special thanks for our great colleague

Mujtaba Fadhel Radhi

for designing the front cover
TOPIC PAGE NUMBER
1- Principles of fractures…………………………………. 1
2- Complications of fractures…………………………….. 9
3- Shoulder joint orthopedic……………………………… 18
4- Shoulder joint injuries…………………………………. 22
5- Elbow joint orthopedic………………………………… 32
6- Elbow joint injuries……………………………………. 33
7- Forearm Injuries……………………………………….. 46
8- Wrist & Hand orthopedic……………………………… 51
9- Wrist injuries…………………………………………... 54
10- Hand injuries…………………………………………. 63
11- Spine orthopedic……………………………………... 68
12- Spine injuries…………………………………………. 83
13- Pelvic injuries………………………………………… 89
14- Hip orthopaedic………………………………………. 94
15- Hip Joint Injuries and femur fracture………………… 99
16- Knee orthopedic……………………………………… 110
17- Knee joint injuries……………………………………. 113
18- Ankle & Foot orthopaedic……………………………. 126
19- Ankle & foot injuries………………………………… 129
20- Principles of Peripheral nerve injuries……………….. 144
21- Bone Tumour & tumour like lesions…………………. 147
22- Metabolic bone diseases……………………………… 165
23- Infections of bone…………………………………….. 171
References………………………………………………... 176
Principles of fractures
What is fracture? - Break in the structural continuity of bone.
- Crack in cortex is also considered a fracture.

What are the types of 1- closed (simple): - if overlying skin is intact.

fractures? 2- open (compound): - if fracture site had breech the skin
and communicated with environment or a body cavity and
its liable to contamination and infection.

How fracture happen? 1- From single traumatic incident.

2- Repetitive stress (marsh fracture and tibial fractures).
3- Abnormal weakening of the bone (pathological
fracture).

What fracture usually comminuted crush fracture?

occurs in cancellous
bone?

What are the common - Transverse (direct blow force or tension force).
shapes of fractures? - Spiral (twisting force).
- Butterfly or triangular (bending force).
- Oblique (compression force).
- Green-stick.

What are patterns of 1- Complete fractures: - The bone is completely broken

fractures? into two or more fragments. It may be:
Transverse.
Oblique.
Spiral.
Impacted (the fragments are jammed tightly together)
Comminuted (there are more than two fragments)
2- Incomplete fractures: -The bone is incompletely
divided and the periosteum remains in continuity.
- Greenstick fracture the bone is buckled or bend, this seen
in children.
- Compression fracture the bone is compressed or
crumpled.

1
Principles of fractures
What is the Gustillo classification: -
classification system of Type I: - wound < 1 cm.
open fracture? Type II: - wound 1-10cm.
Type III A: - wound > 10 cm, high energy, adequate
tissue for coverage includes segmental / comminuted
fractures even if wound <10cm (farm injuries are
automatically Gustillo III).
Type III B: - Extensive periosteal stripping and requires
free soft tissue transfer.
Type III C: - Vascular injury requiring vascular repair.

What is the Tscherne classification

classification system Grade 0 • Minimal soft tissue damage
closed fracture? • indirect injury to limb (torsion)
• simple fracture pattern

Grade 1 • Superficial abrasion or contusion

• mild fracture pattern
Grade 2 • Deep abrasion
• skin or muscle contusion
• severe fracture pattern
• direct trauma to limb

Grade 3 • Extensive skin contusion or crush injury

• severe damage to underlying muscle
• compartment syndrome
• subcutaneous avulsion

What cause fracture to 1) By force of the injury.

displace? 2) Gravity.
3) By pull of the muscle attached to them.

What are types of 1.Transulation, Shift(apposition): - The fragments may

displacement? be shifted sideways, backward, forward in relation to each
other.

2
Principles of fractures
2. Angulation, Tilt (alignment): - The fragment may have
angulated in relation to each other.
3. Twist (rotation): - One of the fragments rotates on its
longitudinal axis.
4.Length: - The fragments may be separated causing
lengthening of the bone. OR They overlap due to muscle
spasm causing shortening of the bone.

What are types of 1- Primary bone healing

fracture healing? • Rigid fixation (e.g. internal fixation).
• No callus.
• aka contact/gap healing.
2- Secondary bone healing
• Non-rigid fixation (plaster of Paris cast)
• Callus formation.
• aka endochondral ossification.

What are the steps of 1. Tissue destruction & hematoma formation.

secondary healing 2. Inflammation & cellular proliferation.
(healing by callus)? 3. Callus formation (soft callus).
4. Consolidation (woven bone).
5. Remodeling (lamellar bone).

What factors influence l- Type of bone (Cancellous bone heals faster than cortical
healing of fractures? bone).
2-Type of fracture (Transverse fracture takes longer time
than a spiral fractures).
3-The state of blood supply (Poor circulation means slow
healing).
4-The patient general condition (Healthy bone heals
faster).
5-Age of the patient (Healing is almost twice as fast in
children as in adult).

3
Principles of fractures
How would you by Perkins role (timetable): - A spiral fracture in the
estimate time of upper limb unites in 3 weeks; for consolidation multiply
healing? by 2; for the lower limb multiply by 2 again; for
transverse fractures multiply again by 2.

What is the role of 2s in Two views — A fracture or dislocation may not be seen
x-ray imaging? on a single film, & at least two views AP & Lat.
Two limbs — In children, the appearance of immature
epiphysis may be confused the diagnosis of a fracture. X-
ray of normal limb is need for comparison.
Two injuries — Severe force often causes injury in more
than one level. Thus, with fracture of the calcaneum or
femur it important to also x ray the pelvis & spine.
Two occasions — some fractures are difficult to detect
soon after injury, but another x- ray examination a week
or two later may show the lesion, e.g. scaphoid, lateral
malleolus & femoral neck fractures.
Two joints — the joint above & below the fracture site
must be included, otherwise miss injury occur especially
in the leg & forearm.

What are the steps of Step 1: - ATLS as any trauma patient.

closed fracture Step 2: - treat fracture itself by REDUCE the displaced
management? fracture, HOLD the reduction then EXERCISE to
prevent stiffness and restore function.

How would you reduce - Closed reduction (manipulation under anesthesia or

a fracture? traction).
- Open (operative) reduction.

What are the rules of 1- Early (before swelling which make it difficult).
reduction? 2- Alignment is more important than apposition.
3- Fractures involving an articular surface should be
reduced as near to perfection otherwise any irregularity
will predispose to degenerative arthritis.

What are the 1- Failure of closed reduction.

indications of operative 2- Intra-articular fracture.
reduction? 3- Some avulsion fractures.

What is the aim of 1- To alleviate pain.

HOLDING a fracture? 2- To ensure that union takes place in good position.

4
Principles of fractures
What are the methods 1) Continuous traction.
of immobilization? 2) Cast splintage (plaster).
3) Functional bracing.
4) Internal fixation.
5) External fixation.

When would you use a For long bone (humerus and femur).
continuous traction? For some shoulder and hip fractures.

What are the methods 1. Gravity (e.g. arm sling).

of continuous traction? 2. Skin traction: - Elastoplast is applied to the skin of the
leg & hold on with a bandage, traction is by cord, this
traction produces a pull of up to 5 kg.
3. Skeletal traction: - A wire or pin is inserted through
the bone distal to the fracture & traction is applied via
hook or a stirrup.

What are the risks of vascular problem, nerve injury, compartment syndrome &
continuous traction? pin tract infection.

When would you use a Roughly for distal limb fractures.

cast splintage?

What materials used in 1- Plaster of Paris (POP): - is hemi hydrated calcium

cast splintage? sulphate, it reacts with water to form hydrated calcium
sulphate & the reaction is exothermic.
2- fiberglass: - replaced POP recently (light).
3- cortex cast (don’t write it in exam, experimental 3D
printed).

What are the risks of 1- Tight cast: -this may cause vascular compression, need
cast splintage? torn split the cast down to skin.
2- Pressure sores: - the cast may press the skin & causing
the ulcer.
3- Skin laceration or abrasion: - may be seen on
removing the plasters.
4- loose cast.

What is functional - Segments of a cast are applied only over the shafts of the
bracing? bones, leaving the joints free. Used if union occurs but
still not complete in tibial or femoral fractures.

5
Principles of fractures
What is internal This is an operative fixation of bone fragments by screws,
fixation? pins, plate, wire, intramedullary nail.

What are the 1- Fractures that cannot be reduced except by operation.

indications of internal 2- Unstable fractures (like forearm # & displaced ankle #
fixation? & traction injury like patella & olecranon #).
3- Fractures that prone to non-union (Femoral neck #).
4- Pathological fracture in which bone disease may
prevent healing.
5- Poly trauma patient to minimize the risk of ARDS.
6- Fracture in patient who present nursing difficulties
(paraplegics, multiple injuries & the very elderly).

What are the 1- Infection.

complications of 2- Non-union.
internal fixation? 3- Implant failure: - implant may be break if subjected to
stress (e.g. early walking).
4- Refracture: - if implant removed early, the bone may
refracture. So, the implant should be kept for at least one
year and 18 or 24 months safer.

What is external Transfixing pins, which pass through the bone above &
fixation? below the fracture site & are attached to an external frame.

6
Principles of fractures
What are the types of
external fixation?

What are the 1- Fractures associated with sever soft tissue damage.
indications for external 2- Fractures associated with nerve or vessel damage.
fixation? 3- Severely comminuted & unstable #.
4- Fracture of the pelvis.
5- Infected fracture.

What are the 1- Pin tract infection: - this needs regular cleaning of the
complications of pin entry sites.
external fixation? 2- Delayed union: - because:
- The fragments are held apart by the rigid fixator.
- There is reduced load transmission through the bone.

What is the aim of 1- Reduce edema.

exercise in fractured 2- Preserve joint movement.
patient? 3- Restore muscle power.
4- Guide the patient back to normal activity.

What are the principles 1- Antibiotic prophylaxis (Third Gen. cephalosporin).

of management of open 2- Wound (soft tissue) debridement.
fracture? 3- Stabilization of the fracture (the bone).
4- Early wound cover.

How would you - Grade I&II gustillo treated as closed.

stabilize an open - Grade III gustillo treated with external fixation.
fracture? - Open intra-articular left open for 5 days until become
clean then internal fixation.

What is the Salter-Harris classification.

classification used in
physeal fracture?

7
Principles of fractures
What is salter Harris Type I: - Physeal separation.
classification? Type II: - Fracture physis and metaphysis.
Type III: - Fracture physis & epiphysis.
Type IV: - Fracture epiphysis, physis, and metaphysis.
Type V: - Crush injury to the physis.

8
Complications of fractures
LOCAL
COMPLICATIONS

EARLY -may present as part of the primary injury or may appear

COMPLICATIONS only after a few days or weeks.

1) Visceral injury -Fractures around the trunk with penetration of the lung
with life-threatening pneumothorax following rib
fractures
-Rupture of the bladder or urethra in pelvic fractures.

2) Vascular injury -Often major artery are those around the knee and elbow
and those of the humeral and femoral shafts.
-Even if its outward appearance is normal, the intima may
be detached and the vessel blocked by thrombus, or a
segment of artery may be in spasm.

Clinical features? -paraesthesia or numbness in the toes or the fingers.

-The injured limb is cold and pale, or slightly cyanosed,
and the pulse is weak or absent.
Injuries associated with
vascular trauma?

Treatment? -All bandages and splints should be removed.

-The fracture is re-x-rayed and, if the artery is being
compressed or kinked, prompt reduction is necessary.
-The circulation is then reassessed repeatedly over the
next 30 minutes. If there is no improvement, the vessels
must be explored by operation – preferably with the
benefit of perioperative angiography.

9
Complications of fractures
Treatment of cut -Suturing, or a segment may be replaced by a vein graft.
vessel?

3) Compartment Increase the pressure within one of the osteofascial

syndrome? compartments due to bleeding, edema or inflammation.
This causes reduced capillary flow which results in
muscle ischemia, further edema causing profound
ischemia.

The vicious circle of

Volkmann’s ischemia?

Volkmann’s ischemic - because the circle of Volkmann’s ischemia ends (after

contracture? 12 hours or less) in necrosis of nerve (can recover) and
muscle within the compartment that is replaced by
inelastic fibrous tissue.

Clinical features -High-risk injuries are fractures of the elbow, the forearm
bones, the proximal one-third of the tibia and multiple
fractures of the hand or foot.
-History of crush injury, a circumferential burn or even in
a tight plaster cast.

The classic features of -5Ps:

ischemia? Pain, Paraesthesia, Pallor, Paralysis and Pulselessness.
-Three or more signs present, diagnosis is almost certain.

How to confirm the By measuring the intercompartmental pressures.

diagnosis?

Differential pressure the difference between the general diastolic pressure and
ΔP? the compartment pressure – of less than 30 mmHg (4.00
kP) is an indication for immediate compartment
decompression.

Treatment? -Casts, bandages and dressings must be completely

removed.
-The limb should be nursed flat.
-The ΔP should be carefully monitored
#if it falls below 30 mmHg, immediate open fasciotomy
is performed.

10
Complications of fractures
Fasciotomy in the case -Means opening all four compartments through medial
of leg? and lateral incisions.
#The wounds should be left open and inspected 2 days
later;
-If there is muscle necrosis, debridement can be done
-If the tissues are healthy, the wound can be sutured
(without tension), or skin grafted.

4)Nerve injury

5) Hemarthrosis -Occurs with fractures involving a joint.

-The joint is swollen and tense and the patient resist any
attempt at moving it.
-The blood should be aspirated before dealing with the
fracture.

6) Infection -Open fractures may become infected; closed fractures

hardly ever do unless they are opened by operation.
-Post-traumatic wound infection is now the most common
cause of chronic osteomyelitis.

Treatment -Prophylactic antibiotics

-Debridement
-Drainage if there is pus
-Replace internal fixation with external fixation if the
infection not respond to antibiotic.

6) Gas gangrene -produced by clostridial infection (especially C. welchii

“anaerobic”).
-Toxins produced by the organisms destroy the cell wall
and rapidly lead to tissue necrosis, thus promoting the
spread of the disease.

Clinical features? appear within 24 hours of the injury:

-the patient complains of intense pain
-swelling around the wound and a brownish discharge

11
Complications of fractures
Continued -Rapidly the patient becomes toxemic and may lapse into
coma and death.
-It is essential to distinguish gas gangrene, which is
characterized by myonecrosis, from anaerobic cellulitis,
in which superficial gas formation is abundant but
toxemia usually slight.

How to prevent this? -Deep, penetrating wounds in muscular tissue are

dangerous; they should be explored.
-All dead tissue should be completely excised and
-Any doubt about tissue viability, the wound should be
left open.

Treatment? The key to life-saving treatment is early diagnosis.

-General measures, such as fluid replacement and
intravenous antibiotics.
-Hyperbaric oxygen has been used to limit the spread of
gangrene.
-The mainstay of treatment is prompt decompression of
the wound and removal of all dead tissue.
-In advanced cases, amputation may be essential.

7)Fracture blisters -due to elevation of the epidermal layer of skin from the
dermis.
-treated with surgical incisions through blisters only when
swelling has decreased.

8) plaster sores and -Plaster sores occur where skin is pressed directly onto
pressure sores bone.
-Pressure sores may be produced by splints.

LATE
COMPLICATIONS
1)Delayed union
-causes: 1- Poor blood supply
A badly displaced fracture will cause tearing of the
periosteum and interruption of the intramedullary blood
supply.
2- Severe soft-tissue damage
-Most important cause of delayed union and non-union.
-It disrupts the blood supply, reduces osteogenesis from
mesenchymal stem cells and impairs the effectiveness of
muscle splintage.

12
Complications of fractures
Continued 3- Periosteal stripping
4- Imperfect splintage
5- Over-rigid fixation
6- Infection
7- Implant failure
Patient related

Clinical features -Fracture tenderness persists and if the bone is subjected

to stress, pain may be acute.
-On x-ray the fracture line remains visible and there is
very little callus formation or periosteal reaction.

Treatment Conservative
-Immobilization by cast prevent movement at the fracture
site.
-But fracture loading is an important stimulus to union
and this can be enhanced by encouraging muscular
exercise and weightbearing in the cast or brace.
Operative
- if union is delayed for more than 6 months and there is
no sign of callus formation, internal fixation and bone
grafting are indicated.

2)Non-union - Movement can be elicited at the fracture site and pain

diminishes.

Types of non-union? -In hypertrophic non-union the bone ends are enlarged,
suggesting that osteogenesis is still active but not quite
capable of bridging the gap.
-In atrophic non-union osteogenesis seems to have
ceased; the bone ends are tapered.

Non-union case

Treatment Conservative
- functional bracing may be sufficient to induce union.
Operative
- Hypertrophic non-union with absence of deformity:
Rigid fixation alone (internal or external) may lead to
union.

13
Complications of fractures
Continued -Atrophic nonunion, fixation alone is not enough. Fibrous
tissue in the fracture gap, as well as the hard, sclerotic
bone ends, should be excised and bone grafts packed
around the fracture.

3)Malunion -Failure to reduce a fracture adequately.

-Causes -Failure to hold reduction while healing proceeds.
-Gradual collapse of comminuted or osteoporotic bone.

Treatment -In adults, Angulation of more than 10–15 degrees in a

long bone, or a noticeable rotational deformity, may need
correction by re-manipulation, or by osteotomy and
internal fixation.
-In young children, angular deformities near the bone
ends will often re-model with time; rotational deformities
will not.
-In the lower limb, shortening > 2 cm; shoe raise is
indicated, if severe discrepancy, limb lengthening is
considered.
#malalignment of >15 degrees may cause asymmetrical
loading of the joint above or below and the late
development of secondary osteoarthritis.

Malunion X-ray

4) Avascular necrosis

What are the certain (1) the head of the femur (after fracture of the femoral
regions reliable to neck or dislocation of the hip)
develop AVN after (2) the proximal part of the scaphoid (after fracture
injury? through its waist)
(3) the lunate (following dislocation)
(4) the body of the talus (after fracture of its neck).

X-ray findings? Increase in bone density (the consequence of new bone in

growth in the necrotic segment and disuse osteoporosis in
the surrounding parts).

14
Complications of fractures
Treatment? Femoral head:
-elderly: arthroplasty
-Young: re-alignment osteotomy
Scaphoid or talus: symptomatic treatment,
wrist or ankle: arthrodesis may need.

5)Growth disturbance In children, damage to the physis.

6) Joint instability -Bone loss or malunion close to a joint may lead to

instability or recurrent dislocation.
-The commonest sites are the shoulder, the elbow and the
patella.

7) Osteoarthritis -Damage the articular cartilage > post-traumatic

osteoarthritis within a period of months.
-Incongruity of the joint surfaces > secondary
osteoarthritis years later.

LATE SOFT-TISSUE
COMPLICATIONS
Causes:
1)Joint stiffness - hemarthrosis forms and leads to synovial adhesions.
- edema and fibrosis of the capsule, the ligaments and the
muscles around the joint.
- adhesions of the soft tissues.
- made worse by prolonged immobilization.

Common joints are The knee, the elbow, the shoulder and (worst of all) the
affected? small joints of the hand.

Treatment? The best treatment is prevention:

-elevation to minimize edema
-functional bracing rather than full cast immobilization
-exercises that keep the joints mobile.
#prolonged cases need surgical release of tight structures.

2) Heterotopic - occurs muscles after an injury, particularly around the

ossification elbow.
- The patient complains of pain and local swelling.

X-ray findings? -X-ray is normal at first but a bone scan may show
increased activity.

15
Complications of fractures
Continued -Over the next 2–3 weeks the pain gradually subsides, but
joint movement is limited and x-ray may show fluffy
calcification in the soft tissues.
-By 8 weeks bony mass is easily palpable.

Treatment? - Active movements should be introduced gently and

gradually, alternating with rest periods.
- Excise heterotopic bone if it is blocking movement.
-Indomethacin or radiotherapy to prevent recurrence.

Myositis ossificans X-
ray

3) Muscle contracture - Following arterial injury or a compartment syndrome.

- The sites most commonly affected are the forearm and
hand, the leg and the foot.

Treatment -Detachment of the flexor muscles at their origin and

along the interosseous membrane in the forearm
-If sensation and active movement are not restored. Nerve
grafts and tendon transfers (wrist extensors to finger and
thumb flexors) will allow active grasp.

4)Tendon rupture As rupture of the extensor pollicis longus tendon treated

by transferring the extensor indicis (proprius) tendon.

5) Nerve compression -Damage the lateral popliteal nerve if an elderly or thin

patient lies with the leg in full external rotation.
-Radial palsy may follow the faulty use of crutches.

6) Nerve entrapment Common sites:

-Ulnar nerve (due to a post-traumatic valgus deformity of
the elbow)
-Median nerve (following injuries around the wrist)
- Posterior tibial nerve (following fractures around the
ankle).
#Treatment is by early decompression of the nerve.

16
Complications of fractures
7) Complex regional - known as reflex sympathetic dystrophy or
pain syndrome algodystrophy.
(Sudeck’s atrophy) -occurs due to some type of neurovascular dysfunction.

Clinical features -Pain, often described as ‘burning’ in character.

-At first there is local swelling, redness and warmth,
tenderness and moderate joints stiffness.
-As the weeks go by the skin becomes pale and atrophic
-Movements are increasingly restricted and the patient
may develop fixed deformities.

Treatment -Elevation and active exercises are essential.

-During the early stage anti-inflammatory drugs and
amitriptyline are helpful.
-Sympathetic block or sympatholytic drugs.
-Prolonged physiotherapy.

17
Shoulder joint orthopedic
What is impingement This is a clinical syndrome in which there is pain in the
syndrome(s)? shoulder and upper arm during the mid-range of gleno-
humeral abduction (60-120 degrees).

What are the causes of 1- Minor tears of the supraspinatus tendon

it? 2- Supraspinatus tendinitis
3- Calcification of supraspinatus tendon
4- Subacromial bursitis
5- Fracture of the greater tuberosity

What would make you 1- pain: - sudden, mid-range of abduction with medial
suspect impingement rotation, appear in front and lateral aspect of shoulder.
syndrome? 2- tenderness
3- weakness of shoulder abduction
4- positive impingement tests (Hawkins and neer)

Neer’s test Hawkins test

Are there any - X-ray of the shoulder may show calcific deposit, or a
investigations may aid fracture of the greater tuberosity or acromion.
in diagnosis? - MRI of shoulder may show supraspinatus tear.

What are treatment 1- physiotherapy: - ultrasound and active movement.

modalities available?
2- NSAID
3- steroid injection: - just if other modalities failed you
can use 1 or 2 injections of hydrocortisone.
4- repair of tear if present.
5- acromioplasty: - removal of coraco-acromial ligament
or excision of anterior part of acromion to relieve
compression.

18
Shoulder joint orthopedic
What does the term A shoulder disorder characterized by the gradual loss of
“frozen shoulder” motion and onset of pain within the shoulder.
mean?
How it may arise? The exact pathophysiology is unclear but it is
characterised by fibrosis and scarring of the joint capsule
(hence the term “adhesive capsulitis”) resulting in pain
and restriction of both passive and active ranges of
movement.
An autoimmune theory has been postulated, with elevated
levels of C-reactive protein and an increased incidence of
HLA-B27 histocompatibility antigen reported in patients
with frozen shoulder versus control subjects.

What are risk factors Trauma, surgery (including but not limited to the
associated with it? shoulder), inflammatory disease, diabetes, regional
conditions, and various shoulder maladies.

How would the patient - sequence of pain, then stiffness, then thawing.
present? - limited elevation and external rotation (ER) both
passively and actively.

What is the role of x- To exclude other causes of pain and stiffness (e.g.
ray in suspected frozen osteoarthritis or fracture/dislocation of the glenohumeral
shoulder? joint, bone neoplasm, and calcific Tendinitis).

What are the 3 stages of (1) the painful phase, (2) the stiffening phase, and (3) the
frozen shoulder? thawing phase.

What is the DDx? 1)glenohumeral arthritis 2) posterior glenohumeral joint

fracture/dislocation 3) bicipital tenosynovitis 4) rotator
cuff disease, including calcific tendinitis of the rotator
cuff 5) cervical radiculopathy.

Prognosis? It is usually self‐limiting but recovery may take up to 2

years.

How would you treat 1- Manipulation under anaesthesia (MUA).

it? 2- steroid injections.
3- arthroscopic debridement.

19
Shoulder joint orthopedic
What do we mean by This is a broad term used for shoulder problems, where
shoulder instability? head of the humerus is not stable in the glenoid. It has a
wide spectrum - from minor instability or a 'loose
shoulder' to a frank dislocation.

How would you classify Anterior, posterior or atraumatic.

instability?

What are the causes of 1- hill-sachs lesion: - depression in the

anterior instability? posterosuperior part of the humeral head resulting from
previous trauma.
2- bankart lesion: - where the labrum or capsule are
detached from glenoid.

What would bring the The shoulder is repeatedly dislocated and the patient has
diagnosis to you mind? its own manoeuvre of reduction usually.
The arm is usually abducted, extended and externally
rotated.
Positive apprehension sign.

What will you see in X-Ray will show hill-sachs lesion.

imaging? MRI will show hill-sachs and bankart lesion.

How would it be Physiotherapy and avoidance of extreme movements

managed? unless the operation is indicated.

What are the 1- frequent and painful dislocations.

indications to operative 2- if the patient is afraid of dislocation the preventing him
intervention? from doing his normal daily activity.

What surgical Putti-Platt operation: Double-breasting of the

treatment is available subscapularis tendon to prevent external rotation and
for anterior instability? abduction, thereby preventing recurrences.
Bankart's operation: The glenoid labrum and
capsule are re-attached to the front of the
glenoid rim. (open or arthroscopic)
Bristow's operation: osteotomy to coracoid process
making the attached muscles lies anterior to glenoid.

What about posterior Rare may persist after acute posterior dislocation, usually
instability? treated by physiotherapy and operation is indicated if
disability is very large.

20
Shoulder joint orthopedic
Atraumatic instability? With no history of trauma the shoulder feels “going out”
of it place, may be due to fatigue of muscles or those who
trained voluntarily to dislocate it, it’s treated usually by
physiotherapy and rarely needs surgery.

What’s SLAP lesion? Superior labrum anterior posterior tear

Diagnosed arthroscopically only and treated by re-
attachment or debridement.

21
Shoulder joint injuries
Acromioclavicular joint

What’s the mechanism -Direct trauma resulting from a fall on the shoulder.
of acromioclavicular -Indirect injuries are rare.
joint injury?

Which ligament(s) is -Acromioclavicular ligament tear only cause upward

torn causing upward subluxation.
subluxation or -Acromioclavicular + coracoclavicular ligaments tears
complete dislocation of cause complete dislocation of the joint.
the joint?

What are clinical -The patient points to the site of injury that may be
features? bruised.
-If there is tenderness but no deformity probably a sprain
or a subluxation.
-Severe pain and a prominent ‘step’ since dislocation
-Shoulder movements may be limited.

What is Rockwood’s
classification?

Stress view -Taken with the patient holding a 5 kg weight in each

hand, may reveal the displacement more clearly
-Helpful in distinguishing between a type II and type III.

Tx of type 1(sprain)& Conservative;

type 2 (subluxation)? -The arm is rested in a sling until pain subsides (usually
for 1 week), and shoulder exercises are then begun.

Surgical treatment a. Acute type IV, V, and VI separations.

(wires, lag screw & b. Type III in younger, physically active patients, manual
trans-articular suture) laborers, with cosmetic concerns, or persistent symptoms.
Indications?
-Rotator cuff muscles as supraspinatus tendinitis
What are complication -Unreduced reduction
of AC joint injuries? -Ossification of ligaments as coracoclavicular ligaments
-Secondary osteoarthritis

22
Shoulder joint injuries
Modified Weaver–
Dunn operation for
unreduced AC joint
dislocation?

What’s Tx of this case Tx: conservative (sling until pain subsides)

in the x-ray? since AC joint dislocation type 3 presumed without
indications of surgery

# Nonsurgical treatment resulted in quicker recovery and

return to work in type 3 while surgical treatment resulted
in an increase in complications.

-Piano key/sign: Supporting the elbow with one hand and

What we missed? gently pushing the clavicle with the other, positive if there
is pain or increased movement of clavicle indicate AC
separation
- Velpeau bandage and Sling and Swathe splint is most
effective in acromioclavicular dislocation
Sternoclavicular joint -Uncommon injury
- Anterior dislocation is much more common than
posterior
-prominent bump over the sternoclavicular joint.
What’s the mechanism - lateral compression of the shoulders as RTC or crushing
of Sternoclavicular injuries.
joint dislocation? -Rarely, it follows a direct blow to the front of the joint.
Which type of -Posterior dislocation is much more serious.
dislocation is more -There may be pressure on the trachea or large vessels,
serious? why? causing venous congestion of the neck and arm and
circulation to the arm may be decreased.

How to treat anterior Ice, analgesia and a short period of sling immobilization.
sprain or subluxation?
-Closed reduction under conscious sedation or general
How to treat anterior anesthesia
dislocation? -The arm is immobilized for 6 weeks in a figure-of-8
brace or sling.
# Reduction by exerting pressure over the clavicle and
pulling on the arm with the shoulder abducted.

23
Shoulder joint injuries
How to treat posterior -Closed reduction
dislocation? -The shoulders are braced back with a figure-of-eight
bandage for 3 weeks.

Explain maneuver of -Lying the patient supine with a sandbag between the
closed reduction? scapulae and then pulling on the arm with the shoulder
abducted and extended. Reduced with a snap.
-If this manoeuvre fails, the medial end of the clavicle is
grasped with bone forceps and pulled forwards.
-If this also fails, open reduction is justified.

Which is ideal method Computed tomography

of imaging?

Clavicle fracture

What’s the mechanism -Fall on shoulder (87%).

of clavicle fracture? -Direct trauma to clavicle (7%).
-FOOSH ’fall on out stretched hand’ (6%).

What are clinical • pain and tenting of skin

features? • arm is clasped to chest to splint shoulder and prevent
movement

Allman classification • Group I – middle-third fractures (85%)

for clavicle fractures? • Group II – lateral-third fractures (15%)
• Group III – medial-third fractures (5%)

Why in the midshaft The lateral fragment is pulled down by the weight of the
fracture, the lateral arm and the inner, medial half is held up by the
half is pulled down and sternomastoid muscle.
the medial half is held
up?

What’s imaging • x-ray: AP, 30° cephalic tilt

technique is required? • CT: useful for medial physeal fractures and
sternoclavicular injury

What’s treatment of • sling for 1-2 wk

medial and middle • early ROM and strengthening once pain subsides
third clavicle fractures? • if fracture is shortened(displaced) >2 cm consider ORIF
as screw and plate.

24
Shoulder joint injuries
What’s treatment of • undisplaced (with ligaments intact): sling for 1-2 wk
lateral third clavicle • displaced (CC ligament injury): ORIF with locking plate.
fractures?

What are the Early:

complications of pneumothorax, damage to the subclavian vessels and
clavicle fracture? brachial plexus injuries are all very rare.
Late:
Non-union
Malunion
Stiffness of the shoulder that is common but usually
temporary.

What we missed? -Floating shoulder (clavicle fracture + proximal humerus

or glenoid fracture) and lateral third clavicle fracture with
disruption of AC joint need ORIF.
-Risk factors of non-union include increasing age,
displacement, comminution and female sex.
-Lateral clavicle fractures have a higher rate of non-union
(11.5–40%).
Scapula fracture
-The body of the scapula is fractured by a crushing force,
What’s the mechanism usually with fractures ribs and dislocate the
of scapula fractures? sternoclavicular joint.
-The neck of the scapula may be fractured by a blow or by
a fall on the shoulder.

What are clinical -Shoulder movements are painful but possible.

features? -If breathing also is painful, thoracic injury must be
excluded.

What about imaging? -X-rays for fracture of the body and neck of the scapula.
-Occasionally a crack is seen in the acromion or the
coracoid process.
-CT is useful for glenoid fractures.

What about treatment? -Sling for comfort and from the start practices active
exercises of the shoulder, elbow and fingers.
-Large glenoid fracture requires ORIF.

Why scapulothoracic The scapula and arm are wrenched away from the chest,
dissociation with great rupturing the subclavian vessels and brachial plexus.
chance of death?

25
Shoulder joint injuries
Fracture in the middle
third of clavicle

Shoulder dislocation
- Anterior dislocation is more common.
What are factors
causing shoulder (1) shallowness of the glenoid socket
dislocation? (2) loose capsule
(3) ligamentous laxity or glenoid dysplasia

What’s the mechanism -FOOSH.

of anterior dislocation? -Forced abduction and external rotation of the shoulder.
-Blow to posterior shoulder.

What are clinical 1) sever pain

features of anterior 2) patient supports the arm with the opposite hand and is
dislocation of the unwilling to permit any kind of examination.
shoulder? 3) lateral outline of the shoulder is flattened and a small
bulge below the clavicle.

What about imaging? In addition to anterior view, lateral view is essential to

show whether or not the head is in the socket.

Methods of reduction? -Sedation and occasionally general anaesthesia is required.

-Closed reduction with Stimson’s technique or
Hippocratic or Kocher’s method
-Obtain post-reduction x-rays.
-Check post-reduction NVS.
-Sling for 3w, then shoulder rehabilitation.

Neurovascular Exam -Axillary nerve: sensory patch over deltoid and deltoid
Including? contraction
-Musculocutaneous nerve: sensory patch on lateral
forearm and biceps contraction & brachial artery.

26
Shoulder joint injuries
Stimson’s technique The patient is left prone with the arm hanging over the
side of the bed with 4 kg. After 15 or 20 minutes the
shoulder may reduce.

Hippocratic method Gently increasing traction is applied to the arm with the
shoulder in slight abduction, while an assistant applies
firm countertraction to the body (a towel slung around the
patient’s chest, under the axilla, is helpful).

Kocher’s method The elbow is bent to 90 degrees and held close to the
body; no traction should be applied. The arm is slowly
rotated 75 degrees laterally, then the point of the elbow is
lifted forwards, and finally the arm is rotated medially.

Above methods
respectively

Complications of Early:
anterior dislocation of -Rotator cuff tear suggested by inability to initiate
shoulder? abduction of the arm.
-Nerve injury (axillary nerve), Occasionally the posterior
cord of the brachial plexus, the median nerve or the
musculocutaneous nerve.
-Vascular injury (axillary artery)
-Fracture- dislocation
Late:
-Shoulder stiffness especially with those over 30 years
-Unreduced dislocation
-Recurrent dislocation especially for those under 30 years

What we missed? -The arm must always be examined for nerve and vessel
injury before and after reduction
- An x-ray is taken to confirm reduction and exclude a
fracture after reduction.
- Direct blow to the shoulder: x-ray for associated cervical
spine injury.
-Kocker’s method with risk for nerve, vessel and bone
injury and is not recommended.

27
Shoulder joint injuries
Posterior shoulder Rare, less than 2% of all dislocations around the shoulder.
dislocation

Mechanism of injury? -Forced internal rotation of the abducted arm

-FOOSH
-3 Es (epileptic seizure, EtOH, electrical shock)
-Blow to anterior shoulder

What are clinical The arm is held in medial rotation and is locked in that
features? position.

What is electric light-

bulb’ appearance in x-
ray for posterior
dislocation?

What’s about -Closed reduction with sedation and muscle relaxation

treatment? - The arm is pulled and rotated laterally, while the head of
the humerus is pushed forwards
-Obtain post-reduction x-rays
-Check post-reduction NVS
-Sling in abduction and external rotation x 3 wk, followed
by shoulder rehabilitation.

Luxatio erecta? Inferior dislocation of shoulder with risk of axillary nerve

injury

Fractures of proximal
humerus
What is the • young: high energy trauma (MVC)
mechanism? • elderly: FOOSH from standing height in osteoporotic
individuals

What are the clinical -Not very severe pain since usually firmly impacted
features? fracture
- large bruise in the upper arm

Investigation? • test axillary nerve function (deltoid contraction and skin

over deltoid) and brachial plexus.
• x-rays: AP, trans-scapular, axillary are essential
• CT scan: to evaluate for articular involvement and
fracture displacement

28
Shoulder joint injuries
How Neer’s According to the number of displaced fragments, with
classification displacement defined as greater than 45 degrees of
distinguish between angulation or 1 cm of separation.
proximal humerus - Fragments of proximal humerus (greater tuberosity, head
fractures? of the humerus, lesser tuberosity, and shaft).

Neer’s classification? -One-part fracture: any of the 4 parts with none displaced
-Two-part fracture: any of the 4 parts with 1 displaced
-Three-part fracture: displaced fracture of surgical neck +
displaced greater tuberosity or lesser tuberosity
-Four-part fracture: displaced fracture of surgical neck +
both tuberosities.

Vascular supply of the The anterior circumflex humeral artery mainly (ACHA)
humeral head? and posterior circumflex humeral artery (PCHA) branch
off of the axillary artery.

Treatment? • treat osteoporosis if needed

1) one-part fracture: rest for 1- 2 wk, broad arm sling,
active movement after 6wk.
2) two-part fracture:
-Surgical neck: closed reduction with sling for 4 wk if
sling fails, we use percutaneous pins or bone suture
- Greater tuberosity (usually with anterior dislocation):
Reduced with shoulder reduction if not Reduced, use
interosseous suture or cancellous screw in young.
- Anatomical neck(rare): ORIF if elderly use
hemiarthroplasty
3) three parts: ORIF with locked nail.
4) four parts: ORIF with locked plate if elderly use
hemiarthroplasty

Two-part fracture and Greater tuberosity with anterior dislocation and lesser
dislocation tuberosity with posterior dislocation.
relationship?

Complications? -Vascular injuries and nerve injuries particularly axillary

nerve
- Avascular necrosis (AVN)
- Dislocation and stiffness of the shoulder
- Malunion
Reduction need not be
perfect in children? Because of re-modelling will compensate for malunion.

29
Shoulder joint injuries
(a) Two-part fracture.
(b) Three-part fracture
involving the neck and
the greater tuberosity.
(c) Four-part fracture.
(1 shaft of humerus; 2
head of humerus; 3
greater tuberosity; 4
lesser tuberosity).
(d) fracture dislocation -Anatomic neck fractures disrupt blood supply to the
of the shoulder. humeral head and AVN of the humeral head may ensue

Humeral Shaft
Fracture

What’s the mechanism • high energy: direct blows/MVC (especially young)

of injury? • low energy: FOOSH, twisting injuries, metastases (in
elderly

Why the proximal -Fractures above the deltoid insertion, the proximal
fragment of humerus fragment is adducted by pectoralis major.
after shaft fracture -Fractures lower down, the proximal fragment is abducted
may be adducted or by the deltoid.
abducted?

Clinical features? The arm is painful, bruised and swollen

Neurovascular injury? Risk of radial nerve since run in radial groove and
brachial artery injury.

How to examine for Active extension of the wrist and fingers (MCP joints) and
radial injury? sensation of dorsum of hand

Active extension of the Because extensor carpi radialis longus is sometimes

wrist can be misleading supplied by a branch arising proximal to the injury.
for radial nerve injury?

Fractures of the The weight of the arm with an external cast is usually
humerus require enough to pull the fragments into alignment.
neither perfect
reduction nor total
immobilization?

30
Shoulder joint injuries
Treatment? Sling or a plaster U-slab hanging cast (or ready-made
brace).

Indications of ORIF? • displaced intra-articular extension of the fracture

• a pathological fracture
• a ‘floating elbow’ (simultaneous unstable humeral and
forearm fractures)
• radial nerve palsy after manipulation
• non-union
• problems with nursing care in a dependent person.

Indications of external • severe multiple injuries

fixation in humerus • an open fracture
fracture? • segmental fractures

What are the Early:

complications? -Vascular injury (brachial artery)
- Nerve injury (radial nerve)
Late:
-Delayed union and non-union.
-Joint stiffness can be minimized by early activity.

Holstein–Lewis Oblique fractures at the junction of the middle and distal

fracture? thirds of the humerus bone, particularly associated with
radial injury.

Collar and cuff Since the strong periosteum and the power of rapid
bandage for 3–4 weeks healing in children.
in children is enough?

31
Elbow joint orthopedic
What are common - Cubitus Varus (gun-stock deformity).
deformities of elbow? - Cubitus Valgus.
- Stiff elbow.

- Obvious when the elbows are extended and the arms are
How does cubitus
elevated. It’s a result of malunion of supracondylar
Varus present? how
fracture.
would you correct it?
- Corrected by a wedge osteotomy.

How does cubitus - Gross deformity and a bony knob on the inner side of
valgus present? what is the joint.
the cause of it? - the cause is non-union of a fractured lateral condyle

What is the most Ulnar nerve palsy (develop lately and treated by
common complication transportation of the nerve in front of elbow).
of cubitus valgus?

How does stiff elbow Usually caused by congenital disorders, trauma or

present and how would arthritis. Treated by physiotherapy or surgery
you treat it?

Epicondylitis
What is tennis elbow It is inflammation of lateral and medial humeral
and golfer elbow? epicondyles respectively. Usually due to excessive and
sudden use of forearm muscles resulting in pain due to
vascular repair process.

What features would - In tennis elbow >> tender lateral epicondyle, pain on
you see clinically? passive flexion or resisted extension of wrist.
- In golfer elbow >> tender medial epicondyle, pain on
passive extension of wrist while in supination.

What conservative - Rest and avoidance of precipitating activity.

measures would you - Splint and physiotherapy.
offer? - Injection of corticosteroid and local anaesthetic.

What are indications of Failure of conservative measures make us shift to

operative treatment? detachment of common tendon from its origin on humeral
epicondyle.

32
Elbow joint injuries
Distal Humeral Fracture
• Type A – extra-articular supracondylar fracture
Types of distal humeral • Type B – intra-articular unicondylar fracture (one condyle
fracture? sheared off)
• Type C – intra-articular bicondylar fracture with varying
degree of comminution.

Supracondylar fractures Rare in adults, usually displaced and unstable or severely

comminuted (high-energy injuries).

Mechanism of injury? >96% are extension injuries via FOOSH.

<4% are flexion injuries.

Treatment of Nondisplaced: long arm plaster slab in 90º flexion x 3 wk

Supracondylar Displaced, vascular injury, open fracture:
fractures? -ORIF is Tx of choice since closed reduction is unstable.
- transverse or oblique displaced fracture: single contoured
plate and screws.
- Comminuted displaced fractures: double plates and
transfixing screws.

Specific complications? • stiffness is most common

• brachial artery injury, Anterior interosseous, Median,
Radial, Ulnar nerve injury(AMRU), compartment
syndrome (leads to Volkmann’s ischemic contracture),
cubitus varus.

Mechanism of A severe blow on the point of the elbow drives the

Intraarticular fractures? olecranon process upwards, splitting the condyles apart.

Treatment of Undisplaced fracture: posterior slab with the elbow flexed

intraarticular fracture? almost 90 degrees;
-movements are commenced after 2 weeks.
Displaced condylar fracture: ORIF from posterior
approach is treatment of choice.
-A unicondylar fracture without comminution: screws if the
fragment is large, a contoured plate is added
-Bicondylar and comminuted fractures: double plate and
screw fixation.
-Elderly osteoporotic patients: elbow replacement.

33
Elbow joint injuries
Complications? Early:
-Vascular injury
- Nerve injury: ulnar nerve but the radial nerve may be
injured by a long lateral plate and median nerve injury.
Late
-Stiffness
- Heterotopic ossification
X-ray explain:
1)supracondylar
fracture of humerus
2) bicondylar fracture of
humerus respectively.

Fractured capitulum
What is the mechanism Falls on the hand, usually with the elbow straight.
of fracture? -Only in adult.
What are the clinical -The elbow is held at around 70 degrees of flexion for
features? accommodating the haemarthrosis.
-Tenderness and bruising in the lateral side of the elbow.
What is treatment? Undisplaced fractures(rare): analgesia and a collar and
cuff.
Displaced fractures: ORIF
-Not comminuted use lag screw.
-Comminuted use dorsal lateral plate.
#Closed reduction with immobilization not preferred since
cause elbow stiffness.
X-rays showing lateral
and posterior
displacement of the
elbow.

34
Elbow joint injuries
Simple Dislocation of the -Dislocation of the ulnohumeral joint is the second most
elbow common major joint dislocation after the shoulder.
- Over 90% of cases the forearm dislocates in a posterior
direction.

What is the mechanism Fall on an outstretched hand with the elbow in extension
of injury? often with a valgus force.

Which ligaments may be Medial collateral ligament will torn in all cases, but in up to
torn? 20% the lateral ligament intact or have only a low-grade
partial tear.

Bony isosceles triangle of In elbow flexion, the tips of the medial and lateral
the elbow? epicondyles and the olecranon prominence form an
isosceles triangle; with the elbow extended, they lie
transversely in line with each other.

What are the clinical • elbow pain, swelling, deformity

features? • flexion contracture
• ± absent radial or ulnar pulses

Treatment of anterior -First, assess NVS before reduction: brachial artery, median
elbow dislocation? and ulnar nerves
• Non-operative
-Closed reduction under conscious sedation
- Check NVS after reduction
- Obtain x-ray after reduction
- Collar and cuff sling with forearm in neutral rotation and
elbow in 90° flexion
- early ROM after 1wk
• operative
■ indications: complex dislocation or persistent instability
after closed reduction
■ ORIF

35
Elbow joint injuries
Complications? Early:
-Vascular injury (brachial artery)
- Nerve injury (median and ulnar nerves); Spontaneous
recovery after 6–8 weeks.
Late
-Stiffness
- Heterotopic ossification (myositis officans)
- Recurrent dislocation
- Osteoarthritis
- Unreduced reduction: Tx; open reduction, soft-tissue
release and ligament reconstruction with external fixator if
the elbow remains unstable

How to treat Heterotopic -Exercises are stopped

ossification? -The elbow is splinted in comfortable flexion until pain
subsides;
-Gentle active movements and continuous passive motion
then resumed.
-Anti-inflammatory drugs may help to reduce stiffness

Fracture–dislocation of -Lateral or external rotation injury (Terrible triad)

the elbow examples? -Bending injury (Monteggia Fracture–dislocation)

Terrible triad injury? Elbow dislocation with fracture of the radial head, coronoid
process and medial collateral ligament ruptured.

Radial head fractures -Most common fracture of the elbow in adults.

-In children radial neck fractures are more common because
the head is largely cartilaginous.

Mechanism of injury? -Fall on the elbow

-FOOSH with elbow extended and forearm pronated
#The injury may be associated with lateral ligament
avulsion and/or medial ligament tear.

What are clinical • marked local tenderness on palpation over radial head
features? (lateral elbow)
• decreased ROM at elbow, ± mechanical block to forearm
• pain on pronation/supination

36
Elbow joint injuries
X-ray: enlarged anterior
fat pad (“sail sign”) or
the presence of a
posterior fat pad
indicates effusion.

What’s Mason
classification and
treatment of each type?

#The head of the radius must never be excised in children

because this will interfere with the synchronous growth of
radius and ulna.

Three main(first) types

of adult radial head
fracture:
(a) split of head;
(b) a marginal fracture;
(c) a comminuted
fracture.

Specific Complications? • joint Stiffness

• myositis ossificans – calcification of muscle
• recurrent instability (if MCL injured and radial head
excised)
• Osteoarthritis of the radiocapitellar joint
Fracture of the radial Undisplaced: non-operative management as collar and cuff
neck in adult? sling
Displaced: open reduction with fixation by pre-contoured
locking plate

37
Elbow joint injuries
Olecranon fracture Divided into two broad categories:
(1) a simple transverse fracture occurs as an avulsion due to
a fall on an outstretched hand with the triceps contracting
(2) a comminuted fracture due to a direct blow or a fall on
the elbow
Mayo classification of
olecranon fractures?

What are the clinical -Graze or bruise over the elbow suggests a comminuted
features? fracture
-Palpable gap may be transverse fracture

X-ray view? AP and lateral (require true lateral to determine fracture

pattern)

Treatment? Comminuted
-internal fixation with Modern Metal Plate
-non-displaced in elderly and osteoporotic patient treated
with sling until the pain subsides.

Transverse
-non-displaced: cast in about 60 degrees of flexion for 1
week but sling is better
-displaced: ORIF
1) stable joint: suture repair or tension-band wiring
2) non-stable joint: plate and screw
# In children, if displaced, they should be reduced and held
with K-wires.

Complications? -Ulnar nerve symptoms

-Stiffness
-Non-union
-Osteoarthritis

Fractured olecranon
(a) Slightly displaced
transverse fracture.
(b) Markedly displaced
transverse fracture

38
Elbow joint injuries
Fractures around the -The elbow is second only to the distal forearm for
elbow in children frequency of fractures in children.
- Most of these injuries are supracondylar fractures.
- Boys are injured more often than girls.
- the average carrying angle in children is about 15 degrees.
- the secondary ossific centers (in the epiphysis as in long
bone) can be seen on X-ray; they should not be mistaken for
fracture fragments.
The average ages at
which the ossific centers The mnemonic “CRITOE”
appear? – C: Capitulum – 2 years
– R: Radius head – 4 years
– I: Internal (medial) epicondyle – 6 years
– T: Trochlea – 8 years
– O: Olecranon – 10 years
– E: External (Lateral) epicondyle – 12 years

Baumann’s angle Made by the longitudinal axis of the humeral shaft and a
line through the coronal axis of the capitellar physis.

b) Normally less than 80

degrees
c) increased with varus
deformity

What’s the advantage of To detect epiphyseal displacements (degree of medial

this angle. angulation) before and after reduction.

Supracondylar fracture -Posterior angulation or displacement (95% of cases)

in children suggests a hyperextension injury, usually due to a fall on
the outstretched hand.
- Anterior displacement is rare; it is thought to be due to
direct violence (e.g. a fall on the point of the elbow) with
the joint in flexion.

What are the clinical -Painful and swollen elbow, The S-deformity of the elbow
features? ‘gun-stock deformity’ (posteriorly displacement)
-check pulse and check capillary return; passive extension
of the flexor muscles should be pain-free

39
Elbow joint injuries
Gartland (Willikins) • Type I – an undisplaced fracture
classification of • Type II – an angulated fracture with the posterior cortex
Supracondylar fracture? still intact
– IIA: a less severe injury with the distal fragment merely
angulated
– IIB: a severe injury; the fragment is both angulated and
malrotated
• Type III – a completely displaced fracture (although the
posterior periosteum is usually preserved, which will assist
surgical reduction)
• Type IV – an anteriorly displaced fracture(rare)

Treatment -Any suspicion of a fracture, the elbow is gently splinted in

30 degrees of flexion to prevent movement and possible
neurovascular injury.
TYPE I: UNDISPLACED FRACTURES
-Elbow is immobilized at 90 degrees and neutral rotation in
a lightweight splint or cast for 3 weeks with sling for arm.
-obtain an X-ray 5–7 days later to check for a displacement.

TYPE IIA: POSTERIORLY ANGULATED

FRACTURES – MILD
-manipulation under general anesthesia with the aid of
fluoroscopy
- check NVS after reduction
- obtain x-ray to confirm the reduction
#if the reduction is unstable, use percutaneous K-wires.
- Apply backslab for 3–4 weeks.

TYPES IIB AND III: ANGULATED AND

MALROTATED OR POSTERIORLY DISPLACED
FRACTURES
-manipulation under general anesthesia with the aid of
fluoroscopy
- check NVS after reduction
- obtain x-ray to confirm the reduction
- Held with percutaneous smooth K-wires.
- Apply backslab for 3–4 weeks.

40
Elbow joint injuries
Indications of ORIF (1) a fracture that simply cannot be reduced closed;
withheld by two(cross) (2) an open fracture
K-wires? (3) a fracture associated with vascular damage.

Treatment of anteriorly -Reduced by pulling on the forearm with the elbow semi-
displaced fracture? flexed, applying thumb pressure over the front of the distal
fragment and then extending the elbow fully.
-Percutaneous smooth pins are used if unstable.
-A posterior slab for 3–4 weeks.

Complications? EARLY
-Vascular injury (brachial artery) causing edema and
compartment syndrome
- Nerve injury: radial nerve, median nerve (particularly the
anterior interosseous branch) or the ulnar nerve, recovery
can be expected in 3-4 months.
LATE
-Malunion: Cubitus Varus is disfiguring and cubitus valgus
may cause late ulnar nerve palsy treated with supracondylar
osteotomy, usually once the child approaches skeletal
maturity.
-Elbow stiffness and heterotopic ossification
Supracondylar fracture
– malunion
(a) Varus deformity of
the right elbow, due to
incomplete correction of
the varus and rotational
displacements in a
supracondylar fracture.
(b) ‘gunstock deformity’

Fractures of the lateral -The lateral condylar (or capitellar) epiphysis begins to
condyle in children ossify during the first year of life and fuses with the shaft at
12–16 years.
- Between these ages it may be sheared off or avulsed by
forceful traction.

Mechanism of injury? The child falls on the hand with the elbow extended and
forced into varus or sudden pull of the forearm.

41
Elbow joint injuries
What are the clinical -The elbow is swollen and deformed.
features? -Tenderness over the lateral condyle.
-Passive flexion of the wrist (pulling on the extensors) may
be painful.

Milch classification? • Type I – (Commonest) a fracture lateral to the trochlea:

the ulnohumeral joint is not involved and is stable. (Salter–
Harris type IV)
• Type II – (Less common) a fracture through the middle of
the trochlea. This injury is more common; the elbow is
unstable since it reaches the articular surface in the
capitulotrochlear groove. (Salter–Harris type II injury).

Treatment? Undisplaced
- the arm splinted in a backslab with the elbow flexed 90
degrees, the forearm in neutral rotation and the wrist
extended (this position relaxes the extensor mechanism
which attaches to the fragment).
-Repeat the X-ray after 5 days
-Remove the splint after 2 weeks and exercises encouraged.
Displaced
-Closed reduction and internal fixation with percutaneous
pins or Kirchner wire.
- If this fails ORIF with pins or screws
- Immobilization in a cast that is removed with the pins
after 3–4 weeks.

Complications? - Non-union and malunion, cause cubitus valgus, and

delayed ulnar nerve palsy
- Recurrent dislocation of the elbow, Tx: reconstruction of
the lateral side
X-rays explain
a) lateral condyle is
capsized
b) ORIF by Kirchner
wire of the fracture

42
Elbow joint injuries
Separation of the medial
epicondyle in children

What is the mechanism -Falls on the outstretched hand (FOOSH) with the wrist and
of injury? elbow extended; the elbow is wrenched into valgus.
-The unfused epicondylar apophysis is avulsed by tension
on either the wrist flexor muscles or the medial ligament of
the elbow.

What are the clinical -Pain, swelling and bruising to the medial side of the elbow.
features? - Sensation and power in the fingers should be tested to
exclude ulnar nerve damage.

Treatment? -Minor displacement: elbow is splinted for 2–3 weeks and

exercises are then encouraged.
-Displaced fracture:
1) If the epicondyle is trapped in the joint, it must be freed
with Manipulation if this fails, the joint must be opened’
and the fragments retrieved and fixed back in position.
2) Not trapped;
- the epicondyle is sutured back in position.
# If there is valgus instability or marked displacement,
then open reduction and pinning, or screw fixation is
recommended.

Complications? Early: Ulnar nerve damage

Late: Stiffness

Apophysitis A painful traction injury of the medial epicondyle

apophysis, and it occurs in young athletes as a result of
repeated forced valgus moments of the elbow, such as when
bowling a ball or throwing. The condition usually settles
with rest.

Fracture of the medial -Much less common than either a fracture of the lateral
condyle in children condyle or a separation of the medial epicondylar
apophysis.
- Treated in the same way as lateral condyle fractures.

43
Elbow joint injuries
Complications? EARLY
-Lateral dislocation of the elbow when there is severe
valgus strain
- Ulnar nerve damage
LATE
-Stiffness of the elbow
X-ray explains:
(a) Avulsion of the
medial epicondyle
following valgus train.
(b) Avulsion associated
with dislocation of the
elbow

Fracture–Separation of - occur with fairly severe violence, such as in birth injuries

the entire distal humeral or child abuse.
epiphysis - pain and markedly swelling in the elbow.
- The child is distressed history may be uninformative.

Treatment Undisplaced:
-the elbow is splinted for 3 weeks;
Displaced: closed reduction and held with smooth
percutaneous wires.
-The wires are removed at 3 weeks.

Fractured neck of radius - Mechanism of injury and clinical features as in fractured

in children neck of radius in adult
- May cause Salter–Harris type II injury.

Treatment -If ≤ 30 degrees of radial head tilt and ≤ 3 mm of transverse

displacement.
Tx: The arm is rested in a collar and cuff, and exercises are
commenced after 1 week.
--If > 30 degrees of radial head tilt.
Tx: Closed reduction. if fails, perform open reduction and
then the elbow is splinted in 90 degrees of flexion for 1–2
weeks and then movements are encouraged.
#Fractures that are seen 1 week or longer after injury should
be left untreated (except for light splintage).

44
Elbow joint injuries
Subluxation of the radial -It is a subluxation of the annular ligament that slips up over
head (‘pulled elbow) the head of the radius into the radiocapitellar joint.
-There are no X-ray changes.

Mechanism of injury? In young children the elbow may be injured by pulling on

the arm, usually with the forearm pronated.

Treatment Supinating and then flexing the elbow; the ligament slips
back with a snap

X-ray explains
Fractured neck of radius
in a child

45
Forearm injuries
Fractures of the shafts -Injuries to the bones of the forearm should be considered
of the radius and ulna intra-articular fractures, because the forearm is a
quadrilateral joint –proximal and distal radioulnar joints.

Mechanism of injury? -A twisting force (usually a fall on the hand) produces a

spiral fracture with the bones broken at different levels.
-An angulating force causes a transverse fracture of both
bones at the same level.
-A direct blow causes a transverse fracture of just one
bone, usually the ulna.

The bone fragments are Since the contraction of strong muscles attached to the
easily displaced? radius.

Clinical features? -Pain and deformity

-Check neurovascular system (NVS).
-Bear in your mind compartment syndrome lately.

Treatment Children
-full-length cast, from just distal to the axilla to the
metacarpal shafts (to control rotation), with the elbow at
90 degrees for 6–8 weeks.
-obtain x-ray after 1 week.
# If reduction is impossible or unstable, then fixation with
small plates or intramedullary pins or plate or K-wire.
#If the radial fracture is proximal to pronator teres, the
forearm is supinated; if it is distal to pronator teres, the
forearm is held in neutral.

Adults
Undisplaced: conservative(cast)
Displaced:
-ORIF with Plate and screw.
-the arm is kept elevated until the swelling subsides.
Open fractures
-Antibiotics and tetanus prophylaxis are given as soon as
possible
-Major soft tissue loss: external fixation
- No major soft tissue: compression Plate and screw

#If there is any question of a compartment syndrome, the

wounds should be left open and closed 24–48 hours later,
with a skin graft if needed.

46
Forearm injuries
Complications? EARLY
-Nerve injury: posterior interosseous nerve that is covered
by supinator muscle.
-Vascular injury: Injury to the radial or ulnar artery
seldom presents any problem, as the collateral circulation
is excellent.
- Compartment syndrome: distal pulse does not exclude
it!
Late
- Delayed union and non-union
- Malunion: if restrict pronation and supination,
Tx: corrective osteotomy
- Complications of plate removal: damage to vessels and
Fractured radius and nerves, infection and fracture through a screw hole.
ulna in adults
(a,b) These fractures
are usually treated by
internal fixation with
sturdy plates and
screws. However,
removal of the implants
is not without risk.
(c,d) the radius
fractured through one
of the screw holes.

Incisions to relieve a
compartment syndrome
in the forearm.

Fracture of a single - Fracture of the radius alone is very rare and fracture of
forearm bone the ulna alone is uncommon.
- These injuries are usually caused by a direct blow – the
‘nightstick fracture’.

Why These fractures For two reasons:

are important? • An associated dislocation may be undiagnosed;
-One forearm bone is displaced then either the proximal
or the distal radioulnar joint must be dislocated.
-Entire forearm, elbow and wrist should be X-rayed.
• Non-union is liable to occur.

47
Forearm injuries
Plastic deformation In children, the intact bone sometimes bends without
actually breaking.

What about imaging? Ulnar fractures are easily missed – even on X-ray. If there
is local tenderness, a further X-ray a week or two later is
wise.

Treatment of isolated -Undisplaced: cast leaving the elbow free for 8 weeks
fracture of the ulna? -Angulated or rotated: rigid internal fixation to reduces
the risk of displacement or non-union.

Treatment of isolated -To achieve reduction the forearm needs to be supinated

fracture of the radius? for upper third fractures, neutral for middle third fractures
and pronated for lower third fractures.
-Internal fixation with a compression plate and screws in
adults
-Preferably intramedullary nails in children, is better to
achieve reduction without redisplacement as in
conservative treatment.

Middle/distal third Being deformed by the pull of the thumb abductors and
fracture of the radius in pronator quadratus.
children are unstable?

Treatment of this -Above-elbow cast in supination

condition? -If fails fixation with an intramedullary nail or (K-) wires.

Monteggia Fracture - -Any fracture of the ulna associated with dislocation of

dislocation oF the ulna? the radiocapitellar joint.

Mechanism of injury? -Fall on the hand and forced pronation of the forearm.
-The radial head usually dislocates forwards and the
upper third of the ulna fractures and bows forwards.

What are the clinical -The ulnar deformity is usually obvious but the dislocated
features? head of radius is masked by swelling.
-A useful clue is pain and tenderness on the lateral side of
the elbow.
#The wrist and hand should be examined for signs of
injury to the radial nerve.
#Any apparently isolated fracture of the ulna should raise
the suspicion of a proximal radial dislocation.

48
Forearm injuries
Treatment? -The key to successful treatment is to restore the length of
the fractured ulna; only then can the dislocated joint be
fully reduced and remain stable.
Children
-Incomplete ulnar fractures (greenstick or plastic
deformation): Closed reduction and cast with the elbow in
flexion and supination, for 3 weeks.
-Complete fractures: ORIF
Adult
- ORIF and plaster with the elbow flexed for 6 weeks.

Complications? -Nerve injury (posterior interosseous nerve)

-Malunion
-Non-union
-Unreduced dislocation
X-ray explains
Monteggia fracture-
dislocation

Galeazzi fracture - - The counterpart of the Monteggia injury is a fracture of

dislocation of the radius the distal third of the radius and dislocation or subluxation
of the distal radioulnar joint.
- The Galeazzi fracture is much more common than the
Monteggia.

Clinical features? - Prominence or tenderness over the lower end of the ulna
- The instability of the distal radioulnar joint
- Test for an ulnar nerve lesion

Piano key sign? Push down on distal ulna with forearm is pronated to
assess stability of of the distal radioulnar joint and
comparing with normal forearm.

Treatment? Children: Closed reduction

Adult: ORIF
After reduction
1) if DRUJ is Reduced and stable: arm rested for few days
and check for next 6 weeks.
2) if DRUJ is Reduced but unstable: above-elbow cast for
6 weeks in supination
3) if DRUJ is irreducible: open reduction (use k-wire if
needed) with immobilization for 6 weeks in supination.

49
Forearm injuries
(a)Galeazzi fracture–
dislocation
(b,c) X-rays before and
after reduction and
plating.

50
Wrist & hand orthopedic
What is carpal tunnel compression on median nerve in the carpal tunnel at the
syndrome (CTS)? wrist.

What is the pathology Any swelling inside the carpal tunnel “which is already
behind CTS? narrow” will cause compression and ischemia to median
nerve. Swellings may be due to inflammatory disorders
(e.g. RA), occupational stress on wrist, physiological
conditions (e.g. pregnancy), diseases (e.g. DM), trauma or
ganglion cyst.
Sensory fibers are first affected followed by motor.

What is the incidence of 1-3 person per 1000 per year.

CTS?

What are the clinical Numbness: - at night and in the radial 3 and half fingers.
features of CTS? Wasting: - lately in thenar eminence.
Weakness: - also lately with thump abduction affected.

How can you confirm Tinel sign: - percussion over carpal tunnel reproduce
diagnosis by sensory symptoms.
examination? Phalen sign: - holding both hands in flexion at least for 1
minute will reproduce symptoms.
median nerve compression test, the square wrist sign,
and Durkan’s test may be useful in confirming CTS.

How can you confirm The diagnosis is clinical but nerve conduction studies &
the diagnosis? EMG may support and quantify degree of nerve injury.

What advices to give to Try to change his work and not to avoid extreme
the patient? movements that provoke symptoms.

What treatment would Conservative: - splint and steroid injections.

you offer? Operative: - release of flexor retinaculum (open
/endoscopic).

What are the 1- failure of conservative measurements.

indications of operative 2- severe CTS category (as defined by EMG).
intervention in CTS?

What is the prognosis Surgery is successful in 90% of cases.

of CTS?

51
Wrist & hand orthopedic
What is ganglion? It’s a cyst lesion commonly seen in dorsum of wrist
results from mucoid degeneration of tendon sheath or joint
capsule.

What are the features Site: - dorsum of wrist and not common in front.
of ganglion lump? Pain: - painless and not tender but sometimes it aches.
Margin: - well defined.
Consistency: - cystic.
Attachment: - to one of tendons in the wrist.

What are the outlines of - left untreated if not troublesome.

management? - aspiration is a good choice but recurrence may occur.
- excision of lump but also recurrence reported.

What is De quervain’s It’s a “tenosynovitis” disease results in inflammation and

disease? thickening of tendons of abductor policis longus (APL) &
extensor policis brevis (EPB), the inflammation occurs
due to repetitive use or infection.

What are clinical Pain, swelling and tender radial side of wrist.
features of it?

What clinical test to Finkelstein’s test: - pain in radial thumb with closed fist
do? placed in passive ulnar deviation.

What treatment to NSAIDs, ice, immobilization, and cortisone injections.

offer? Surgery is indicated when conservative measures fail to
work after 1 month (cutting of diseased tendon sheath).

What to know about - Avascular necrosis of lunate bone after injury or stress.
kienbock’s disease? - Increase density of lunate bone in x-ray.
- osteotomy, revascularization, arthrodesis and joint
replacement are choices of treatment.

52
Wrist & hand orthopedic
What is dupuytren’s A benign, progressive fibroproliferative disease of the
contracture? palmar fascia (characterized by thickening and contracture
of the fibrous bands on the palmar surfaces of the hand
and fingers) that has unclear etiology or pathology.

What are clinical Early: -thickening of the palmar aponeurosis and nodules
features of it? are felt at the bases of ring and little fingers.
Later: - a flexion deformity of the fingers develops.

What is the DDX? Skin contracture: - previous laceration is usually obvious.

Tendon contracture: - the ‘cord’ moves on passive flexion
of the finger.

How to manage it? Disability absent >> left untreated.

Disability present>> operation (Z incision and excision).

Mallet finger? - Rupture of distal extensor tendon/fracture distal phalanx.

- Cannot extend the DIP.
- Treated by splintage for 8 weeks (or surgical fixation).

Trigger finger? - Inflammation of the flexor tendon sheath.

- Finger clicking, pain at distal palm and locking.
- Tenderness and nodule feeling at distal palm.
- Managed by splinting, NSAID, physiotherapy, steroid
injection or surgery.

53
Wrist injuries
Fractures of the distal
radius in adults

Colles’ fracture -Extra-articular transverse distal radius fracture (~2 cm

proximal to the radiocarpal joint) at cortico-cancellous
junction with dorsal displacement ± ulnar styloid fracture
- most common of all fractures in older people, the high
incidence related to the onset of postmenopausal
osteoporosis.

Mechanism of injury • Fall on the outstretched hand(FOOSH).

Clinical features? • “dinner fork” deformity

• pain on movement, swelling, ecchymoses, tenderness

Treatment Undisplaced (minimally displaced)

- dorsal splint for a day or two until the swelling resolved,
- then the cast is completed for 5 weeks.
- An X-ray is taken at 10–14 day to exclude slipping
Displaced fractures
-manipulation under anesthesia (hematoma block, Bier’s
block or axillary block)
- dorsal plaster slab of two-thirds of the circumference
from below the elbow to the metacarpal necks, held by a
crepe bandage
-hold in 20ْ of flexion, ulnar deviation (Hand shaking)
- arm is elevated for the next day or two
- check the position again by x-ray 10 days later
Comminuted and unstable fractures
■ indication: failed closed reduction, or loss of reduction
• operative: percutaneous pinning or k-wires, external
fixation or ORIF

Maneuver of Closed 1) traction with extension.

reduction? 2) traction with ulnar deviation, pronation, flexion (of
distal fragment – not at wrist)
X-ray explains Colles
fracture

54
Wrist injuries
Smith fracture? like Colles but distal fragment is displaced and tilted
anteriorly(volar-ward) ‘reversed Colles’

Mechanism of injury fall on the back of the hand and is an unstable injury due
to the force generated by the long flexors crossing the
wrist.

Clinical features? -pain and swelling in wrist

- ‘garden-spade’ deformity.

Treatment • usually unstable and needs ORIF

• if patient is poor operative candidate, may attempt non-
operative treatment
■ closed reduction (by traction and extension of the wrist)
with hematoma block
■ long-arm cast in supination x 6 wks.
Smith’s fracture
(a,b) the displacement
of the lower radial
fragment is forwards –
not backwards.

Fracture of the radial caused by forced radial deviation of the wrist and may
styloid process occur after a fall, or when a starting handle ‘kicks back’ –
the so-called ‘chauffeur’s fracture’

Treatment If displaced it should be reduced and held with screws or

K-wires.
Fractured radial styloid
(a) X-ray; (b) fixation
with cannulated
percutaneous screw.

55
Wrist injuries
Barton’s fracture A split of the volar edge of the distal radius with anterior
(volar) subluxation of the wrist.

Treatment Closed reduction with Internal fixation, using a small

anterior buttress plate.
Fracture–subluxation
(Barton’s fracture)

Fragmented -Simple manipulation under anesthesia and cast may be

(comminuted) intra- successful.
articular fractures in -X-rays are needed at about 7 days
young adults -If fails closed reduction with percutaneous wires or an
Treatment? open reduction and fixation with Volar locking plates.

The ‘die-punch
fragment’ of the lunate
fossa of the distal radius
(a,b) closed reduction
and percutaneous K-
wire fixation (c). wires
can be used as ‘joy
sticks’ to manipulate Early
- Circulatory problems
Complications of distal - Nerve injury: Compression of the median nerve that
radius fractures may relieve release of the dressings and elevation.
- Complex regional pain syndrome (CRPS) (previously
known as reflex sympathetic dystrophy or Sudeck’s
dystrophy)
- Ulnar corner pain and instability due to ulnar styloid
fracture
- Associated injuries of the carpus
- Re-displacement
LATE
- Malunion
- Delayed union and non-union
- Tendon rupture, Rupture of extensor pollicis longus
treated with Colles and flexor pollicis longus with smith
treated with Tendon transfer.
- Carpal instability
- Secondary osteoarthritis

56
Wrist injuries
Distal Forearm -The distal radius and ulna are among the commonest
Fractures in children sites of childhood fractures.
- Metaphyseal fractures are often incomplete or
greenstick.
- juvenile Colles’ fracture as Colles facture in adult
- Lesser force may do no more than buckle the
metaphyseal cortex (a type of compression fracture, or
torus fracture).

What are the clinical -There is a history of a fall

features? -The wrist is painful, and often quite swollen
-There is an obvious ‘dinner-fork’ deformity.

Types of fractures? • Physeal fractures are usually Salter–Harris type II, Type
V injuries, the latter are unusual
• Incomplete fractures:
– torus (buckle) fractures: appear as a mere ‘buckle’ on a
cortex
– greenstick fractures: where one cortex is broken and the
other is just bent.
• Undisplaced fractures.
• Adult-pattern displaced fractures.

Treatment Physeal fracture

- reduction under anesthesia, by pressure on the distal
fragment.
-The arm is immobilized in a full-length cast for 4 weeks
with the wrist slightly flexed and ulnar deviated, and the
elbow at 90 degrees.
Buckle fractures
- plaster for 3–4 weeks
Greenstick fractures
-Closed reduction and immobilization with cast.
-Residual angulation can be accepted: in children under
10, up to 30 degrees; in children over 10, up to 15
degrees.
- if angulation more than above: closed reduction with
full-length cast for 6 weeks with the wrist and forearm in
neutral and the elbow flexed 90 degrees.

57
Wrist injuries
Treatment of Complete -manipulation
fractures in children? - the reduction is checked by x-ray
-Full-length cast is applied with the wrist neutral and the
forearm supinated for 6 weeks
-After 1 week, a check x-ray is obtained

Complications? EARLY
-Forearm swelling and threatened compartment syndrome
LATE
-Malunion
-Radioulnar discrepancy

Carpal injuries -These should never be regarded as isolated injuries since

the entire carpus suffers.

The commonest carpal • sprains of the joint capsule and interosseous ligaments
injuries, after the distal • unstable tears of the joint capsule and interosseous
radius fracture? ligaments
• fracture of a carpal bone (usually the scaphoid)
• injury of the triangular fibrocartilage complex (TFCC)
and distal radioulnar joint
• dislocations of the lunate or the bones around it.

Site of tenderness? -When the scapholunate ligament is injured, tenderness is

present just beyond Lister’s tubercle;
-For lunate dislocation, in the middle of the wrist;
-For triquetral injuries, beyond the head of the ulna
-For hamate fractures, at the base of the hypothenar
eminence
-For TFCC injuries, over the dorsum of the ulnocarpal
joint.

Carpal injuries:
(a,b) Normal
appearances in AP and
lateral X-rays

58
Wrist injuries
Dorsal intercalated the lunate is torn from the scaphoid and tilted backwards.
segment instability
(DISI)?

volar intercalated the lunate is torn from the triquetrum and turns towards
segment instability the palm; the capitate shows a complementary dorsal tilt
(VISI)?

(c) scapholunate
dissociation and (d)
dorsal rotation of the
lunate (the typical DISI
pattern). (e,f) sprained
wrist. The AP and
lateral X-rays show
foreshortening of the
scaphoid and volar
rotation of the lunate
(VISI).

Wrist arthroscopy The best way of demonstrating TFCC or interosseous

benefit? ligament tears

Treatment of wrist Until the x-ray is normal, splint or plaster should be

sprain? applied and the x-ray examination repeated 2 weeks later.

Fracture of the -75% of all carpal fractures.

scaphoid -Rare in the elderly and in children.

Mechanism of injury? -Fall on the dorsiflexed hand.

40% of non-union or The blood supply of the scaphoid arises from the dorsal
avascular necrosis of distal pole. This means that the proximal pole has a poor
scaphoid bone in the blood supply.
proximal
segment(pole)?

What you should do in • anatomical snuffbox tenderness, although this is non-

exam scaphoid specific
fracture? • pain on pushing the scaphoid tubercle backwards, which
is more specific
• pain on axial loading of the thumb
• pain on passive ulnar deviation.

59
Wrist injuries
What about imaging? -The crack is usually transverse through the narrowest
part of the bone (the waist) but may be in proximal pole
fracture
- CT scan is more sensitive for diagnosing a scaphoid
fracture.
X-ray explains scaphoid
fracture:
(d) the proximal pole,
(e) the waist
(f) the scaphoid tubercle

Treatment of fracture Cast for 4–6 weeks.

of the scaphoid
tubercle?
-Scaphoid plaster in the ‘glass-holding’ position for 6–8
Undisplaced waist weeks. Used for 90% of waist fractures.
fractures Treatment? - Percutaneous fixation with screw, used for who don’t
want prolonged plaster immobilization and who want to
get back to work or sport earlier.

Displaced waist Closed reduction or open and fixation it with a

fractures Treatment? compression screw

Proximal pole fractures Surgical fixation is earlier than plaster in getting back in
Treatment? work

Complications? - Avascular necrosis: proximal fragment more liable

- Non-union
- Osteoarthritis

Ulnar-side wrist -Comprise tears of the triangular fibrocartilage complex

injuries (TFCC), avulsion of the ulnar styloid process and
articular fractures of the head of the ulna.
Occurs with sudden supination (e.g. playing tennis or
golf) the extensor carpi ulnaris (ECU) can be pulled out
of its sheath.

Treatment? -Closed manipulation;

-The arm and wrist are then immobilized in an above-
elbow cast (to prevent rotation) for 4 weeks.
- If Closed reduction fails, use open reduction.

60
Wrist injuries
lunate and peri-lunate
dislocations

Mechanism of injury? A fall with the hand forced into dorsiflexion may tear the
tough ligaments (the scapholunate ligament and the
lunotriquetral ligament) that normally bind the carpal
bones.

Perilunate dislocation? The lunate usually remains attached to the radius and the
rest of the carpus is displaced backwards (Most common)

lunate dislocation? The lunate may be levered out of position to be displaced

anteriorly

Trans-scaphoid The scaphoid remains attached to the radius and the force
perilunate dislocation? of the perilunar dislocation causes it to fracture through
the waist.

What are the clinical -The wrist is painful and swollen and is held immobile.
features? -If the carpal tunnel is compressed, there may be
paresthesia or blunting of sensation in the territory of the
median nerve and weakness of palmar abduction of the
thumb
(a,b) Lateral x-ray of
normal wrist
(c,d) lunate dislocation;
(e,f) perilunate
dislocation.

Treatment -Closed reduction and plaster slab is applied, holding the

wrist neutral.
-ORIF with screw and K-wires

Complications Avascular necrosis of the lunate may follow disruption of

its blood supply

Scapholunate - There is pain and swelling with tenderness over the

dissociation dorsum just distal to Lister’s tubercle.
- due to disruption of the ligaments between scaphoid and
lunate after a fall on the outstretched hand.

61
Wrist injuries
Watson’s test? Pushing backwards on the scaphoid tubercle is very
painful and, if performed while moving the wrist radial-
wards and ulnar-wards, it can elicit a clunk.

Treatment? If the patient is seen <4 weeks after injury

- the scapholunate ligament should be repaired directly
with interosseous sutures, and protected by K-wires for 6
weeks and a cast for 8–12 weeks.
If seen 4–24 weeks after the injury, the ligament is
unlikely to heal.
1)without secondary osteoarthritis: a ligament
reconstruction may be attempted but the results are
unpredictable.
2) with arthritis develops: a proximal row carpectomy,
four-corner fusion or radio-scapho-lunate arthrodesis.

X-ray explains
Scapholunate
dissociation

62
Hand injuries
Important 1)Safe splintage.
requirements in the -Splint only injured fingers as can as possible
treatment of any hand -If splint whole hand, keep it position of safe
injury? immobilization’ – with the CMP joints flexed at least 70
degrees, the finger joints straight and the thumb abducted.
2)Prevention of swelling by elevating the hand and by
early and repeated active exercises.
3)Dedicated rehabilitation

Fractured metacarpal - A direct blow may cause transverse fracture

shaft - A twisting or punching force may cause a spiral fracture.

Treatment of oblique or Slight displacement:

transverse fractures? -Firm crepe-bandage for 2 or 3 weeks.
Considerable displacement or spiral fractures:
- Closed reduction and fixed surgically with compression
plates
-If plates are not available, percutaneous K-wires.
- Then plaster for 4–5 weeks

Fractured metacarpal - A blow may fracture the metacarpal neck, usually of the
neck fifth finger (the ‘boxer’s fracture’).

Treatment - angulation of up to 50 degrees in the fourth and fifth

metacarpals and 20 degrees in the second and third can be
accepted
- All other displaced metacarpal fractures should be
reduced by traction and pressure.
-Holding by a plaster slab extending from the forearm
over the fingers (only the damaged ones).

Fractured metacarpal Undisplaced closed fractures: non-operative

head treatment Displaced fragments: ORIF with buried screws.
-A fight-bite needs immediate washout

Complications of -Malunion
fractured metacarpal? -Stiffness

Bennett’s fracture– Fracture at the base of the thumb metacarpal with

subluxation of the first extension into the CMC joint.
metacarpal - If the CMC joint is seriously damaged or subluxated,
osteoarthritis may ensue

63
Hand injuries
This fracture is very because of the strong pull of the abductor pollicis longus
unstable? tendon that remains attached to the shaft of the metacarpal

Treatment? - Closed reduction and K-wiring or open reduction and

plate fixation if need.
- thumb spica for 6 wk

Rolando’s fracture -intra-articular comminuted fracture of the base of the

first metacarpal with a T or Y configuration.

Treatment Closed reduction and K-wiring or open reduction and

plate fixation.

Fractured proximal and Undisplaced fractures

middle phalanges - functional splintage ‘buddy/neighbor strapping’ for 3–4
Treatment? weeks.
Displaced fracture
-Closed reduction with splinting for 3 weeks
- If fails, use K-wires, a small plate or screws

Phalangeal fractures

Distal phalangeal injury

64
Hand injuries
Mallet finger injury -Fingertip is forcibly bent during active extension,
-The extensor tendon may rupture or a flake of bone may
be avulsed from the base of the distal phalanx.
- The finger is hit when making a bed or catching a ball.

Treatment Tendinous avulsions

- splint for 8 weeks and then only at night for 4 weeks.
Bone avulsions
- splint for 6 weeks

Complications of Mallet - Non-union

finger - Persistent droop
- Swan neck deformity

Rugger jersey finger Avulsion of the flexor tendon caused by sudden

hyperextension of the distal joint, typically when a game
player catches his finger on an opponent’s shirt (hence the
nickname ‘rugger jersey finger’.

Carpometacarpal
dislocation x-ray

Metacarpophalangeal - Usually the thumb is affected, sometimes the fifth finger

dislocation? and rarely the other fingers.
- Hyperextension force may dislocate the phalanx
backwards, and the volar capsule may be torn.

Treatment? For a dislocation:

-Closed reduction is attempted by pulling on the thumb
and levering the phalanx forwards.
-If this fails, the joint is exposed from the dorsum and,
while strong traction is applied, the metacarpal head is
levered into place.
-The joint is then strapped in the flexed position for 1
week before mobilizing.

Collateral ligament avulsion:

-strapping the finger to its neighbor for 3 or 4 weeks.
-Markedly displaced or unstable fracture can be fixed
with a small screw or bone suture.

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Hand injuries
Ulnar collateral - In former years, gamekeepers who twisted the necks of
ligament of the thumb little animals ran the risk of tearing the UCL of the thumb
metacarpophalangeal MCP joint.
joint (‘gamekeepers -Nowadays this injury is seen in skiers who fall onto the
thumb’; skier’s thumb) extended thumb, forcing it into hyper-abduction.

Clinical assessment? -Tenderness and swelling precisely over the ulnar side of
the thumb MCP joint.

Evaluation of UCL -Radially deviate thumb MCP joint in full extension and
injury? at 30° flexion and compare with non-injured hand.
-UCL rupture (at least a partial rupture) is presumed if
injured side deviates more than 30° in full extension or
more than 15° in flexion.

Stener Lesion? The distal portion of the UCL can detach and flip
superficial to the adductor aponeurosis and will not
appropriately heal – requires open repair.

Treatment? Partial tears:

- Splint for 2–4 weeks followed by increasing movement
short period.
-Pinch should be avoided for 6–8 weeks.
Complete tears: need operative repair.
-Postoperatively, the joint is immobilized in a removable
thumb splint leaving the interphalangeal joint free) for 6
weeks.
-Gentle flexion–extension movements out of the splint are
allowed early to prevent stiffness, but no pinch against the
repair is permissible for 6 weeks.
-Care should be taken during the surgery not to injure the
superficial radial nerve branches.
Skier’s thumb

66
Hand injuries
Sprains of the finger -due to forced angulation at the joint.
joints -Milder injuries require no treatment.
-Severe strains: the finger should be splinted for 1–2
weeks.
-The joint is likely to remain swollen and slightly painful
for 6–12 months.

Interphalangeal - Dislocation at the proximal joint is common and is

Dislocation easily reduced by pulling on the finger.

Treatment? -The joint is strapped to its neighbor for a few days and
movements are begun immediately.
- If closed reduction is successful and the joint is stable,
an extension blocking splint or temporary trans-articular
wire is used.
- If it cannot be reduced or remains unstable, screw
fixation or a trans-articular
- If there is very marked comminution and instability, a
spring-loaded external fixator

‘PILON’ fractures of - These are quite common injuries and can be very
the middle phalanx troublesome.
-The head of the proximal phalanx impacts into the base
of the middle phalanx, causing the latter to spread in
several pieces.

The principles of soft- Elevate, keep splintage to a minimum, move, exercise.

tissue care?

Testing the flexor

tendons

67
Spine orthopedic
DEFORMITIES OF
THE NECK

Torticollis (‘wry neck’, - The chin is twisted upwards and towards one side.
‘skew neck’) - It may be either congenital or secondary to other local
disorders.

Infantile (congenital) -The sternomastoid muscle on one side is fibrous and fails
torticollis to elongate as the child grows.

Clinical features? - In some cases, a well-defined lump is felt in the muscle

during the first few weeks of life.
-As the neck grows (child is 2 or 3 years), the contracted
sternomastoid tethers the skull on one side, thus twisting
the chin towards the opposite side.
-May cause secondary facial deformities (facial
hemiatrophy).

Treatment of congenial Nonoperative: gentle, daily manipulation of the neck

torticollis? Operative: if the condition persists beyond 1 year.
-division of the contracted muscle and manipulating the
head into neutral position.

Secondary torticollis due to muscle spasm, acute disc prolapses (the most
common cause in adults), inflamed neck glands, vertebral
infection, injuries of the cervical spine or ocular
disorders.

Torticollis

Odontoid anomalies - may be absent or hypoplastic.

- usually asymptotic but some patients present with pain
or torticollis, or neurological complications.
- There is risk of the atlantoaxial joint subluxation under
general anaesthesia.
-Treated with surgical stabilization.

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Spine orthopedic
Acute intervertebral
disc prolapse - not as common in the neck as in the lower back.

Precipitated factors? - local strain or injury, especially sudden unguarded

flexion and rotation.
What are most
commonly affected C5–C6 and C6/C7.
levels?

Pathology? The disc protrusion may press on the posterior

longitudinal ligament or compress the dura or the nerve
roots causing neck pain and stiffness as well as pain
referred to the upper arm.

Clinical features? (1) pain (often radiating to the scapular region) and
stiffness of the neck.
(2) pain and paraesthesia in one upper limb (rarely both),
often radiating to the outer elbow, back of the wrist and to
the index and middle fingers. Weakness is rare.

Imaging - X-rays may show loss of the normal cervical lordosis

(due to muscle spasm) narrowing of the disc space.
- The diagnosis should be confirmed by MRI.

Differential diagnosis – Acute soft tissue strain

– Neuralgic amyotrophy (acute brachial neuritis) causes
winging of the scapula.
– Cervical spine infections
– Cervical tumors
– Rotator cuff lesions

Treatment -Heat and analgesics+3Rs

Rest:
-Neck collar: to prevent unguarded movement
Reduce:
-Intermittent traction: may enlarge the disc space
Remove:
-by anterior discectomy and disc arthroplasty, indicated if
the symptoms are refractory and severe

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Spine orthopedic
Disc herniation imaging

Chronic disk -Intervertebral disc degeneration is common in patient,

degeneration (cervical usually aged over 40 years.
spondylosis) -most common in the C5–C6 and C6–C7 segments

Pathology? -With time, the discs collapse and flatten

-Bony spurs appear at the anterior and posterior margins
of the vertebral bodies on either side of the affected discs
-those that develop posteriorly may invade the
intervertebral foramina, causing pressure on the nerve
roots.

Clinical features? -Neck pain (radiates widely: to the occiput, the scapular
muscles and down one or both arms) and stiffness.
- Features of radiculopathy (pain, paraesthesia and
weakness): if there is narrowing of the intervertebral
foramina causing compression on the nerve roots.
- Cervical myelopathy (due to spinal stenosis) causes:
– LMN lesion in the upper limb (sensory, motor, reflexes)
– UMN lesion in the lower limb (sensory, motor, reflexes)

Imaging - X-rays show Osteoarthritis changes

- MRI will show whether there is nerve root compression.

Differential diagnosis -Nerve entrapment syndromes (ulnar, median nerves)

-Rotator cuff lesions
-Cervical tumors
-Thoracic outlet syndrome.

Treatment Conservative Rx:

– Analgesia, heat, massage and physiotherapy
– restricting neck movements in a collar during pain
attacks

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Spine orthopedic
Continued Operative Rx:
– Indications
•Refractory symptoms
•neurological symptoms and signs (radiculopathy)
–Options:
•Foraminotomy: for radiculopathy
•Anterior discectomy and fusion (by bone graft):
for unrelieved neck pain & stiffness
-Complications: injury to recurrent laryngeal nerve or
vertebral artery, graft dislodgment and failed fusion
•Intervertebral disc replacement

Cervical spondylosis X-
rays

Rheumatoid arthritis -The cervical spine is severely affected in 30% of patients

with rheumatoid arthritis.

Types of RA lesion? 1) erosion of the atlantoaxial joints (main target in

cervical spine) and the transverse ligament, with resulting
instability
2) erosion of the atlanto-occipital articulations, allowing
the odontoid peg to ride up into the foramen magnum
causing basilar problems
3) erosion of the facet joints in the midcervical region,
which can lead to fusion and subluxation.

Clinical features? - A woman with advanced rheumatoid arthritis presents

with neck pain and markedly restricted movements.
- Features of root compression in the upper limb and/or
less often UMN features in the lower limb (may mimic by
peripherally involvement)
- Vertebrobasilar insufficiency: vertigo, tinnitus and
visual disturbance
#serious neurological complications are uncommon.

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Spine orthopedic
X-ray imaging? - Features of erosive arthritis at several levels.
-Atlantoaxial instability (lateral films taken in flexion and
extension).

Treatment? -Pain can usually be relieved by wearing a collar.

-Indications of operation:
1) severe and unremitting pain
2) neurological signs of root or cord compression.
Arthrodesis (usually posterior) is by bone grafting
followed by a halo body cast, or by internal fixation
(posterior wiring or a rectangular fixator) and bone
grafting.

Ankylosis spondylitis - causing neck pain and stiffness some years after the
onset of backache.
- An unacceptable ‘chin-on-chest’ deformity, indicated
for cervical spine osteotomy.

Scoliosis apparent lateral (sideways) curvature of the spine.

What’s the commonest & Tri-planar deformity (anteroposterior, lateral

form of the scoliosis? .(rotational

Postural Scoliosis? secondary or compensatory to some condition outside the

spine, such as a short leg, a pelvic tilt due to contracture
of the hip, or due to local muscle spasm associated with a
prolapsed lumbar disc.

How to disappear When the patient sits, thereby cancelling leg length
postural scoliosis (skew asymmetry” correctable type “.
back)?

Structural scoliosis? Non-correctable deformity of the affected spinal segment,

an essential component of which is vertebral rotation.
- liable to increase throughout the growth period.

Clinical features? Deformity: skew back, rib hump

-Balanced deformity: when the occiput is in the midline
-Unbalanced deformity: the occiput is not
Backache: Balanced curves sometimes pass unnoticed
until backache develops.

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Spine orthopedic
Continued The diagnostic feature of fixed scoliosis is that forward
bending makes the curve more obvious.

Prognosis? -The younger the child, the worse the prognosis

-The higher the curve, the more likely to affect
cardiopulmonary function.

Structural scoliosis

Idiopathic scoliosis -80% of all cases of scoliosis

-According to the age, three subgroups:
adolescent, juvenile and infantile.
-A simpler division now in general use is:
early onset (before puberty) and late-onset scoliosis (after
puberty).
-if the Cobb’s angle over 30 degrees, needing surgery.

Late-onset (adolescent) - This is the commonest type, occurring in 90% of cases,

idiopathic Scoliosis mostly in girls.
(aged 10 years or over) - Primary thoracic curves are usually convex to the right,
lumbar curves to the left.

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Spine orthopedic
Reliable predictors of (1) a very young age.
progression? (2) marked curvature.
(3) an incomplete Risser sign at presentation.

Treatment Conservative: exercise, Milwaukee brace, Boston brace.

Operative:
- The Harrington system
- Rod and sublaminar wiring (Luque)
- Anterior instrumentation
- The Cotrel–Dubousset system

Early-onset (juvenile) Uncommon, worse prognosis, surgical correction may be

idiopathic Scoliosis necessary before puberty.
(aged 4–9 years)

Early-onset (infantile) -Rare, perhaps because most babies nowadays are

idiopathic Scoliosis allowed to sleep prone
(aged 3 years or under) - 90% resolve spontaneously

Osteopathic The commonest bony cause is some type of vertebral

(congenital) Scoliosis anomaly hemivertebra, wedged vertebra (failure of
formation) and fused vertebrae sometimes combined with
absent or fused ribs.

Neuropathic and Neuromuscular conditions associated with scoliosis

myopathic Scoliosis include poliomyelitis, cerebral palsy, syringomyelia,
Friedreich’s ataxia and the rarer lower motor neuron
disorders and muscle dystrophies

Kyphosis -The term ‘kyphosis’ is used to describe both the normal

(the gentle rounding of the dorsal spine) and the abnormal
(excessive dorsal curvature).

Postural kyphosis Common (‘round back’ or ‘drooping shoulders’) and may

be associated with other postural defects such as flat-feet.

Structural kyphosis Fixed and associated with changes in the shape of the
vertebrae.

Causes of structural -osteoporosis of the spine (the common round back of

kyphosis? elderly people).
-ankylosing spondylitis.
-Scheuermann’s disease (adolescent kyphosis).

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Spine orthopedic
Kyphos or gibbus? Sharp posterior angulation due to localized collapse or
wedging of one or more vertebrae.

Kyphosis and kyphos

Congenital kyphosis

Pathology? Vertebral anomalies:

-Failure of formation (Type I)
-Failure of segmentation (Type II)
-A combination of these.

Type I (failure of - is the commonest (and the worst) type.

formation) - may lead to cord compression.

Type II (failure of - Usually takes the form of an anterior intervertebral bar

segmentation) -The risk of neurological compression is much less.

Adolescent kyphosis Developmental disorder in which there is abnormal

(Scheuermann's ossification of the ring epiphysis of the upper and lower
disease) surfaces of each vertebral body.
- causes wedging of thoracic vertebrae, this exacerbate
normal kyphosis.

Schmorl’s nodes Small central herniations of disc material into the

vertebral body.

Treatment
- conservative: extension brace (1 year or 18 months)
-If this fails, operative correction may be used from the
outset.

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Spine orthopedic
Pyogenic infection of Risk factors: elderly, chronically ill and immunodeficient
spine patients.
- usually begins in the vertebral end-plates with secondary
spread to the disc, adjacent vertebra, ALL and the
paravertebral soft tissues.

Etiology? -Staph. Aureus (50-60% of cases)

-Gram –ve like E. coli and pseudomonas in
immunocompromised patient.

The usual sources of (1) haematogenous spread from a distant focus of

infection? infection
(2) inoculation during invasive procedures (spinal
injections and disc operations).

Clinical features? Back pain: Localized, often intense, unremitting and a/w
muscle spasm and restricted movement and tenderness.
History of invasive spinal procedure or a distant infection
during the preceding few weeks.
Systemic signs: such as pyrexia and tachycardia (often
present but not marked).

X-ray findings? -No change for several weeks.

-Early signs are loss of disc height (distinguishes
vertebral osteomyelitis from metastatic disease),
-Irregularity of the disc space,
-Erosion of the vertebral end-plate and reactive new bone
formation.

Special investigations -WCC, CRP level and ESR are usually elevated.
-Antistaphylococcal antibodies.
-Agglutination tests for Salmonella and Brucella.
-Blood culture.

Treatment Conservative:
Bed rest, pain relief and empirical IV antibiotic
administration (until culture & sensitivity results are
available) followed by oral antibiotics if patient condition
improves
Operative treatment is seldom needed.

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Spine orthopedic
Tuberculosis of spine -The spine is the most common site of skeletal TB (50%).
-Concurrent pulmonary TB is a feature in most children
under 10 years.

Special investigations -Mantoux test

-ESR
-With no neurological signs a needle biopsy is
recommended to confirm the diagnosis.

Treatment Conservative:
Rifampicin, isoniazid and pyrazinamide daily for 6–12,
but stopping the pyrazinamide after the first 2 months.
Operative treatment indicated when there is:
(1) an abscess that can readily be drained.
(2) advanced disease.
(3) neurological deficit.
INTERVERTEBRAL
DISC LESIONS

Intervertebral disc With increasing age, as the lumbar intervertebral discs

degeneration gradually dry out (glycosaminoglycan production
diminishes).

What are the changes of – the nucleus pulposus changes from a turgid bulb to a
the nucleus pulposus brownish desiccated structure.
and the he annulus – The annulus fibrosus develops fissures parallel to the
fibrosus vertebral end-plates running mainly posteriorly, and small
herniations of nuclear material squeeze into and through
the annulus.

Clinical features -condition is usually asymptomatic.

-Then, patients experience the common and ill-defined
symptoms of recurrent backache, sometimes with pain
radiating towards the buttocks or thighs. These are
secondary effects due to:
– slight displacement of the posterior vertebral facet joints
– facet joint osteoarthritis
– narrowing of the lateral recesses of the spinal canal and
the intervertebral foramina.

Imaging X-ray: flattening of the ‘disc spaces’, spur formation, OA

changes in the small facet joints.
MRI: bulging of one or more discs.

77
Spine orthopedic
Treatment Conservative: postural and muscle strengthening
exercises, activity modification
Or operative

Acute intervertebral Bulging of the disc with the outer part of the annulus
disc herniation intact, either directly posteriorly or to one or other side of
the posterior longitudinal ligament towards the
intervertebral foramen.

Mechanism of injury -Mechanical stress a combination of flexion and

and Pathology compression in addition to disturbance of the hydrophilic
properties of the nucleus pulposus.
-Herniation affects spinal nerve roots of second vertebra
in articulation.

How does the pain -Disruption of the outermost layers of the annulus
arise? fibrosus and stretching or tearing of the posterior
longitudinal ligament.
-If the disc protrudes to one side, it may irritate the dural
covering of the adjacent nerve root causing pain in the
buttock, posterior thigh and calf (sciatica).
-Pressure on the nerve root itself causes sensory sand
motor symptoms.

Clinical features? -Usually in a fit young adult.

-While lifting or stooping (or perhaps merely coughing)
the patient is seized with back pain and is unable to
straighten up.
- sciatica after day or two later
-Both backache and sciatica are made worse by coughing
or straining
- Sciatic Scoliosis

Examination findings? -Tenderness in the midline of the low back

-paravertebral muscle spasm
-positive straight leg raising test, bowstring test
-Features of LMN lesion in the lower limb

Features of cauda Bladder and bowel incontinence

equina syndrome (red Perineal numbness
flag signs)? Bilateral sciatica and Crossed straight-leg raising sign
Lower limb weakness
-Scan urgently and operate urgently if a large central disc.

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Spine orthopedic
Imaging X-rays are essential, not to show the disc space but to
exclude bone disease.
CT and MRI are the best ways of identifying the disc and
localizing the lesion.

Differential diagnosis - Ankylosing spondylitis

- Vertebral tumours
- Nerve tumours

Treatment 4R
Rest: during an acute attack the patient should be kept in
bed, with hips and knees slightly flexed. An anti-
inflammatory medication is useful.
Reduction: continuous bed rest and traction for 2 weeks
may allow the herniation to reduce
– If no improvement, an epidural injection of
corticosteroid and local anesthetic may help
Removal
– Laminectomy with Discectomy
Indications:
1)emergency: a cauda equina compression syndrome
which does not clear up within 6 hours of starting bed rest
and traction
2)Elective: persistent pain and severely limited straight
leg raising after 2 weeks of conservative treatment
3)neurological deterioration while under conservative
treatment
4)frequently recurring attacks.
Rehabilitation: exercise with least life strain.

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Spine orthopedic
Lumbar Osteoarthritis Advanced dic degeneration >> displacement of the
posterior vertebral facet joints>> osteoarthritis.

Clinical features -Intermittent backache relieved with lying down

-usually in over 40 years patients.
-With either history of acute disc rupture followed by
recurrent attacks or there is no history (most cases) of
such episode and there is chronic backache and muscle
weakness.

Treatment Conservative:
instruction in modified activities, physiotherapy,
manipulation during acute episodes, wearing of a lumbar
corset, lumbar splint.
Operative: spinal fusion, stabilization
Spondylosis and
Osteoarthritis changes

spondylolesthysis - means vertebral displacement.

- Always between L4-L5 or L5 and sacrum.

Which does prevent Normal laminae and facets constitute a locking

each vertebra from mechanism.
moving forward?

Causes of – Lytic spondylolesthysis: Separation or stress fracture

spondylolesthysis? through the neural arch (50% of cases) occurs in adults.
#intermittent backache exacerbated by strain, A ‘step’ can
be felt on examination
–Degenerative spondylolesthysis: OA of facet joints
(25%), in patients over 40 years with long-standing
backache.
– Dysplastic spondylolesthysis: Dysplasia of facet joints
(20% of cases), is seen in children.
– Destructive spondylolesthysis: lesions e.g. Fractures,
TB and neoplasia (5% of cases).

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Spine orthopedic
Treatment Conservative: as above
Operative: indications;
1) disabling symptoms.
2) slippage more than 50%
3) neurological symptoms

Spondylolisthesis – x-
rays

Spinal stenosis Abnormal narrowing of the central spinal canal, the

lateral recesses or the intervertebral foramen and neural
compression and may be congenital (as achondroplasia or
hypochondroplasia) or acquired.

Pathology Results from disc degeneration and osteoarthritis that

causes narrowing of the spinal canal due to hypertrophy at
the posterior disc margin and the facet joints.

Clinical features -Typically, a patient with backache complains of aching

and/or numbness and paraesthesia in the thighs, legs or
feet.
-The symptoms come on after standing upright or walking
for 5–10 minutes and are consistently relieved by sitting
or squatting with the spine somewhat flexed (hence the
term ‘spinal claudication’).

Treatment -Conservative
-Operative decompression

Spinal stenosis

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Spine orthopedic
THE BACKACHE
PROBLEM

Transient backache -simple back strain (as thoracic kyphosis and fixed
following muscular flexion deformity) that will respond to a short period of
activity rest followed by gradually increasing exercise.

Sudden, acute pain and Acute disc prolapse (in young), compression fracture (in
sciatica elderly)

Intermittent low back lumbar spondylosis, OA, AS, Chronic infection,

pain after exertion myelomatosis.

Back pain plus pseudo >50yrs with spinal stenosis

claudication

Severe and constant local bone pathology, such as a compression fracture,

pain localized to a Paget’s disease, a tumour or infection.
particular site

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Spine injuries
How does the human
vertebra look like?

What is 3 columns
model (Denis columns)?

What do you mean by Stable: - no risk of displacement with normal movement.

stable spinal injury and Unstable: - there is a risk of displacement & hence
how would you decide damage to neural tissue (10% of #).
it? All fractures involving the middle column alone or at
least one other column should be regarded as unstable.

What to examine in - LOOK, FEEL BUT DON’T MOVE.

spinal injury? - neurological exam. (sensory-motor-urine continence).

What are the objectives - Preserve neurological function.

of treatment in spinal - Relieve any reversible neural compression.
injuries? - Restore alignment of the spine.
- Stabilize the spine.
- Rehabilitate the patient.

What are indications of 1- unstable fracture with risk of neuro, damage.

surgical stabilization? 2- unstable fracture with multiple injuries.

What is the general -ve neural #, stable>> collar/ brace & rest.
treatment plan? -ve neural #, unstable>>cervical: - traction/ halo vest.
Thoracolumbar: -internal fixation.

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Spine injuries
+ve incomplete neural # >> open reduction and internal
fixation (ORIF).

What is Jefferson’s A burst Fracture of C1(atlas) vertebral arch with splitting

fracture? of the ring.

What is the mechanism A sudden, severe load (hit) on the head.

of injury in Jefferson
fracture?

How to diagnose it? - Usually there is no neurological injury.

- open mouth view X-Ray will show lateral mass
displaced laterally from odontoid peg.
- a CT scan will show the fracture clearly.

What are the principles Undisplaced >> rigid collar

of management? Sideway displacement>> skull traction/halo body orthosis
for 6 weeks followed by semi-rigid collar in next 6 weeks.

What other injuries to Odontoid fracture and hangman fracture occurs in 50% of
be excluded? cases.

What is hangman C2/3 disk tear + C2 pars inter-reticularis fracture.

fracture?

What is the mechanism - Extension with distraction or varying degrees of

behind it? extension, compression and flexion. In accidents occurs
when forehead hit the dashboard.
- The fracture is unstable no neurological # as posterior
arch is fractured also hence decompress the spinal cord.

What are the principles - Undisplaced (usually stable): - immobilization for 6-12
of management? weeks (by halo-vest or rigid collar).
- Displaced: - reduction + immobilization as above.
- AVOID traction because the mechanism of # is traction.

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Spine injuries
What are the - flexion: - young, high speed injury or severe fall.
mechanisms of - hyperextension: - old, osteoporotic people with low
odontoid fracture? energy trauma.

How would you classify By Anderson d’Alonzo classification

odontoid fractures? Type 1: - Avulsion fractures of the tip of the odontoid.
Type 2: - Fractures that occur through the waist of the
odontoid process.
Type 3: - Fractures that extend into the C2 vertebral body.

What about stability of - Type 1&3 are usually stable.

odontoid fractures? - Type 2 is usually unstable.

How would you manage Type 1: - halo vest until discomfort subsides.
this fracture? Type 2: - 1) Undisplaced immobilized by halo vest.
2) Displaced Reduced by traction.
Immobilized by C1/2 fusion or anterior
screw fixation.

Type 3: - 1) Undisplaced>> halo vest for 8-12 weeks.

2) Displaced Reduced by traction
Immobilized by halo vest for 8-12 weeks.

What is tear-drop - Fracture of anteroinferior part of vertebral body caused

fracture? by flexion compression force.
- unstable (middle column & posterior element damage).

How to treat it? - operative anterior or posterior stabilization.

What is the role of CT? - To exclude other fractures.

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Spine injuries
What is the mechanism - Flexion or flexion-compression injury causes bilateral
of # in cervical vertebra articular facet dislocation.
fracture-dislocation? - The inferior articular facet goes forward over the
superior articular facet of the below vertebra (above goes
forward).
- Unstable due to posterior ligament rupture.

What would you see on The vertebra above displaced anteriorly by more than half
X-ray? of its antero-posterior width.

What are the treatment - Reduction by skull traction (5-30 kg progressively).

options? - Immobilize by halo vest for 12 weeks.
- close reduction failure then do posterior fusion followed
by cervical brace for 6-8 weeks.

What is the whiplash - It’s a soft tissue sprain (ALL, capsule or IVD).
injury? - occurs when body is thrown forward and neck jerked
backward (e.g. car hit from back).

What are the C/F? - pain, stiffness & tenderness.

- sometimes headache, dizziness, blurring of vision
temporo-mandibular joint discomfort, tinnitus or
paresthesia may occur

What could you see on - straightening of spine due to muscle contraction (pain
X-Ray? effect).

What is the DDx? - fracture, IVD herniation or suprascapular nerve

compression (seat-belt injury).

How would you manage Analgesia for few weeks followed by exercise.
it?

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Spine injuries
What is the commonest T11-L2 because this site is transition between the rigid
site of thoracolumbar thoracic (dorsal) to the flexible lumbar spine.
injury?

What is the mechanism - Spine is flexed and compressed (simple fall from
behind wedge fracture? standing height onto the bottom). Usually occurs in old
osteoporotic people.
- Stable (only anterior column affected).

What is the Minimal wedging: - bed rest for 1-2 weeks.

management plan? Moderate wedging (loss of 20-40% of anterior column
height): - thoracolumbar brace or body cast in extension
position for 3 months if no improvement then posterior
fixation with fusion.

What is the mechanism - Severe axial compression that ‘explode’ the vertebral
of burst injury? body.
- Shattering the posterior part of the vertebral body and
bone pieces will enter to the spinal canal.
- The injury is usually unstable.

What radiological x-ray won’t give a clear picture so CT is needed.

modality to use?

What are the available 1) Bed rest followed by 12 wks. brace: - if no neurological
treatment options? damage with minimal anterior wedging
2) Anterior decompression and stabilization: - if there is a
sign of neurological damage.

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Spine injuries
What is chance injury - burst fracture to the anterior and middle columns,
(AKA jack-knife #)? combined with distraction fracture to the posterior
column.
- Extreme flexion combined with distraction (body jack-
knifed against seat-belt in accident).
- unstable as anterior and middle columns involved.

How would you manage - As it involves ligamentous injury so posterior fusion is

it? mandatory.

What is the mechanism - Usually all mechanisms can cause it and all columns are
of fracture-dislocation unstable.
#? - Dangerous commonly with cauda equina (lowermost
part of spinal cord) is injured.

What are the - X-ray will show # in body, pedicle, articular process &
radiological features? laminae.
- subluxation or dislocation may also seen.
- CT is needed to assess spinal canal.

What is your 1) If no or partial neurological damage then surgical

management plan? decompression and stabilization.
2) There is no role for surgery in complete neurological
damage

What is spinal shock? A temporary state in which there is signs of lower motor
neuron lesion (flaccid paralysis & absent reflex) occurs at
early time in cord injuries.

What is the grading Frankel Grading

system used in spinal
cord injury?

88
Pelvic injuries
What are the types of 1- Isolated fracture.
pelvic injury? 2- Pelvic ring fractures.
3- acetabular fractures.
4- sacrococcygeal fracture.

What types of isolated 1- avulsion: - piece of bone pulled by muscle.

fractures could occur? 2- direct: - blow on pelvis.
3- stress: - in osteoporotic and osteomalacic people.

Avulsion fracture? Sartorius pulls ASIS (a)

Rectus femoris pulls AIIS(b)
Adductor longus pulls part of pubis
Hamstrings pulls part of ischium

- all these injuries need no more than rest for few days and
reassurance.

Direct fracture? - Fall from height may cause direct blow fracturing iliac
blade or ischium.
- Managed by bed rest until the pain subsides.

What is Young and It is Classification by direction of injury: -

Burgess classification of 1- Anteroposterior compression (APC).
pelvic ring injury? 2- lateral compression (LC).
3- vertical shear (VS).
4- combination.

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Pelvic injuries
What are the levels of APC I -- Symphysis widening < 2.5 cm.
anteroposterior Treated by reduction of weightbearing & binder.
compression (APC) & APC II -- Symphysis widening >2.5 cm.
their treatment? Anterior Sacro-iliac ligament is torn.
Sacrotuberous & sacrospinous ligament torn.
Treated by symphysial plate or external fixator.
APC III -- Disruption of posterior sacroiliac ligament.
Usually associated with vascular injury.
Treated by anterior multi-hole symphysial plate
Or External fixator + sacroiliac screw.

What are the levels of LC I -- pubic ramus fracture.

lateral compression Treated by reduction of weightbearing.
(LC) & their LC II -- ramus + ipsilateral ilium fracture (crescent).
treatment? Treated by ORIF of ilium.
LC III -- Ipsilateral LC and contralateral APC.
Treated by ORIF anteriorly and posteriorly.

What are the effects of Innominate bone displaced vertically, fracture pubic
vertical shear (VS) ramus and disrupting the ipsilateral sacroiliac region.
injury & how would Treated same as LC III.
you treat it?

90
Pelvic injuries
List the mechanisms of - motorcyclist straddles on the fuel tank causes APC.
pelvic # and the - side pedestrian or car accident causes LC.
expected class of - fall from height on one-foot causes VS.
fracture. - pedestrian hit on the ground or motorcyclist thrown on
the ground causes a combination injury.

Unstable types? APC III, LC III, VS & combination.

“Open book” type? APC III.

What’s the most Primary survey and resuscitation due to high risk of
important step in vascular injury & other site injuries.
management of pelvic
injury?

What’s the other Tile classification which is complicated and needs a CT

system of classification? scan to determine it. (not so applicable in Iraq).
Limitation?

What clinical features - Pain and inability to bear weight.

you could see in pelvic - External rotation & limb length difference.
fracture? - Frank hematoma.
- Hematuria.
- signs of shock.

What are the most - Neurological injuries (L5 root related to sacral ala joint).
common complications - DVT (70%) & PE (26%) so consider prophylaxis.
of pelvic ring fractures? - Chronic instability.
- Infection.
- Urogenital injuries (be aware of catheterization).

What are the 1- blow on the side (e.g. fall from height).
mechanisms that could 2- blow on front of the knee (e.g. dashboard injury).
cause acetabular
fractures?

What determine the The position of the leg (i.e. rotation and
pattern of acetabular abduction/adduction).
fracture?

What classification is Letournel classified acetabular fractures to 5 elementary

used? and 5 associated fractures.

91
Pelvic injuries
What are the
acetabular columns?

What are the 5 1- posterior wall: - commonest, ass. posterior dislocation.

elements of Letournel 2- anterior wall: - rarest, ass. Anterior dislocation.
classification? 3- Posterior column: - from obturator foramen to sciatic
notch & may cause media migration of femoral head.
4- anterior column: - makes a segment anterior to
acetabulum between Anterior inferior iliac spine and
obturator foramen.
5- transverse: - runs horizontally through acetabulum.

What are the 5 1- a T-shaped: - transverse + vertical split in obturator

associated fractures in foramina.
letournel classification? 2- posterior wall + posterior column.
3- transverse + posterior wall (70% sciatic nerve cut).
4- anterior column + posterior hemi-transverse.
5- combined (both columns).

How does the patient - Present usually as trauma & maybe in shock state.
present? - Hematoma or bruising.
- Limb internally rotated (dislocation of hip).
- Rectal and neurological examination are mandatory.

What is the role of - AP and oblique view to classify the fracture.

imaging? - CT is mandatory to exclude other pelvic #.

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Pelvic injuries
What is the initial - Traction (4.5 Kg)
management? - Don’t forget shock and other injuries.

What is the Minimal weightbearing and early mobilization with close

conservative treatment monitoring for 6 weeks to assure position is maintained.
here?

What are the 1- Unstable hip.

indications for surgery? 2- Significant distortion of joint congruence.
3- Associated fractures of the femoral head.
4- Retained bone fragments in the joint.

What are the 1- nerve injury (sciatic)

complications of 2- avascular necrosis (if severe consider arthroplasty).
acetabular fracture? 3- heterotopic bone formation (prophylactic
indomethacin).
4- osteoarthritis.

What is the proposed Blow on the back or fall on the “tail”.

mechanism of sacrum
or coccyx fracture?

What is the Isler classification: -

classification of sacral Type 1: - Fractures lie lateral to the sacral foramina.
fractures? Type 2: - Through the foramina.
Type 3: - Medial to the foramina.

What are x Ray - a transverse fracture of the sacrum.

findings? - fractured coccyx, sometimes with the lower fragment
angulated forwards.
- normal appearance if the injury was merely a sprained
sacrococcygeal joint.

What are principles of - Displaced #: reduced backward by a finger in the rectum

management? & patient is allowed to resume normal activity, but is
advised to use a rubber ring cushion when sitting.
- If urinary problems, necessitating sacral laminectomy.
- If the pain is not relieved by the use of a cushion or by
the injection of local anesthetic into the tender area,
excision of the coccyx may be considered.

93
Hip orthopedic
What is Developmental Spectrum of congenital anomalies in the hip (e.g. shallow
dysplasia of hip(DDH)? acetabulum- frank dislocation) (1-4 yrs. of age).

What is the incidence? - 5-20 per 1000 live birth (most stabilize spontaneously).
- 1-2 per 1000 live births after 3 weeks re-examination.

What is the female: 7:1 female predominance.

male ratio?

What are the etiologic 1- Genetic (tends to run in family).

factors for DDH? 2- Hormonal (maternal relaxin crosses the placenta).
3- Intrauterine (breech, oligohydramnios & first birth).
4- Postnatal factors (swaddling).

What are the 1- shallow acetabulum (femoral head slides posteriorly).

pathological features of 2- stretched capsule and elongated ligamentum teres.
DDH? 3- retarded maturation of acetabulum and femoral head.

What are the clinical Some may have asymmetrical gluteal folds but this
features? usually unnoticeable by all mothers so neonatal screening
is essential.
Late (6-18 months) features may include clicking, limb
shortening (unilateral) or wide perianal gap (bilateral).

What clinical tests are Barlow’s test – detects a hip that can be dislocated
the basis of neonatal posteriorly. Flex hip and knee to 90° and gently axially
diagnosis? load, feeling for a clunk. Aide‐memoire: Barlow’s push
Backwards (left figure).
Ortolani’s test – this test detects a hip that is already
dislocated and can be reduced. Flex the hip and knee to
90° and keep your index finger on the greater trochanter.
Abduct the hip gently and exert gentle forward pressure
with your finger feeling for the hip popping back into
joint. Aide memoire: Ortolani’s Open the legs (right).
Galeazzi test – flex hips and knees to 90° and look from
the side for difference in patellar height indicating leg
length discrepancy.

94
Hip orthopedic
What is the role of US It is safe to use before 6 months and we can see if the α
in DDH? angle is greater than 60°, β angle is less than 55° or
acetabulum covers more than 50% of femoral head.
(what are these angles is postgraduate).

What lines to be drawn 1- Hilgenreiner line: -drawn horizontally through each

in plain X Ray? triradiate cartilage.
2- Perkin line: - drawn perpendicular to the Hilgenreiner
line at the lateral edge of the acetabulum.
3- Shenton line: - a continuous arch drawn along the
medial border of the femoral neck and inferior border of
the superior pubic ramus.
4- Von Rosen line: - old method

What are the X Ray 1- shallow acetabulum.

findings in DDH? 2- femoral head lies out of inferomedial quadrant.
3- broken Shenton line.
4- delayed ossification of femoral head.

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Hip orthopedic
What are the treatment depending on age: -
lines in DDH? 1) < 6 months: - Abduction splinting/bracing (Pavlik
harness).
2) 6-18 months: - closed reduction and Spica casting.
3) > 18 months: - open reduction and Spica casting.
4) > 2 yrs. with persistent dysplasia: - femoral/pelvic
osteotomy.

What are the Persistent dysplasia, recurrent dislocation, avascular

complications of DDH? necrosis of the femoral head and femoral nerve palsy (due
to Pavlik).

What is perthes Idiopathic avascular necrosis of the proximal femoral

disease? epiphysis in children (4-8 yrs. of age).

What is the incidence - 1 per 10,000 children.

and male to female - 4-5:1 male predominance.
ratio?

What are the risk family history, low birth weight, abnormal birth
factors of perthes? presentation & passive smoke.

What are the stages of 1- Death stage (initial).

the disease? 2- Fragmentation stage.
3- Re-ossification (repair).
4- Healing (remodeling).

What are clinical Pain, limping (antalgic), limited abduction and internal
features of disease? rotation (DDx is irritable hip).

What are the X ray - AP and frog-leg views are required.

findings? - medial joint space widening (earliest), sclerosis of head
and crescent sign (represent subchondral fracture).

96
Hip orthopedic
What is herring according to the height of the lateral pillar: -
classification? Group A: - normal height
Group B: - collapse but still > 50% of height.
Group C: - collapse with < 50% of height.

What is the treatment? 1- < 6 yrs. symptomatic treatment.

2- 6-8 yrs. symptomatic + Containment (brace) (consider
bone age and class of disease).
3- > 9 yrs. operative containment.

What is slipped capital a displaced insufficiency fracture through the hypertrophic

femoral epiphysis? zone of the cartilaginous growth plate (10-20 yrs.).

What is the pathology Delayed gonadal development: - in these children there is

behind it? an imbalance between pituitary growth hormone (which
stimulates bone growth) and gonadal hormone (which
promotes stable physeal fusion). Thus, during the pubertal
growth spurt the relatively immature physis might be too
weak to resist the stress imposed by the increased body
weight.

What are the grades of Based on percentage of slippage: -

the disease? Grade I 0-33% of slippage.
Grade II 34-50% of slippage.
Grade III >50% of slippage.

What are clinical - patient is tall, thin, sexually under-developed.

features of it? - pain in groin, anterior thigh & knee.
- leg is externally rotated & shortened.
- limitation of abduction & internal rotation

What you see in x-ray? AP shows Trethowan’s sign, lateral shows angulation.

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Hip orthopedic
What is Trethowan’s A line drawn along the superior surface of the femoral
sign? neck remains superior to the head instead of passing
through it.

How would you treat According to grade: -

it? Mild: - 2 pins and screws under X-Ray.
Moderate: - pinning with later osteotomy.
Severe: - corrective surgery + pinning.

Congenital coxa vara? - Due to a defect of endochondral ossification in the

medial part of the femoral neck.
- X-ray shows a separate triangular fragment of bone in
the inferior portion of the metaphysis (Fairbank’s
triangle).
- Corrected by a sub-trochanteric valgus osteotomy.

Irritable hip (transient - A 3-8 yrs. with painful limping associated with activity.
synovitis)? - Restriction of all movements with pain at the extremes
of the range in all directions.
- X-rays show slight widening of the medial joint space.
- DDx includes perthes disease, slipped epiphysis, septic
arthritis, tuberculous arthritis, juvenile chronic arthritis
and ankylosing spondylitis.
- Treatment involves bed rest, reduced activity and
observation.

98
Hip joint Injuries and femur fracture
Dislocation of the hip posterior occurs most frequently (80% of cases), followed
by anterior and central.
Posterior dislocation

Mechanism of injury? - Severe force to knee with hip flexed and adducted e.g.
knee into dashboard in MVC
-Simple fall in osteoporotic people or Fall from height
-Stress fracture
#Often a piece from the acetabulum is sheared off,
making a fracture-dislocation.

What are the clinical The leg is short and lies adducted, internally rotated and
features? slightly flexed.

What about imaging? The golden rule (whenever the facilities exist) is to obtain
a ‘trauma computed tomography (CT)’ scan which
includes the pelvis, the entire femur and the knee in every
case of severe injury.

Thompson and Epstein -Type I: Dislocation with or without minor hip fracture
classification for -Type II: Dislocation with single large fracture of the
posterior hip posterior rim of the acetabulum
dislocation? -Type III: Dislocation with comminuted fracture of the
rim, with or without a large major fragment
-Type IV: Dislocation with fracture of the acetabular floor
-Type V: Dislocation with fracture of the femoral head
(a) typical posture
(b)a simple dislocation,
with the femoral head
lying above and behind
the acetabulum.
(c) Dislocation and
acetabular rim fracture.

- any type start with analgesia.

Treatment of posterior Type I:
hip dislocation? -Closed reduction as soon as possible
-X-ray confirm reduction
-C. T:
If stable rest > (traction) 3-6 weeks, patient then walk
with crutches
If there is intra-articular fragment >removed through the
posterior approach.

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Hip joint Injuries and femur fracture
Continued Type II: immediate open reduction internal
fixation(ORIF)
Type III: treatment closed, traction 6 wks.
Type IV, V: treatment closed
-check up C.T
if not reduced > open reduction and traction 4 weeks, then
full WT. bearing after 12 weeks
# Rates of osteonecrosis and subsequent osteoarthritis are
increased if the hip is dislocated for more than 6 hours.
# Closed reduction should not be attempted if there is an
associated femoral neck fracture, to prevent further
displacement of the femoral neck supply and disruption of
the blood supply to the femoral head.

Complications? Early
-Sciatic nerve injury: test before and after reduction
-Vascular injury: superior gluteal artery.
-Associated fractured femoral shaft.
-Thromboembolism – DVT/PE
Late
-Osteonecrosis of the femoral head
-Myositis ossificans
-Unreduced dislocation
-Secondary osteoarthritis
-Recurrent instability (uncommon).
Maneuver of Closed
reduction? An assistant steadies the pelvis; the surgeon flexes the
patient’s hip and knee to 90 degrees and pulls the thigh
vertically upwards.

Femoral head fractures -Always seen in association with a dislocation or

subluxation of the femoral head.
-The majority of femoral head fractures occur in posterior
hip dislocation, although, if an anterior dislocation occurs,
it is more likely to lead to a femoral head fracture.
Pipkin classification of
femoral head fractures

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Hip joint Injuries and femur fracture
Treatment? -A dislocated hip should be reduced regardless of the
presence of a femoral head fracture.
-If a femoral neck fracture is present, it must be treated
before any attempt at reduction of the hip.
-start with analgesia.
• Type 1 – The fragment should be excised if small or
fixed if large.
• Type 2 – This must be treated with open reduction and
internal fixation.
• Type 3 – The femoral neck fracture must be stabilized
first, before any attempt to reduce and fix the dislocated
femoral head.
• Type 4 – The femoral head fracture should be fixed if
large enough.

Complications? -osteoarthritis
-osteonecrosis
-sciatic nerve palsy,
-fracture malreduction
-non-union
-heterotropic ossification.

Anterior dislocation? -The leg lies externally rotated, abducted and slightly
flexed.
-A lateral film helps confirm the diagnosis.

Treatment? ■ closed reduction under conscious sedation/GA

■ post-reduction CT to assess joint congruity

Central dislocation? -Fall on the side, or a blow over the greater trochanter,
may force the femoral head medially through the floor of
the acetabulum.
- It is really a complex fracture of the acetabulum.

Hip fractures? -They are subdivided into intracapsular and extracapsular

fractures.
-The blood supply to the femoral head is typically
damaged in intracapsular fractures and rarely in
extracapsular fractures.
-typically occur in the elderly patient and are secondary to
osteoporosis.

101
Hip joint Injuries and femur fracture
Fracture of the Femoral -Intracapsular hip fracture
neck(Subcapital) -results from a fall directly onto the greater trochanter.

Garden classification of
femoral neck fractures

Treatment? Type 1&2:

-Analgesia, then Internal fixation (cannulated screws, or
sliding(dynamic)compression screw) to prevent displace.
Type 3&4: analgesia, then
-Young: ORIF
-Elderly: hemi-/total hip arthroplasty
#When the operation is dangerous. Tx: Lying in bed on
traction with prophylaxis against thromboembolism in
addition to movement and exercise.

Treatment of Fractures -Undisplaced: plaster cast (a hip spica) until it unites.

in children? -Displaced: Closed reduction and fixation with screws.

Complications? -General complications: DVT, pulmonary embolism,

pneumonia and bed sores
-Avascular necrosis:
#Sources of femoral head blood supply:
1)the intramedullary artery 2) ascending cervical branches
3) via the ligamentum teres from obturator artery
# the first two sources are severed in neck fracture and the
last insufficient to prevent ischemia of the femoral head.
-Non-union
-Osteoarthritis due to Subarticular bone necrosis or
femoral head collapse.

Causes of avascular - Poor blood supply

necrosis? - Imperfect reduction & Inadequate fixation
- Tardy healing of intra articular fracture

102
Hip joint Injuries and femur fracture
Basicervical fractures occur at the very distal extent of the femoral neck and
anatomically are intracapsular injuries but treated like
intertrochanteric fractures.

Intertrochanteric - common in elderly, osteoporotic women.

fracture - extracapsular fractures usually and seldom cause
avascular necrosis.
-Following a fall, the patient is in pain and unable to
stand. -The limb is shortened and lies in external rotation.

Kyle classification of
the Intertrochanteric
fractures?

- Types 1 and 2 accounts for the majority (nearly 60%).

Unstable fracture - poor contact as in type 3

conditions? - reverse oblique pattern or with a subtrochanteric
extension

Treatment? Analgesia and Closed reduction under fluoroscopy then

compression screw and plate or dynamic hip screw or IM
used nail for type4

Why intertrochanteric (1) to obtain the best possible position.

fracture always treated (2) to get the patient up and walking as soon as possible.
by early internal
fixation?

Complications? -General: DVT, pulmonary embolism, pneumonia, bed

sores
- Failure of fixation
- Malunion: causesVarus and external rotation deformities
- Non-union
Intertrochanteric
features – x-rays
a) Type 2
b) Type 4

103
Hip joint Injuries and femur fracture
Subtrochanteric hip -Occur between the inferior margin of the lesser
fractures trochanter and 5 cm below this point.
-Fractures more distal than this are considered to be
femoral shaft fractures.
-rare in young adults
-common in elderly patients with osteoporosis,
osteomalacia, Paget’s disease or a secondary(metastatic)
deposit and use of bisphosphonates.
-Blood loss is greater than with femoral neck or
trochanteric fractures.

Proximal part is By gluteal muscles, flexed by psoas

abducted & externally
rotated?

Treatment? -Analgesia
-Skin traction, or Thomas splint
-Open reduction and internal fixation is the treatment of
choice. Intramedullary nails with locking screws.

Complications? -General complications: DVT, pulmonary embolism,

pneumonia and bed sores
-Malunion Varus and rotational malunions are fairly
common.
-Non-union

X-ray explains
Subtrochanteric
fracture

Proximal femoral -due to high-energy trauma or Pathological

fracture in children -In addition to x-ray, Ultrasonography, magnetic
resonance imaging (MRI) and arthrography may help.

104
Hip joint Injuries and femur fracture
Delbet classification

Treatment? - Initially the hip is supported or splinted

- should be treated within 24 hours of injury.
- Undisplaced: plaster spica for 6–8 weeks
- Displaced
1) type IV: closed reduction, traction and spica
immobilization.
2) Type I, II and III: closed reduction and then internal
fixation with smooth pins or cannulated screws.

Complications? - Osteonecrosis of the femoral head

- Coxa vara
- Diminished growth due to Physeal damage

Important risk factors (1) an age of more than 10

of Osteonecrosis of the (2) a high-energy injury
femoral head (3) a type I or II fracture (femoral neck)
(4) fracture displacement.

Femoral shaft Fractures - Is well padded with muscles, (advantage): protect the
bone from all forces, (disadvantage): the fractures are
often displaced by muscles
- its fracture of young adult and result from high energy
injury
- diaphyseal fractures in elderly pt. considered
(pathological until prove otherwise)

Imaging -Pelvis & knee must always be x-rayed for associated

injury since high energy fracture.

• In proximal shaft fractures the proximal fragment is

Causes of Fracture flexed, abducted and externally rotated because of gluteus
displacement? Medius and iliopsoas muscle pull; the distal fragment is
frequently adducted.

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Hip joint Injuries and femur fracture
Continued • In mid-shaft fractures the proximal fragment is again
flexed and externally rotated but abduction is less marked.
• In lower-third fractures the proximal fragment is
adducted and the distal fragment is tilted by
gastrocnemius pull.

Winquist’s
classification

Source of extensive -perforators of the profunda femoris

bleeding from femoral -Fractures at the junction of the middle and distal thirds of
fractures? the femoral shaft can damage the femoral artery in the
adductor canal.

Treatment? Start with Emergency treatment includes:

-I.V fluid and analgesia
-Traction with a splint is mandatory
-The Definitive treatment

Definitive treatment Traction, bracing and spica casts

-The main indications for traction are:
(1) fractures in children.
(2) contraindications to anaesthesia or surgery.
(3) lack of suitable skill or facilities for internal fixation.
-Infants less than 12 kg in weight are most easily
managed by suspending the lower limbs from overhead
pulleys (‘gallows traction’).
-For young children, skin traction without a splint is
usually all that is needed.
-Older children are better suited to Russell’s traction or
use of a Thomas splint.
-Adults (and older adolescents) require skeletal traction.
-The chief drawback: length of time spent in bed (10–14
weeks for adults) can be overcome by reducing the time
in traction and then changing to a plaster spica or – in the
case of lower-third fractures – functional bracing.

106
Hip joint Injuries and femur fracture
Definitive treatment Open reduction and Plate and screw fixation
- The main indications:
(1) the combination of shaft and femoral neck fractures.
(2) a shaft fracture with an associated vascular injury.
- high complication rate: implant failure, infection … etc.
Intramedullary nailing
- it’s a method of choice for treatment.
External fixation, - The main indications:
(1) the treatment of severe open injuries
(2) management of patients with multiple injuries
(3) dealing with severe bone loss
(4) treating femoral fractures in adolescents.
Early
Complications -blood loss
- shock
- Fat embolism and ARDS
- Thromboembolism
- Infection
Late
-Delayed union and non-union
- Malunion
- Joint stiffness
- Refracture and implant failure

Open fractures
Which things should be (1) skin and soft-tissue loss
carefully assessed? (2) wound contamination
(3) compartment syndrome
(4) injury to vessels and nerves

Immediate treatment? -Antibiotic

-Wound cleansing & debridement
-Stabilization of fracture (external fixator)

Treatment of femoral - Infants need no more than 1 or 2 weeks in balanced

fractures in children? traction ,then spica for 3 or 4 weeks.
- Children (2-10) years: balanced traction for 2–3 weeks,
then Spica cast for 4 weeks.
- Teenagers (4–6 weeks) in balanced traction.
# Pathological fractures are common in generalized
disorders such as spina bifida and osteogenesis
imperfecta, and local bone lesions (e.g. a benign cyst or
tumour).

107
Hip joint Injuries and femur fracture
Supracondylar - In young adults, usually as a result of high-energy
fractures of the femur? trauma, and in elderly, osteoporotic.
-The pull of the gastrocnemius attachments may tilt the
distal fragment backwards.

Special features? -The knee is swollen because of a haemarthrosis and

deformed
-The tibial pulses should always be palpated.

Hoffa fractures -Interesting variant of supracondylar femoral fractures.

-The defining characteristic is the presence of a fracture
line in the coronal plane.

Treatment of Non-operative
supracondylar -indicated if slightly displaced and extra-articular fracture.
fracture? - skeletal traction through the proximal tibia (knee in
flexion position) with Thomas’ splint
- At 4–6 weeks replaced by a cast-brace with partially
weight-bearing
Operative
- indication: displaced fracture, intra-articular fracture,
non-union
- open reduction & internal fixation with Locked
intramedullary nails or dynamic condylar screw-plates or
Simple lag screws.

Complications? Early
-Arterial damage
Late
-Joint stiffness
- Malunion
- Non-union

Condylar Fractures -One condyle may be fractured and shifted upward.

-Occasionally the condyles are split apart and there may
be a supracondylar fracture, too.

Treatment -The haemarthrosis must be aspirated as soon as possible.

-Open reduction and internal fixation
-An intra-articular multi-fragmentary condylar fracture in
osteoporotic bone poses no alternative to performing a
hinged joint replacement.

108
Hip joint Injuries and femur fracture
Complications - Stiffness of the knee
- Osteoarthritis

Femoral condyle
fractures – treatment

109
Knee orthopedic
What are the causes of 1- Acute, Entire joint: - traumatic synovitis, post-
knee swelling? traumatic hemarthrosis, non-traumatic hemarthrosis, acute
septic arthritis or aseptic inflammatory arthritis.
2- Chronic, Entire joint: - Non-infective arthritis,
chronic infective arthritis or other synovial disorders.
3- Front knee: - prepatellar or infrapatellar bursitis.
4- Back knee: - semimembranosus bursitis, popliteal
(baker’s) cyst or popliteal aneurysm.
5- Side knee: - meniscal cyst, calcification of collateral
ligament or bony swellings (e.g. bone tumor).

What is Blount’s - A progressive bow-legged deformity due to abnormal

disease? growth of the posteromedial part of the proximal tibia.
- Treated by corrective osteotomy.

What are the roles of 1- Improving articular congruency and stability.

menisci? 2- Control rolling and gliding of the joint.
3- Distributing load during weightbearing.

Which menisci is more The medial meniscus because it is less mobile than the
subjected to stress? lateral one.

What are the 1-Traumatic (grinding).

mechanisms of meniscal 2- Degenerative (horizontal tears usually).
tears?

What is the prognosis Peripheral (outer third) tears can heal after suture but
of meniscal tears? others, closer to the center of the joint, do not heal because
they are avascular.

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Knee orthopedic
What are the clinical - History of twisting injury.
features of the disease? - Pain and locking.
- Patient reports sudden jerk while walking, or
‘something flicking over’ inside the joint.

What are the special 1- Thessaly test: - the patient flexes the knee to 20° while
tests available? standing on the affected extremity and twists in internal
and external rotation. This maneuver often reproduces
pain in patients with a meniscal tear.
2- McMurray and Apley tests: - not specific for
meniscal pathology.

How would you - MRI.

confirm the diagnosis? - Arthroscopy (diagnose and treat at the same time).

What is the treatment? - Previously open but now by arthroscope.

- Peripheral tears are repaired.
- Central tears are excised.
- Physiotherapy is essential.

What about meniscal - Cyst in the peripheral margin of the meniscus, associated
cysts? with horizontal meniscal tears.
- Pain and lump (small, lateral and firm).
- Arthroscopic removal or decompression is curative.

What are the 1- Generalized ligamentous laxity.

predisposing factors in 2- Under-development of the lateral femoral condyle and
recurrent patellar flattening of the intercondylar groove.
dislocation? 3- Maldevelopment of the patella (unusually small or
seated too high).
4- valgus deformity of the knee.
5- External tibial torsion.
6- A primary muscle defect.

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Knee orthopedic
What are the clinical - knee “give away”, fall, pain (sometimes) and knee locks
features of it? in flexion in some cases.
- positive apprehension test.

How would you manage - Relocate patella.

it? - 2 to 3 weeks in plaster cylinder or splint.
- 3 months of quadriceps strengthening exercises.
- if recurrence then surgical reconstruction is advised
(change tendon insertion site to support patella).

Chondromalacia - ‘softening’ of the patellar articular cartilage.

patellae? - Teenage girl or an athletic young adult with front knee
pain & tenderness.
- skyline & lateral X Ray may show patellofemoral
malposition (MRI & CT show the same).
- physiotherapy or lateral release with re-alignment.

Osgood–Schlatter’s - Tibial tubercle apophysitis due to excessive, repeated

disease? traction of quadriceps muscles.
- Prominent and tender Tibial tuberosity.
- X-rays show displacement or ‘fragmentation’ of the
tibial apophysis.
- Rest is only needed and the recovery is spontaneous.

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Knee joint injuries
Acute knee ligament
injuries
Most ligament injuries Because the capsule and ligaments are relaxed and the
occur while the knee is femur is allowed to rotate on the tibia.
bent?

Mechanism of injury? -Straight thrust such as a dashboard injury forcing the

tibia backwards or, more commonly, a combined
rotation and thrust as in a football tackle.

Ligaments functions? -Anterior displacement of the tibia (as in the anterior

drawer test) is resisted by the ACL with.
-Posterior displacement is prevented by the posterior
cruciate ligament (PCL).
-Both cruciate ligaments help to resist excessive valgus
and Varus angulation.
-Valgus stresses are resisted by the medial collateral
ligament, fascia Lata, pes anserinus.
-The main checks to Varus angulation are the iliotibial
band and the lateral (fibular) collateral ligament (LCL),
the popliteus tendon and the popliteo-fibular ligament.

- History of a twisting or wrenching injury and may

Clinical features? even claim to have heard a ‘pop’ as the tissues snapped.
- Tenderness is most acute over the torn ligament.
-Partial tears may permit no abnormal movement, but
the attempt can cause pain. Complete tears tend to
permit abnormal movement, which sometimes is almost
painless.

-If the knee angulates only in slight flexion (30

Sideways tilting degrees), there is probably an isolated tear of the
(Varus/valgus) tests? collateral ligaments;
-If it angulates in full extension, there is almost certainly
rupture of the capsule and cruciate ligaments as well as
the collateral ligament.

Demonstrate ACL and PCL, respectively and the knee

Anterior and posterior flexed at 90°
drawer tests?
Demonstrates ACL instability; anteroposterior glide is
Lachman test? tested with the knee flexed 15–20 degrees.

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Knee joint injuries
Posterior sag sign? Demonstrates torn PCL

Pivot shift sign? Demonstrates torn ACL

Second fracture? Avulsion fracture of the edge of the lateral tibial

condyle, indicating an ACL injury

Pellegrini-Stieda lesion? ossified post-traumatic lesions at (or near) the medial

femoral collateral ligament adjacent to the margin of the
medial femoral condyle.
Magnetic resonance Gold standard imaging tool for the assessment of knee
imaging? ligament injuries.

Anterior cruciate -One of the most common knee injuries, particularly in

ligament injury women.
- The classic history is of an axial-loading twisting
injury on a slightly flexed knee.
-This commonly occurs when suddenly changing
direction or landing and twisting from a jump in
pivoting sports such as football, netball and rugby.

Risk factors of this -Hypermobility, genetic predisposition, elevated BMI

injury? and increased tibial slope.

Treatment? -Stable knee with minimal functional impairment:

immobilization 2-4 wks. with early ROM and
strengthening of quadriceps.
-High demand lifestyle: ligament reconstruction
# Graft options most commonly used are autologous
hamstring tendons (semitendinosus + gracilis) or patella
tendon.

Posterior cruciate - Direct anterior blow or a rapid deceleration injury such

ligament injury as the knee striking the dashboard in a MVC.
- PCL rupture is much less common than ACL rupture.
- PCL is a much stronger ligament with higher load to
failure than the ACL.

Treatment? -Quadriceps rehabilitation

-If rehabilitation fail, use Surgical reconstruction.

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Knee joint injuries
Bony ACL /PCL ligament - severe strain in the younger patient, without rupturing
avulsions a cruciate ligament.
- PCL bony avulsions are from the central posterior
portion of the tibia.

Tibial spine fracture Bony avulsion of the tibial insertion of the ACL.

Treatment -Manipulation with laster cylinder for 6 weeks.

-If fails, operative reduction and fixation with strong
sutures or screw if physis has closed.

Collateral Ligament - Isolated collateral ligament tears are relatively rare.

Tears

Mechanism of injury? • valgus force to knee = MCL tear

• Varus force to knee = LCL tear

Clinical features? • swelling/effusion

• tenderness above and below joint line medially (MCL)
or laterally (LCL)
• joint laxity with Varus or valgus force to knee
-laxity with endpoint suggests partial tear
-laxity with no endpoint suggests a complete tear
• test for other injuries (e.g. O’Donoghue’s unhappy
triad), common peroneal nerve injury

O’Donoghue’s Unhappy • ACL rupture

Triad • MCL rupture
• Meniscal damage (medial and/or lateral)

Treatment? • non-operative
- partial tear: immobilization x 2-4 wks. with early
ROM and strengthening
- complete tear: immobilization at 30° flexion Knee
• operative
- indication: multiple ligamentous injuries
- surgical repair of ligaments

Knee dislocation / multi- - A knee dislocation describes a multi-ligament knee

ligament injury injury (usually combined ACL and collateral ligament
injury).

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Knee joint injuries
Mechanism of injury? -Half of them are secondary to road traffic accidents
(high-velocity dislocations)
-Third are sports injuries (low-velocity dislocations)
-10% are from simple falls (ultra-low-velocity
dislocations).

Treatment -After, checking NVS.

- Reduction under conscious sedation or in the operating
theatre as soon as possible.
-Holding with brace, plaster with the knee in 15 degrees
of flexion or external fixator If the joint is unstable.
-physiotherapy
-ACL or PCL reconstruction if need.
#The collateral ligament does not usually need
reconstruction.

Complications? Early
-Arterial damage (Popliteal artery injury). If there is any
doubt about the circulation, an arteriogram should be
obtained.
- Common peroneal nerve injury.
Late
-Joint instability
- Stiffness
Stress X-rays
(a) complete tear of
medial ligament, left knee
(b) complete tear of
lateral ligament. In both,
the anterior cruciate also
was torn.

Bony avulsion fractures

(a,b) AP, lateral X-rays
showing a large,
displaced avulsion
fracture of the tibial
spine consistent with a
bone ACL injury.
(c,d) AP and lateral X-
rays showing a bony
avulsion of the PCL

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Knee joint injuries
X-rays:
(1,2) showing an anterior
dislocation of the knee.
(b,c) An arteriogram
showed vascular cut-off
just above the knee; had
this not been recognized
and treated, amputation
might have been
necessary.

Patellofemoral injuries -History of stumbling on a stair, catching the foot while

running, or kicking hard at a muddy football.

Mechanism of injury? -Sudden resisted extension of the knee

-Sudden passive flexion of the knee while the
quadriceps is contracting.

The lesion tends to occur -adolescents: avulsion fractures of the tibial tubercle
at progressively higher -young adult sportspeople: tear the patellar tendon
levels with increasing -middle-aged adults: fracture their patellae
age? -older people: acute tears of the quadriceps tendon.

Quadriceps tendon - usually in elderly.

rupture - history of DM or rheumatoid disease, corticosteroids.

What are the clinical -Tearing pain and giving way of the knee.
features? -Bruising and local tenderness
-Sometimes a gap can be felt proximal to the patella.
- Active knee extension is either impossible (suggesting
a complete rupture) or weak (partial rupture).
# Diagnosis can be confirmed by ultrasound or MRI.

Treatment? Partial tears

- Non-operative: extension brace or plaster cylinder
followed by physiotherapy
Complete tears
-Early operation by suturing
-The knee is held in extension in a hinged brace.

Patella tendon rupture - uncommon injury; it is usually seen in young athletes

- previous history of ‘tendinitis’ and local injection of
corticosteroid.

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Knee joint injuries
Clinical features? -History of sudden pain on forced extension of the knee,
-Bruising, swelling and tenderness at the lower edge of
the patella or more distally.

What about imaging? - X-rays may show a high-riding patella and the bone
avulsed from the proximal or distal attachment of the
ligament.
-Ultrasound or MRI distinguish a partial from a
complete tear.

Treatment? Acute tears

-Partial tears: extension brace or plaster cylinder.
-Complete tears: operative repair or reattachment to
bone.
Late cases
-Two-stage operation
- first stage: release the contracted tissues and apply
traction directly to the patella
-second stage: repair the patellar tendon and augment it
with autologous hamstrings.

Patella Fractures

Mechanism of injury? -Direct injury: fall onto the knee or a blow against the
dashboard of a car – causes either an undisplaced crack
or a comminuted (‘stellate’) fracture without severe
damage to the extensor expansions.
-Indirect injury: sudden flexion of knee against
contracted quadriceps (often tears the extensor
expansions). This is a transverse fracture with a gap
between the fragments.

Clinical features? -The knee becomes swollen and painful.

- may be an abrasion or bruising over the front of the
joint.
-The patella is tender and sometimes a gap can be felt.
-Associated hemarthrosis.

Types of patella fracture? (1) an undisplaced fracture across the patella due to a
direct blow
(2) a comminuted or ‘stellate’ fracture, due to a fall or a
direct blow on the front of the knee

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Knee joint injuries
Continued (3) a transverse fracture with a gap between the
fragments due to indirect traction injury and active knee
extension is impossible.

Treatment -The key to the management of patellar fractures is

assessment of the state of the entire extensor
mechanism.
Undisplaced or minimally displaced crack
-If there is a hemarthrosis threatening the skin, it is
aspirated.
-plaster cylinder holding the knee straight for 4–6 weeks
-Quadriceps exercises every day.
Comminuted (stellate) fracture
-Open reduction and fixation with combination of K-
wires, mini fragment screws, cerclage wires or sutures
-Partial Patellectomy If needs to restore articular surface
-After initial period in back-slab, then use a hinged
brace
Displaced transverse fracture
-Open reduction and internal fixation (using the tension
band principle)
-The extensor expansions are repaired.
-Brace use until active extension of the knee is regained,
-Flexion and extension exercises are practiced each day.
Patella dislocation

Risk Factors of patella • young, female

dislocation? • shallow intercondylar groove (trochlea dysplasia)
• obesity
• high-riding patella (patella alta)
• weak vastus medialis
• genu valgus
• Q-angle (quadriceps angle) ≥20°
• tight lateral retinaculum
• ligamentous laxity (Ehlers-Danlos)

Why the patella pulled Because the knee is normally angled in slight valgus
laterally when the
quadriceps muscle
contracts?

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Knee joint injuries
Mechanism of injury? -Traumatic dislocation: due to sudden, severe
contraction of the quadriceps muscle while the knee is
stretched in valgus and external rotation.
-This occurs in sports when a runner dodges to one side.
-Atraumatic dislocations: with predisposing factors as
trochlea dysplasia, patella alta or hypermobility.

Which structures are -Medial retinacular fibers (part of the quadriceps

affected with patella expansion) may be torn along with the medial
dislocation? patellofemoral ligament (MPFL).

What are the clinical • tearing sensation and a feeling that the knee has gone
features? ‘out of joint
• knee catches or gives way with walking
• severe pain, tenderness anteromedially from rupture of
capsule
• weak knee extension or inability to extend leg unless
patella reduced
• positive patellar apprehension test
- passive lateral translation results in guarding and
patient apprehension

Treatment? • non-operative first

■ NSAIDs
■ patella is pushed back into place without anesthesia
■ plaster back-slab for 2 weeks then 6 wks.-controlled
motion
■ progressive weight bearing and isometric quadriceps
strengthening, and physiotherapy
• operative
■ indication: if recurrent or if loose bodies present
■ surgical tightening of medial capsule and release of
lateral retinaculum, possible tibial tuberosity transfer, or
proximal tibial osteotomy
# Recurrent dislocation in 15–20% patient non-
operatively treated

Cozen’s fracture -occurs between the ages of 4 and 8 years, resulting in

fracture of the medial cortex with valgus angulation at
proximal tibial metaphysis.

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Knee joint injuries
Tibial plateau fracture - caused by a Varus or valgus force combined with axial
loading as a car striking a pedestrian (hence the term
‘bumper fracture’);
-more often it is due to a fall from a height in which the
knee is forced into valgus or Varus.
-The tibial condyle is crushed or split by the opposing
femoral condyle.

Clinical features? • frequency: lateral > bicondylar > medial

• medial fractures require higher energy – often have
concomitant vascular injuries
• knee effusion (doughy feel)
• inability to bear weight
• swelling
• associated with compartment syndrome, ACL injury
and meniscal tears
• Traction injury of the peroneal or tibial nerves is not
uncommon.

Schatzker’s classification

Undisplaced and minimally displaced fractures of

Treatment? the lateral condyle:
-The hemarthrosis is aspirated if the skin is threatened
and a compression bandage for 1 week.
-Hinged cast-brace is fitted for another 3 weeks.
Markedly displaced and/or comminuted fractures of
the lateral condyle:
-open reduction and internal fixation with lag screws
and a buttress plate.
-Depressed areas should be elevated by bone grafts.
Fractures of the medial condyle:
-open reduction and fixation with a buttress plate and
screws.
-Associated lateral ligament damage will need repair.

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Knee joint injuries
Continued Bicondylar fractures:
-ORIF with risk of wound complications.
-Combination of screw fixation and circular external
fixation with a lower risk of wound complications.
-Bicondylar fractures increase risk of compartment
syndrome.
# Osteoporotic condylar fractures: as above but if the
fracture pattern permits, a total knee replacement.

Complications? Early
-Compartment syndrome
Late
-Joint stiffness
-Deformity (valgus or Varus deformity is quite
common).
-Osteoarthritis
(a) X-rays showing tibial
plateau fractures type 3
(b,c) CT reconstructions
reveal the extent and
direction of
displacements.
(d) x-ray showing perfect
fixation with a buttress
plate and screws.

Tibial Shaft Fracture

- most common long bone fracture and open fracture.
More commonly sustains
an open fracture? Because of its subcutaneous position.

Mechanism of injury?
-Twisting force causes a spiral fracture of both leg
bones at different levels.
-Angulatory force produces transverse or short oblique
fractures, usually at the same level.
-Indirect injury (low-energy): a spiral or long oblique
fracture one of the bone fragments as torsional injury.
-Direct injury (high-energy injury): crushes or splits the
skin over the fracture most common cause is MVC.

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Knee joint injuries
Clinical features -Signs of soft-tissue damage:
bruising, severe swelling, crushing or tenting of the
skin, an open wound.
-Circulatory changes, weak or absent pulses,
-Diminution or loss of sensation and inability to move
the toes.
- Be aware for signs of compartment syndrome.

X-rays - The entire length of the tibia and fibula, as well as the
knee and ankle joints, must be seen.

Treatment? Undisplaced or minimally displaced or adequate

closed reduction:
-full-length cast for 8-12 wks. from upper thigh to
metatarsal necks and the knee slightly flexed and the
ankle at right angle then, changed below-knee cast or
brace.
Displaced and closed
- ORIF
-Methods of fixation:
1)Locked intramedullary nailing: method of choice for
diaphyseal (shaft) fractures.
2) Plate fixation: best for metaphyseal fractures that are
unsuitable for nailing.
3) External fixation: more rarely used alternative to
closed nailing.
Open fracture:
- suitable regimen:
1)Antibiotics.
2)Debridement.
3)Stabilization (external fixation is preferable)
4)Soft-tissue cover (exposed bone should preferably be
covered within 5 days of the injury)
5)Rehabilitation.

# Antibiotics: started immediately.

-A first- or second-generation cephalosporin or co-
amoxiclav is suitable in most cases and should be
continued until soft-tissue closure or for a maximum of
72 hours, whichever is sooner.
-Aminoglycoside, such as gentamicin used, too.
-Metronidazole should be added if soil contamination
has occurred.

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Knee joint injuries
Complications Early:
- vascular injury (requiring angiograms, exploration and
repair)
- Compartment syndrome (Tibial fractures – both open
and closed – and intramedullary nailing are the
commonest causes of compartment syndrome in the leg)
- Infection (Open fractures are always at risk)
Late:
- Malunion (angulation more than 7 degrees in either
plane is unacceptable)
- Delayed union and non-union
- Joint stiffness
- Osteoporosis
- Complex regional pain syndrome (algodystrophy):
distal-third fractures

Fractured tibia and

fibula – intramedullary
nailing:
Closed intramedullary
nailing is now the
preferred treatment for
unstable tibial fractures.
This series of X-rays
shows the fracture before
(a) and after (b,c) nailing.

Circular external fixation

(a–d) This method of
fixation offers the benefit
of multilevel stability and
can be carried out with
little additional damage
to the soft tissues around
the injury.

Fasciotomies for
compartment
decompression

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Knee joint injuries
Tibial stress fractures -Repetitive stress may cause a fatigue fracture of the
tibia (usually in the upper half of the bone) or the fibula
(most often in the lower third).
-This injury is seen in army recruits, mountaineers,
runners and ballet dancers, who complain of pain in the
leg.

What about imaging? For the first 4 weeks there may be no visible
radiographic signs, but a bone scan shows increased
activity at the fracture site.

Treatment? -Avoid the stressful activity. Usually after 8–10 weeks

the symptoms settle down.
-A short leg gaiter for comfort during weight-bearing.

Fractured tibia and

fibula late complications

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Ankle & Foot orthopedic
What are the 3 regions
of foot?

What does the term talipes = foot, equino= horse (plantarflexion), Varus=
Talipes equinovarus inward, collectively it means foot pointed inward and
means? downward.

What is congenital A group of foot deformities (club-foot): -

Talipes Equinovarus Cavus – a high arch and plantar‐flexed first ray.
(CTEV)? Adductus of the midfoot – the foot turns inwards.
Varus of the hindfoot.
Equinus – a tight Achilles tendon.

What is the incidence of - 1–3 per 1000 births.

this disorder? - 2:1 male predominance.

What is the cause of Unknown. There are theories: -

CTEV? - Chromosomal defect.
- Arrested development in utero.
- Embryonic event such as a vascular injury.
- Neuromuscular (supported by abnormal distribution of
types 1 and 2 muscle fibers in the affected leg and
alteration of electromyography and nerve conduction
velocities).

What are clinical - Obvious deformity & resisted dorsiflexion and eversion.
features of CTEV? - Examine for other associated anomalies.

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Ankle & Foot orthopedic
What is the role of - no role in infancy due to incomplete ossification.
imaging in CTEV? - In older children we can measure the Talo-calcaneal
angle to assess progression of disease and efficacy of
treatment.

How would you manage By ponseti method (a repeated serial of manipulation,

it conservatively? casting supported sometimes by percutaneous tenotomy).
After correction occurs it will be hold by splintage in de-
rotated boots (Denis Browne boots) till age of 3 yrs.

What are operations Failure of ponseti method force us to do the following: -

you could do? 1- Release of joint capsule and ligament contractures.
2- Lengthening of tendons (z-plasty for Achilles tendon).
3- In rare occasions k-wires and ilizarov may be used.

What are the congenital DDH, Spina bifida & other rare anomalies.
anomalies associated
with CTEV?

Write few words on

each of the following: -
Metatarsus adductus - Same as club-foot but deformity is in tarsometatarsal
joint not at talonavicular joint (milder than club-foot).
- Resolve spontaneously in 90% of cases, some need serial
casting or release of abductor hallucis muscle.

Idiopathic flat-foot - Very common, especially in Afro‐Caribbean people.

- Pain and rigidity should investigated.
- Reassurance is normally all that is needed.

Kohler’s disease - osteochondritis’ – flattening and increased density

on x-ray of the navicular (painful foot).
Freiberg disease - osteochondritis of metatarsal head (painful foot).

Hallux Valgus - It is the lateral deviation of the great toe at the metatarso-
phalangeal joint.
- Causes include RA, wearing pointed shoes with high
heels, idiopathic etc.
- if symptomatic treated by osteotomy (head or neck of
metatarsus or base of first phalanx).

Hallux rigidus - Stiff big toe (OA of the metatarso-phalangeal joint).

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Ankle & Foot orthopedic
Hammer toe - Fixed flexion deformity of an inter-phalangeal
joint of the toe, usually with callosity over the
prominent proximal joint.

What are the causes of - Tenosynovitis.

painful ankle? - Rupture of tibialis posterior tendon.
- Osteochondritis dissecans of talus.
- Avascular necrosis of talus.

What are the causes of - Sever’s disease (traction apophysitis).

painful heel? - Calcaneal bursitis.
- Plantar fascitis (spur of bone on x-ray).
- bone lesions (e.g. tumor, infection…. etc.)

What are the causes of - In children: - Kohler’s disease and bony coalition.
painful midfoot? - In adult: - Overbone is the main cause.

What are the causes of - sesamoiditis (rest and padding shoes/steroid injection).
painful forefoot? - Freiberg’s disease.
- Morton metatarsalgia (interdigital nerve compression).
- Stress fracture.

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Ankle & foot injuries
Ankle ligament injuries -In more than 75% of cases it is the lateral ligament
complex that is injured, in particular the anterior
talofibular and calcaneofibular ligaments.
-It is essential to examine the entire leg and foot:
undisplaced fractures of the ankle, the more proximal
fibula or the tarsal bones are easily missed.

Types of ankle -Sprained ankle: no more than a painful wrenching of the

ligaments injury? soft tissues.
- partial tear: healing is likely to restore full function to
the joint.
- complete tear: joint instability may persist.

What are mortise-and- -Mortise: the box formed by the distal ends of the tibia
tenon? and fibula.
-Tenon: the upward projecting talus.

Medial Ligament • eversion injury

Complex (deltoid • usually avulses medial or posterior malleolus and strains
ligament) injuries syndesmosis.

Lateral Ligament • inversion injury, >90% of all ankle sprains

Complex injuries? • ATF ligament most commonly and severely injured if
ankle is plantar flexed
• swelling and tenderness anterior to lateral malleolus
• ecchymoses
• positive ankle anterior drawer test.

Treatment? PRICER
P: protection (crutches, splint or brace).
RICE: rest, ice, compression and elevation for 1–3 weeks
- Cold compression should be applied for about 20
minutes every 2 hours.
R: rehabilitation
- topical non-steroidal anti inflammatory gels or creams in
acute phase of injury.
# Persistent problems at 12 weeks after injury, despite
physiotherapy, may signal the need for operative
treatment.

X-ray views? - anteroposterior, lateral and ‘mortise’ (30-degree

oblique) views

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Ankle & foot injuries
Recurrent lateral
instability – special
tests.

Recurrent lateral
instability – operative
treatment

Tears of inferior -The inferior tibiofibular ligaments may be torn, allowing

tibiofibular ligaments partial or complete separation of the tibiofibular joint
(diastasis).
-Complete diastasis, with tearing of both the anterior and
posterior fibers, follows a severe abduction strain.
-Partial diastasis, with tearing of only the anterior fibers,
is due to an external rotation force.
- usually associated with fractures of the malleoli or
rupture of the collateral ligaments.

Clinical features? -Following a twisting injury, the patient complains of pain

in the front of the ankle.
-swelling and marked tenderness directly over the inferior
tibiofibular joint.

Treatment? -Partial tears: strapping the ankle firmly or bracing for 2–

3 weeks. Thereafter exercises are encouraged.
-Complete tears: internal fixation with a transverse screw
just above the joint as soon as possible to prevent
organizing hematoma and fibrous tissue.

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Ankle & foot injuries
Malleolar fractures of -Called Pott’s fracture.
the ankle -the ‘invisible’ part of the injury is just as important –
rupture of the collateral and/or distal tibiofibular
ligaments.

Mechanism of injury? -Most are low-energy fractures of one or both malleoli,

usually caused by a twisting mechanism.
-Less common are the more severe fractures involving the
tibial plafond – pilon fractures – which are high-energy
injuries, caused by a fall from a height.

Clinical features? -Typically, in skiers, footballers and climbers or result of

much lesser force, in osteoporotic bone.
-The patient complains of intense pain and inability to
stand on the leg –suggesting not a simple ‘sprain’.
-The ankle is swollen and deformity may be obvious,
especially in a fracture–dislocation.

X-ray imaging? -Three views are advisable:

1) anteroposterior
2) lateral
3) 30-degree oblique projection facing the plane of the
inferior tibiofibular joint (the ‘mortise’ view)
-Diastasis is seen in the mortise view.
-Collateral ligament damage is suggested by displacement
or tilting of the talus.
-If the mortise becomes unstable, talus can be displaced.

Denis–Weber -Focuses on the level of the fibular fracture

classification
(a) Type A: a fibular
fracture below the
syndesmosis
(b) Type B: a fracture at
the syndesmosis.
(c)(d) Type C: a fibular
fracture above the
syndesmosis

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Ankle & foot injuries
Lauge–Hansen -Based on the mechanism of injury, which is useful in
classification planning how to reduce the displaced fragments by
reversing the injurious forces during manipulation of the
ankle.
-Describes fracture pattern depending on:
(1) position of the foot (supination or pronation).
(2) direction of force at the moment of injury (abduction,
adduction, external rotation).

Classes of this 1)Supination external rotation (SER) “60%”

classification? 2)pronation external rotation (PER) “12%”
3)supination adduction (SAD) “20%”
4)pronation abduction (PAB)” 8% “

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Ankle & foot injuries

Denis–Weber Lauge-Hansen classification

classification
1)type A Supination+adduction(SAD)

2)type B Supination+external rotation(SER)

3)type C Pronation + abduction or external rotation (PAB or

PER)

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Ankle & foot injuries
Treatment

-tibiofibular diastasis is fixed with diastasis screw.

Postoperative management
-below-knee cast or special boot for 4–6 weeks if stable,
longer for unstable.
-partial weightbearing with the crutches.

Complications Early
-Vascular injury
-Wound breakdown and infection
Late
-Incomplete reduction
-Non-union (especially medial malleolus fracture)
-Joint stiffness
-Complex regional pain syndrome (CRPS)
-Osteoarthritis

A)Weber type C, PER 3

(Maisonneuve fracture)

B)Weber type C, PAB 3

C)Weber type B, SER 2

B) Weber-type B,
unstable SER (stage 4).

D) Weber-type A,
SAD (stage 2).

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Ankle & foot injuries
Pilon(pestle) Fractures Comminuted fracture of the distal end of the tibia (tibial
plafond), extending into the ankle joint.

Mechanism of injury? Severe axial compression of the ankle joint (e.g. in a fall
from a height) may shatter the tibial plafond.

Special features? Swelling is usually severe and fracture blisters are

common.

Imaging? -Accurate definition of the fragments demands a

computed tomography (CT) scan.

Management Early management:

SPAN (apply joint spanning external fixator)
SCAN (CT scan to better define the fracture)
PLAN definitive fixation (as distal locking plates and
rehabilitation)
# physiotherapy is focused on joint movement and
reduction of swelling.
# Swelling is relieved by elevation or applying an external
fixator across the ankle joint. It can take 3 weeks
# Pilon fractures usually take several months to heal.
# Fracture blisters were de-roofed and treated with
Flamazine (silver sulphadiazine)

Complications Secondary osteoarthritis, stiffness and pain.

Pilon fracture and its

treatment

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Ankle & foot injuries
Ankle fractures in -One-third of physeal fractures occur around the ankle.
children -The tibial (or fibular) physis fracture, usually resulting in
a Salter–Harris Type 1 or 2 fracture.
-Types 3 and 4 fractures are uncommon(supination–
adduction).

Mechanism of injury? - The foot is fixed to the ground or trapped in a crevice

and the leg twists to one or other side.

Tillaux fracture? Avulsion of a fragment of lateral part of the epiphysis of

the tibia by the anterior tibiofibular ligament; in the child
or adolescent (Salter–Harris type 3 fracture).

Triplane fracture Occurs on the medial side of the tibia and is a

combination of Salter–Harris type 2 and 3 injuries.

Clinical features? The ankle is painful, swollen, bruised and acutely tender.

Imaging The x-ray examination must be repeated after 1 week to

exclude any suspecting physeal fracture.

Treatment? Salter–Harris Types 1 and 2 injuries are treated closed.

Displaced:
-manipulation under general anesthesia.
-Full-length cast for 3 weeks and then in a below-knee
walking cast for a further 3 weeks.
Type 3 or 4 fractures
Undisplaced
- can be treated in the same manner,
-but the ankle must be x-rayed again after 5 days
Displaced fractures
-ORIF with interfragmentary screws
-Then below-knee cast for 6 weeks.

Complications - Malunion
- Asymmetrical growth
- Shortening

Ankle fractures in
children

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Ankle & foot injuries
MANAGING INJURIES -If a fracture of the talus or calcaneum or fracture-
OF THE FOOT dislocation of the mid-tarsal joints is suspected, a CT scan
of the foot should be obtained.

Injuries of the talus -Talar fractures and dislocations are relatively

uncommon.

Mechanism of injury - Violent hyperextension of the ankle: talar neck fracture

(50%).
- Compression injury due to fall from a height: body
fracture.
- Everting force across the body: the lateral process
fracture (the snowboarder’s fracture).

Clinical features? - painful and swollen foot and ankle and deformity.
- skin may be tented or split.

Tenting is a dangerous if the fracture or dislocation is not promptly reduced, the

sign? skin may slough and become infected.

Injuries of the talus –

X-rays
(a) Talocalcaneal
fracture-dislocation;
(b) undisplaced fracture
of the talar neck;
(c) displaced fracture of
the neck.

High risk of AVN of the Because weak blood supply runs distal to proximal along
body with displaced talar neck.
neck fractures?

Treatment? Non-displaced or minimally displaced:

- split plaster until swelling has subsided, is replaced by a
complete plaster in the plantigrade position for 6–8
weeks.
Displaced fractures and fracture–dislocations:
-Closed manipulation
-If fails, open reduction and fixation with screws.
- Then, below-knee plaster is needed for 6–12 weeks.

Complications? Malunion, Avascular necrosis, Secondary osteoarthritis.

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Ankle & foot injuries
Fractures of the -The calcaneum is the most commonly fractured tarsal
calcaneum bone.

Mechanism of injury? -Falls from a height, often from a ladder, onto one or both
heels.
-Avulsion fractures may cause traction injuries of the
tendo Achillis (as tuberosity fracture) or ankle ligaments.

Lover’s fracture? Fractures of the calcaneal body and may be intra- or

extra-articular.

Types of fractures? - Extra-articular fractures (25%)

- Intra-articular fractures (split the talocalcaneal articular
facet)

Extra-articular
fractures of the
calcaneum

Intra-articular
fractures of the
calcaneum

• marked swelling, bruising on heel/sole

Clinical features? • wider, shortened, flatter heel when viewed from behind
• Varus heel
- Always check for signs of a compartment syndrome of
the foot.

- loss of Bohler’s angle (25–40 degrees).

X-rays? - With severe injuries – and especially with bilateral
fractures – it is essential to assess the knees, the spine and
the pelvis as well (20% of patients).
Bohler’s angle

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Ankle & foot injuries
Treatment? -For all except the most minor injuries, the patient is
admitted to hospital so that the leg and foot can be
elevated and treated with ice-packs or Cryo-Cuff until the
swelling subsides.
Extra-articular or Non-Displaced Intra-articular:
1)compression bandaging
2)ice-packs and elevation
3)exercises as soon as pain permits
4)non-weight-bearing for 6–8 weeks.

-Displaced fracture of the anterior process: Reduction

with internal fixation, then closed routine above.
-Displaced Fractures of the tuberosity: reduced and fixed
with cancellous screws, the foot is then immobilized in
slight equinus to relieve tension on the tendo Achillis.
Displaced intra-articular fractures:
- ORIF with interfragmentary screws as soon as the
swelling subsides.
- Exercises are begun as soon as pain subsides
- Non-weightbearing on crutches until 8 weeks.

Complications Early
-Swelling and blistering
- Compartment syndrome
Late
- Malunion (Broadening of the heel)
- Peroneal tendon or sural nerve impingement
- Insufficiency of the tendo Achillis
- Talocalcaneal stiffness and osteoarthritis

X-rays of calcaneum
fracture?

139
Ankle & foot injuries
Midtarsal injuries - Isolated injuries of the navicular, cuneiform or cuboid
bones are rare.
- A medial midtarsal dislocation looks like an ‘acute
clubfoot’.
- Lateral dislocation produces a valgus deformity.

Clinical features? -The foot is bruised and swollen.

-Tenderness is usually diffuse across the midfoot.
- It is important to exclude distal ischemia or a
compartment syndrome.

Treatment of -The foot may be bandaged until acute pain subsides

Ligamentous strains? -Thereafter, movement is encouraged.
-If symptoms do not settle, suspect (and investigate for) a
missed fracture!

Treatment of -The foot is elevated to relieve swelling.

Undisplaced fractures? -After 3–4 days a below-knee cast or removable splintage
boot for 4–6 weeks. With partial weight-bearing.

Treatment of Displaced - Isolated navicular or cuboid fracture if displaced may

fractures? need open reduction and screw fixation.

Treatment of Fracture- - Closed manipulation under general anesthesia

dislocation? -Fixed with K-wires or screws is better to prevent
redisplacement.
- below-knee cast for 6–12 weeks.
-Exercises practiced persistently.
- 6–8 months before function is regained.

Treatment of - splinting in the best possible position and elevated until

Comminuted fractures? swelling subsides.
- Then, Early arthrodesis

Midtarsal injuries x-
rays?

Tarsometatarsal - Sprains are quite common but dislocation is rare

injuries - Twisting and crushing injuries are the usual cause.
- A fracture–dislocation should always be suspected if the
patient has pain, swelling and bruising of the foot after an
accident, even if there is no obvious deformity.

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Ankle & foot injuries
Treatment? Undisplaced sprains: cast or boot immobilization for 4–6
weeks.
Subluxation or dislocation:
-Reduction by traction and manipulation under anesthesia.
-Percutaneous K-wires or screws and cast immobilization
-The cast is changed after a few days when swelling has
subsided.
-The new cast is retained, non-weight-bearing, for 6–8
weeks.
- K-wires are then removed and rehabilitation

# Compartment syndrome is main complications.

Metatarsal Fractures - Metatarsal fractures are relatively common and are of

four types:
(1) crush fractures due to a direct blow
(2) a spiral fracture of the shaft due to a twisting injury
(3) avulsion fractures due to ligament strains
(4) insufficiency fractures due to repetitive stress.

Clinical features? -Acute injuries: pain, swelling and bruising of the foot are
usually quite marked;
-Stress fractures: symptoms and signs are more
insidious(gradual).

Treatment of - Blow-knee cast or removable boot splint

Undisplaced and - The foot is elevated and active movements are started
minimally displaced - partial weight-bearing for about 4–6 weeks.
fractures?

Treatment of displaced - Reduction by traction under anesthesia

fractures? - The leg immobilized in a cast – non-weight-bearing for
4 weeks.

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Ankle & foot injuries
Fracturs of the fifth - Forced inversion of the foot (the ‘pothole injury’) may
metatarsal base (the cause avulsion of the base of the fifth metatarsal, with
pothole injury). pull-off by the peroneus brevis tendon or the lateral band
of the plantar fascia
-Can be treated closed.

Robert Jones fracture?

Stress injury (March - In a young adult (often a military recruit or a runner

fracture) building up training) the foot may become painful and
slightly swollen after overuse.
-A tender lump is palpable just distal to the midshaft of a
metatarsal bone.
-The X-ray appearance may at first be normal but a
radioisotope scan will show an area of intense activity in
the bone.
-Later a hairline crack may be visible and later still (4–6
weeks) a mass of callus is seen.
Injuries of - Sprains and dislocations are common in dancers and
metatarsophalangeal athletes.
joints

Treatment? simple sprain:

-light splinting; strapping a lesser toe (second to fifth) to
its neighbor for a week or two is the easiest way.
Dislocation:
-Reduction by traction and manipulation
- short walking cast for a few weeks.
Fractured toes - caused by heavy object falling on the toes.
-If the skin is broken: covered with a sterile dressing, and
antibiotics are given; a contaminated wound will require
formal surgical washout and exploration.
-Patient encouraged to walk in supportive boot or shoe.
-If pain is marked, splinting by strapping it to its neighbor
for 2–3 weeks.

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Ankle & foot injuries
Fractured sesamoids -One of the sesamoids (usually the medial) may fracture
from either a direct injury (landing from a height on the
ball of the foot) or sudden traction.
-chronic, repetitive stress is more often seen in dancers
and runners.

Clinical features? -pain directly over the sesamoid.

- tender spot in the same area and sometimes pain can be
exacerbated by passively hyperextending the big toe.

X-rays Sesamoid fracture must be distinguished from a smooth-

edged bi-partite sesamoid

Treatment? - Treatment is often unnecessary, though a local injection

of lignocaine helps for pain.
-If discomfort is marked, the foot can be immobilized in a
short-leg walking cast for 2–3 weeks.
-Occasionally, intractable symptoms call for excision of
the offending ossicle.

143
Principles of peripheral nerve injury
In general, what are the
components of a nerve?

How does the nerve - By Wallerian degeneration in which the axonal stump
regenerate? from the proximal segment begins to grow distally.
- If the endoneural tube with its contained Schwann cells
is intact, the axonal sprout may readily pass along its
primary course and reinnervate the end-organ.
- The rate of recovery of axon is 1 mm per day.

144
Principles of peripheral nerve injury
List the nerve that
associated with: -
Deformities? Wrist drop >> radial nerve
Foot drop >> common peroneal
Winging of scapula >> long thoracic
Claw hand >> ulnar +/- median
Ape thump >> median
Pointing index >> median (prox. to elbow)
Erb’s >> upper brachial plexus (C5,6)
Klumpke’s >> C8-T1

Wasting?

How would you assess Tinel's sign: On gently tapping over the nerve along its
recovery of nerve? course, from distal to proximal, a pins and needle
sensation is felt in the area of the skin supplied by the
nerve. A distal progression of the level at which this
occurs, suggests regeneration.
Motor examination: The muscles begin to contract from
proximal to distal as they are reinnervated one after
another (motor march).
Electrodiagnostic test: This can help in predicting nerve
recovery even before it is apparent clinically.

Closed injury: - Low energy >> conservative

High energy >> explore
Open injury >> explore
Neurotmesis >> nerve repair

145
Principles of peripheral nerve injury
Large segment >> nerve graft (sural)
No recovery within 18-24 mnths, >> consider tendon
transfer (e.g. radial nerve).

What are the principles - Splintage of the paralyzed limb.

of conservative - Preserve mobility of the joints.
management? - Care of the skin and nails.
- Physiotherapy.
- Relief of pain.

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Bone TUMOURS & TUMOUR-LIKE LESIONS
EPIDEMIOLOGY -Bone and soft tissue sarcomas derived from
mesenchymal tissue.
-The incidence of sarcomas is higher in males.
-More than 60% of tumours of bone will arise from the
long bones of the lower limb, particularly around the
knee.

Histological
classification of
tumours.

#Intermediate: locally aggressive.

Staging of benign bone
tumours as described
by Enneking

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Bone TUMOURS & TUMOUR-LIKE LESIONS
Surgical stages as
described by Enneking.

Position diagnosis

Clinical presentation - paraesthesia or numbness are suggestive of compression

of a nerve by an expanding mass.
-progressive neurological dysfunction is far more
worrisome and is suggestive of direct tumour invasion.

Differential diagnosis of 1)Soft-tissue haematoma

tumor? 2) Myositis ossificans
3) Stress fracture
3) Tendon avulsion injuries
4)Infection (Osteomyelitis)
4) Gout
5) Osteopetrosis

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Bone TUMOURS & TUMOUR-LIKE LESIONS
BENIGN LESIONS OF
BONE

Non-ossifying fibroma -the commonest benign lesion of bone.

(fibrous cortical defect) -It is asymptomatic and is almost always encountered in
children as an incidental X-ray finding.
- There is no risk of malignant change.
The commonest sites?
The metaphyses of long bones; occasionally there are
multiple lesions.
X-ray imaging?
-appears as more-or-less oval radiolucent area surrounded
by a thin margin of dense bone (looks cystic).
Management?
-Heals spontaneously with bone growing.
- If there are pathological fractures, it can be treated by
curettage and bone grafting.
-Recurrences are rare.
Non-ossifying fibroma
imaging?

Fibrous dysplasia - benign, medullary fibro-osseous lesion which may affect

one bone (monostotic)” more frequent” or a number of
bones (polyostotic).
- affect children and adults with equal sex.
- The craniofacial bones and the femur are the most
frequently affected bones.
-In the polyostotic form, the pelvis, femur and tibia are
commonly involved.

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Bone TUMOURS & TUMOUR-LIKE LESIONS
Clinical features? -Small, single lesions are asymptomatic.
-Large, monostotic lesions may cause pain or discovered
only with a pathological fracture.
-Patients with polyostotic disease present in childhood or
adolescence with pain, limp, bony enlargement, deformity
or pathological fracture.

Fibrous dysplasia - Associated with endocrinopathies and café-au-lait

associations? patches on the skin and (in girls) precocious sexual
development (Albright’s syndrome).
-Malignant transformation, to fibrosarcoma of bone, is
rare but more frequently seen in McCune–Albright
syndrome.

What do the X-rays -radiolucent ‘cystic’ areas in the metaphysis or shaft; have
show? a slightly hazy or ‘ground-glass’ appearance.
-The weightbearing bones may be bent, and one of the
classic features is the ‘shepherd’s crook’ deformity of the
proximal femur.

Treatment? - Treatment is often not needed.

-Correction of deformities is sometimes required
-If there’s fracture or impending fracture, intralesional
curettage and bone grafting may be required and, for very
large lesions, internal fixation may be required.
-However, recurrence following treatment is not
uncommon.

Fibrous dysplasia

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Bone TUMOURS & TUMOUR-LIKE LESIONS
Fibrous dysplasia

Osteoid osteoma -Benign tumour consisting of osteoid and newly formed

bone. It is small (usually less than 1 cm in size).
-Most common in young patients but are rare below 5
years of age and equally rare over 30. They are more
common in men than women.
-It is more often diaphyseal than metaphyseal.
-It is most commonly seen in the long bones, particularly
the proximal femur, also occurs in tibia.

Clinical features? -Most often present with pain, which classically is worse
at night and relieved by non-steroidal anti-inflammatories
(aspirin)” salicylate “.
-Chronic cases patient may have muscle wasting and if
spine involved then spinal muscle spasm and scoliosis
may present.

X-ray imaging? -Tiny radiolucent area, the so-called ‘nidus’.

-In the diaphysis the nidus is surrounded by dense bone
and the cortex is thickened.
-Lesions in the metaphysis show less cortical thickening.

Differential diagnosis -Brodie's abscess.

-Ewing's sarcoma.
-Chromic periostitis.

Treatment? -The only effective treatment is complete removal of the

nidus by CT-guided radiofrequency ablation.
-The specimen should be x-rayed immediately to confirm
that it does contain the little tumour.
-no risk of malignant transformation.

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Bone TUMOURS & TUMOUR-LIKE LESIONS
Osteoid osteoma

Chondroma -Islands of cartilage may persist in the metaphyses of

(enchondroma) bones formed by endochondral ossification.
-The commonest location is the tubular bones of the hand
and foot followed by the femur and humerus.
- Malignant change –less than 2 per cent (and hardly ever
in a child) with solitary lesions.

What is Ollier’s -Multiple chondromas may be found within the hand of

disease? one limb, or the entire body.
-Transformation to a secondary sarcoma in 20–30% of
patients.

What is Maffucci - Multiples chondromas are associated with multiple

syndrome? cutaneous or deep hemangiomas.
- Transformation to a secondary sarcoma is likely to be
greater than 50%.

Clinical features of - usually asymptomatic and discovered incidentally on x-

chondroma? ray or after a pathological fracture.
-They are seen at any age (mostly in young people).

X-ray imaging? -Well-defined, centrally placed radiolucent area at the

junction of metaphysis and diaphysis.
-In mature lesions there are flecks or wisps of calcification
within the lucent area; this is a pathognomonic feature.

Treatment? If the tumour is painful or is enlarging, or if it presents as

a pathological fracture, it should be removed as by
curettage; the defect is filled with bone graft.

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Bone TUMOURS & TUMOUR-LIKE LESIONS
Chondroma imaging

Osteochondroma - One of the commonest ‘tumours’ of bone.

(cartilage-capped -Is a developmental lesion which starts as a small
exostosis) overgrowth of cartilage at the edge of the physeal plate
and develops by endochondral ossification into a bony
protuberance still covered by the cap of cartilage.
- Very frequent and more common in males.
-They typically present in adolescent years.
- Any further enlargement after the end of the growth
period of the bone is suggestive of malignant
transformation.

Clinical features
- They normally present as a painless mass.
- Can cause symptoms secondary to formation of an
overlying bursa due to friction, or to activity-related
discomfort.
- Rarely, the lesion may cause neuropathic symptoms due
to compression of a nearby nerve.
- most commonly occur in long bones, particularly the
femur and humerus and fast-growing ends of long bones
and the crest of the ilium.

The x-ray appearance?

-Well-defined exostosis emerging from the metaphysis,
its base co-extensive with the parent bone (this is
pathognomonic).
-It looks smaller than it feels because the cartilage cap is
usually invisible on x-ray.

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Bone TUMOURS & TUMOUR-LIKE LESIONS
The incidence of -1% for single and 6% for multiple.
malignant - Multiple lesions may develop as part of a heritable
transformation? disorder – hereditary multiple exostosis.

Features suggestive of (1) enlargement of the cartilage cap in successive

malignant change? examinations.
(2) a bulky cartilage cap (more than 1 cm in thickness).
(3) irregularly scattered flecks of calcification within the
cartilage cap.
(4) spread into the surrounding soft tissues.

Treatment? -If the tumour causes symptoms it should be excised.

-If, in an adult, it has recently become bigger or painful
then operation is urgent, for these features suggest
malignancy.
-This is seen most often with pelvic exostoses – not
because they are inherently different but because
considerable enlargement may, for long periods, pass
unnoticed.

Osteochondroma

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Bone TUMOURS & TUMOUR-LIKE LESIONS
Chondromyxoid -Like other benign cartilaginous lesions, this is seen
fibroma mainly in adolescents and young adults.
-It may occur in any bone but is more common in those of
the lower limb.

Clinical features? - Patients seldom complain

- The lesion is usually discovered by accident or after a
pathological fracture.

x-ray findings? Ovoid cyst situated eccentrically in the metaphysis.

-The lesion should be excised thorough curettage and

followed by autogenous bone grafting.

X-rays of
Chondromyxoid
fibroma

Simple bone cyst -known as a solitary cyst or unicameral(unilocular) bone

cyst
-appears during childhood, typically in the metaphysis of
one of the long bones and most commonly in the
proximal humerus humerus, the proximal femur or the
proximal tibia.

Clinical features? - The condition discovered after pathological fracture or

incidental finding on the x ray.
- Males are more frequently affected and the majority
occur within the first two decades of life.

X-ray findings? Well demarcated radiolucent area in the metaphysis don’t

cross epiphyseal growth plate.

How to confirm the Aspiration of straw-like colored fluid from the cyst.
diagnosis?

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Bone TUMOURS & TUMOUR-LIKE LESIONS
Treatment Asymptomatic lesions in older children can be left alone
but the patient should be cautioned to avoid injury which
might cause a fracture.
Active cysts in young children:
-Injection of methylprednisolone.
-Curettage and bone graft.
#Pathological fracture: prophylactic fixation.

Simple bone cyst

imaging

Aneurysmal bone cyst -Cystic tumour-like lesionCommonly seen in the

metaphyses of long bones, particularly the femur, tibia
and humerus.
-They may occur in the spine (posterior elements).
-They predominantly affect children and teenagers.
-Usually it arises spontaneously but may be after
degeneration or haemorrhage.

Clinical features? -Pain and swelling.

-When affecting the spine, presentation can be with nerve
root impingement and neurological impairment.

X-ray findings? -Well-defined radiolucent cyst, often trabeculated and

eccentrically placed.

Which tumors do mimic -Giant-cell tumour that usually extend right up to the
ABC? articular margin.

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Bone TUMOURS & TUMOUR-LIKE LESIONS
-Careful curettage and pack with bone graft
Treatment? -if there is recurrence; packing with methylmethacrylate
cement.
# There is no risk of malignant transformation.

Aneurysmal bone cyst

imaging

Giant-cell tumour -benign but locally aggressive tumour of bone.

-approximately 5% of all primary bone lesions and are
most common between 20 and 45 years of age.
-rare in the immature skeleton.
-most commonly in the distal femur, proximal tibia,
proximal humerus and distal radius.

Percentage of malignant -Malignant transformation can occur in GCTs though this

transformation? is rare (<1%) and is marginally more common in females.
-Concise: About one-third of these tumours remain truly
benign; one-third become locally invasive and one-third
metastasize.
-Rarely metastases are discovered in the lungs. The
tumour has the potential to transform into an
osteosarcoma.

Clinical features? -Pain and, less frequently, an increasing mass, particularly

around the knee with warmth of the overlying tissues.
-In 5–10% cases, pathological fracture is the presenting
feature.

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Bone TUMOURS & TUMOUR-LIKE LESIONS
Investigation? X-rays show a radiolucent area situated eccentrically at
the end of a long bone and bounded by the subchondral
bone plate.
-The centre sometimes has a soap-bubble appearance
-CT scans and MRI will reveal the extent of the tumour,
both within the bone and beyond.
-Biopsy is essential.

Treatment? - Well-confined, slow-growing lesions: be treated by

thorough curettage and ‘stripping’ of the cavity with burrs
and gouges, followed by swabbing with hydrogen
peroxide or by the application of liquid nitrogen; the
cavity is then packed with bone chips.
-More aggressive tumours, and recurrent lesions:
-excision followed, if necessary, by bone grafting or
prosthetic replacement.
#Tumours in awkward sites (e.g. the spine) may be
difficult to eradicate; supplementary radiotherapy is
sometimes recommended, but it carries a significant risk
of causing malignant transformation.
Giant-cell tumor
imaging

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Bone TUMOURS & TUMOUR-LIKE LESIONS
Hemangioma of bone -Benign lesions of bone composed of capillary blood
vessels of small or large calibre.
- common lesions, often asymptomatic and often
identified incidentally.
-Present in the vertebrae of 10% of the adult population.
-most commonly present in the fifth decade. They are
slightly more common in females than males.

Treatment? Treatment is often not required but when indicated,

curettage and stabilization.

Haemangioma X-rays

PRIMARY MALIGNANT
BONE TUMOURS
Osteosarcoma - Most common primary malignant bone tumour.
-Osteosarcoma has age distribution peaking in
adolescence (10–14 years) and the seventh decade.
- High-grade, medullary osteoid-producing tumour
spreading rapidly outwards through the periosteum and
into surrounding tissues.
- most commonly involves the long-bone metaphyses,
especially around the knee and at the proximal end of the
humerus.

-Worsening pain and swelling, particularly suffering night

Clinical features?
pain, joint restriction.
-Pathological fracture is rare.
-Fever, elevated alkaline phosphatase (ALP) and lactate
dehydrogenase (LDH).
X-ray findings?
- Hazy osteolytic areas may alternate with unusually
dense osteoblastic areas. Often the cortex is breached.
- Periosteal reaction as sunburst appearance and
Codman’s triangle are typical of osteosarcoma.

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Bone TUMOURS & TUMOUR-LIKE LESIONS
Osteosarcoma X-rays

Diagnosis and staging -CT and MRI reliably show the extent of the tumour.
-Chest x-rays are done routinely, but pulmonary CT is a
much more sensitive detector of lung metastases.
-About 10 per cent of patients have pulmonary metastases
by the time they are first seen.
-A biopsy carried out before commencing treatment.

Treatment - Biopsy after clinical assessment and advanced imaging.

- The lesion will probably be graded IIA or IIB.
- Multiagent neoadjuvant chemotherapy is given for 8–12
weeks and then, provided the tumour is resectable and
there are no skip lesions, a wide resection is carried out
(limb sparing surgery or amputation).

What next step in -The pathological specimen is examined to assess the

management after response to preoperative chemotherapy.
resection? 1)If tumour necrosis is marked (more than 90 per cent),
chemotherapy is continued for another 6–12 months
2)If the response is poor, a different chemotherapeutic
regime is substituted.
- Pulmonary metastases completely resected if they are
small and peripherally situated.

Ewing’s sarcoma - is believed to arise from endothelial cells in the bone

marrow.
-It occurs most commonly between the ages of 10 and 20
years, usually in the mid-diaphysis in tubular bone and
the femur (most common long-bone site), the tibia, fibula
or clavicle.

Clinical features -pain – often throbbing in character – and swelling.

-Generalized illness and pyrexia, together with a warm,
tender swelling.
-Raised ESR, WBC may suggest a diagnosis of
osteomyelitis.

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Bone TUMOURS & TUMOUR-LIKE LESIONS
Imaging -X-rays shows aggressive, permeative, poorly defined
osteolytic lesion with cortical destruction with periosteal
reaction.
- Periosteal reaction is common in young patients with the
lamellar ‘onionskin’ appearance causing fusiform bone
enlargement, may mimic infection or eosinophilic
granuloma.
- CT and MRI reveal the large extraosseous component.
-Radioisotope scans may show multiple areas of activity
in the skeleton.

Treatment - The best results combination of chemotherapy, surgery

and radiotherapy:
1st) course of preoperative neoadjuvant chemotherapy;
wide excision if the tumour is in a favorable site.
2nd) OR radiotherapy followed by local excision if it is
less accessible.
-further course of chemotherapy for 1 year.

Ewing’s tumour X-rays

-the second most common primary malignant bone

Chondrosarcoma
tumours after osteosarcoma.
-The highest incidence is in the fourth and fifth decades
and men are affected more often than women.
-Most frequently located in the proximal femur, pelvis,
proximal humerus, distal femur, scapula and proximal
tibia, these metaphyseal lesions can extend in the bone.

- usually designated according to:

Forms of
(a) their location in the bone (central”85%” or peripheral)
chondrosarcoma
(b) whether they develop without benign precursor
(primary chondrosarcoma” 85%”) or by malignant change
in a pre-existing benign lesion (secondary
chondrosarcoma)

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Bone TUMOURS & TUMOUR-LIKE LESIONS
Clinical features -Patients may complain of a dull ache or a gradually
enlarging lump.
-Medullary lesions may present as a pathological fracture.

X-ray findings? large, intraosseous, osteolytic tumors with a narrow zone

of transition and irregular, granular calcifications within
the matrix described as ‘honeycomb’ or ‘popcorn’

Chondrosarcoma–
central
chondrosarcoma X-rays

Secondary
chondrosarcoma X-rays

- malignant B-cell lymphoproliferative disorder of the

Multiple myeloma marrow, with plasma cells predominating.

How does it affect the By marrow cell proliferation and increased osteoclastic
bone? activity, resulting in osteoporosis and the appearance of
discrete lytic lesions throughout the skeleton
(myelomatosis).

Clinical features - The patient, typically aged 45–65 years

- weakness, backache, bone pain or a pathological
fracture.
-Hypercalcaemia may cause symptoms such as thirst,
polyuria and abdominal pain.
- plasma protein abnormalities, increased blood viscosity
and anaemia.
-Bone resorption leads to hypercalcaemia in about one-
third of cases.
- poor prognosis with median survival of 2 or 3 years.

X-ray findings? Generalized osteoporosis.

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Bone TUMOURS & TUMOUR-LIKE LESIONS
Investigation? -Mild anaemia is common, and an almost constant feature
is a high ESR.
-Raised creatinine level and hypercalcaemia.
-Over one-half the patients have Bence–Jones protein in
their urine, and abnormal serum protein may find.

Treatment - The immediate need is for pain control and, if necessary,

treatment of pathological fractures.
-General supportive measures include correction of fluid
balance and treatment for hypercalcaemia.

Myelomatosis X-rays

- Metastatic disease is the most common malignancy of

METASTATIC BONE bone.
DISEASE - The skeleton is one of the commonest sites of secondary
cancer; in patients over 50 years bone metastases are seen
more frequently than all primary malignant bone tumours
together.
The common source of -The commonest source is carcinoma of the breast; next
metastasis? in frequency are carcinomas of the prostate, kidney, lung,
thyroid, bladder and gastrointestinal tract.
-In about 10 per cent of cases no primary tumour is found.

The commonest sites for Vertebrae, pelvis, the proximal half of the femur and the
bone metastases? humerus.
- Spread is usually via the blood stream.
- occasionally, visceral tumours spread directly to
adjacent bones (e.g. the pelvis or ribs).
Clinical features - The patient is usually aged 50–70 years.
The sudden appearance of backache or thigh pain in an
elderly person (with history of carcinoma)

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Bone TUMOURS & TUMOUR-LIKE LESIONS
Treatment - Radical treatment (combined chemotherapy,
radiotherapy and surgery) targeted at a solitary secondary
deposit and the parent primary lesion may be rewarding
and even apparently curative as in solitary renal cell,
breast and thyroid tumour metastases.
- With multiple secondaries, treatment is entirely
symptomatic.

Palliative care? Control of pain and metastatic activity

- Most patients require analgesics, but the more powerful
narcotics should be reserved for the terminally ill.
-Unless specifically contraindicated, radiotherapy is used
both to control pain and to reduce metastatic growth.
-Secondary deposits from breast or prostate can often be
controlled by hormone therapy: stilboestrol for prostatic
secondaries and androgenic drugs or estrogens for breast
carcinoma.
Treatment of limb fractures
Prophylactic fixation

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Metabolic Bone diseases
What is the difference Osteopenia: -mild to moderate degree of loss in bone
between osteopenia and mass.
osteoporosis? Osteoporosis: -significant reduction in bone density.

What is the best test for The gold standard is the dual-energy x-ray absorptiometry
screening and (DEXA) scan.
diagnosis?

What is the scoring of Osteoporosis is diagnosed as a T-score < -2.5.

osteoporosis on DEXA? Osteopenia a T-score < -1.1

What is the z score? Bone mass density related to age, gender & risk factors.

Where are the most The distal forearm (Colles fracture), thoracic and lumbar
common fractures seen spine, and proximal femur.
in osteoporosis?

What are the symptoms Both conditions are asymptomatic, although fractures
of osteopenia and that develop cause pain, loss of height, and kyphosis.
osteoporosis?

What are the risk Family history (genetic), increasing age, female gender,
factors for Caucasian or Asian extraction, early menopause, poor
osteoporosis? calcium intake, thin body habitus, alcohol abuse,
hyperthyroidism, glucocorticoid excess syndromes, &
perhaps type 1 diabetes mellitus.

What are the types of Primary: - post menopause and senile

osteoporosis? Secondary: -hyperparathyroidism, thyrotoxicosis,
Cushing, RA, steroid use, CRF, malnutrition & cancer.

What are the common - Calcium supplementation.

approaches to - Weight-bearing exercise.
preventing bone loss? - Vitamin D intake.
- Avoidance of smoking and excess alcohol.
- Avoidance of medications such as glucocorticoids.

What are the Risk Oophorectomy and early hysterectomy with other general
factors for risk factor.
postmenopausal
osteoporosis?

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Metabolic Bone diseases
What strategies are - Hormone replacement (estrogen in women, testosterone
available for treating in men).
osteoporosis? - Selective estrogen receptor modulators (SERMs) (e.g.
Raloxifene).
- Bisphosphonates
- Recombinant human PTH (teriparatide)
- Denosumab {a monoclonal antibody directed against the
Receptor Activator of Nuclear Factor κB (RANK) ligand
causing a decrease in osteoclastic activity}.

What are the - Administered by mouth in once-weekly.

considerations when - Should be taken on standing position.
use alendronate - drink amount of water after it.
(bisphosphonate)? - Prevent lying down or sleeping after take it at least for 1
hour.
(The main side effect is Esophagitis and rarely esophageal
cancer).

What are the risk of Increased risks of thromboembolism, stroke, breast cancer
using HRT? and uterine cancer.

What is osteomalacia - A defect in the mineralization of osteoid (bone matrix) in

(OM)? adults (termed “rickets” in children).
- The demineralization results in a loss of bone mineral
density and bone strength.

What are the C/F of - Diffuse bone pain that may be localized to the hip area.
OM? - A waddling gait is often present (attributable to pelvic
deformation and bowing of the long bones of the legs).
- Thin radiolucent pseudo-fractures (Looser zones), which
are focal accumulations of nonmineralized osteoid, are a
distinguishing feature.

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Metabolic Bone diseases
What are the causes of - Nutritional lack
vit. D deficiency? - Under-exposure to sunlight.
- Intestinal malabsorption
- Defective conversion to the active metabolites in the
liver or kidney.

What are the deformity - Enlargement of the costochondral junctions (‘rickety

associated with vit D rosary’)
deficiency RICKETS? - Lateral indentation of the chest (Harrison’s sulcus) may
also appear.
- Distal tibial bowing has been attributed to sitting or lying
cross-legged.

What are the - Serum calcium and phosphate [decreased].

investigations needed? - Serum vit D [decreased].
- ALP may be normal or increased.
- Urinary calcium excretion is diminished.
- Investigation of underlying cause if renal or liver or
gastrointestinal problem.

What will you see in X- looser zone, compression of vertebrae and the champagne
ray? glass pelvis [due to indentation of the acetabula].

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Metabolic Bone diseases

How is the definitive Bone biopsy reveals increased osteoid and delayed
diagnosis of OM made? mineralization.

What is the treatment - Correction of the underlying disorder.

for osteomalacia? - Replacement of vitamin D and calcium.
What condition lead to - Hypophosphataemic rickets
rickets other than vit. d - Treatment is by large doses of vitamin D (50,000 IU or
deficiency and how more) and up to 4 g of inorganic phosphate per day (with
treated? careful monitoring to prevent overdosage), continued until
growth ceases.
What is Paget disease? - Bone remodeling disorder.
- Formation of an unorganized mosaic of woven and
lamellar bone that is less compact and weaker than the
normal bone.

What does turnover Cortices are thickened but irregular, at one stage more
mean? porous (osteoclastic)than usual and at another more
sclerotic(osteoblastic).

What bones are - Pelvis and tibia (commonest).

affected? - Femur, skull, spine and clavicle (less common).
What are the C\F? - Large skull (hat not fit anymore).
- Short neck.
- Kyphosis (ape like).
- Brittle bone (easily fractured).
- Pain occurs that is dull and constant.

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Metabolic Bone diseases
What are the X-ray skull is Large and flat with dots like lesion “geographic
findings? skull”.

What is of Paget disease - Cranial nerve compression may lead to impaired vision,
on nervous system? facial palsy, trigeminal neuralgia or deafness.
- Vertebral thickening may cause spinal cord or nerve root
compression.

How to diagnose it? High serum ALP and brittle bone on x-ray.

complications? - Osteosarcoma (most important).

- Fracture.
- Nerve compression and spinal stenosis.
- High-output cardiac failure.

Why dos patients with Due to increased bone blood flow in response to high
Paget disease develop turnover activity.
cardiac failure?

How are bone scans The most sensitive method to identify affected areas of
helpful in Paget bone; however, they are not specific because they show all
disease? areas of increased bone turnover.

What are the medical - Bisphosphonates (reduce bone resorption, improve pain
treatments for active and quality of life).
and/or symptomatic - Calcitonin (nasal spray).
Paget disease?

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Metabolic Bone diseases
What is scurvy? - Vitamin C (ascorbic acid) deficiency.
- Result in failure of collagen synthesis and osteoid
formation That result in osteoporosis.

What are the C/F? - The infant is irritable and anemic.

- The gums may be spongy and bleeding.
- Subperiosteal hemorrhage causes excruciating pain and
tenderness near the large joints.

What is the radiological The ring sign.

hallmark of scurvy? Subperiosteal hematomas.

How would you treat Large dose of vitamin C.

it?

What other condition Fluorosis.

lead to osteoporosis and
bone abnormalities?

Osteitis fibrosa cystica? - Endosteal cavitation and replacement of the marrow

spaces by vascular granulations and fibrous tissue.
- Occurs in severe hyperparathyroidism.

Brown tumor? - Hemorrhage and giant-cell reaction within the fibrous

stroma (of the osteitis fibrosa cystica).
- Brownish, tumor-like masses, whose liquefaction
leads to fluid-filled cysts.

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Infections of bone
What is osteomyelitis? An inflammation of bone and bone marrow.

What are the modes for Contiguous spread, hematogenous spread, and direct
development of inoculation.
osteomyelitis?

What are the principles 1- Provide analgesia and general supportive measures.
of bone infection Rx? 2- Rest the affected part.
3- Initiate antibiotic treatment or chemotherapy.
4- Evacuate pus and remove necrotic tissue.
5- Stabilize the bone if it has fractured.
6- Maintain soft-tissue and skin cover.

What are the features - Bone seeding from bacteraemia.

of hematogenous - Prepubertal children and in the elderly.
osteomyelitis? - It most often involves the metaphyseal area of the long
bones or the vertebrae.

What are the most Neonates: Staphylococcus aureus, gram -ve streptococcus
likely causative Children: S. aureus, Haemophilus influ., streptococci
organisms? Adults: S. aureus
Immunocompromised/drug addicts: S. aureus, gram -ve
Sickle cell: Salmonella.

What is the most Salmonella because the sickled RBC lodge in the
common isolated circulation of GI tract lead to ischemia of the wall of colon
organism in patients and release of salmonella.
with sickle cell disease?

What is the 1- Inflammation: characterized by acute inflammatory

pathological sequence reaction with vascular congestion, exudation of fluid &
in osteomyelitis? infiltration by polymorphonuclear leukocyte this will
cause increase intra osseous pressure & intense pain,
obstruction to blood flow & intra vascular thrombosis so
that tissue threatened by impending ischemia
2- suppuration: by the end of 2nd or 3rd day pus form
within the bone & force it’s way along the Volkmann
canals to the surface where it produces subperiosteal
abscess, in infant infection extend through the physis to
the epiphysis & then to the joint. Vertebral infection may
spread through the end plate & the intervertebral disc into
the adjacent vertebral body.

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Infections of bone
3- Necrosis: causes; 1) increase intra osseous pressure. 2)
vascular stasis. 3) infective thrombosis. 4) periosteal
stripping. 5) bacterial toxin. 6) leukocyte enzymes. With
gradual ingrowth of granulation tissue. The boundary
between dead & living bone become defined, pieces of
dead bone separate as sequestra.
4- New bone formation: by the end of 2nd weak new
bone form from the deep layers of stripped periosteum
with time this new bone thickens to form involucrum
enclosing the infected tissue & sequestra.
Perforations “cloacae” may form in the involucrum
though which pus & sequestra discharge & track through
the tissue by sinus to the surface of the skin.
5- Resolution: if infection is controlled & the intra
osseous pressure released at an early stage the progression
of OM. can be aborted, in some cases remodelling may
restore the normal contour, in other though healing is
sound the bone is left permanently deformed.

What are C/F? Tenderness, decreased movement, swelling.

What is the difference Acute osteomyelitis: - initial infection before 2 wks.

between acute and Chronic osteomyelitis: - after 2 wks. when sequestra
chronic osteomyelitis? forms.

What are the diagnostic - History and physical examination.

steps? - Blood cultures, CBC & ESR.
- X-ray (after two weeks just in chronic osteomyelitis).
- MRI (less than 2 weeks can detect acute osteomyelitis)
- Needle aspiration.
- Bone scan (early changes can be detected).

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Infections of bone
Are cultures of sinus - No, they reflect colonization of the tract and do not
tracts useful in correlate with the under- lying bone infection.
osteomyelitis? - However, if S. aureus is isolated from a sinus tract, the
likelihood is high (80%) that S. aureus is also present in
bone.

What is the Rx of acute 1- Analgesic & IV fluid

osteomyelitis? 2- Splinting: for comfort & to prevent joint contracture.
3- Empiric antibiotic until C\S results.
4- Drainage (if there is features of deep pus or abscess).

What is the duration of 6 weeks IV therapy.

therapy for acute
osteomyelitis?

What is the Rx of 1- Bactericidal antibiotic.

chronic osteomyelitis? 2- Treatment For sinus (dressing & colostomy paste) to
protect skin.
3- Operation: indicated when there are significant
symptoms combined with clear evidence of sequestrum
under AB. cover all infected soft tissue & dead bone must
be excised, double lumen tube laid down in the resulting
cavity & tissues are closed then AB. solution instilled 4
hourly & cleared shortly before the next instillation until
the effluent is sterile, usually 3-6 Wk.

What is the duration of 6 weeks IV therapy, then several months of oral therapy.
therapy for chronic
osteomyelitis?

What are the reasons 1- Undrained abscess.

for lack of response to 2. Formation of sequestra.
therapy in 3. Presence of foreign body.
osteomyelitis? 4. Development of resistance.
5. Altered pharmacokinetics or inadequate dosing of
antibiotics.
6. Undiagnosed or untreated pathogens.

What is the DDx? 1- Cellulitis: there is wide spread superficial redness &
lymphangitis.

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Infections of bone
2- Streptococcal necrotizing myositis: caused by group
A, beta haemolytic streptococci cause acute myositis
although rare should be kept in mind because it may
rapidly go out of control toward muscle necrosis,
septicaemia & death.
3- Acute suppurative (septic) arthritis: progressive rise
in CRP. value over 24-48 hour is suggestive of septic
arthritis.
4- Acute rheumatism: pain less sever & flit from one
joint to another.
5- Sickle cell crises: sometimes indistinguishable from
Ac. OM.
6- Gaucher’s disease: pseudo arthritis may closely
resemble OM.

What are the Squamous cell carcinoma of draining sinus tract and
complications of amyloidosis.
chronic osteomyelitis?

What is the role of Destruction of fragment and fill the gap with using
surgery in chronic external fixator for stabilization.
osteomyelitis?

What are the - In most cases a combination of Flucloxacillin and

antibiotics that can be Benzylpenicillin (or sodium fusidate).
used in OM? - Teicoplanin and Vancomycin (used in MRSA)
Ceftriaxone.
- Metronidazole to control both aerobic and non-aerobic.

Subacute osteomyelitis
Why is it become - Organism is less virulent.
subacute? - The patient more resistant.

What is the favourite - Distal femur.

site for it? - Proximal and distal tibia.

What is meant by Subacute osteomyelitis that appear early on MRI.

brodie abscess?

What is the DDx of Osteoid osteoma.

brodie abscess?

How can be diagnosed? MRI or open biopsy.

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Infections of bone
What is the treatment? - Immobilization.
- Antibiotics (flucloxacillin and fusidic acid) IV for 4 or 5
days and then orally for another 6 weeks often result in
healing.
- If not healed, surgical curettage is needed.
Septic arthritis

What is it? Inflammation of a joint beginning as synovitis and ending

with destruction of articular cartilage if left untreated.

What are the causative - Same as osteomyelitis.

agents? - Gonococcus is common cause in adults.

What are the findings - Joint pain.

on physical - Decreased motion.
examination? - Joint swelling.
- Joint warm to the touch (hotness).

What are the diagnostic - Inflammatory markers (ESR, CRP & WBC).
steps? - US detect joint effusion.
- Needle aspiration (- Bacteriology: culture and
Sensitivity.
- Biochemistry: glucose, protein (if
bacterial or viral cause).
- Colour.

What is the DDx? acute hemarthrosis, transient synovitis, gout, pseudogout

and Gaucher disease.

What are the Dislocation, ankylosis, epiphyseal destruction and growth

complications? restrictions.

What is the treatment? Drainage, antibiotics (same as above), splint & rest.

What is Pott’s disease? - Tuberculosis of spine.

- may cause angular kyphosis (gibbus) or paraplegia.
- may cause abscess (vertebral or psoas).

What are the Rx - Drainage of abscess

options? - Anti-TB medications (HRZE)

What is HRZE? Isoniazid, Rifampicin, Pyrazinamide & Ethambutol.

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REFERENCES
1- Martin I. Boyer, AAOS comprehensive orthopedic review, 2nd edition,
2014.
2- Ashley W. Blom, David Warwick & Michael R. Whitehouse, Apley &
Solomon’s system of orthopedics and trauma, 10th edition, CRC press
Taylor & Francis group: 2018.
3- Louis Solomon, David Warwick & Selvadurai Nayagam, Apley and
Solomon’s Concise System of Orthopedics and Trauma, 4th edition, CRC
press Taylor & Francis group: 2014.
4- Parvizi, Javad, High-yield orthopedics, 1st edition, Saunders Elsevier:
2010.
5- J. Maheshwari, Vikram A Mhaskar, Essential orthopedics, 5th edition,
Jaypee publications: 2015.
6- Willmott, Henry, Trauma and orthopedics at a glance, 1st edition, John
Wiley & Sons Ltd: 2016.
7- Orthobullets website “http://www.orthobullets.com/”

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