity
traction x 6 weeks, then ROM
ORIF if unstable, intra-articular fragments, or posterior wall fractures
3. Central
associated with acetabular fracture
4. After Total Hip Arthroplasty (THA)
occurs in 1-4% of primary THA and 16% in revision cases
about 74% of THA dislocations are posterior, 16% anterior and 8% central
THA are unstable in the position of flexion and internal rotation
Treatment
complete muscle relaxation is key – conscious sedation (IV fentanyl and versed) or spinal or GA
assistant applies downward pressure to pelvis
reduction for posterior dislocation – fully flex hip, abduct and externally rotate hip,
apply upward traction on femur
reduction for anterior dislocation – fully flex hip , adduct and internally rotate hip,
apply downward pressure on femur
Complications
post-traumatic arthritis due to cartilage injury or intra-articular loose body
femoral head injury including osteonecrosis + fracture; 100% if nothing12 hours before reduction
sciatic nerve palsy in 25% (10% permanent)
fracture of femoral shaft or neck
heterotopic ossification
coxa magna (occurs in up to 50% of children after a hip dislocation)
sciatic nerve palsy in 25% (10% permanent)
fracture of femoral shaft or neck
knee injury (posterior cruciate ligament (PCL) tear with dashboard injury)
HIP FRACTURE
Epidemiology
common fracture in elderly
female > male
in osteopenic individual, fracture may precede simple fall (muscle stronger than bone)
in younger individual, fracture related to high energy injury
• markedly displaced
• associated with other injuries
Diagnosis
characteristic history, unable to bear weight on affected limb
limb shortened, externally rotated, painful ROM, antalgic gait
obtain AP of pelvis and lateral of involved hip
if findings equivocal - bone scan and tomograms
MCCQE 2006 Review Notes Orthopedics – OR21
 HIP . . . CONT.

Subcapital
(Intracapsular)
Intertrochanteric
(Extracapsular)

Subtrochanteric
(Extracapsular)

Basicervical
(Intracapsular)

Figure 22. Blood Supply to Femoral Head

and Fracture Classification
Adapted with permission from McRae, Practical Fracture Treatment, 2nd ed. Churchill Livingstone, New York, 1989.

1. Subcapital Fractures
fracture between femoral head and intertrochanteric line
main vascular supply to femoral head from distal arterial ring to proximal head through femoral neck
fracture interrupts blood supply
• articular surface restricts blood supply to femoral head
• AVN risk depends on degree of displacement

Table 13. Garden Classification of Subcapital Fractures

Type Extent Displacement Alignment Trabeculae
I Incomplete Impacted Valgus Malaligned
2 Complete None Neutral Aligned
3 Complete Some Varus Malaligned
4 Complete Marked Varus Aligned

Treatment
if needed, treat osteoporosis
restore anatomy, attempt to save head
type of treatment depends on displacement and patient age
undisplaced (Garden 1,2) – internal fixation to prevent displacement
displaced (Garden 3,4) - depends on patient age and function
• older patient, low function ––> unipolar hemiarthroplasty (Moore’s Prosthesis)
• older patient, high function ––> bipolar hemiarthroplasty
• young patient, high function ––> reduction with internal fixation within 12 hrs of fracture
Complications
avascular necrosis (AVN), non-union, deep vein thrombosis (DVT)
2. Intertrochanteric Fracture
extra-capsular fracture, therefore good femoral head viability
fracture stability determined by number of fragments, integrity of calcar and direction of fracture line
greater and lesser trochanters may be separate fragments
posterior fragment may be avascular, therefore possible delayed union
Classification
classification based on number of parts and stability
• 2 part - stable, trochanter intact
• 3 part - one trochanter separated, unstable if large calcar fragment
• 4 part - unstable, both trochanters separated
• reverse obliquity – about 15% of intertrochanteric fractures;
fracture line runs inferiolaterally from lesser trochanter
Treatment
obtain a good closed reduction under fluoroscopy on the fracture table
after reduction obtained, internal fixation with dynamic hip screw and plate
reverse obliquity fractures are highly unstable and require fixation with dynamic condylar screw and plate

OR22 – Orthopedics MCCQE 2006 Review Notes

 HIP . . . CONT.

3. Subtrochanteric Fracture
least common hip fracture
highly unstable
transverse, spiral or oblique fracture passes below lesser trochanter
younger population with high energy injuries
x-rays show flexed and abducted proximal fragment, from pull of iliopsoas
on lesser trochanter, gluteus medius and minimus on greater trochanter
Treatment
obtain a good closed reduction under fluoroscopy on the fracture table
internal fixation with intramedullary nail
ARTHRITIS OF THE HIP
many causes (osteoarthritis, post-traumatic, developmental dysplasia of the hip, RA, etc.)
Diagnosis
usually in an older individual
gradual onset of groin/medial thigh pain, increasing with activity
limb shortening
decreased internal rotation/abduction of hip
fixed flexion deformity
positive Trendelenburg sign
x-ray - joint space narrowing, sclerosis, subchondral cysts, osteophytes
Treatment
non-operative
• weight loss, walking aids, physiotherapy, analgesia (acetaminophen), NSAIDs
surgery
• realign - osteotomy
• replace - arthroplasty
• ablate - arthrodesis, excision
Trendelenberg Test (see Figure 23)
patient stands on affected leg, normally gluteus medius
muscle on ipsilateral side contracts to keep pelvis level
a positive test is if the contralateral side drops or if patient
compensates by leaning way over supported leg
may occur anywhere along line "ab"
• e.g. weak abductors, avulsion of gluteus medius,
trochanteric fracture/removal
may occur anywhere along line “bc”
• e.g. painful hip due to osteoarthritis, femoral neck
in varus, acetabular instability Figure 23. Causes of a Positive
may occur anywhere along line “ac” Trendelenberg Sign
• e.g. fractured pelvic side wall

AVN OF THE FEMORAL HEAD (see Avasular Necrosis section)

Clinical
sudden onset of severe pain, related to weight-bearing
worse at night
rapid progression (compared to osteoarthritis)
Diagnosis
x-ray - r/o hip fracture
bone scan - see healing fracture
MRI (best)
Treatment
early: vascularized fibular graft to preserve femoral head, rotational
osteotomy in young patient with moderate disease
late: hip replacement
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
soft tissue trauma

MCCQE 2006 Review Notes Orthopedics – OR23

 FEMUR
Clinical
leg is shortened, externally rotated
unable to weight bear
assess neurovascular status
r/o: open fracture, soft tissue compromise
r/o: child abuse with spiral fractures in children
Treatment
ABCs of trauma are essential
immobilize leg with Thomas Splint
adequate analgesia
surgical fixation (intramedullary nail) within 24 hours
• high rate of surgical union after 6 to 12 weeks
early mobilization of hip and knee
SUPRACONDYLAR FEMORAL FRACTURE
high energy, multiple trauma
knee joint is disrupted severely with bicondylar fracture
poor prognosis with comminuted fractures
high incidence of post-traumatic arthritis
Treatment
internal fixation and early knee ROM
quadriceps strengthening

KNEE

Figure 24. Diagram of Right Tibial Plateau

Adapted with permission from McRae, Clinical Orthopedic Examination, 3rd ed. Churchill Livingstone, New York, 1994.

COMMON KNEE SYMPTOMS

locking = spontaneous block to extension
• torn meniscus, loose body
pseudo-locking = restricted ROM without mechanical block
• arthritis (effusion, pain), muscle spasm following injury
instability = “giving out”
• torn arterior cruciate ligament (ACL), patellar subluxation, torn meniscus, loose body
traumatic knee swelling
• effusion, usually represents hemarthrosis
• ligamentous injury with hemarthrosis
• meniscal injury
• traumatic synovitis
non-traumatic knee swelling without trauma
• septic or crystal-induced arthritis
• seronegative arthritis (AS, Reiter's, Psoriatic, IBD)
• seropositive arthritis (RA, SLE)
• avascular necrosis
• sickle cell disease
EVALUATION OF KNEE COMPLAINTS
History
ligament injuries require high energy force
meniscal injury in young person requires moderate force, while in older person only requires mild force

OR24 – Orthopedics MCCQE 2006 Review Notes

 KNEE . . . CONT.
Physical Examination
LOOK:SEADS, alignment
FEEL: effusion, crepitus
MOVE: gait, strength, ROM
Special Tests of the Knee
Anterior and Posterior Draw Tests
• demonstrate torn ACL and PCL, respectively
• knee flexed at 90 degrees, foot immobilized, hamstrings released
• if able to sublux tibia anteriorly then ACL may be torn
• if able to sublux tibia posteriorly then PCL torn
Lachmann Test
• demonstrates torn ACL
• hold knee in 10-20 degrees flexion, stabilizing the femur
• try to sublux tibia anteriorly on femur
• similar to anterior drawer test, more reliable due to less muscular stabilization
Posterior Sag Sign
• demonstrates torn PCL
• may give a false positive anterior draw sign
• flex knees and hips to 90 degrees, hold ankles and knees
• view from the lateral aspect
• if one tibia sags posterior than the other, its PCL is torn; loss of prominence of tibial tuberosity
Pivot Shift Sign
• demonstrates torn ACL
• start with the knee in extension
• internally rotate foot, apply valgus force to knee
• look and feel for anterior subluxation of lateral tibial condyle
• slowly flex while palpating knee and feel for pivot which is the tibiofemoral reduction
• reverse pivot shift (start in flexion, externally rotate,
apply valgus and extend knee) suggests torn PCL
Collateral Ligament Stress Test
• palpate ligament for "opening" of joint space while testing
• with knee in full extension apply valgus force to test MCL, apply varus force to test LCL
• repeat tests with knee in 20 degrees flexion to relax joint capsule
• opening only in 20 degrees flexion due to MCL damage only
• opening in 20 degrees of flexion and full extension is due to MCL, cruciate, and joint capsule damage
test for Meniscal tear
• Crouch Compression test is the most sensitive test
• joint line pain when squatting
• McMurray’s test useful collaborative information
• with knee in flexion palpate joint line for painful “pop”
• internally rotate foot, varus stress, and extend knee to test lateral meniscus
• externally rotate foot, valgus stress, and extend knee to
test medial meniscus
X-Rays of the Knee
AP standing, lateral
skyline view
• with knees in flexion, beam is aimed from anterior tibia to anterior femur
• allows for view of patellofemoral joint
obliques for intra-articular fractures
3 foot standing view
• radiograph from hip to foot with patient in standing position
• useful in evaluating leg length and genu varus / valgus
LIGAMENTOUS INJURIES OF THE KNEE
may have hemarthrosis and/or effusion in acute phase
deceleration or pivoting injury
must check for effusion and tenderness on physical exam
ANTERIOR CRUCIATE LIGAMENT (ACL) TEAR
History
indirect varus blow to knee
hyperextended knee + internal rotation
audible pop, knee instability, “giving way”
immediate swelling
inability to continue activity
Physical
posterolateral joint line tenderness
positive Lachmann, pivot shift, anterior draw
effusion, +/– hemarthrosis
+/– associated medial meniscus tear, MCL injury (O'Donahue's Unhappy Triad)
associated with Segond fractures - lateral tibial avulsion fractures
MCCQE 2006 Review Notes Orthopedics – OR25
 KNEE . . . CONT.
Treatment
based on activity and functional impairment
stable with minimal functional impairment
• early mobilization
• physiotherapy and quadriceps strengthening
instability with functional impairment / high demand lifestyle
• ACL reconstruction
POSTERIOR CRUCIATE LIGAMENT (PCL) TEAR
much less common than ACL injury
History
fall onto flexed knee with plantar flexed foot
hit anterior tibia on dashboard in motor vehicle accident
hyperflexion or hyperextension with anterior tibial force
Physical
positive posterior sag sign
false positive anterior draw
true positive posterior draw
reverse pivot shift sign
Treatment
non-operative vs. surgical PCL reconstruction
MEDIAL COLLATERAL LIGAMENT (MCL) TEAR
History
valgus force to knee
+/– "pop" heard
severe pain with partial tears
complete tear may be painless
Physical
swelling
tender above and below medial joint line
assess joint space opening with valgus force
• pain
• MCL laxity with end point - partial tear
• absence of end point - complete tear
• rule out ACL and medial meniscus tear
Treatment
minor
• immobilize briefly, early ROM and strengthening
moderate
• knee immobilizer or cast
• early physiotherapy with ROM and strengthening
severe or combined
• surgical repair of associated injuries
• surgical repair of isolated MCL tear is controversial
LATERAL COLLATERAL LIGAMENT TEAR
varus force to knee
similar history, physical to MCL
rule out common peroneal nerve injury (difficult dorsiflexion and decreased sensation at the top of the foot)
treatment as for MCL
MENISCAL TEAR
medial meniscus torn 8x more than lateral
1/2 are traumatic, 1/2 are degenerative
usually associated with other ligamentous injuries if traumatic
History
twisting force when the knee is partly or completely flexed
e.g. squatting and then rotating rapidly, skiing, football, tennis
acute
• immediate pain, difficulty weight bearing, +/– locking
chronic
• pain, swelling, instability

OR26 – Orthopedics MCCQE 2006 Review Notes

 KNEE . . . CONT.
Physical
effusion
lack of full extension (locking)
pinpoint joint line tenderness
McMurray's test
Diagnosis and Treatment
MRI is diagnostic only
non-operative (unless locked)
• ROM and strengthening exercises
• NSAIDs
failed non-operative
• arthroscopy (diagnostic and therapeutic)
PATELLAR/QUADRICEPS TENDON RUPTURE
low energy injury, sudden forceful contraction during attempt to stop fall
partial or complete
more common in patients with diabetes, SLE, RA, steroid use
History
fall onto flexed knee
inability to extend knee
Physical
palpable gap between patella and quadriceps
may have hemarthrosis / effusion of knee
Investigations
knee radiographs to rule out patellar fracture
joint aspirate may show hemarthrosis
Treatment
surgical repair of tendon
DISLOCATED KNEE
bad high energy injury
associated injuries
• popliteal artery intimal tear or disruption 35-50%
• capsular, ligamentous and common peroneal nerve injury
Investigations
angiogram
Treatment
closed reduction, above knee cylinder cast x 4 weeks
alternately, external fixation especially if vascular repair
surgical repair of all ligaments if high demand patient

PATELLA
PATELLA DISLOCATION
Etiology
commonly seen in young adults
patella dislocates laterally over flexed knee
predisposition - weak vastus medialis muscle and tight lateral retinaculum, valgus knees
can be acute, chronic or recurrent
• acute occurs with direct blow, excessive muscular forces
• recurrent type is associated with shallow intercondylar groove or patella alta (high riding patella)
may have associated osteochondral fracture of anterior lateral femoral condyle or avulsion of medial patella
Diagnosis
severe pain
difficulty extending knee
positive patellar apprehension sign
• sublux patella laterally over extended knee
• pain if subluxation is reproduced, patient apprehensive
chronic patient reports catching, giving way with walking or turning

MCCQE 2006 Review Notes Orthopedics – OR27

 PATELLA . . . CONT.
Treatment
acute - non-operative
• reduce patella
• gentle ROM
• strengthen quadriceps, especially vastus medialis
• support during sports activities
chronic / recurrent
• often non-operative treatment unsuccessful
• lateral retinacular release (surgical) plus medial plication
• tibial tubercle transfer corrects line of force by reinserting patella medially and distally
CHONDROMALACIA PATELLAE
also known as patellofemoral syndrome
commonly seen in young adults, especially females
softening of articular cartilage, usually medial aspect of patella
etiologies: malalignment, trauma, congenital abnormal shape of patella or femoral
groove, recurrent patellar subluxation or dislocation, excessive knee strain (athletes)
History
deep aching anterior knee pain
exacerbated by prolonged sitting, strenuous athletic activities, stair climbing
Physical
pathognomonic: pain with firm compression of patella into medial femoral groove
tenderness to palpation of underside of medially displaced patella
increased Q-angle - angle formed between thigh and patellar tendon
pain with extension against resistance through terminal 30-40 degrees
X-Rays
AP, lateral, skyline
Treatment
non-operative treatment
• physio (isometric quads strengthening)
• NSAIDs
surgical treatment with refractory patients
• tibial tubercle elevation
• arthroscopic shaving and debridement and lateral release
PATELLAR FRACTURE
History
direct - blow to patella
indirect - sudden muscular contraction
immediate pain
Physical
marked tenderness, pain
patellar deformity
inability to extend knee
proximal displacement of patella
unable to straight leg raise because disruption of extensor mechanism
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 weeks, early ROM
transverse displaced fracture - ORIF
comminuted fracture - ORIF; may require complete or partial patellectomy

OR28 – Orthopedics MCCQE 2006 Review Notes

 TIBIA
TIBIAL PLATEAU FRACTURE
result from femoral condyle(s) being driven into the proximal tibia often due to a valgus or varus force
lateral > medial
Treatment
if depression is < 3 mm
• long leg cast-brace, NWB x 2 months
if depression > 3 mm, displaced or comminuted
• ORIF +/– bone graft to elevate fragment
TIBIAL DIAPHYSIS FRACTURE
high intensity injury
• associated with crush injuries and MVAs
soft tissue, nerve and vessel injury common
• assess neurovascular status
• rule out open fracture
displacement is difficult to control
good reduction is required
• minimal shortening and angulation
healing time: 16 weeks on average
Treatment
ABCs
closed injuries = closed reduction
• long leg cast x 4-6 weeks
• followed by BK cast until healed
open injuries
• ORIF with external fixator
• wounds on anterior surface heal poorly and may necrose
unstable injuries or failed closed reduction require IM nail
high risk of compartment syndrome
• closed reduction and cast; admit and observe for compartment syndrome surgery;
prophylactic fasciotomy if operating on tibia fracutre

ANKLE
EVALUATION OF ANKLE COMPLAINTS
history
• ask about pain, swelling, mechanism of injury, effect on standing/walking
physical examination
• 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
• AP, Lateral and Mortise (15 degrees internal rotation)
• Mortise gives true view of talus in tibiotalar joint
• space between talus ––> tibia and talus ––> fibula
• space should be symmetric and < 4 mm with no talar tilt
• disrupted space signifies ligamentous or bony injury
when to x-ray - Ottawa ankle rules
• ankle x-ray is only required with
• pain in malleolar zone AND
• 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
• pain in midfoot zone AND
• bony tenderness over navicular or base of fifth metatarsal
OR inability to weight bear both immediately and in E.R.

MCCQE 2006 Review Notes Orthopedics – OR29

 ANKLE . . . CONT.
ANKLE FRACTURES

Figure 25.
Ring Principle of Ankle Fractures
and Danis-Weber Classification

Adapted with permission from Dandy, Essential

Orthopedics and Trauma, 2nd ed. Churchill Livingstone,
New York, 1993.

Ring Principle of the Ankle

the ankle can be thought of as a ring (see Figure 25)
• a: lateral malleolus
• b: medial malleolus
• c: posterior malleolus (posterior medial malleolus)
• d: deltoid ligament
• e: syndesmotic ligament (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
• avulsion fractures are transverse
• shear fractures are oblique if pure inversion / eversion
• shear fractures are spiral if rotational force
Danis-Weber Classification
based on level of fibular fracture relative to syndesmosis
Type A (infra-syndesmotic)
• pure inversion injury
• avulsion of lateral malleolus below plafond or torn calcaneofibular ligament
• +/– shear fracture of medial malleolus
Type B (trans-syndesmotic)
• external rotation and eversion
• avulsion of medial malleolus or rupture of deltoid ligament
• spiral fracture of lateral malleolus starting at plafond
Type C (supra-syndesmotic)
• pure external rotation
• avulsion of medial malleolus or torn deltoid ligament
• fibular fracture is above plafond
• frequently tears syndesmosis
• Maisonneuve fracture if at proximal fibula
• posterior malleolus avulsed with posterior tibio-fibular ligament
Lauge Hansen Classification
based on mechanism of injury; first word= position of foot,
second word = direction of movement of the talus in relation to the leg
Supination-External Rotation
• most common (45-65%)
• supination and external rotation, resulting in oblique fracture at the level of the sydesmosis
• equivalent to Weber Type B
Pronation-Abduction
• sequence of injury:
1) avulsion fracture of medial malleolus or rupture of deltoid ligament;
2) abduction force then either ruptures the syndesmosis or avulses its bony attachment sites;
3) lateral force from talus impacts and fractures fibula at or above level of
syndesmosis and ruptures interosseous membrane
Pronation-External Rotation
• sequence of injury:
1) transverse fracture of the medial malleolus or disruption of deltoid ligament;
2) external rotation then results in rupture of the anterior tibiofibular ligament or its bony insertion;
3) oblique or spiral fracture of fibula above the level of the joint;
4) posterior injury with tibiofibular ligament rupture or avulsion of posterior malleolus
• fibular fracture may be proximal (i.e., Maisonneuve fracture)
• equivalent to Weber Type C
Supination-Adduction
• 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
• Equivalent to Weber Type A
OR30 – Orthopedics MCCQE 2006 Review Notes
 ANKLE . . . CONT.
Treatment
undisplaced fractures: NWB BK cast
displaced fractures: reduction 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
LIGAMENTOUS INJURIES
Medial Ligament Complex (deltoid ligament)
responsible for medial stability
usually avulses medial or posterior malleolus
• posterior malleolus = posterior part of medial malleolus
usually associated with syndesmotic or lateral ankle sprain

Figure 26. Lateral View of Ligaments of Left Ankle

Lateral Ligament Complex (ATFL, CFL, PTFL)

responsible for lateral stability
clinical: swelling and discoloration, ‘pop’ sound, giving way
diagnosis: stress x-rays and mortise view
• 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
Grade I (microscopic stretch or tear)
• pain
• RICE (Rest, Ice, Compression, Elevation)
Grade II (macroscopic tear)
• pain on motion
• strap ankle in dorsiflexion and eversion
• no more than 6 weeks, physio for proprioceptive re-training
Grade III (complete tear)
• unstable ankle
• talar tilt apparent on mortise view
• BK walking cast x 3 weeks, physiotherapy for proprioceptive re-training
surgical intervention may be required
RECURRENT ANKLE SUBLUXATION
etiology
• 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
• arthroscopy / arthrotomy for internal derangement
MCCQE 2006 Review Notes Orthopedics – OR31
 FOOT
EVALUATION OF FOOT COMPAINTS
history
• pain, swelling, loss of function, sensory changes, deformity, mechanism
of injury, activity level of patient
physical
• inspection, palpation, active and passive ROM, weight bearing status
• neurovascular status
x-rays
• AP, lateral, oblique (as a minimum)
TALAR FRACTURE
60% of talus covered by articular surface
• decreased surface area for vascular perforation
• blood supply to talus: distal to proximal
• fractures of the neck at risk of AVN
mechanism: MVA or fall from height
• axial loading or hyper-plantar flexion injury
• talar neck driven into tibial margin
rule out potential associated injuries
• spinal injuries, femoral neck fractures, tibial plateau fractures
X-Rays
AP/lateral films with CT scan or tomograms of talus
Treatment
BK cast, NWB x 6 months
ORIF: to reduce displacement and prevent AVN or non-union
Complications
undisplaced: 0-10% risk of AVN
displaced: 100% risk of AVN
CALCANEAL FRACTURE
mechanism is axial loading (eg. fall from a height
onto the heels)
rule out potential associated injuries
• spinal injuries (10%)
• femoral neck fractures
• tibial plateau fractures
Physical
heel viewed from behind is wider, shorter, flatter,
varus tilt
may be swollen, with bruising on soles
X-Rays (see Figure 27)
Broden’s views (oblique views of subtalar joint)
Bohler's Angle decreased (normal: 20 - 40 degrees)
Treatment
goal is to prevent widened heel and maintain
subtalar joint congruency
NWB, early ROM
ORIF if depressed centrally or tongue-type fracture
closed vs. open treatment is controversial
Figure 27. Bohler's Angle
ACHILLES TENDONITIS
chronic inflammation from running and shoe-wear Illustration by Marc Dryer
(high heels)
may develop heel bumps (inflammation of superficial
bursa overlying lateral insertion of Achilles tendon into calcaneus)
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)
ACHILLES TENDON RUPTURE
usually an audible ‘pop’ or a sensation of being kicked at site
mid tendon or musculotendinous junction (2-6 cm from insertion on calcaneus)
spontaneously ruptures
• during loading activity (e.g. squash, tennis)
• secondary to steroid injection
OR32 – Orthopedics MCCQE 2006 Review Notes
 FOOT . . . CONT.

Diagnosis
history of pain and inability to walk
tenderness, palpable gap, weak plantar flexion
apprehensive to toe-off when walking
Thompson Test (patient lying prone)
• squeezing calf does not passively plantar flex foot
Treatment
low demand or elderly patient
• cast with foot in plantar flexion to relax tendon
high demand or young
• surgical repair vs. cast (controversial)
PLANTAR FASCIITIS
repetitive strain injury of plantar fascia
• common in runners, jumpers, ballet dancers, obesity
chronic inflammation due to microtears of plantar fascia
History
intense pain on waking or after rest
subsides as patient walks
may be associated with systemic diseases
• diabetes mellitus
• enthesopathies including seronegative and seropositive arthritis
Physical
swelling, local tenderness over plantar fascia
• mostly at medial calcaneal tubercle
pain with toe dorsiflexion (stretches plantar fascia)
X-Ray
sometimes show heel spur at insertion of fascia into medial calcaneal tubercle
Note: spur is reactive, not the cause of pain
Treatment
non-operative (90% resolve)
• rest and NSAIDs x 4-6 months
• steroid injection
• ultrasound and stretching exercises
• supportive shoes with heel cup
surgical in refractory cases (must r/o nerve entrapment as cause of pain first)
• release of plantar fascia
• 50% effective at pain relief
• spur removal not required
• can now be done endoscopically
BUNIONS
two primary causes: heriditary, shoewear, 10x more frequent in women
Hallux Valgus
• may be associated with metatarsus primus varus
• valgus alignment of MTP joint is aggrevated by eccentric pull of EHL and intrinsics
• secondary exostosis forms with bursa and thick skin creating the bunion
Treatment
treatment is cosmetic and for pain with shoes
non-operative first
• 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
(see Table 14)

MCCQE 2006 Review Notes Orthopedics – OR33

 FOOT . . . CONT.

Table 14. Types of Metatarsal Fractures

Fracture Mechanism Clinical Treatment

Avulsion of Base Sudden inversion Tender base of 5th MT Requires ORIF if displaced
of 5th MT followed by contraction x-ray foot
of peroneus brevis
Jones Fracture Stress injury Painful shaft of 5th MT NWB BK cast x 6 weeks
midshaft 5th MT ORIF if athlete
March Fracture Stress injury Painful shaft of 2nd or Symptomatic
shaft 2nd, 3rd MT 3rd MT
1st MT Fracture Trauma Painful 1st MT ORIF if displaced
otherwise NWB BK
cast x 3 weeks then
walking cast x 2 weeks
Lisfranc Fracture Fall onto plantar Shortened forefoot ORIF
Tarso-MT fracture- flexed foot or direct prominent base
dislocation crush injury

ORTHOPEDIC INFECTIONS
OSTEOMYELITIS
bacterial, viral or fungal infection of bone OR bone marrow
infants, young children, patients with sickle cell anemia, septic arthritis, open fractures, diabetes and
immuncompromised more susceptible than healthy adults
infection can be due to direct (trauma, surgery) or hematogenous route
• S. aureus (most common cause of hematogenous route)
• mixed infection i.e. Staph, Enterobacteriaceae, Pseudomonas (trauma, post-op, diabetic or IV drug use)
• Salmonella(Sickle Cell Disease)
• H. influenzae(young children)
• M. tuberculosis (affects both sides of joint)
History
asymptomatic (chronic)
history of infection at another site, direct trauma to the area
acute sepsis
• fever, chills, dehydration, lethargy
• MEDICAL EMERGENCY
presentation is typically less acute in adults
Physical
febrile
local tenderness, swelling, heat at metaphysis, decreased joint motion
neonates
• pseudoparalysis
• associated with septic arthritis
often few signs and symptoms in the adult; usually tender, inflammation
Diagnostic Tests
bloodwork
• elevated ESR, serial WBC, C-reactive protein
• blood cultures before antibiotics started (often negative in adults)
cultures and gram stain from wound or bone biopsy
X-rays
• acute: often normal, lucencies appear after 2-4 weeks
• chronic: onion-skin appearance
CT/MRI
• reveal medullary edema and destruction, periosteal reaction, cortical destruction,
articular damage, and soft-tissue involvement
bone scan
• Indium, Gallium and Technetium show locally increased uptake; Gallium more specific for infection
Treatment
IV antibiotics x 4-6 weeks
irrigation and debridement +/- amputation of extremity
antibiotic bead insertion at site of wound: tobramycin, gentamycin, or
vancomycin-impregnated bone cement beads
removal or replacement of prosthesis
OR34 – Orthopedics MCCQE 2006 Review Notes
 ORTHOPEDIC INFECTIONS. . . CONT.
SEPTIC ARTHRITIS
routes of spread
• hematogenous (most common)
• direct spread from adjacent infection
• inoculation

Table 15. Organisms in Septic Arthritis

Age Organisms Antibiotic Choice
0-6 months S. aureus Cloxacillin
E. coli Tobramycin / Gentamycin
6-36 months S. aureus Cloxacillin
H. influenzae +/– Ampicillin
>36 months S. aureus Cloxacillin
streptococci +/– Penicillin G
Adults S. aureus Cloxacillin (S.aureus)
N. gonorrhoeae Ceftriaxone (N. gonorrhoeae)
(especially adults < 30 years)
N. gonorrhoeae - most common cause of septic arthritis; can affect multiple joints;
if disseminated can have tenosynovitis, skin lesions, young adult males
S. aureus - most common cause of non-gonococcal adults
M. tuberculosis - often accompanies bone lesions (direct spread), also commonly via hematongenous spread
others
• B. burgdorferi (Lyme disease)
• S. schenckii (most common fungal cause)
• Salmonella(Sickle Cell disease)
• Pseudomonas (IV drug use)
History
severe pain
acute sepsis
• fever, chills, dehydration, lethargy
• MEDICAL EMERGENCY!
Physical
local joint tenderness, swelling, heat
neonates get pseudoparalysis
joint held in slight flexion to reduce intra-articular pressure
unable or unwilling to move joint
Diagnostic Tests
blood and throat swab cultures
joint aspirate for cultures, crystals, WBC, Gram stain, ESR, C-reative protein (CRP), glucose
bone scan (hip only)
• not used to make diagnosis
• assesses viability of femoral head
Treatment
medical: IV fluids and antibiotics, analgesia
surgical: aspiration or open surgical debridement
Complications
early
• septic dislocation
• AVN femoral head (increased intra-articular pressure due to pus)
late
• cartilage and epiphyseal destruction
• osteomyelitis
Other Joint Infections
Reactive Arthritis
• post infectious
• most common cause streptococci
• do not need antibiotics (culture is sterile)
Viral Arthritis
• hepatitis B, rubella, mumps, parvovirus B19

MCCQE 2006 Review Notes Orthopedics – OR35

 PEDIATRIC ORTHOPEDICS
FRACTURES IN CHILDREN
different from fractures in adults
periosteum is thicker and stronger in children
type of fracture
• usually greenstick or buckle because periosteum is intact on one or both sides
• adults fracture through both cortices
epiphyseal growth plate
• plate often mistaken for fracture and vice versa
• x-ray opposite limb for comparison
ligamentous injury
• rarely occur in children
• mechanism which causes ligamentous injury in adults causes growth plate injury in children
anatomic reduction
• gold standard with adults
• may cause limb length discrepancy in children (overgrowth)
• accept greater angular deformity in children (remodelling)
• intra-articular fractures have worse consequences in children because they usually involve the
growth plate
time to heal
• shorter in children
always be aware of the possibility of child abuse
• make sure injury mechanism compatible with injury
• high index of suspicion, look for other signs, including x-ray evidence of healing fractures at other sites
EVALUATION OF THE LIMPING CHILD(see Pediatrics Chapter)

EPIPHYSEAL INJURY

Figure 28. Salter-Harris Classification of Epiphyseal Injury

Adapted with permission from Dandy, Essential Orthopedics and Trauma, 2nd ed. Churchill Livingstone, New York, 1993.

Salter-Harris Classification (see Figure 28)

SALT(E)R
Stable (Type I)
• transverse through growth plate
Above (Type II, most common)
• through metaphysis and along growth plate
Low (Type III - involves articular surface)
• through epiphysis to plate and along growth plate
Through (Type IV - involves articular surface)
• through epiphysis and metaphysis
Ram (Type V)
• crush injury of growth plate
Treatment of Epiphyseal Injury
Type I and II
• closed reduction and cast immobilization
• heals well, 95% do not affect growth
Type III and IV
• anatomic reduction by ORIF since intra-articular, and also to prevent growth arrest
Type V
• high incidence of growth arrest
• no specific treatment
PULLED ELBOW
annular ligament slips between radial head and capitellum
• follows pull on child's forearm
• rule out child abuse
2-6 years old, due to underdeveloped radial head
forearm is pronated, painful and “will not move”
• point tenderness over radial head
• pseudoparalysis of arm
radiographs
• not for diagnosis, but to rule out fracture
treatment
• gentle supination while moving from extension to flexion
• pain relieved and function returns immediately
• may immobilize x 1 day in sling for comfort
OR36 – Orthopedics MCCQE 2006 Review Notes
 PEDIATRIC ORTHOPEDICS. . . CONT.
DEVELOPMENTAL DYSPLASIA OF THE HIP (DDH)
formerly called congenital dysplasia of the hip (CDH)
due to ligamentous laxity and abnormal slope of acetabular roof
predisposing factors (6 Fs)
• Family history, F emales (> males), Frank breech, First born, le Ft side
spectrum of conditions
• dislocated femoral head completely out of acetabulum
• dislocatable head in socket
• head subluxes out of joint when provoked
• dysplastic acetabulum, more shallow and more vertical than normal
if painful suspect septic dislocation
Physical
diagnosis is clinical
limited abduction of the flexed hip (< 50-60 degrees)
affected leg shortening results in asymmetry in skin folds and gluteal muscles, wide perineum
Barlow's test (unstable but located hip)
• flex hips and knees to 90 degrees and grasp thigh
• fully adduct hips, push posteriorly
Ortolani's test (for dislocated hip)
• initial position as above but try to reduce hip with fingertips during abduction
• palpable clunk if reduction is a positive test
Galleazzi's Sign
• difficult test if child < 1 year
• knees at unequal heights when hips and knees flexed
• dislocated hip on side of lower knee
Trendelenburg test and gait useful if older (> 2 years)
Imaging
can U/S in first few months to view cartilage
follow up radiograph after 3 months
CT scan (rarely done)
Treatment and Complications
0-6 months: Reduce hip using Pavlik harness to maintain abduction and flexion
6-18 months: reduction under GA, hip spica cast x 2-3 months (if Pavlik harness fails)
> 18 months: open reduction; pelvic and/or femoral osteotomy
complications
• redislocation, inadequate reduction, stiffness
• AVN of femoral head
LEGG-CALVE-PERTHES DISEASE
self-limited AVN of femoral head
etiology unknown, 20% bilateral, males more common increased incidence with family history,
low birth weight, and abnormal pregnancy/delivery
male:female = 4:1
key features: AVN of proximal femoral epiphysis, abnormal growth of the physis, and eventual
remodeling of regenerated bone
clinical picture
• limping child usually 4-10 years old
• tender over anterior thigh
• flexion contracture; decreased internal rotation, abduction
x-ray
• may be negative early
• eventually, characteristic collapse of femoral head (diagnostic)
• subchondral fracture
• metaphyseal cyst
treat to preserve ROM and preserve femoral head in acetabulum
• physiotherapy for ROM
• brace in flexion and abduction x 2-3 years
• femoral or pelvic osteotomy
prognosis better in
• males < 5 years old, < 1/2 head involved, abduction > 30º
• 50% of involved hips do well with conservative treatment
complicated by early onset osteoarthritis and decreased ROM
SLIPPED CAPITAL FEMORAL EPIPHYSIS
Type I Salter-Harris epiphyseal injury
most common adolescent hip disorder, peak at 12-15 years
risk: male, obese, hypothyroid
• acute (sudden displacement) and chronic (insidious displacement) forms
Etiology is Multifactorial
genetic (autosomal dominant, Blacks > Caucasians)
cartilaginous physis thickens rapidly under growth hormone (GH) effects
sex hormone secretion, which stabilizes physis, has not yet begun
overweight - mechanical stress
History
acute - sudden, severe pain with limp
chronic - limp with medial knee or anterior thigh pain
MCCQE 2006 Review Notes Orthopedics – OR37
 PEDIATRIC ORTHOPEDICS. . . CONT.
Physical
Whitman’s sign: with flexion there is an obligate external rotation of the hip
restricted internal rotation, abduction, flexion
pain at extremes of ROM
tender over joint capsule
X-Rays
need AP and frog-leg lateral views
posterior and medial slip
• if mild slip, AP view may be normal or slightly widened growth plate compared with opposite side
Treatment and Complications
acute - gentle reduction, possible ORIF
chronic- ORIF of slip to fix in current position and prevent progression
• complications - AVN (most common), chondrolysis, pin penetration, premature OA, chronic loss of ROM
CONGENITAL TALIPES EQUINOVARUS (CTEV)
also known as club foot
3 parts to deformity
• Talipes: talus is inverted and internally rotated
• Equinus: ankle is plantarflexed
• Varus: heel and forefoot are in varus (supination)
may be idiopathic, neurogenic, or syndrome-associated
• examine hips for associated DDH
• examine knees for deformity
• examine back for dysraphism (unfused vertebral bodies)
1/1,000 newborns, 50% bilateral, occurrence M > F, severity F > M
treat by changing cast q 2-3 weeks
• correct deformities in order
• forefoot adduction, ankle inversion, equinus
surgical release in refractory case (50%)
• delayed until 3-4 months of age
• 3 year recurrence 5-10%
• mild recurrence common; affected foot is permanently smaller/stiffer
that normal foot, with decreased calf circumference
SCOLIOSIS
Table 16. Etiology of Scoliosis
Type Cause
Idiopathic Most common (90%)
Congenital Vertebrae fail to form or segment
Secondary Leg length discrepancy, muscle spasm
Neuromuscular UMN or LMN lesion, myopathy
Other Osteochondrodystrophies, neoplastic, traumatic
age: 10-14 years
appears to be multifactorial with evidence of idiopathic scoliosis being a single –gene disorder
following Mendelian patterns with variable penetrance and heterogeneity
more frequent and more severe in females
Physical
asymmetric shoulder height when bent forward
• Adam’s Test: rib hump when bent forward
scapulae prominent, flank creased, pelvis asymmetric
associated posterior midline skin lesions
• cafe-au-lait spots, dimples, neurofibromas
• axillary freckling
• hemangiomas, hair patches
pelvic obliquity
associated pes cavus or leg atrophy
apparent leg length discrepancy
X-Rays
3 foot standing films
• use Cobb's method to measure curvature
may have associated kyphosis
Treatment Based on Degree of Curvature
< 20 degrees: observe for changes
> 20 degrees or progressive: bracing (many types)
> 40 degrees, cosmetically unacceptable or respiratory problems
• require surgical correction
OR38 – Orthopedics MCCQE 2006 Review Notes
 BONE TUMOURS
primary bone tumours are rare after 3rd decade
metastases to bone are relatively common after 3rd decade
Diagnosis
pain, swelling, tenderness
routine x-ray - describe by:
• location (which bone, diaphysis, metaphysis, epiphysis)
• size
• involvement (cortex, medulla, soft tissue)
• radiolucent, radiodense or calcified
• reaction of surrounding bone (sclerosis, borders)
• margin
• any pathological fracture
malignancy is suggested by rapid growth, warmth, tenderness, lack of sharp definition
staging should include
• bloodwork
• CT chest
• liver function tests
• bone scan
as much information as possible on anatomic extent of tumour (including plain films, tomography,
bone scanning, angiography,CT, +/– MRI if necessary) should be obtained prior to biopsy
should be referred to specialized centre prior to biopsy
“if you are not going to resect it don’t biopsy it”
classified into benign, benign aggressive, and malignant
BENIGN BONE TUMOURS
1. Osteoid Osteoma
age 10-25 years
small, round radiolucent nidus (< 1 cm) surrounded by dense bone
tibia and femur; diaphyseal
produces severe intermittent pain, mostly at night
characteristically relieved by ASA
2. Osteochondroma
metaphysis of long bone
cartilage-capped bony spur on surface of bone (“mushroom” on x-ray)
may be multiple (hereditary form) - higher risk of malignant change
generally not painful unless impinging on neurovascular structure
malignant degeneration occurs in 1-2 %
3. Enchondroma
age 20-40 years
50% occur in the small tubular bones of the hand and foot; others in femur, humerus, ribs
benign cartilage growth, develops in medullary cavity
single/multiple enlarged rarefied areas in tubular bones
lytic lesion with specks of calcification on x-ray
4. Cystic Lesions
includes unicameral bone cyst, aneurysmal bone cyst, fibrous cortical defect
children and young adults
local pain, pathological fracture or accidental detection
translucent area on metaphyseal side of growth plate
cortex thinned/expanded; well defined lesion
treatment of unicameral bone cyst with steroid injections +/– bone graft
Treatment
in general, curettage +/– bone graft
BENIGN AGGRESSIVE BONE TUMOURS
1. Giant Cell Tumours
80% occur > 20 years, average 35 years
distal femur, proximal tibia, distal radius
pain and swelling
cortex appears thinned, expanded; well demarcated sclerotic margin
1/3 benign, 1/3 invasive, 1/3 metastasize
30% reccur within 2 years of surgery
2. Osteoblastoma
aggressive tumour forming osteoid
lesions > 2 cm in size and grow rapidly
painful
most frequent in spine and long bones (humerus, femur, tibia)
Treatment
controversial, should do metastatic work up
wide local excision +/– bone graft
MCCQE 2006 Review Notes Orthopedics – OR39
 BONE TUMOURS. . . CONT.
MALIGNANT BONE TUMOURS
Table 17. Most Common Malignant Tumour Types For Age
Age Tumour
1 Neuroblasotma
1 - 10 Ewing’s of tubular bones
10 - 30 Osteosarcoma, Ewing’s of flat bones
30 – 40 Reticulum cell sarcoma, fibrosarcoma, parosteal osteosarcoma, malignant giant cell tumour, lymphoma
>40 Metastatic carcinoma, multiple myeloma, chondrosarcoma
1. Osteosarcoma
bimodal age distribution
• ages 10-20 (60%)
• > 50 with history of Paget's disease
invasive, variable histology; frequent metastases
predilection for distal femur (45%), tibia (20%) and proximal humerus (15%)
history of trauma common
painful, tender, poorly defined swelling
x-ray shows Codman's Triangle: characteristic periosteal elevation and spicule formation representing tumour
extension into periosteum with calcification
treatment with complete resection (limb salvage, rarely amputation) adjuvant chemo, radiotherapy
2. Chondrosarcoma
primary: previous normal bone, patient over 40; expands into cortex to give pain,
pathological fracture, flecks of calcification
secondary: malignant degeneration of preexisting cartilage tumour such as enchondroma or osteochondroma
occurs in pelvis, femur, ribs, shoulder
x-ray shows large exostosis with calcification in cap
highly resistant to chemotherapy, treat with aggressive surgical resection
3. Ewing's Sarcoma
thought to be undifferentiated member of a family of neural tumours distinct form neuroblastoma
most occur between 5 - 20 years old
florid periosteal reaction in diaphysis of long bone; ages 10-20
present with mild fever, anemia, leukocytosis and elevated ESR
moth-eaten appearance with periosteal "onion-skinning"
metastases frequent
treatment: chemotherapy, resection, radiation
4. Multiple Myeloma
most common primary malignant tumour of bone in adults
90% occur in people > 40 years old
anemia, anorexia, renal failure, nephritis, ESR elevated
osteoporosis, punched out lesions, compression fracture
weakness, bone pain
diagnosis
• serum/urine protein electrophoresis
• bone marrow aspirate
treatment: resection, chemotherapy, radiation
5. Bone Metastases
see “bonezine ring” (see Figure 29)
PT B arnum Loves Kids
2/3 from Breast or P rostate
also consider T hyroid, Lung, Kidney
usually osteolytic; prostate occasionally osteoblastic
bone scan may be helpful
stabilization of impending fractures
• internal fixation
• IM rods
• bone cement Figure 29. Bonezine Ring

OR40 – Orthopedics MCCQE 2006 Review Notes

 SURGICAL PROCEDURES
SLIDING HIP SCREW INSERTION
Objective
to reduce and stabilize a hip fracture.
Indications
intertrochanteric fractures
Landmarks
palpate the greater trochanter and the shaft of the femur.
Procedure
fracture reduction
• the patient is positioned supine on an orthopaedic fracture table
• traction is placed on the fractured leg and the distal portion of the
leg is abducted and internally rotated to obtain an anatomical
reduction of the fracture
• an image intensifier (fluoroscope) is used to ensure the fracture is
properly reduced
• obtaining a good closed reduction prior to the surgery is crucial
incision
• an Incision is made over the middle of the greater trochanter and
extended distally down the lateral side of the thigh
• the length of the incision depends on the length of the plate
approach
• the fascia lata is incised in line with the skin incision
• the fascial covering of the vastus lateralis muscle is incised
• this exposes the vastus lateralis muscle
• this muscle is divided by blunt dissection in line with its fibers
• finally, the periosteum is incised and divided to expose the lateral
aspect of the femoral shaft
• Note: care must be taken to coagulate the perforating branches of
the profunda femoris arteries that are divided during this approach
screw insertion
• a guide wire is inserted just distal to the greater trochancter (distal
to the fracture site) and angled at 135º into the femoral neck and
head
• the guide wire should run into the femoral neck just superior
to the calcar
• Note: the guide wire must not enter the hip joint
• the image intensifier is used to ensure the position of the guide wire
is correct
• ext a reamer is used to drill a hole over the guide wire
• finally, the lag screw is advanced into the femoral head over the
guide wire
• the guide wire is removed and the lag screw remains in place
plate insertion
• the proximal end of the plate articulates with the end of the lag
screw
• this allows for dynamic compression across the fracture site
• the plate is fixed to the lateral aspect of the femoral shaft using
bicortical screws
closure
• the plate is buried under the vastus lateralis muscle
• the fascia of the vastus lateralis and the fascia lata are sutured
closed
• finally the skin is closed
Complications
varus collapse with lag screw cut out (migration of the lag screw into the hip joint)
avascular necrosis of the femoral head
deep vein thrombosis and pulmonary embolism

MCCQE 2006 Review Notes Orthopedics – OR41

 REFERENCES
Miller, MD. Review of orthopedics. 3rd ed. 2000. WB Saunders Co.

OR42 – Orthopedics TMCCQE 2006 Review Notes